Primary Care Airway Obstruction

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11/23/2010 1

Primary Care:Primary Care:

Respiratory Tract Respiratory Tract Infections and Infections and

Asthma Asthma

Tamra N. Fortenberry, MD

Department of Ob/Gyn

The University of Tennessee

Memphis, TN



11/23/2010 2

Obj ectives - Respiratory

Tract Infections1. List the differential diagnosis for

respiratory tract infection.

2. Obtain a pertinent history in a patientwith a suspected respiratory tract

infection.

3. Describe the usual symptoms and signs

of respiratory tract infection.4. Perform a targeted physical

examination to confirm the diagnosis of

respiratory tract infection.



11/23/2010 3

Obj ectives ± Respiratory

Tract Infections5. Interpret selected tests to diagnose

respiratory tract infection:

a. Chest X-ray

b. Sputum Gram stain and culture

c. Tuberculin skin test

d. Serologic tests for viral or bacterial infection

e. Pulse Oximetry

6. Treat uncomplicated respiratory tractinfections.



11/23/2010 4

Differential Diagnosis

for Respiratory Tract Infections Upper respiratory infection (URI)

Viral Rhinitis (Common cold)

Sinusitis Pharyngitis

Influenza

Pneumonia

Bronchitis Tuberculosis

Asthma



11/23/2010 5

The Common Cold An estimated 2 of every 5

Americans are affected each year

Some experience multipleepisodes in 1 year



11/23/2010 6

The Common Cold Rhinoviruses are the most

common viral agents

Over 100 serotypes have beenimplicated

Other viruses implicated included

coronaviruses, influenza C,

parainfluenza virus, adenoviruses,

and respiratory syncytial virus



11/23/2010 7

The Common Cold No specific virus can be identified

in 50% of the cases

Highly contagious, respiratorydroplets spread by sneezing,

coughing, or hand contact with the

nose, eyes, or face

75% of patients infected with

rhinovirus will have symptoms



11/23/2010 8

The Common Cold Is not caused by a change in

weather, loss of sleep, going

outside with wet hair, or fatigue Risks for contracting a cold are

due to exposure to the causative

viruses through personal contact



11/23/2010 9

The Common Cold Signs and symptoms

Has an incubation period of 2 ± 4

days

Thereafter, sneezing, coughing,

malaise may last from 6 ± 10 days

or possibly up to 3 weeks after

incubation period



11/23/2010 10

The Common Cold Signs and symptoms

Patient may complain of

headache, nasal congestion, andscratchy throat

Subsequently, may complain of

sneezing and clear, watery

rhinorrhea in association with nasal

obstruction with general malaise

but no fever



11/23/2010 11

The Common Cold Signs and Symptoms

After 2 ± 3 days, nasal discharge

becomes thicker, cloudy, andyellowish in color as systemic

symptoms improve

Hoarseness, cough, and sore

throat may last up to 7 ± 10 days



11/23/2010 12

The Common Cold Diagnosis

Made on clinical grounds ± pt symptoms,

nasal exam showing reddened,edematous mucosa, narrowed nasal

passages, and watery discharge

Laboratory and/or imaging only indicated

if other conditions are strongly suspected

Viral isolation/culture is not practical



11/23/2010 13

The Common Cold Management/Treatment

No curative treatment

Supportive therapy ± 10

treatment Fluids, rest, humidification, and

decongestants

Analgesics, cough suppressants,mucolytics, and antihistamines are also

helpful Short term use of zinc lozenges (zinc

gluconate 10-15 mg q 2 hrs) shown toreduce duration of subjective symptomsif begun early in course of disease



11/23/2010 14

The Common Cold Inappropriate prescribing of antibiotics is

common

Due to patient beliefs/misinformation of

cold being bacterial in origin

Rural location

Female gender

Patients with purulent secretions

Antibiotics should be considered if symptoms last longer than 10-14 days,due to an 80% chance of a secondaryinfection occurring



11/23/2010 15

S

inusitis Over 35 million people in the US

are affected each year

Causative agents are usuallynormal inhabitants of therespiratory tract

H emophilus influenzae and

Streptococcus pneumoniae are themost common causes

Viral and fungal agents are rare



11/23/2010 16

S inusitis

Signs and symptoms

Patient may complain of a µfeeling of

fullness¶ and pressure over the involvedsinuses, nasal congestion, and purulent

nasal discharge

Other associated symptoms include sore

throat, malaise, low grade fever,

headache, toothache, cough >1 weeks

duration

Symptoms may last 10 ± 14 days



11/23/2010 17

S inusitis

As part of the history, the physician

may inquire about the following:

Are symptoms exacerbated bypositional changes, preceded by

air travel, URI, or seasonal

allergies?

Exposure to tobacco smoke, coldor damp weather, pollution?



11/23/2010 18

S inusitisDiagnosis

Based on clinical signs and symptoms

Physical exam may reveal patient

described symptoms ± palpate over sinuses, observe for structuralabnormalities such a deviated nasalseptum

Sinus radiographs may reveal cloudiness

and air fluid levels Limited coronal CT are more sensitive to

inflammatory changes and bonedestruction



11/23/2010 19

S inusitis

Management/Treatment

2/3 of untreated patients will improvesymptomatically within 2 weeks

Antibiotics may be appropriate in certainpatients

Amoxicillin (500mg TID) or Trimethoprim-sulfamethoxazole (1 double strengthtablet BID) for 10 days, or up to 21 days

Alternative antibiotic therapy shouldinclude drugs with activity against betalactamase-producing bacteria



11/23/2010 20

S inusitis

Supportive therapy such as

humidification, antihistamines,

analgesics, and/or vasoconstrictorsmay relieve congestion and

fullness

OTC decongestant sprays for use

of more than 5 days durationshould be discouraged



11/23/2010 21

Pharyngitis

Fewer than 25% of patients with a

sore throat have true pharyngitis

Primarily seen in 5 ± 18 year oldpopulation, it is common in adult

women



11/23/2010 22

Pharyngitis

May be of bacterial or viral origin

Most common cause is viral; most

common agent is rhinovirus Self-limiting; usually lasts 3-4 days

Group A, beta-hemolytic strep is the

primary bacterial pathogen, in 1/3 cases

- early detection reduces incidence of

acute rheumatic fever and post

streptococcal pharyngitis



11/23/2010 23

Pharyngitis

Signs and symptoms

Inflammation of the pharynx andlymphoid tissue results in fever, sorethroat, malaise, and rhinorrhea

There is usually a lack of cough

Classic triad of findings for Group A streppharyngitis include:

High fever Tonsillar exudates

Anterior cervical adenopathy (in absenceof significant cough)



11/23/2010 24

Pharyngitis

Diagnosis

On PE: observe throat for tonsillar

exudates; obtain throat swab Rapid streptococcal identification

tests are most commonly used;there is a sensitivity of 80% and a

specificity of 95% Throat cultures may be collected if

rapid strep screen is negative



11/23/2010 25

Pharyngitis


Symptomatic treatment ± includes salt-water gargles, acetaminophen, cool-misthumidification, and throat lozenges

Antibiotics treatment is necessary totreat proven strep infections

Benzathine penicillin G 1.2 million unitsas a single dose, is optimal therapy

For pen ± allergic pts, erythromycin500mg po QID x 10 days or Azithromycin500mg once daily x 3 days.



11/23/2010 26

Influenza

Responsible for over 4 million respiratoryillnesses each year

Attributable for up to 40,000 deaths and200,000 hospitalizations annually

Several types including Influenza A andB with each having a variety of strains;which may vary each year

Susceptibility/incidence in pregnancyvaries

Incubation period 1-5 days; contagious24 hours before to 7 days after Sx began



11/23/2010 27

Influenza

Signs and symptoms

Often necessary to differentiate

influenza from the common cold Symptoms include high fever (up

to 1040 F) exhaustion, generalizedaches, and cough

Patients occasionally reportheadache,nasal congestion,sneezing, and sore throat



11/23/2010 28

Influenza

Diagnosis

Diagnosis is based on clinical

signs and symptoms Nasopharyngeal swab or aspirate

can be obtained for a rapid antigen

test

Chest xray usually normal



11/23/2010 29

Influenza

Options for the prevention and treatment

are available

The vaccine is a inactivated ³killed´ formthat is 70 ± 80 % effective in preventing

illness or reducing severity of symptoms

ACOG recommends vaccination of all

pregnant women in 2nd and 3rd

trimesters during flu season or anytrimester if pt at high risk for pulmonary

complications



11/23/2010 30

Influenza


Analgesics and a cough suppressantsfor supportive therapy

Amantadine and rimantadine (both atdoses of 200 mg/day) have beeneffective at treating Influenza A.Rimantadine is preferred in renal failurepatients

Zanamivir and Tamiflu are effective for patients with Influenza A and B, but withless side effects



11/23/2010 31

Pneumonia

Most commonly community-acquired

Common etiologic agents are

Streptococcus pneumoniae or Mycoplasma pneumoniae

Viral and fungal causes have been

indicated but less common

Increased incidence of SAB and PTL has

been reported

Major cause of nonobstetric maternal

death, approximately 3.6 ± 8.6%



11/23/2010 32

Pneumonia

Signs and symptoms

Fever or hypothermia, cough with

or without sputum, dyspnea, chestdiscomfort, sweats, or rigors

Malaise may precede

Atypical pneumonia associated

with headaches, diarrhea,nonexudative pharyngitis, bullousmyringitis, slow onset, myalgias



11/23/2010 33

Pneumonia

Diagnosis

Based on clinical signs and symptoms

PE may reveal fever, tachypnea,tachycardia. Lung exam - altered breathsounds; dullness to percussion

Gram stain

gram positive lancet shaped diplococci

(Strep. pneumoniae) gram negative coccobacilli (H.

influenzae)

PMNs and monocytes ± no bacteria(Mycoplasma pneumoniae)



11/23/2010 34

Pneumonia

Diagnosis

Sputum cultures with sensitivities±

collected on patients requiringhospitalization

Pulse oximetry on patient with dyspnea ±

O2 sat should > 93%

Labs: CBC/diff, CMP with LFts

ABGs may reveal hypoxemia,

hypocarbia, and respiratory alkalosis



11/23/2010 35

Pneumonia

Diagnosis

Chest xray essential (AP and Lateral)

Patchy airspace infiltrates (Mycoplasma)

Lobar or segmental consolidation (w/air bronchogram) (Pneumococcal)

Diffuse alveolar or interstitial infiltrates(viral or Mycoplasma and other)

Utilize the PO

RT score to determine if patient needs to be hospitalized (score of

<70 may be management as anoutpatient)



11/23/2010 36

PneumoniaIndications for Hospitalization of Patients with

Community-Acquired Pneumonia

(PORT score = 71 or greater)

Age > 65 Altered mental status

Immunocompromised status

Unstable vitals signs

HypoxemiaSignificant comorbid condition

Significant metabolic/hematologic derangement

Failure to respond to outpatient therapy



11/23/2010 37

Pneumonia

Management/Treatment (outpatient)

Empiric therapy for 10 ± 14 days

Doxycycline 100 mg po BID

Fluoroquinolones (Gatifloxacin

400mg po QD, Levofloxacin

500mg po QD)

Macrolides (Azithromycin 500mg

po x 1, then 250mg QD x4 days)



11/23/2010 38

Pneumonia

Prevention

Polyvalent pneumococcal vaccine

may be given at same time withinfluenza vaccine

ACOG recommends vaccination of

pregnant women with asplenia;

metabolic, renal, cardiac,

pulmonary diseases; smokers;

immunosuppressed



11/23/2010 39

Tuberculosis

Approximately 15 million people affected

in US

Infects an estimated 20 ± 43% of theworld¶s population

Causative agent, Mycobacterium

tuberculosis, an acid fast aerobic bacillus

±spread by respiratory droplets

If adequately treated in pregnancy, fetal

complications unlikely



11/23/2010 40

Tuberculosis

Sign and symptoms

Slowly progressive constitutional

symptoms of fatigue, anorexia,weight loss, fever, and nightsweats

Chronic cough is most common

pulmonary symptom Dyspnea is unusual, unless

extensive disease



11/23/2010 41

Tuberculosis

Diagnosis

Gather detailed history including:

Known exposure to TB infectedpersons

Recently traveled from country withhigh TB prevalence

History of previous disease andtreatment

Recent history of incarceration



11/23/2010 42

Tuberculosis

Diagnosis

Laboratory studies needed for definitivediagnosis

Tuberculin skin test is most importantscreening test

Should be performed in high risk populations ± especially early in pregnancy

Positive test ± induration at site of 10mm or more; >5mm in immunocompromised pts ±get CXR

Negative test requires no further evaluation



11/23/2010 43

TuberculosisReactiveSize

Group

> 5 mm 1. HIV + pts

2. Recent contacts of people w/active TB

3. Pts w/fibrotic changes on CXR suggestive of prior TB

infections4. Organ transplant/other immunosuppressed pts

> 10 mm 1. Recent immigrants

2. HIV neg IVDA

3. Employees/residents of healthcare facilities, nursing

homes, correctional facilities

4. Patients w/cormorbidities: silicosis, DM, CRF,

leukemias/lymphomas, cancer of head or neck and lung, wt

loss >10% of IBW, gastrectomy, jejunoilieal bypass

5. Children <4 yrs or exposed adolescents

> 15mm 1. Any person with no risk factors for TB



11/23/2010 44

Tuberculosis

Diagnosis

On PE: crepitant rales may be

auscultated Chest xray may reveal multiple bilateral

infiltrates; upper lobes most commonly

involved

Proof of active infection is via sputum

cultures; takes 6 weeks

Preliminary smear may reveal tubercle

bacilli



11/23/2010 45

Tuberculosis


Inactive (latent) infection: positive skintest with chest xray WNL

Isoniazid (INH) 300mg poQD for 6-12months

Active infection: oralRx for minimum of 9 months

INH 5mg/kg(max 300mgdaily)w/pyridoxine 50 mg daily

Rifampin 10mg/kg daily (max 600mg)substitute Rifabutin 300mg QD in HIV pts

Ethambutol 5-25mg/kg daily (max 2.5g)

Pregnancy category C



11/23/2010 46

Obj ectives - Asthma

1.Obtain a targeted history from thepatient with asthma.

2. Perform a focused physical examination

to detect findings associated withasthma.

3. Interpret basic pulmonary function tests,such as:

a. Forced expiratory volume in1 second (FEV1)

b. Pulse oximetry

c. Blood gas assessment



11/23/2010 47

Obj ective - Asthma

4. Describe the differential diagnosisof asthma.

5. Treat mild asthma withmedications such inhaled beta-mimetics, corticosteroids, andmast cell stabilizers.

6. Describe the indications for referral of a patient with moresevere asthma to a medicalspecialist.



11/23/2010 48

Asthma

Chronic inflammatory condition of

airways which leads to reversible

airway obstruction andhyperrsponsiveness

Prevalence in U.S. adult population

is approximately 3 ±7 %

Affects approximately 1 % of pregnant patients



11/23/2010 49

Asthma

Focused history determinespresence of precipitants:

Respiratory irritants - perfumes,cigarettes, detergents, strong

odors, dust, areoallergens

Infections - URI, sinusitis)

Drugs ± aspirin, beta blockers,morphine

Others - GERD, cold air, emotionalstress, seasonal



11/23/2010 50

Asthma

Focused history also inquires aboutprior exacerbations:

Frequency

Duration

Severity

Need for steroid tapers

ER visits, hospital and/or ICU admissions

Intubations

Use of home nebulizer

Diurnal peak flow variability

Medications



11/23/2010 51

Asthma

Signs and symptoms

Patient may complain of wheezing,

SOB especially with inspiration,and cough (dry or productive)

Chest tightness

Difficulty completing sentences



11/23/2010 52

Asthma

On PE :

Observe for increased WOB,retractions

Lung exam may reveal wheezing,increased expiratory phase,hyperresonance w/chestpercussion; chest becomes more

silent as obstruction worsens Check for nasal polyps

Pt may be tachycardic



11/23/2010 53

Asthma

Diagnostic tests

Pulmonary function tests

FEV1 is forced expiratory volumein 1 second; used to evaluate an

exacerbation

Correlates w/peak expiratory flow

Overall decreased in asthma If >50% of predicted, mild-moderate

If <50% of predicted, severe



11/23/2010 54

Asthma

Diagnostic Tests

Pulse oximetry

Supplemental oxygen should be given to

patient awaiting assessment of arterial

oxygen tension

Saturation should be maintained at > 90%

(>95% in pregnant patients or those with

coexisting cardiac disease

Chest xray may show hyperexpansion

used to r/o other causes of obstruction



11/23/2010 55

AsthmaDiagnostic tests

Blood gas measurement

Obtain in patients in severe distress and/or FEV1 <30% of predicted values after initial treatment

PaO2 of <60 mmHg (nl 80-105mmHg) sign of severe bronchoconstriction or of a complicating

condition

PaCO2 of may initially be low due increased respiratory rate(nl 35-45 mmHG)

With prolonged attack, value will increase secondary to severeairway obstruction, increased dead space ventilation, andmuscle fatigue

A normal or increased value is a sign of impending respiratory failure and requires hospitalization



11/23/2010 56

H oney, all That Wheezes

ain¶t Asthma«. Upper airway obstruction

Chronic bronchitis

Carcinoid tumors

CHF

Pneumonias

COPD

Pulmonary embolus

Allergic reaction

Croup



11/23/2010 57

Treatments for Mild

Asthma Inhaled beta mimetics

Beta 2 selectivity ± promotes bronchodilation

Short acting class - rapid onset, within 5 minutes

and lasts approximately 4-6 hours Albuterol MDI w/spacer 2 puffs q 4-6 hr prn

Levalbuterol (nebulizer soln) BID-QID prn

Long acting class ± duration up to 12 hours

Salmeterol MDI 2 puffq12/diskus: DPI 1inhalation

q 12



11/23/2010 58

Treatments for Mild

Asthma Inhaled corticosteroids

Utilized to reduce airway

inflammation and reactivity All can be administered twice daily

Flunisolide (Aerobid)

Budesonide (Pulmicort)

Fluticasone propionate (flovent)

Triamcinolone (Azmacort)



11/23/2010 59

Treatments for Mild

Asthma Mast cell stabilizing agents

Alternative choices when initiatingpreventive therapy in mild asthma

Virtually devoid of side effects Well-suited for steroid phobic pts

Less effective than inhaledcorticosteroids

Inhibits degranulation of sensitized mast

cells following exposure to specificantigens

Cromolyn 2-4 puffs QID

Nedocromil 2 puffsQID



11/23/2010 60

When to refer«.

Referral to an asthma specialist is

recommended if

There are difficulties achieving or maintaining control

Patient meets criteria of moderate

or persistent asthmatic



11/23/2010 61

Classification of Asthma

Severity Symptoms Nighttimesymptoms

PFTs (FEV1 or PEF)

Mild

Intermittent

< 2/week < 2/month >80% predicted

Normal between

exacerbationsMild

persistent

> 2/ week

but < 1/day

> 2/month >80% predicted

Moderate

persistent

Daily w/daily

beta agonist

use;

exacerbations

>2/ week

> 1/week 60-80% predicted

Severe

persistent

Continual;

Frequent

exacerbations

frequent <60% predicted



References

Williams Obstetrics, 21st Edition,

2001

WashingtonManual Up to Date, www.uptodate.com

Obstetrics and gynecology, Ling

and Duff

Documents

Primary Care Airway Obstruction