Upper respiratory tract infections

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In Process

Author / Curator:

Faculty Advisor:

GUIDELINES:
The format of each page are recommended guidelines. They should be fluid as each topic will have a unique flow.

(1) Be concise.

(2) Be evidence-based. (Everything should have a reputable citation and resource)

(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).


Top Teaching Points

Background

- Epidemiology: adults typically have 2-4/year, which totals 5 years of suffering over a lifetime -> $60B economic loss annually

- Physiology / Pathophysiology: Hand contact, sneezing, coughing. Most contagious for first 1-3 days but up to 2 weeks

- Progression and Complications of Disease:

  • Acute rhinosinusitis - most patients are viral and recover clinically w/i 21 days w/o abx (Puhakka J Allergy Clin Immunol 1998); signs of (rare) bacterial sinusitis include maxillofacial or dental pain
  • Lower respiratory tract infection
  • Asthma attack
  • Acute otitis media

Diagnosis

All diagnosis information should be evidence-based only. Recommended sub-headers:

- Risk factors: Immunosuppression, Malnutrition, Cigarette smoking, Sleep <7h, Severe chronic stress

- Signs and Symptoms

  • Rhinorrhea (vs. tonsillitis, pharyngitis)
  • Nasal congestion/discharge (initially clear and watery -> white/yellow/green) (vs. tonsillitis)
    • NOTE: color of secretion is not alone predictive of bacterial infection
  • Sneezing
  • Sore or "scratchy" throat (vs. rhinitis)
  • Cough (vs. rhinitis) later on
  • Malaise
  • +/- low-grade fever (rarely in adults; vs. influenza)
  • No facial pain or ear pain (vs. rhinosinusitis), myalgias (vs. influenza), headache (vs. influenza)

- Differential Diagnosis (i.e. what else to look for): Rhinitis, Rhinosinusitis, Pharyngitis, Tonsillitis, Influenza, Pertussis

- Physical Exam Findings

- Recommended Work-up (Evidence-based Labs / Imaging / Diagnostics)

Management

Rhinorrhea and congestion

  • Netti pot (not effective Cochrane 2010)
  • Antihistamine/decongestant combination (Cochrane 2012)
    • NyQuil, DayQuil, Claritin [loratidine] D
  • Atrovent nasal spray (Cochrane 2013)
  • Antihistamines (Cochrane 2015) have small effect to reduce symptoms on day 1 on 2 only
    • Benadryl at night
  • Decongestants (Cochrane 2015)
    • Pseudoephedrine (Sudafed) but concern for rebound congestion
    • Phenylephrine - no data, likely useless
  • Intranasal glucocorticoid - no benefit (Cochrane 2015)

Cough

  • Guaifenesin (Cochrane 2014 with almost no effect)
  • Dextromethorphan (Chest 2001 with possible improvement, not recommended by ACCP)
  • Codeine syrup (Cochrane 2014 with no effect, not recommended by ACCP)

Generalized

  • NSAIDs and Tylenol (Cochrane 2015 with good data for symptom relief)
  • Vitamin C 200 mg reduces duration of symptoms
  • Echinacea (Cochrane 2014) with possible evidence for prevention and symptom relief
  • Zinc > 75mg daily reduces viral replication, if taken within 24 hours reduction symptoms by about 1 day, but not generally recommended because of little understanding of side effects (e.g. anosmia from early administration intranasally)

- Things to Avoid (e.g. dietary, medication restrictions)

Other Teaching Pearls

These should be short one-liners (with citations) of unique or interesting "pearls" that can offer teaching points for more advanced practitioners. (e.g. Losartan is the only ARB hypertensive agent that is associated with a lower incidence of gout attacks [1])

Trial Summaries

These are brief one-line summaries of relevant trials and studies. One recommendation is to like to discussion pages like WikiJournalClub for further information.

Ongoing controversies / New updates

What's the latest scuttlebutt? This is a place to include new guidelines, controversies, or other recent updates on the topic.

Teaching Resources

Blogs:

Videos:

Podcast episodes:

Core review articles / Guidelines:

Other links:

References


Upper respiratory tract infections

  1. Choi et al.: Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study. BMJ 2012;344:d8190.