Upper Respiratory Tract Infections

Dr. Meenakshi Aggarwal MD Emory Family Medicine

Definition

Inflammation of the respiratory mucosa from the nose to the lower respiratory tree, not including the alveoli.

Objectives

List the various categories of upper respiratory tract infectionsObtain a pertinent history in a patient with a suspected URI.Perform a targeted and thorough physical examination to confirm the diagnosis of URI.Perform and interpret selected tests to diagnose URIManage and treat uncomplicated URI’s.

Categories

Acute Rhinosinusitis Acute Pharyngitis Acute Bronchitis

Differential Diagnosis

Influenza Pneumonia Tuberculosis Asthma

Anatomy of Sinuses

Acute Rhinosinusitis (Viral) Common Symptoms: Nasal discharge, nasal congestion, facial pressure, cough, fever, muscle aches, joint pains, sore throat with hoarseness.

Symptoms resolve in 10-14 days

Common in fall, winter and spring.

Treatment: Symptomatic

Acute Bacterial Sinusitis

Causative agents are usually the normal inhabitants of the respiratory tract.

Common agents: Streptococcus pneumoniae Nontypeable Haemophilus

Influenzae Moraxella Catarrhalis

Signs and Symptoms

Feeling of fullness and pressure over the involved sinuses, nasal congestion and purulent nasal discharge. Other associated symptoms: Sore throat, malaise, low grade fever, headache, toothache, cough > 1 week duration. Symptoms may last for more than 10-14 days.

Diagnosis

Based on clinical signs and symptoms Physical Exam: Palpate over the sinuses, look for structural abnormalities like DNS. X-ray sinuses: not usually needed but may show cloudiness and air fluid levels Limited coronal CT are more sensitive to inflammatory changes and bone destruction

Ethmoid Sinusitis

Coronal computed tomographic scan showing ethmoidal polyps. Ethmoid opacity is total as a result of nasal polyps, with a secondary fluid level in the left maxillary antrum.

Treatment About 2/3rd of patients will improve without treatment in 2 weeks.

Antibiotics: Reserved for patients who have symptoms for more than 10 days or who experience worsening symptoms.

OTC decongestant nasal sprays should be discouraged for use more than 5 days

Supportive therapy: Humidification, analgesics, antihistaminics

a) Amoxicillin (500mg TID) OR b) TMP/SMX ( one DS for 10 days).

c) Alternative antibiotics: High dose amoxi/clavunate, Flouroquinolones, macrolides

Antibiotics

Acute Pharyngitis

Fewer than 25% of patients with sore throat have true pharyngitis. Primarily seen in 5-18 years old. Common in adult women.

EtiologyA) Viral: Most common. Rhinovirus (most common). Symptoms usually last for 3-5 days.

B) Bacterial: Group A beta hemolytic streptococcus (GABHS).

Early detection can prevent complications like

acute rheumatic fever and post streptococcal GN.

Signs and Symptoms

Absence of Cough Fever Sore throat Malaise Rhinorrhoea Classic triad of GABHS: High fever, tonsillar exhudates and ant. cervical lymphadenopathy.

NO COUGH

Diagnosis

Physical Exam: Tonsillar exhudates, anterior cervical LAD Rapid strep: Throat swab. Sensitivity of 80% and specificity of 95%.

Throat Cultures: Not required usually.

Needed only when suspicion is high and rapid strep is negative.

Exhudates

Management

A) Symptomatic: Saline gargles, analgesics, cool-mist humidification and throat lozenges.

B) Antibiotics: a) Benzathine Pn-G 1.2 million units IM x 1OR Pn V orally for 10 days b) For Pn allergic pts: Erythromycin 500mg QID x 10 days OR Azithro 500 mg Qdaily x 3 days.

Acute Bronchitis

Inflammation of the bronchial respiratory mucosa leading to productive cough.

Acute Bronchitis

Etiology: A)Viral B) Bacterial (Bordetella

pertussis, Mycoplasma pneumoniae, and Chlamydia pneumoniae)

Diagnosis: Clinical

S/S: Productive cough, rarely fever or tachypnea.

Treatment

A) Symptomatic

B) If cough persists for more than 10 days:

Azithro x 5 days OR

Clarithro x 7 days

Non specific URI’sCommon ColdEtiology: Rhinovirus

Adenovirus RSV Parainfluenza EnterovirusesDiagnosis: ClinicalTreatment: Adequate fluid intake, rest,

humidified air, and over-the-counter analgesics and antipyretics.

Influenza

Etiology: Influenza A & BSymptoms: Fever, myalgias, headache, rhinitis, malaise, nonproductive cough, sore throatDiagnosis: Influenza A &B antigen testingTreatment: Supportive care, oseltamivir, amantidine

Questions?