infectious disorders of the pulmonary system III

laryngitis

-upper airway inflammatory disorder

-MCC: viral infection

-< 3 weeks

laryngitis etiology/RF

-viral: rhinovirus, influenza, adenovirus, RSV

-smoking, allergy

-recent URI

-vocal overuse or abuse

-GERD for chronic cases

laryngitis sx

-primary sx: hoarseness or voice change

-throat pain, dry cough, fullness, fever

-hoarse, raspy, weak voice

-vocal cord edema, erythema

-red flag sx: SOB, dysphagia, odynophagia, drooling, tripod

laryngitis dx/tx

-clinical

-sx >3 weeks = direct laryngoscopy

-tx: self limited in 3-7d, vocal rest, supportive care (OTC)

viral upper respiratory tract infections (URIs)

-common cold

-MCC: rhinovirus

-viral invasion of respiratory epithelium leading to inflammatory response > vascular permeability

-kids can have up to 12/year

URI sx

-begin gradually, peak early, can last up to 14 days

-nasal fullness, rhinorrhea, sore throat, laryngitis, lymphadenopathy

-cough, low grade fever, myalgia, epistaxis, headache, malaise

-conjunctivitis

-pharyngeal erythema, cobblestoning

-diffuse wheezing and bronchial breath sounds, lung sound should NOT be focal

URI dx/tx

-clinical

-PCR: only order tests if it will change tx or concerned for complications

-tx: self limiting 5-10d, up to 14d

-supportive care (OTC), anti-tussives, mucolytics, decongestant

-secondary infections: abx

Croup- laryngotracheobronchitis

-viral infection of upper airway > edema

-MCC: parainfluenza virus

-sx occur from edema

-6mon to 3yrs

croup patho

infection leads to inflammation and edema in subglottic space > upper airway obstruction

croup etiology/RF

-parainfluenza

-influenza A and B, RSV, adenovirus, rhinovirus

-6mon-3yrs

-male

-hx

-GERD hx

-recurrent URI

-second hand smoke exposure

croup sx

-mild URI 1-3 days > seal-like barking cough

-cough is worse overnight

-hoarse voice

-stridor can hear without stethoscope

-severe: vital abnormalities, stridor at rest, tachypnea, nasal flaring, belly breathing, lethargy

croup dx

-clinical: westley croup severity score

-XR of neck: steeple sign

-lateral neck radiograph different croup from epiglottitis

croup tx

most self limiting within 3 days

-mild: supportive care, one dose oral dexamethasone

-moderate: supportive care, one dose oral dexamethasone, nebulized epinephrine, watch for 3hrs

-severe: supportive care, one dose oral or IV dexamethasone, nebulized epinephrine, hospital admission, intubation

bronchitis

-self limited respiratory infection of the large airways

-cough without evidence of pneumonia

bronchitis patho

infection of the bronchi > inflammation and thickening of bronchial mucosa > airflow obstruction and bronchial hyperresponsiveness

-secondary bacterial infection is uncommon

-MCC: viruses

bronchitis sx

-hallmark= acute cough 1-3 weeks

-viral URI sx for >5 days to qualify for bronchitis may last 4 weeks

-sputum clear or white, can be yellow or green

-chest discomfort

-dyspnea with exertion

-vital signs normal

-rhonchi or wheezing that clear w coughing

-NO focal adventitious sounds

bronchitis dx/tx

-clinical

-CXR (rule out): fever, tachy, dyspnea, hypoxia, altered mental, focal abnormalities

tx: supportive care, antitussive, expectorants, antihistamines, mucolytics

-benzonatate and guaifenesin for cough relief

-smoking cessation

acute bronchiolitis

-inflammatory process that affects the bronchioles (lower respiratory tract)

-MCC: RSV

-most common cause of hospitalization <1yo

acute bronchiolitis sx

-URI, LRTI sx, peak at 3-5 days

-wheezing diffuse and non-focal

-crackles less common

-cough, clear rhinorrhea

-low fever, tachypnea, tachycardia

-severe: ill, toxic, O2 sat <95%, RR >70, cyanosis

acute bronchiolitis dx

-clinical

-confirmatory- nasal PCR

-CXR (rule out): patchy atelectasis, patchy interstitial infiltrates, peribronchial cuffing, hyperinflation

acute bronchiolitis tx

-supportive care: nasal suctioning, antipyretic, fluids, humidified air

-DO NOT USE SABA AND CORTICOSTEROIDS

-ribavirin: high risk patients

-RSV vaccination: abrysvo (maternal 32-36weeks), nirsvimab (8-19mon infants)

-prophylaxis: palivizumab 1/mon high risk infants 0-24 mons during RSV season

pertussis

-whooping cough

-MCC (bacteria): bordetella pertussis

-infants <1 year

pertussis patho

-bordetella pertussis attaches to ciliated epithelium

-toxin prevents immune cell recruitment, progressive damage, impair mucus clearance

-paroxysmal coughing fits result

pertussis sx

-catarrhal stage (1-2w): URI sx, most contagious

-paroxysmal stage (2-6w): paroxysmal coughing fit followed by inspiratory whoop, post tussive vomiting, cyanosis during episodes, NO fever

-convalescent stage (weeks to mon): gradual resolution of cough, may recur with viral infection

pertussis dx

-confirmatory:

-first 2 weeks: PCR + culture

-2-4 weeks: PCR

->4 weeks: serology

pertussis tx

-supportive care

-hospitalize <6 mon or severe

-isolate for 5 days after antibiotics

-first line: azithromycin 10-12mg/kg/day for 5 days

-most effective in catarrhal stage

-prevention: 5 dose DTaP vaccine

-6-10 weeks to resolve

antitussive- dextromethorphan

-cough

-OTC

-delsym, robitussin

-MOA: decrease sensitivity of cough receptors and interrupts cough impulses

-can use in pregnancy

antitussive- benzonatate

-cough

-prescription only

-MOA: suppresses cough by topical anesthetic action on respiratory stretch receptors

-ADR: chest discomfort

antitussive- codeine

-opioid

-prescription only

-dosing is lower for cough

-ADR: somnolence, dysphoria, respiratory depression

mucolytics + expectorants- guaifenesin

-mucinex

-OTC

-chest congestion

-MOA: increases hydration of mucus and can cough it out better

decongestant: pseudoephedrine

-nasal congestion and rhinorrhea

-sudafed

-MOA: stimulate alpha adrenergic receptor of respiratory mucosa causing vasoconstriction

-avoid use in cardiovascular disease, DM

decongestant- phenylephrine

-nasal congestion and rhinorrhea

-OTC

-sudafed PE

-MOA: systemic arterial vasoconstriction

nasal decongestant- oxymetazoline

-nasal congestion and rhinorrhea

-afrin

-OTC

-MOA: nasal mucosa to produce vasocontriction

-rebound congestion if use for >5 days

rhinitis medicamentosa

-nasal inflammation and congestion from overuse of topical nasal decongestants

-develope 3 days after use

-nasal obstruction

-boggy, swollen, leaky nasal mucosa

-tx: oral corticosteroids