Assessment of Patients with Upper Respiratory Tract Symptoms

Assessment of Patients with Upper Respiratory Tract Symptoms

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Assessment of Patients with Upper Respiratory Tract Symptoms Daniel J.G. Thirion, BPharm, MSc, PharmD, FCSHP Date of Revision: December 2014

Introduction

Upper respiratory tract infection is a nonspecific term used to describe a spectrum of acute infections that may involve the nose, sinuses, pharynx, larynx, trachea and bronchi. These infections are very common in adults and children and may be caused by a virus, bacteria and, less frequently, fungi. Most viral infections are self-limited, resolve spontaneously and are managed symptomatically. Some patients are at risk of complications of viral infections including influenza (see Table 1), respiratory syncytial virus and cytomegalovirus and may require specific antiviral treatment. Bacterial infections or complications should be medically evaluated to determine the need for antibiotic therapy and possibly further specific intervention. Viral and bacterial infections can be difficult to differentiate. Bacterial infection should be investigated in the presence of fever for more than 72 hours, severe sudden throat pain, prolonged congestion (>7 days), difficulty breathing, earache (especially in children) or double sickening (worsening after a few days of initial improvement); refer the patient to a physician (see Figure 1). Patients suffering from the common cold usually first complain of discomfort of the throat (dryness, scratchiness), followed by nasal congestion and rhinorrhea. Nasal discharge is clear and watery at the beginning and becomes mucopurulent as the infection progresses. Cough may be present and may persist for 1–2 weeks. Usually dry at the beginning, it often becomes productive. In pharyngitis, compared to the common cold, the onset of throat pain is more rapid and the pain is more severe. Prolonged nasal congestion and purulent drainage are consistent with possible sinusitis; especially if accompanied by fever, headache and facial pain. Cough is present in most upper respiratory tract infections, such as the common cold and influenza, but may be caused by many other conditions. Many of those require a consultation with a physician (See Acute Cough, Table 1). Cough persisting longer than 3 weeks should be assessed by a physician. See Table 2 for a comparison of common upper respiratory tract ailments. For more detailed information see Viral Rhinitis, Influenza, Sinusitis and Pharyngitis. Symptoms suggestive of croup, epiglottitis or otitis media (Table 3) require referral to a physician. Allergic rhinitis can resemble the common cold but does not have an infectious etiology. Allergic rhinitis is characterized by sneezing and rhinorrhea which may progress to nasal congestion. Eye symptoms, such as conjunctivitis and lacrimation may also be present. See Conjunctivitis and Allergic Rhinitis. 2,3,4,5,6,7,8,9,10,11,12,13,14

Figure 1: Assessment of Patients with Upper Respiratory Tract Symptoms

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Assessment of Patients with Upper Respiratory Tract Symptoms

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See Allergic Rhinitis. See Viral Rhinitis, Influenza, Sinusitis and Pharyngitis. c See Acute Cough.

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a b

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Table 1: Persons at High Risk of Complications Due to Influenza

Adults and children with chronic conditions, such as cardiac or pulmonary disorders, diabetes mellitus or other metabolic disease, cancer, immunodeficiency or immunosuppression, renal disease, anemia or hemoglobinopathy, morbid obesity (BMI≥40) Any resident of a nursing home or other chronic care facility, regardless of age Persons 65 years of age and older

Conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration Children and adolescents with conditions treated for long periods with acetylsalicylic acid Healthy children 6–59 months of age Pregnant women

Aboriginal persons Table 2: Differential Diagnosis of Upper Respiratory Tract Conditions Symptom/Cause

Common Cold

Allergic Rhinitis

2,3,4,5,6,7,8,9,10,11,12,13,14

Influenza

Sinusitis

Pharyngitis

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Symptom/Cause

Common Cold

Allergic Rhinitis

Influenza

Sinusitis

Pharyngitis

Nasal discharge and congestion

Clear at the beginning, then can become mucopurulent

Abundant; aqueous and clear

Persistent, purulent rhinorrhea

Rare

Nasal congestion is common

Nasal congestion may be present

Clear at the beginning, then mucopurulent

Fever

Rare. Mild

No

Yes (38–40°C)

Possible

Yes

Sore throat

Common

No

Sometimes

No

Severe, sudden onset

Cough

Mild to moderate

Possible via post-nasal drip

Common

Possible via postnasal drip

Rare

Headache

Rare, via sinus congestion

Via sinus congestion

Yes

Via sinus congestion

General aches and pain

Rare. Mild

Earaches, especially in children

Common (myalgia)

Rare

Other

Sneezing in the first couple of days

Pruritus (palate, nose, eyes)

Fatigue, weakness, chills, nausea, vomiting, diarrhea

Facial tenderness; jaw and tooth pain

Duration

Usually 5–7 days but 25% last 14 days

As long as exposed to the allergen

10 days

Days to weeks

3 days

Etiology

Viral

Noninfectious

Viral

Viral, bacterial, fungal (rare)

Viral (most common), bacterial

Mild (dry, scratchy, sore) Dry at the beginning; often changes to productive as the cold progresses

Nasal congestion is rare

Sudden onset

Sneezing, lacrimation

Table 3: Croup, Epiglottitis and Otitis Media in Children

Unproductive

Coloured (yellow, green)

Possible

9,15,16,17

Condition

Croup

Epiglottitis

Otitis Media

Possible signs

Barking, seal-like cough,

Sore throat and difficulty

Fever, especially one

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Condition

Croup

Epiglottitis

Otitis Media

and symptoms

usually unproductive

swallowing

beginning several days after the start of a cold

Gradually worsening inspiratory stridor Dyspnea Fever

Hoarseness

Fever, chills Stridor

Use of accessory muscles and positioning for breathing (laboured, sitting upright, and leaning slightly forward) Hoarseness Drooling

Cyanosis Other characteristics

Fluctuating course with rapid improvements and declines; symptoms often worse at night

Rapidly progressive, usually absence of cough

Earache or child tugging at or fingering ear Irritability and/or lethargy Vomiting

Purulent drainage from ear For more information see Acute Otitis Media in Childhood.

Prodrome (2–5 days) consisting of mild fever, rhinorrhea, malaise, sore throat and cough

For more information see Croup.

Suggested Readings

Committee on Infectious Diseases, American Academy of Pediatrics. Principles of appropriate use for upper respiratory tract infections. In: Pickering LK, ed. Red Book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village: American Academy of Pediatrics; 2012. p. 802-5. Heikkinen T, Jarvinen A. The common cold. Lancet 2003;361:51-9. Plaut M, Valentine MD. Clinical practice. Allergic rhinitis. N Engl J Med 2005;353:1934-44.

References 1. National Advisory Committee on Immunization (NACI). An Advisory Committee Statement (ACS). Statement on seasonal influenza vaccine for 2014-2015. Ottawa (ON): PHAC; 2014. Available from: www.phacaspc.gc.ca/naci-ccni/flu-grippe-eng.php. Accessed November 24, 2014. 2. Heikkinen T, Jarvinen A. The common cold. Lancet 2003;361:51-9. 3. Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006;129:72S-74S. 4. Canadian Paediatric Society. Caring for Kids. Colds in children. Available from: www.caringforkids.cps.ca/handouts/colds_in_children. Accessed February 20, 2013. 5. Irwin RS, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000;343:1715-21. 6. Desrosiers M, Evans G, Keith PK et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol 2011;7:2. 7. Worrall G. Acute sinusitis. Can Fam Physician 2011;57:565-7. 8. Worrall G. Acute sore throat. Can Fam Physician 2011;57:791-4.

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9. Committee on Infectious Diseases, American Academy of Pediatrics. Principles of appropriate use for upper respiratory tract infections. In: Pickering LK, ed. Red Book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village: American Academy of Pediatrics; 2012. p. 802-5. 10. May JR, Smith PH. Allergic rhinitis. In: DiPiro JT et al., eds. Pharmacotherapy: a pathophysiologic approach. 7th ed. New York: McGraw-Hill Medical; 2008. p. 1565-75. 11. Khaliq Y, Forgie S, Zhanel G. Upper respiratory tract infections. In: DiPiro JT et al., eds. Pharmacotherapy: a pathophysiologic approach. 7th ed. New York: McGraw-Hill Medical; 2008. p. 1779-89. 12. Plaut M, Valentine MD. Clinical practice. Allergic rhinitis. N Engl J Med 2005;353:1934-44. 13. Wallace DV, Dykewicz MS, Bernstein DI et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol 2008;122:S1-84. 14. Nahata MC, O'Mara NB, Benavides S. Viral infections. In: Koda-Kimble MA, Young LL, eds. Applied therapeutics: the clinical use of drugs. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 72-1-72-20. 15. Canadian Paediatric Society. Management of acute otitis media. Paediatr Child Health 2009;14:457-64. 16. Worrall G. Croup. Can Fam Physician 2008;54:573-4. 17. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008;41:551-66. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-02-2016 11:59 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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