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June 25, 2024
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№ 2. Diseases of the upper respiratory tract. Diseases of the lower respiratory tract.

 

Upper respiratory tract infection

Upper and lower respiratory tracts

Upper respiratory infections, commonly referred to the acronym URI or URTI, is the illness caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx. In the United States, this represents approximately one billion acute upper respiratory illnesses annually.

Signs and symptoms

Acute upper respiratory tract infections includes rhinosinusitis (common cold), sinusitis, pharyngitis/tonsillitis, laryngitis and sometimes bronchitis. Symptoms of URI’s commonly include congestion, cough, running nose, sore throat, fever, facial pressure and sneezing. Onset of the symptoms usually begins after 1-3 days after exposure to a microbial pathogen, most commonly a virus. The duration of the symptoms is typically 7 to 10 days but may persist longer.

It is important to mention that up to 15% of acute pharyngitis cases may be caused by bacteria, commonly Group A Strep (“Strep Throat”). Generally, patients with “Strep Throat” start with a sore throat as their first symptom and usually do not have runny nose or cough or sneezing.

Pain and pressure of the ear caused by a middle ear infection (Otitis media) and the reddening of they eye caused by Viral Conjunctivitis are often associated with upper respiratory infections.

Influenza (the flu) is a more systemic illness, which can also involve the upper respiratory tract, should be recognized as distinct from other causes of URI.

Treatment

Judicious use of antibiotics can decrease unnecessary adverse effects of antibiotics as well as out-of-pocket costs to the patient. But more important, decreased antibiotic usage will prevent development of drug resistant bacteria, which is now a growing problem in the world. International, as well as local US health agencies, have been strongly encouraging physicians to decrease the prescribing of antibiotics to treat common upper respiratory tract infections because antibiotic usage does not significantly reduce recovery time for these viral illnesses . Some have advocated a delayed antibiotic approach to treating URIs which seeks to reduce the consumption of antibiotics while attempting to maintain patient satisfaction. Most studies show no difference in improvement of symptoms between those treated with antibiotics right away and those with delayed prescriptions. Most studies also show no difference in patient satisfaction, patient complications, symptoms between delayed and no antibiotics. It should be noted that a strategy of “no antibiotics” results in even less antibiotic use than a strategy of “delayed antibiotics”. Until more effective treatments are available to treat the common respiratory viruses responsible for the majority of cases, treatment of URIs with rest, increased fluids, and symptomatic care with over-the-counter medications will remain the treatment of choice. However, in certain higher risk patients with underlying lung disease, such as chronic obstructive pulmonary disease (COPD), evidence does exist to support the treatment of URIs with antibiotics to shorten the course of illness and decrease treatment failure.

The use of Vitamin C in the prevention and treatment of upper respiratory infections has been suggested since the initial isolation of vitamin C in the 1930s. Several studies have failed to demonstrate that vitamin C supplementation reduces the incidence of colds in the normal healthy population, indicating that routine large dose prophylaxis with Vitamin C is not beneficial in widespread community usage. Some evidence exists to indicate that it could be justified in persons exposed to brief periods of severe physical exercise and/or cold environments. The evidence does not support the use of Vitamin C at the onset of colds as effective therapy.

TRACHEITIS

 

Tracheitis is a bacterial infection of the trachea (wind pipe) capable of producing.

Bacterial tracheitis is most often caused by Staphylococcus aureus and frequently follows a recent viral upper respiratory infection. It affects mostly young children, possibly because their small trachea is easily blocked by swelling.

 

Children may still have a cough from their previous infection but this rapidly worsens. The child quickly develops stridor, a high pitched, crowing sound with breathing and increasing breathing difficulty. Fever is generally high and the child looks very ill. This condition may progress very rapidly.

 

These children may sound as if they have croup, but the usual croup treatments do not improve the breathing difficulty. Tracheitis requires hospitalization and, usually, a breathing tube (endotracheal tube) in order to maintain an open airway.

The infection is treated with an antistaphylococcal medications such as penicillin or a cephalosporin that covers Staphylococcus. If a different organism is at fault, the appropriate antibiotic is used.

 

Pathophysiology

 

Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.

 

Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.

 

Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury to trachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms.

 

History

Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.

In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful.

In a study by Salamone et al, a significant subset of older children (mean age, 8 y) did not have severe clinical symptoms.

The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.

Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened.

Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea.

A high index of suspicion for bacterial tracheitis is needed in children with viral croup–like symptoms who do not respond to standard croup treatment or clinically worsen.

 

Causes

§        S aureus: Community-associated methicillin-resistant S aureus (CA-MRSA) has recently emerged as an important agent in the United States; this could result in a greater frequency of MRSA strains that cause tracheitis.

§        S pyogenes, Streptococcus pneumoniae, and other alpha hemolytic streptococcal species

§        Moraxella catarrhalis: Recent reports suggest it is a leading cause of bacterial tracheitis and associated with increased intubation.

§        Haemophilus influenzae type B (Hib): This cause is less common since the introduction of the Hib vaccine.

§        Klebsiella species

§        Pseudomonas species

§        Anaerobes

§        Peptostreptococcus species

§        Bacteroides species

§        Prevotella species

 

Other:

§        Mycoplasma pneumoniae

§        Mycobacterium tuberculosis (endobronchial disease)

 

 

Symptoms

·        increasing deep or barking croup-like cough following a previous upper respiratory infection

·        crowing sound when the child inhales (inspiratory stridor)

·        high fever

·        very sick-looking child (toxic)

·        breathing difficulty, increasing in severity over time

·        intercostal retractions (the muscles between the ribs pull in as the child attempts to breathe)

 

Signs and tests

·        nasopharyngeal culture (shows Staphylococcus aureus or other organisms)

·        tracheal culture (shows Staphylococcus aureus or other organisms)

·        blood gasses (show decreased oxygen saturation, decreased pO2)

·        X-ray of the trachea (shows narrowing of the tracheal airway, but normal epiglottis)

·        purulent (pus-filled) tracheal secretions may be obtained while placing the breathing tube in the patient

 

Treatment

 

Treatment of bacterial tracheitis consists of the following:

 

Airway

·        Maintenance of an adequate airway is of primary importance.

·        Avoid agitating the child. If the patient’s respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.

·        If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotracheal tube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation.

Intravenous access and medication

·        Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.

·        Antibiotic regimens have traditionally included a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and a penicillinase-resistant penicillin (eg, oxacillin, nafcillin). Recently, clindamycin (40 mg/kg/d intravenously [IV], divided every 8 h) is used instead of penicillinase-resistant penicillin against community acquired–methicillin-resistant S aureus (CA-MRSA) in places where resistance rates of CA-MRSA to clindamycin is low.6 

·        Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community.

 

The child ofteeeds to have an airway or breathing tube placed (endotracheal tube). Antibiotics are given through a vein, usually a type of penicillin or one of the cephalosporins. Oxygen is usually given, and the blood gases are monitored to be sure that the child is breathing adequately.

 

Surgical Care

·        Tracheostomy

·        Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged.

·        Pulmonary toilet is potentially better with tracheostomy.

·        Consultations

·        Otorhinolaryngology – For endoscopic procedures and acute airway management

·        Pediatric intensivist – Necessary because of potential for acute decompensation

 

Medication

Antibiotic agents

Empiric antimicrobial therapy in bacterial tracheitis must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

 

Expectations (prognosis)

Full recovery is expected if the patient can be brought to a medical facility in time.

·        fairway obstruction with cardiorespiratory arrest and possibly death — the breathing stops, then the heartbeat stops

·        toxic shock syndrome (only if the organism is Staphylococcus)

Rhinitis

Rhinitis (pron.: /raɪˈnaɪtɪs/) is a medical term for irritation and inflammation of the mucous membrane inside the nose. Common symptoms of rhinitis are a stuffy nose, runny nose, and post-nasal drip. The most common kind of rhinitis is allergic rhinitis, which is usually triggered by airborne allergens such as pollen and dander. Allergic rhinitis may cause additional symptoms, such as sneezing and nasal itching, coughing, headache, fatigue, malaise, and cognitive impairment. The allergens may also affect the eyes, causing watery, reddened or itchy eyes and puffiness around the eyes.

 

Rhinitis is very common. Allergic rhinitis is more common in some countries than others; in the United States, about 10%-30% of adults are affected annually.

 

In rhinitis, the inflammation of the mucous membrane is caused by viruses, bacteria, irritants or allergens. The inflammation results in the generation of large amounts of mucus, commonly producing a runny nose, as well as a stuffy nose and post-nasal drip. In the case of allergic rhinitis, the inflammation is caused by the degranulation of mast cells in the nose. When mast cells degranulate, they release histamine and other chemicals, starting an inflammatory process that can cause symptoms outside the nose, such as fatigue and malaise.

Types

 

Rhinitis is categorized into three types: (i) infective rhinitis includes acute and chronic bacterial infections; (ii) nonallergic (vasomotor) rhinitis includes autonomic, hormonal, drug-induced, atrophic, and gustatory rhinitis, as well as rhinitis medicamentosa; (iii) allergic rhinitis, triggered by pollen, mold, animal dander, dust and other similar inhaled allergens.

 

Infectious

 

Rhinitis is commonly caused by a viral or bacterial infection, including the common cold, which is caused by Rhinoviruses and Coronaviruses, or bacterial sinusitis. Symptoms of the common cold include rhinorrhea, sore throat (pharyngitis), cough, congestion, and slight headache.

 

Vasomotor rhinitis

Non-allergic rhinitis refers to runny nose that is not due to allergy. Non-allergic rhinitis can be classified as either non-inflammatory or inflammatory rhinitis. One very common type of non-inflammatory, non-allergic rhinitis that is sometimes confused with allergy is called vasomotor rhinitis, in which certain nonspecific stimuli, including changes in environment (temperature, humidity, barometric pressure, or weather); airborne irritants (odors, fumes); dietary factors (spicy food, alcohol); sexual arousal; and emotional factors. There is still much to be learned about this entity, but it is thought that these non-allergic triggers cause dilation of the blood vessels in the lining of the nose, which results in swelling, and drainage. Vasomotor rhinitis can coexist with allergic rhinitis, and this is called “mixed rhinitis.” (Middleton’s Allergy Principles and Practice, seventh edition.) The pathology of vasomotor rhinitis appears to involve neurogenic inflammation and is as yet not very well understood. Vasomotor rhinitis appears to be significantly more common in women than men, leading some researchers to believe that hormones play a role. In general, age of onset occurs after 20 years of age, in contrast to allergic rhinitis which can be developed at any age. Individuals suffering from vasomotor rhinitis typically experience symptoms year-round, though symptoms may be exacerbated in the spring and autumn when rapid weather changes are more common. An estimated 17 million United States citizens have vasomotor rhinitis. The antihistamines azelastine and olopatadine, applied as nasal sprays, may both be effective for vasomotor rhinitis. Fluticasone propionate or budesonide (both are steroids) in nostril spray form may also be used for symptomatic treatment.

 

Allergic

Pollen grains from a variety of common plants can cause hay fever

 

Allergic rhinitis or hay fever may follow when an allergen such as pollen or dust is inhaled by an individual with a sensitized immune system, triggering antibody production. These antibodies mostly bind to mast cells, which contain histamine. When the mast cells are stimulated by pollen and dust, histamine (and other chemicals) are released. This causes itching, swelling, and mucus production. Symptoms vary in severity between individuals. Very sensitive individuals can experience hives or other rashes. Particulate matter in polluted air and chemicals such as chlorine and detergents, which caormally be tolerated, can greatly aggravate the condition.

 

Characteristic physical findings in individuals who have allergic rhinitis include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, lateral crease on the nose, swolleasal turbinates, and middle ear effusion.

 

Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. Many people who were previously diagnosed with nonallergic rhinitis may actually have local allergic rhinitis.

Allergic rhinitis is an allergic inflammation of the nasal airways. It occurs when an allergen, such as pollen, dust or animal dander (particles of shed skin and hair) is inhaled by an individual with a sensitized immune system. In such individuals, the allergen triggers the production of the antibody immunoglobulin E (IgE), which binds to mast cells and basophils containing histamine. When caused by pollens of any plants, it is called “pollinosis“, and if specifically caused by grass pollens, it is known as “hay fever”. Hay fever isn’t caused by hay and does not exhibit symptoms of fever, but since grasses shed their pollens into the air at about the same time that hay is being cut, the common term hay fever is used.

 

IgE bound to mast cells are stimulated by pollen and dust, causing the release of inflammatory mediators such as histamine (and other chemicals). This usually causes sneezing, itchy and watery eyes, swelling and inflammation of the nasal passages, and an increase in mucus production. Symptoms vary in severity between individuals. Very sensitive individuals can experience hives or other rashes. Particulate matter in polluted air, and chemicals such as chlorine and detergents, which can normally be tolerated, can greatly aggravate allergic rhinitis. The physician John Bostock first described hay fever in 1819 as a disease.

 

Allergies are common. Heredity and environmental exposures may contribute to a predisposition to allergies. It is roughly estimated that one in three people have an active allergy at any given time and at least three in four people develop an allergic reaction at least once in their lives. In Western countries between 10–25% of people annually are affected by allergic rhinitis.

 

Signs and symptoms

 

The characteristic symptoms of allergic rhinitis are: rhinorrhea (excess nasal secretion), itching, and nasal congestion and obstruction. Characteristic physical findings include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, swolleasal turbinates, and middle ear effusion.

 

Other physical signs include folds in the skin below the lower eyelid known as Dennie–Morgan folds, and rings under the eyes, known in patients with allergic rhinitis as “allergic shiners”. There can also be behavioural signs; in order to relieve the irritation or flow of mucus, patients may wipe or rub their nose with the palm of their hand in an upward motion: an action known as the “nasal salute” or the “allergic salute”. This may result in a crease running across the nose, commonly referred to as the “transverse nasal crease”, and can lead to permanent physical deformity if repeated enough.

 

Sufferers might also find that cross-reactivity occurs. For example, someone allergic to birch pollen may also find that they have an allergic reaction to the skin of apples or potatoes. A clear sign of this is the occurrence of an itchy throat after eating an apple or sneezing when peeling potatoes or apples. This occurs because of similarities in the proteins of the pollen and the food. There are many cross-reacting substances.

 

Some disorders may be associated with allergies: Comorbidities include eczema, asthma and depression

 

Allergy testing

 

Allergy testing may reveal the specific allergens to which an individual is sensitive. Skin testing is the most common method of allergy testing. This may include intradermal, scratch, patch, or other tests. Less commonly, the suspected allergen is dissolved and dropped onto the lower eyelid as a means of testing for allergies. This test should only be done by a physician, never the patient, since it can be harmful if done improperly. In some individuals who cannot undergo skin testing (as determined by the doctor), the RAST blood test may be helpful in determining specific allergen sensitivity.

 

Allergy testing can either show allergies that aren’t actually causing symptoms, or miss allergies that do cause symptoms. The intradermal allergy test is more sensitive than the skin prick test but is more often positive in people who do not have symptoms to that allergen.

 

Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. Specialized testing is necessary to diagnose local allergic rhinitis.

 

Pollen allergies

 

Allergic rhinitis triggered by the pollens of specific seasonal plants is commonly known as “hay fever”, because it is most prevalent during haying season. However, it is possible to suffer from hay fever throughout the year. The pollen which causes hay fever varies between individuals and from region to region; generally speaking, the tiny, hardly visible pollens of wind-pollinated plants are the predominant cause. Pollens of insect-pollinated plants are too large to remain airborne and pose no risk. Examples of plants commonly responsible for hay fever include:

Trees: such as pine (Pinus), birch (Betula), alder (Alnus), cedar, hazel, hornbeam (Carpinus), horse chestnut (Aesculus), willow (Salix), poplar, plane (Platanus), linden/lime (Tilia) and olive (Olea). Iorthern latitudes birch is considered to be the most important allergenic tree pollen, with an estimated 15–20% of hay fever sufferers sensitive to birch pollen grains. A major antigen in these is a protein called Bet V I. Olive pollen is most predominant in Mediterranean regions. Hay fever in Japan is caused primarily by sugi (Cryptomeria japonica) and hinoki (Chamaecyparis obtusa) tree pollen.

“Allergy friendly” trees include: ash, red maple, yellow poplar, dogwood, magnolia, double-flowered cherry, fir, spruce and flowering plum.

Grasses (Family Poaceae): especially ryegrass (Lolium sp.) and timothy (Phleum pratense). An estimated 90% of hay fever sufferers are allergic to grass pollen.

Weeds: ragweed (Ambrosia), plantain (Plantago), nettle/parietaria (Urticaceae), mugwort (Artemisia), Fat hen (Chenopodium) and sorrel/dock (Rumex)

 

Management

 

The goal of rhinitis treatment is to prevent or reduce the symptoms caused by the inflammation of affected tissues. Measures which are effective include avoiding the allergen. Intranasal corticosteroids are the preferred treatment if medications are required with other options used only if these are not effective. Mite proof covers, air filters, and withholding certain foods in childhood do not have evidence supporting their effectiveness.

 

Steroids

 

Intranasal corticosteroids are used to control symptoms associated with sneezing, rhinorrhea, itching and nasal congestion. It is an excellent choice for perennial rhinitis. Steroid nasal sprays are effective and safe, and may be effective without oral antihistamines. They take several days to act and so need be taken continually for several weeks as their therapeutic effect builds up with time.

 

Systemic steroids such as prednisone are effective at reducing nasal inflammation, but their use is limited by their short duration of effect and the side effects of prolonged steroid therapy.

 

Other

 

Other measures that may be used second line include: antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.

 

Antihistamine drugs can have undesirable side-effects, most notably drowsiness. First generation antihistamine drugs such as diphenhydramine cause drowsiness, but not second- and third-generation antihistamines such as cetirizine and loratadine.

 

Antihistamine drugs can be taken orally to control symptoms such as sneezing, rhinorrhea, itching and conjunctivitis. It is best to take the medication before exposure, especially for seasonal allergic rhinitis. Ophthalmic antihistamines (such as ketotifen) are used for conjunctivitis; intranasal forms are used for sneezing, rhinorrhea and nasal pruritus.

 

Pseudoephedrine is also indicated for vasomotor rhinitis. It is only used wheasal congestion is present and can be used with antihistamines. In the United States, oral decongestants containing pseudoephedrine must be purchased behind the pharmacy counter by law to combat the making of methamphetamine.

 

Topical decongestants: may also be helpful in reducing symptoms such as nasal congestion, but should not be used for long periods as stopping them after protracted use can lead to a rebound nasal congestion (Rhinitis medicamentosa).

 

For nocturnal symptoms, intranasal corticosteroids can be combined with nightly oxymetazoline, an adrenergic alpha-agonist, without risk of rhinitis medicamentosa.

 

Desensitization

 

More severe cases of allergic rhinitis not responding to medication may benefit from allergen immunotherapy (allergy shots).

 

Alternative treatments

 

Therapeutic efficacy of complementary-alternative treatments is not supported by currently available evidence. Some evidence shows that acupuncture is effective for rhinitis while other evidence does not. The overall quality of evidence, however, is poor.

 

Local allergic rhinitis

 

Local allergic rhinitis is an allergic reaction in the nose to an allergen, without systemic allergies. So skin-prick and blood tests for allergy are negative, but there are IgE antibodies produced in the nose that react to a specific allergen. Intradermal skin testing may also be negative.

 

The symptoms of local allergic rhinitis are the same as the symptoms of allergic rhinitis, including symptoms in the eyes. Just as with allergic rhinitis, people can have either seasonal or perennial local allergic rhinitis. The symptoms of local allergic rhinitis can be mild, moderate or severe. Local allergic rhinitis is associated with conjunctivitis and asthma.

 

In several studies, over 40% of people who had been diagnosed with nonallergic rhinitis were found to actually have local allergic rhinitis.

 

Steroid nasal sprays and oral antihistamines have been found to be effective for local allergic rhinitis. A preliminary study found that allergy shots were also effective.

 

Rhinitis medicamentosa

 

It is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) that work by constricting blood vessels in the lining of the nose.

This condition typically occurs after 5 to 7 days of use of such medications. Patients often try increasing both the dose and the frequency of nasal sprays upon the onset of RM, worsening the condition. The swelling of the nasal passages caused by rebound congestion may eventually result in permanent turbinate hyperplasia, which may block nasal breathing until surgically removed.

Commercial introduction of Oxymetazoline brand Afrin. The prolonged use of nasal vasoconstrictors cause rhinitis medicamentosa

Pathophysiology

 

While the mechanism of RM is unclear, several theories have been proposed.

 

Sympathomimetic amines, such as phenylephrine and pseudoephedrine, stimulate both alpha and beta adrenergic receptors. At first, the vasoconstrictive effect of alpha-receptors dominates. This effect fades first, allowing the vasodilation due to beta-receptor stimulation to emerge.

 

Imidazolamine derivatives, such as oxymetazoline, may participate iegative feedback on endogenous norepinephrine production. Therefore, after cessation of prolonged use, there will be inadequate sympathetic vasoconstriction in the nasal mucosa, and domination of parasympathetic activity can result in increased secretions and nasal edema.

 

However, if oxymetazoline is used only nightly for allergic rhinitis, it can be used longer than one week without risk of rhinitis medicamentosa.

 

Treatment

 

The treatment of RM involves withdrawal of the offending nasal spray. Both a “cold turkey” and a “weaning” approach can be used. Cold turkey is the most effective treatment method, as it directly removes the cause of the condition, yet the time period between the discontinuation of the decongestant and the relief of symptoms may be too long for some individuals (particularly when trying to go to sleep when they are unable to breathe through their nose). The use of Over the Counter (OTC) saline nasal sprays may help open the nose without causing RM if the spray does not contain a decongestant (or preservative.[citatioeeded]). Symptoms of congestion and runny nose can often be treated with corticosteroid nasal sprays under the supervision of a physician. For very severe cases, oral steroids or nasal surgery may be necessary.

 

There are anecdotal reports of persons having success by withdrawing treatment from one nostril at a time.

 

A study has shown that the anti-infective agent benzalkonium chloride, which is frequently added to topical nasal sprays as a preservative, aggravates the condition by further increasing the rebound swelling.

 

Causes

 

Common issues that lead to overuse of topical decongestants:

·        Deviated septum

·        Upper respiratory tract infection

·        Vasomotor rhinitis

·        Cocaine use

·        Pregnancy (these products are not considered safe for pregnancy)

·        Chronic rhinosinusitis

·        Hypertrophy of the Inferior Turbinates

 

Chronic atrophic rhinitis

 

Chronic rhinitis in form of atrophy of the mucous membrane and glands.

Primary atrophic rhinitis

Etiology

Heredity factors: the disease runs in families

Endocrine imbalance: the disease tends to start at puberty and mostly involves females

Racial factors: whites are more susceptible thaatives of equatorial Africa

Nutritional deficiency: vitamins A or D, or iron

Infection: Klebsiella ozaenae, diphtheroids, Proteus vulgaris, E. coli, etc.

Autoimmune: viral infection or some other unidentified insult may trigger antigenicity of the nasal mucosa.

 

Pathology

 

The ciliated columnar epithelium of the nasal mucosa is replaced by stratified squamous epithelium. Atrophy of mucosa, turbinal bones and seromucinous glands tends to occur, due to obliterative endarteritis causing decreased blood supply, hence the supplying area atrophies.

 

Clinical manifestations

 

The disease is most commonly seen in females, and tends to appear during puberty. It can occur, however, as early as 12 months of age. The nasal cavities become roomy and are filled with foul smelling crusts which are black or dark green and dry, making expiration painful and difficult. Microorganisms are known to multiply and produce a foul smell from the nose, though the patients may not be aware of this, because their elements (responsible for the perception of smell) have become atrophied. Patients usually complain of nasal obstruction despite the roomy nasal cavity, which can be caused either by the obstruction produced by the discharge in the nose, or as a result of sensory loss due to atrophy of nerves in the nose, so the patient is unaware of the air flow. In the case of the second cause, the sensation of obstruction is subjective. Bleeding from the nose, also called epistaxis, may occur when the dried discharge (crusts) are removed. Septal perforation and dermatitis of nasal vestibule can occur. The nose may show a saddle-nose deformity. Atrophic rhinitis is also associated with similar atrophic changes in the pharynx or larynx, producing symptoms pertaining to these structures. Hearing impairment can occur due to Eustachian tube blockage causing middle ear effusion.

 

Permanent loss of smell and impairment of taste may also be a result of this disease, even after the symptoms are cured.

 

Secondary atrophic rhinitis

 

Specific infections, such as syphilis, lupus, leprosy and rhinoscleroma, may cause destruction of the nasal structures leading to atrophic changes. Atrophic rhinitis can also result from long-standing purulent sinusitis, radiotherapy of the nose or excessive surgical removal of turbinates.

 

Unilateral atrophic rhinitis

 

Extreme deviation of nasal septum may be accompanied by atrophic rhinitis on the wider side.

Treatment options

 

Treatment of atrophic rhinitis can be either medical or surgical.

 

Medical measures include:

·        Nasal irrigation using normal saline

·        Nasal irrigation and removal of crusts using alkaline solutions

·        25% glucose in glycerine can be applied to the nasal mucosa to inhibit the growth of foul-smelling proteolytic organisms

·        Local antibiotics, such as chloramphenicol (Kemicetine)

·        Estradiol and vitamin D2

·        Estradiol spray

·        Systemic streptomycin

·        Oral potassium iodide

·        Placental extract injected in the submucosa

 

Surgical interventions include:

·        Young’s operation

·        Modified Young’s operation

·        Narrowing of nasal cavities, submucosal injection of Teflon paste, section and medial displacement of the lateral wall of the nose

·        Transposition of parotid duct to maxillary sinus or nasal mucosa

·        Rhinitis sicca

 

Chronic form of dryness of the mucous membranes.

Polypous rhinitis

Chronic rhinitis associated with polyps in the nasal cavity.

Common cold

The common cold (also known as nasopharyngitis, rhinopharyngitis, acute coryza, or a cold) is a viral infectious disease of the upper respiratory tract which affects primarily the nose. Symptoms include coughing, sore throat, runny nose, and fever which usually resolve in seven to ten days, with some symptoms lasting up to three weeks. Well over 200 viruses are implicated in the cause of the common cold; the rhinoviruses are the most common.

 

Upper respiratory tract infections are loosely divided by the areas they affect, with the common cold primarily affecting the nose, the throat (pharyngitis), and the sinuses (sinusitis). Symptoms are mostly due to the body’s immune response to the infection rather than to tissue destruction by the viruses themselves. The primary method of prevention is by hand washing with some evidence to support the effectiveness of wearing face masks.

 

No cure for the common cold exists, but the symptoms can be treated. It is the most frequent infectious disease in humans with the average adult contracting two to three colds a year and the average child contracting between six and twelve. These infections have been with humanity since antiquity.

A representation of the molecular surface of one variant of human rhinovirus

 

Signs and symptoms

 

The typical symptoms of a cold include cough, runny nose, nasal congestion and a sore throat, sometimes accompanied by muscle ache, fatigue, headache, and loss of appetite. A sore throat is present in about 40% of the cases and a cough in about 50%, while muscle ache occurs in about half. In adults, a fever is generally not present but it is common in infants and young children. The cough is usually mild compared to that accompanying influenza. While a cough and a fever indicate a higher likelihood of influenza in adults, a great deal of similarity exists between these two conditions. A number of the viruses that cause the common cold may also result in asymptomatic infections. The color of the sputum or nasal secretion may vary from clear to yellow to green and does not predict the class of agent causing the infection.

 

Progression

 

A cold usually begins with fatigue, a feeling of being chilled, sneezing and a headache, followed in a couple of days by a runny nose and cough. Symptoms may begin within 16 hours of exposure and typically peak two to four days after onset. They usually resolve in seven to ten days but some can last for up to three weeks. In children, the cough lasts for more than ten days in 35–40% of the cases and continues for more than 25 days in 10%.

Cause

Viruses

Coronaviruses are a group of viruses known for causing the common cold. They have a halo, or crown-like (corona) appearance when viewed under an electron microscope.

 

The common cold is a viral infection of the upper respiratory tract. The most commonly implicated virus is a rhinovirus (30–80%), a type of picornavirus with 99 known serotypes. Others include: coronavirus (10–15%), human parainfluenza viruses, human respiratory syncytial virus, adenoviruses, enteroviruses, and metapneumovirus. Frequently more than one virus is present. In total over 200 different viral types are associated with colds.

 

Transmission

 

The common cold virus is typically transmitted via airborne droplets (aerosols), direct contact with infected nasal secretions, or fomites (contaminated objects). Which of these routes is of primary importance has not been determined. The viruses may survive for prolonged periods in the environment and can be picked up by people’s hands and subsequently carried to their eyes or nose where infection occurs. Transmission is common in daycare and at school due to the close proximity of many children with little immunity and frequently poor hygiene. These infections are then brought home to other members of the family. There is no evidence that recirculated air during commercial flight is a method of transmission. However, people sitting in close proximity appear at greater risk. Rhinovirus-caused colds are most infectious during the first three days of symptoms; they are much less infectious afterwards.

Weather

 

The traditional folk theory is that a cold can be “caught” by prolonged exposure to cold weather such as rain or winter conditions, which is how the disease got its name. The role of body cooling as a risk factor for the common cold is controversial. Some of the viruses that cause the common colds are seasonal, occurring more frequently during cold or wet weather. Some believe this to be due primarily to increased time spent indoors in close proximity; specifically children returning to school. However, it may also be related to changes in the respiratory system that result in greater susceptibility. Low humidity increases viral transmission rates potentially due to dry air allowing small viral droplets to disperse farther and stay in the air longer.

Other

 

Herd immunity, generated from previous exposure to cold viruses, plays an important role in limiting viral spread, as seen with younger populations that have greater rates of respiratory infections. Poor immune function is also a risk factor for disease. Insufficient sleep and malnutrition have been associated with a greater risk of developing infection following rhinovirus exposure; this is believed to be due to their effects on immune function.

 

Pathophysiology

The common cold is a disease of the upper respiratory tract.

 

The symptoms of the common cold are believed to be primarily related to the immune response to the virus. The mechanism of this immune response is virus specific. For example, the rhinovirus is typically acquired by direct contact; it binds to human ICAM-1 receptors through unknown mechanisms to trigger the release of inflammatory mediators. These inflammatory mediators then produce the symptoms. It does not generally cause damage to the nasal epithelium. The respiratory syncytial virus (RSV) on the other hand is contracted by both direct contact and air born droplets. It then replicates in the nose and throat before frequently spreading to the lower respiratory tract. RSV does cause epithelium damage. Human parainfluenza virus typically results in inflammation of the nose, throat, and bronchi. In young children when it affects the trachea it may produce the symptoms of croup due to the small size of their airway.

 

Diagnosis

 

The distinction between different viral upper respiratory tract infections is loosely based on the location of symptoms with the common cold affecting primarily the nose, pharyngitis the throat, and bronchitis the lungs. There however can be significant overlap and multiple areas can be affected. The common cold is frequently defined as nasal inflammation with varying amount of throat inflammation. Self-diagnosis is frequent. Isolation of the actual viral agent involved is rarely performed, and it is generally not possible to identify the virus type through symptoms.

 

Prevention

 

Physical measures to prevent the spread of cold viruses have been deemed the only potentially effective measures for prevention. These measures include primarily hand washing and face masks; in the health care environment, gowns and disposable gloves are also used. Efforts such as quarantine are not possible as the disease is so widespread and symptoms are non-specific. Vaccination has proved difficult as there are so many viruses involved and they change rapidly. Creation of a broadly effective vaccine is thus highly improbable.

 

Regular hand washing appears to be effective at reducing the transmission of cold viruses especially among children. Whether the addition of antivirals or antibacterials to normal hand washing provides greater benefit is unknown. Wearing face masks when around people who are infected may be beneficial; however, there is insufficient evidence for maintaining a greater social distance. Zinc supplementation may be effective at decreasing the rate of colds.[36] Routine vitamin C supplementation does not reduce the risk or severity of the common cold, though it may reduce its duration.

 

Management

 

There are currently no medications or herbal remedies which have been conclusively demonstrated to shorten the duration of infection. Treatment thus comprises symptomatic relief. Getting plenty of rest, drinking fluids to maintain hydration, and gargling with warm salt water, are reasonable conservative measures. Much of the benefit from treatment is however attributed to the placebo effect.

 

Symptomatic

 

Treatments that help alleviate symptoms include simple analgesics and antipyretics such as ibuprofen and acetaminophen/ № 2

№ 2. Diseases of the upper respiratory tract. Diseases of the lower respiratory tract.

 

Upper respiratory tract infection

Upper and lower respiratory tracts

Upper respiratory infections, commonly referred to the acronym URI or URTI, is the illness caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx. In the United States, this represents approximately one billion acute upper respiratory illnesses annually.

Signs and symptoms

Acute upper respiratory tract infections includes rhinosinusitis (common cold), sinusitis, pharyngitis/tonsillitis, laryngitis and sometimes bronchitis. Symptoms of URI’s commonly include congestion, cough, running nose, sore throat, fever, facial pressure and sneezing. Onset of the symptoms usually begins after 1-3 days after exposure to a microbial pathogen, most commonly a virus. The duration of the symptoms is typically 7 to 10 days but may persist longer.

It is important to mention that up to 15% of acute pharyngitis cases may be caused by bacteria, commonly Group A Strep (“Strep Throat”). Generally, patients with “Strep Throat” start with a sore throat as their first symptom and usually do not have runny nose or cough or sneezing.

Pain and pressure of the ear caused by a middle ear infection (Otitis media) and the reddening of they eye caused by Viral Conjunctivitis are often associated with upper respiratory infections.

Influenza (the flu) is a more systemic illness, which can also involve the upper respiratory tract, should be recognized as distinct from other causes of URI.

Treatment

Judicious use of antibiotics can decrease unnecessary adverse effects of antibiotics as well as out-of-pocket costs to the patient. But more important, decreased antibiotic usage will prevent development of drug resistant bacteria, which is now a growing problem in the world. International, as well as local US health agencies, have been strongly encouraging physicians to decrease the prescribing of antibiotics to treat common upper respiratory tract infections because antibiotic usage does not significantly reduce recovery time for these viral illnesses . Some have advocated a delayed antibiotic approach to treating URIs which seeks to reduce the consumption of antibiotics while attempting to maintain patient satisfaction. Most studies show no difference in improvement of symptoms between those treated with antibiotics right away and those with delayed prescriptions. Most studies also show no difference in patient satisfaction, patient complications, symptoms between delayed and no antibiotics. It should be noted that a strategy of “no antibiotics” results in even less antibiotic use than a strategy of “delayed antibiotics”. Until more effective treatments are available to treat the common respiratory viruses responsible for the majority of cases, treatment of URIs with rest, increased fluids, and symptomatic care with over-the-counter medications will remain the treatment of choice. However, in certain higher risk patients with underlying lung disease, such as chronic obstructive pulmonary disease (COPD), evidence does exist to support the treatment of URIs with antibiotics to shorten the course of illness and decrease treatment failure.

The use of Vitamin C in the prevention and treatment of upper respiratory infections has been suggested since the initial isolation of vitamin C in the 1930s. Several studies have failed to demonstrate that vitamin C supplementation reduces the incidence of colds in the normal healthy population, indicating that routine large dose prophylaxis with Vitamin C is not beneficial in widespread community usage. Some evidence exists to indicate that it could be justified in persons exposed to brief periods of severe physical exercise and/or cold environments. The evidence does not support the use of Vitamin C at the onset of colds as effective therapy.

TRACHEITIS

 

Tracheitis is a bacterial infection of the trachea (wind pipe) capable of producing.

Bacterial tracheitis is most often caused by Staphylococcus aureus and frequently follows a recent viral upper respiratory infection. It affects mostly young children, possibly because their small trachea is easily blocked by swelling.

 

Children may still have a cough from their previous infection but this rapidly worsens. The child quickly develops stridor, a high pitched, crowing sound with breathing and increasing breathing difficulty. Fever is generally high and the child looks very ill. This condition may progress very rapidly.

 

These children may sound as if they have croup, but the usual croup treatments do not improve the breathing difficulty. Tracheitis requires hospitalization and, usually, a breathing tube (endotracheal tube) in order to maintain an open airway.

The infection is treated with an antistaphylococcal medications such as penicillin or a cephalosporin that covers Staphylococcus. If a different organism is at fault, the appropriate antibiotic is used.

 

Pathophysiology

 

Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.

 

Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.

 

Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury to trachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms.

 

History

Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.

In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful.

In a study by Salamone et al, a significant subset of older children (mean age, 8 y) did not have severe clinical symptoms.

The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.

Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened.

Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea.

A high index of suspicion for bacterial tracheitis is needed in children with viral croup–like symptoms who do not respond to standard croup treatment or clinically worsen.

 

Causes

§        S aureus: Community-associated methicillin-resistant S aureus (CA-MRSA) has recently emerged as an important agent in the United States; this could result in a greater frequency of MRSA strains that cause tracheitis.

§        S pyogenes, Streptococcus pneumoniae, and other alpha hemolytic streptococcal species

§        Moraxella catarrhalis: Recent reports suggest it is a leading cause of bacterial tracheitis and associated with increased intubation.

§        Haemophilus influenzae type B (Hib): This cause is less common since the introduction of the Hib vaccine.

§        Klebsiella species

§        Pseudomonas species

§        Anaerobes

§        Peptostreptococcus species

§        Bacteroides species

§        Prevotella species

 

Other:

§        Mycoplasma pneumoniae

§        Mycobacterium tuberculosis (endobronchial disease)

 

 

Symptoms

·        increasing deep or barking croup-like cough following a previous upper respiratory infection

·        crowing sound when the child inhales (inspiratory stridor)

·        high fever

·        very sick-looking child (toxic)

·        breathing difficulty, increasing in severity over time

·        intercostal retractions (the muscles between the ribs pull in as the child attempts to breathe)

 

Signs and tests

·        nasopharyngeal culture (shows Staphylococcus aureus or other organisms)

·        tracheal culture (shows Staphylococcus aureus or other organisms)

·        blood gasses (show decreased oxygen saturation, decreased pO2)

·        X-ray of the trachea (shows narrowing of the tracheal airway, but normal epiglottis)

·        purulent (pus-filled) tracheal secretions may be obtained while placing the breathing tube in the patient

 

Treatment

 

Treatment of bacterial tracheitis consists of the following:

 

Airway

·        Maintenance of an adequate airway is of primary importance.

·        Avoid agitating the child. If the patient’s respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.

·        If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotracheal tube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation.

Intravenous access and medication

·        Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.

·        Antibiotic regimens have traditionally included a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and a penicillinase-resistant penicillin (eg, oxacillin, nafcillin). Recently, clindamycin (40 mg/kg/d intravenously [IV], divided every 8 h) is used instead of penicillinase-resistant penicillin against community acquired–methicillin-resistant S aureus (CA-MRSA) in places where resistance rates of CA-MRSA to clindamycin is low.6 

·        Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community.

 

The child ofteeeds to have an airway or breathing tube placed (endotracheal tube). Antibiotics are given through a vein, usually a type of penicillin or one of the cephalosporins. Oxygen is usually given, and the blood gases are monitored to be sure that the child is breathing adequately.

 

Surgical Care

·        Tracheostomy

·        Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged.

·        Pulmonary toilet is potentially better with tracheostomy.

·        Consultations

·        Otorhinolaryngology – For endoscopic procedures and acute airway management

·        Pediatric intensivist – Necessary because of potential for acute decompensation

 

Medication

Antibiotic agents

Empiric antimicrobial therapy in bacterial tracheitis must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

 

Expectations (prognosis)

Full recovery is expected if the patient can be brought to a medical facility in time.

·        fairway obstruction with cardiorespiratory arrest and possibly death — the breathing stops, then the heartbeat stops

·        toxic shock syndrome (only if the organism is Staphylococcus)

Rhinitis

Rhinitis (pron.: /raɪˈnaɪtɪs/) is a medical term for irritation and inflammation of the mucous membrane inside the nose. Common symptoms of rhinitis are a stuffy nose, runny nose, and post-nasal drip. The most common kind of rhinitis is allergic rhinitis, which is usually triggered by airborne allergens such as pollen and dander. Allergic rhinitis may cause additional symptoms, such as sneezing and nasal itching, coughing, headache, fatigue, malaise, and cognitive impairment. The allergens may also affect the eyes, causing watery, reddened or itchy eyes and puffiness around the eyes.

 

Rhinitis is very common. Allergic rhinitis is more common in some countries than others; in the United States, about 10%-30% of adults are affected annually.

 

In rhinitis, the inflammation of the mucous membrane is caused by viruses, bacteria, irritants or allergens. The inflammation results in the generation of large amounts of mucus, commonly producing a runny nose, as well as a stuffy nose and post-nasal drip. In the case of allergic rhinitis, the inflammation is caused by the degranulation of mast cells in the nose. When mast cells degranulate, they release histamine and other chemicals, starting an inflammatory process that can cause symptoms outside the nose, such as fatigue and malaise.

Types

 

Rhinitis is categorized into three types: (i) infective rhinitis includes acute and chronic bacterial infections; (ii) nonallergic (vasomotor) rhinitis includes autonomic, hormonal, drug-induced, atrophic, and gustatory rhinitis, as well as rhinitis medicamentosa; (iii) allergic rhinitis, triggered by pollen, mold, animal dander, dust and other similar inhaled allergens.

 

Infectious

 

Rhinitis is commonly caused by a viral or bacterial infection, including the common cold, which is caused by Rhinoviruses and Coronaviruses, or bacterial sinusitis. Symptoms of the common cold include rhinorrhea, sore throat (pharyngitis), cough, congestion, and slight headache.

 

Vasomotor rhinitis

Non-allergic rhinitis refers to runny nose that is not due to allergy. Non-allergic rhinitis can be classified as either non-inflammatory or inflammatory rhinitis. One very common type of non-inflammatory, non-allergic rhinitis that is sometimes confused with allergy is called vasomotor rhinitis, in which certain nonspecific stimuli, including changes in environment (temperature, humidity, barometric pressure, or weather); airborne irritants (odors, fumes); dietary factors (spicy food, alcohol); sexual arousal; and emotional factors. There is still much to be learned about this entity, but it is thought that these non-allergic triggers cause dilation of the blood vessels in the lining of the nose, which results in swelling, and drainage. Vasomotor rhinitis can coexist with allergic rhinitis, and this is called “mixed rhinitis.” (Middleton’s Allergy Principles and Practice, seventh edition.) The pathology of vasomotor rhinitis appears to involve neurogenic inflammation and is as yet not very well understood. Vasomotor rhinitis appears to be significantly more common in women than men, leading some researchers to believe that hormones play a role. In general, age of onset occurs after 20 years of age, in contrast to allergic rhinitis which can be developed at any age. Individuals suffering from vasomotor rhinitis typically experience symptoms year-round, though symptoms may be exacerbated in the spring and autumn when rapid weather changes are more common. An estimated 17 million United States citizens have vasomotor rhinitis. The antihistamines azelastine and olopatadine, applied as nasal sprays, may both be effective for vasomotor rhinitis. Fluticasone propionate or budesonide (both are steroids) in nostril spray form may also be used for symptomatic treatment.

 

Allergic

Pollen grains from a variety of common plants can cause hay fever

 

Allergic rhinitis or hay fever may follow when an allergen such as pollen or dust is inhaled by an individual with a sensitized immune system, triggering antibody production. These antibodies mostly bind to mast cells, which contain histamine. When the mast cells are stimulated by pollen and dust, histamine (and other chemicals) are released. This causes itching, swelling, and mucus production. Symptoms vary in severity between individuals. Very sensitive individuals can experience hives or other rashes. Particulate matter in polluted air and chemicals such as chlorine and detergents, which caormally be tolerated, can greatly aggravate the condition.

 

Characteristic physical findings in individuals who have allergic rhinitis include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, lateral crease on the nose, swolleasal turbinates, and middle ear effusion.

 

Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. Many people who were previously diagnosed with nonallergic rhinitis may actually have local allergic rhinitis.

Allergic rhinitis is an allergic inflammation of the nasal airways. It occurs when an allergen, such as pollen, dust or animal dander (particles of shed skin and hair) is inhaled by an individual with a sensitized immune system. In such individuals, the allergen triggers the production of the antibody immunoglobulin E (IgE), which binds to mast cells and basophils containing histamine. When caused by pollens of any plants, it is called “pollinosis“, and if specifically caused by grass pollens, it is known as “hay fever”. Hay fever isn’t caused by hay and does not exhibit symptoms of fever, but since grasses shed their pollens into the air at about the same time that hay is being cut, the common term hay fever is used.

 

IgE bound to mast cells are stimulated by pollen and dust, causing the release of inflammatory mediators such as histamine (and other chemicals). This usually causes sneezing, itchy and watery eyes, swelling and inflammation of the nasal passages, and an increase in mucus production. Symptoms vary in severity between individuals. Very sensitive individuals can experience hives or other rashes. Particulate matter in polluted air, and chemicals such as chlorine and detergents, which can normally be tolerated, can greatly aggravate allergic rhinitis. The physician John Bostock first described hay fever in 1819 as a disease.

 

Allergies are common. Heredity and environmental exposures may contribute to a predisposition to allergies. It is roughly estimated that one in three people have an active allergy at any given time and at least three in four people develop an allergic reaction at least once in their lives. In Western countries between 10–25% of people annually are affected by allergic rhinitis.

 

Signs and symptoms

 

The characteristic symptoms of allergic rhinitis are: rhinorrhea (excess nasal secretion), itching, and nasal congestion and obstruction. Characteristic physical findings include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, swolleasal turbinates, and middle ear effusion.

 

Other physical signs include folds in the skin below the lower eyelid known as Dennie–Morgan folds, and rings under the eyes, known in patients with allergic rhinitis as “allergic shiners”. There can also be behavioural signs; in order to relieve the irritation or flow of mucus, patients may wipe or rub their nose with the palm of their hand in an upward motion: an action known as the “nasal salute” or the “allergic salute”. This may result in a crease running across the nose, commonly referred to as the “transverse nasal crease”, and can lead to permanent physical deformity if repeated enough.

 

Sufferers might also find that cross-reactivity occurs. For example, someone allergic to birch pollen may also find that they have an allergic reaction to the skin of apples or potatoes. A clear sign of this is the occurrence of an itchy throat after eating an apple or sneezing when peeling potatoes or apples. This occurs because of similarities in the proteins of the pollen and the food. There are many cross-reacting substances.

 

Some disorders may be associated with allergies: Comorbidities include eczema, asthma and depression

 

Allergy testing

 

Allergy testing may reveal the specific allergens to which an individual is sensitive. Skin testing is the most common method of allergy testing. This may include intradermal, scratch, patch, or other tests. Less commonly, the suspected allergen is dissolved and dropped onto the lower eyelid as a means of testing for allergies. This test should only be done by a physician, never the patient, since it can be harmful if done improperly. In some individuals who cannot undergo skin testing (as determined by the doctor), the RAST blood test may be helpful in determining specific allergen sensitivity.

 

Allergy testing can either show allergies that aren’t actually causing symptoms, or miss allergies that do cause symptoms. The intradermal allergy test is more sensitive than the skin prick test but is more often positive in people who do not have symptoms to that allergen.

 

Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. Specialized testing is necessary to diagnose local allergic rhinitis.

 

Pollen allergies

 

Allergic rhinitis triggered by the pollens of specific seasonal plants is commonly known as “hay fever”, because it is most prevalent during haying season. However, it is possible to suffer from hay fever throughout the year. The pollen which causes hay fever varies between individuals and from region to region; generally speaking, the tiny, hardly visible pollens of wind-pollinated plants are the predominant cause. Pollens of insect-pollinated plants are too large to remain airborne and pose no risk. Examples of plants commonly responsible for hay fever include:

Trees: such as pine (Pinus), birch (Betula), alder (Alnus), cedar, hazel, hornbeam (Carpinus), horse chestnut (Aesculus), willow (Salix), poplar, plane (Platanus), linden/lime (Tilia) and olive (Olea). Iorthern latitudes birch is considered to be the most important allergenic tree pollen, with an estimated 15–20% of hay fever sufferers sensitive to birch pollen grains. A major antigen in these is a protein called Bet V I. Olive pollen is most predominant in Mediterranean regions. Hay fever in Japan is caused primarily by sugi (Cryptomeria japonica) and hinoki (Chamaecyparis obtusa) tree pollen.

“Allergy friendly” trees include: ash, red maple, yellow poplar, dogwood, magnolia, double-flowered cherry, fir, spruce and flowering plum.

Grasses (Family Poaceae): especially ryegrass (Lolium sp.) and timothy (Phleum pratense). An estimated 90% of hay fever sufferers are allergic to grass pollen.

Weeds: ragweed (Ambrosia), plantain (Plantago), nettle/parietaria (Urticaceae), mugwort (Artemisia), Fat hen (Chenopodium) and sorrel/dock (Rumex)

 

Management

 

The goal of rhinitis treatment is to prevent or reduce the symptoms caused by the inflammation of affected tissues. Measures which are effective include avoiding the allergen. Intranasal corticosteroids are the preferred treatment if medications are required with other options used only if these are not effective. Mite proof covers, air filters, and withholding certain foods in childhood do not have evidence supporting their effectiveness.

 

Steroids

 

Intranasal corticosteroids are used to control symptoms associated with sneezing, rhinorrhea, itching and nasal congestion. It is an excellent choice for perennial rhinitis. Steroid nasal sprays are effective and safe, and may be effective without oral antihistamines. They take several days to act and so need be taken continually for several weeks as their therapeutic effect builds up with time.

 

Systemic steroids such as prednisone are effective at reducing nasal inflammation, but their use is limited by their short duration of effect and the side effects of prolonged steroid therapy.

 

Other

 

Other measures that may be used second line include: antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.

 

Antihistamine drugs can have undesirable side-effects, most notably drowsiness. First generation antihistamine drugs such as diphenhydramine cause drowsiness, but not second- and third-generation antihistamines such as cetirizine and loratadine.

 

Antihistamine drugs can be taken orally to control symptoms such as sneezing, rhinorrhea, itching and conjunctivitis. It is best to take the medication before exposure, especially for seasonal allergic rhinitis. Ophthalmic antihistamines (such as ketotifen) are used for conjunctivitis; intranasal forms are used for sneezing, rhinorrhea and nasal pruritus.

 

Pseudoephedrine is also indicated for vasomotor rhinitis. It is only used wheasal congestion is present and can be used with antihistamines. In the United States, oral decongestants containing pseudoephedrine must be purchased behind the pharmacy counter by law to combat the making of methamphetamine.

 

Topical decongestants: may also be helpful in reducing symptoms such as nasal congestion, but should not be used for long periods as stopping them after protracted use can lead to a rebound nasal congestion (Rhinitis medicamentosa).

 

For nocturnal symptoms, intranasal corticosteroids can be combined with nightly oxymetazoline, an adrenergic alpha-agonist, without risk of rhinitis medicamentosa.

 

Desensitization

 

More severe cases of allergic rhinitis not responding to medication may benefit from allergen immunotherapy (allergy shots).

 

Alternative treatments

 

Therapeutic efficacy of complementary-alternative treatments is not supported by currently available evidence. Some evidence shows that acupuncture is effective for rhinitis while other evidence does not. The overall quality of evidence, however, is poor.

 

Local allergic rhinitis

 

Local allergic rhinitis is an allergic reaction in the nose to an allergen, without systemic allergies. So skin-prick and blood tests for allergy are negative, but there are IgE antibodies produced in the nose that react to a specific allergen. Intradermal skin testing may also be negative.

 

The symptoms of local allergic rhinitis are the same as the symptoms of allergic rhinitis, including symptoms in the eyes. Just as with allergic rhinitis, people can have either seasonal or perennial local allergic rhinitis. The symptoms of local allergic rhinitis can be mild, moderate or severe. Local allergic rhinitis is associated with conjunctivitis and asthma.

 

In several studies, over 40% of people who had been diagnosed with nonallergic rhinitis were found to actually have local allergic rhinitis.

 

Steroid nasal sprays and oral antihistamines have been found to be effective for local allergic rhinitis. A preliminary study found that allergy shots were also effective.

 

Rhinitis medicamentosa

 

It is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) that work by constricting blood vessels in the lining of the nose.

This condition typically occurs after 5 to 7 days of use of such medications. Patients often try increasing both the dose and the frequency of nasal sprays upon the onset of RM, worsening the condition. The swelling of the nasal passages caused by rebound congestion may eventually result in permanent turbinate hyperplasia, which may block nasal breathing until surgically removed.

Commercial introduction of Oxymetazoline brand Afrin. The prolonged use of nasal vasoconstrictors cause rhinitis medicamentosa

Pathophysiology

 

While the mechanism of RM is unclear, several theories have been proposed.

 

Sympathomimetic amines, such as phenylephrine and pseudoephedrine, stimulate both alpha and beta adrenergic receptors. At first, the vasoconstrictive effect of alpha-receptors dominates. This effect fades first, allowing the vasodilation due to beta-receptor stimulation to emerge.

 

Imidazolamine derivatives, such as oxymetazoline, may participate iegative feedback on endogenous norepinephrine production. Therefore, after cessation of prolonged use, there will be inadequate sympathetic vasoconstriction in the nasal mucosa, and domination of parasympathetic activity can result in increased secretions and nasal edema.

 

However, if oxymetazoline is used only nightly for allergic rhinitis, it can be used longer than one week without risk of rhinitis medicamentosa.

 

Treatment

 

The treatment of RM involves withdrawal of the offending nasal spray. Both a “cold turkey” and a “weaning” approach can be used. Cold turkey is the most effective treatment method, as it directly removes the cause of the condition, yet the time period between the discontinuation of the decongestant and the relief of symptoms may be too long for some individuals (particularly when trying to go to sleep when they are unable to breathe through their nose). The use of Over the Counter (OTC) saline nasal sprays may help open the nose without causing RM if the spray does not contain a decongestant (or preservative.[citatioeeded]). Symptoms of congestion and runny nose can often be treated with corticosteroid nasal sprays under the supervision of a physician. For very severe cases, oral steroids or nasal surgery may be necessary.

 

There are anecdotal reports of persons having success by withdrawing treatment from one nostril at a time.

 

A study has shown that the anti-infective agent benzalkonium chloride, which is frequently added to topical nasal sprays as a preservative, aggravates the condition by further increasing the rebound swelling.

 

Causes

 

Common issues that lead to overuse of topical decongestants:

·        Deviated septum

·        Upper respiratory tract infection

·        Vasomotor rhinitis

·        Cocaine use

·        Pregnancy (these products are not considered safe for pregnancy)

·        Chronic rhinosinusitis

·        Hypertrophy of the Inferior Turbinates

 

Chronic atrophic rhinitis

 

Chronic rhinitis in form of atrophy of the mucous membrane and glands.

Primary atrophic rhinitis

Etiology

Heredity factors: the disease runs in families

Endocrine imbalance: the disease tends to start at puberty and mostly involves females

Racial factors: whites are more susceptible thaatives of equatorial Africa

Nutritional deficiency: vitamins A or D, or iron

Infection: Klebsiella ozaenae, diphtheroids, Proteus vulgaris, E. coli, etc.

Autoimmune: viral infection or some other unidentified insult may trigger antigenicity of the nasal mucosa.

 

Pathology

 

The ciliated columnar epithelium of the nasal mucosa is replaced by stratified squamous epithelium. Atrophy of mucosa, turbinal bones and seromucinous glands tends to occur, due to obliterative endarteritis causing decreased blood supply, hence the supplying area atrophies.

 

Clinical manifestations

 

The disease is most commonly seen in females, and tends to appear during puberty. It can occur, however, as early as 12 months of age. The nasal cavities become roomy and are filled with foul smelling crusts which are black or dark green and dry, making expiration painful and difficult. Microorganisms are known to multiply and produce a foul smell from the nose, though the patients may not be aware of this, because their elements (responsible for the perception of smell) have become atrophied. Patients usually complain of nasal obstruction despite the roomy nasal cavity, which can be caused either by the obstruction produced by the discharge in the nose, or as a result of sensory loss due to atrophy of nerves in the nose, so the patient is unaware of the air flow. In the case of the second cause, the sensation of obstruction is subjective. Bleeding from the nose, also called epistaxis, may occur when the dried discharge (crusts) are removed. Septal perforation and dermatitis of nasal vestibule can occur. The nose may show a saddle-nose deformity. Atrophic rhinitis is also associated with similar atrophic changes in the pharynx or larynx, producing symptoms pertaining to these structures. Hearing impairment can occur due to Eustachian tube blockage causing middle ear effusion.

 

Permanent loss of smell and impairment of taste may also be a result of this disease, even after the symptoms are cured.

 

Secondary atrophic rhinitis

 

Specific infections, such as syphilis, lupus, leprosy and rhinoscleroma, may cause destruction of the nasal structures leading to atrophic changes. Atrophic rhinitis can also result from long-standing purulent sinusitis, radiotherapy of the nose or excessive surgical removal of turbinates.

 

Unilateral atrophic rhinitis

 

Extreme deviation of nasal septum may be accompanied by atrophic rhinitis on the wider side.

Treatment options

 

Treatment of atrophic rhinitis can be either medical or surgical.

 

Medical measures include:

·        Nasal irrigation using normal saline

·        Nasal irrigation and removal of crusts using alkaline solutions

·        25% glucose in glycerine can be applied to the nasal mucosa to inhibit the growth of foul-smelling proteolytic organisms

·        Local antibiotics, such as chloramphenicol (Kemicetine)

·        Estradiol and vitamin D2

·        Estradiol spray

·        Systemic streptomycin

·        Oral potassium iodide

·        Placental extract injected in the submucosa

 

Surgical interventions include:

·        Young’s operation

·        Modified Young’s operation

·        Narrowing of nasal cavities, submucosal injection of Teflon paste, section and medial displacement of the lateral wall of the nose

·        Transposition of parotid duct to maxillary sinus or nasal mucosa

·        Rhinitis sicca

 

Chronic form of dryness of the mucous membranes.

Polypous rhinitis

Chronic rhinitis associated with polyps in the nasal cavity.

Common cold

The common cold (also known as nasopharyngitis, rhinopharyngitis, acute coryza, or a cold) is a viral infectious disease of the upper respiratory tract which affects primarily the nose. Symptoms include coughing, sore throat, runny nose, and fever which usually resolve in seven to ten days, with some symptoms lasting up to three weeks. Well over 200 viruses are implicated in the cause of the common cold; the rhinoviruses are the most common.

 

Upper respiratory tract infections are loosely divided by the areas they affect, with the common cold primarily affecting the nose, the throat (pharyngitis), and the sinuses (sinusitis). Symptoms are mostly due to the body’s immune response to the infection rather than to tissue destruction by the viruses themselves. The primary method of prevention is by hand washing with some evidence to support the effectiveness of wearing face masks.

 

No cure for the common cold exists, but the symptoms can be treated. It is the most frequent infectious disease in humans with the average adult contracting two to three colds a year and the average child contracting between six and twelve. These infections have been with humanity since antiquity.

A representation of the molecular surface of one variant of human rhinovirus

 

Signs and symptoms

 

The typical symptoms of a cold include cough, runny nose, nasal congestion and a sore throat, sometimes accompanied by muscle ache, fatigue, headache, and loss of appetite. A sore throat is present in about 40% of the cases and a cough in about 50%, while muscle ache occurs in about half. In adults, a fever is generally not present but it is common in infants and young children. The cough is usually mild compared to that accompanying influenza. While a cough and a fever indicate a higher likelihood of influenza in adults, a great deal of similarity exists between these two conditions. A number of the viruses that cause the common cold may also result in asymptomatic infections. The color of the sputum or nasal secretion may vary from clear to yellow to green and does not predict the class of agent causing the infection.

 

Progression

 

A cold usually begins with fatigue, a feeling of being chilled, sneezing and a headache, followed in a couple of days by a runny nose and cough. Symptoms may begin within 16 hours of exposure and typically peak two to four days after onset. They usually resolve in seven to ten days but some can last for up to three weeks. In children, the cough lasts for more than ten days in 35–40% of the cases and continues for more than 25 days in 10%.

Cause

Viruses

Coronaviruses are a group of viruses known for causing the common cold. They have a halo, or crown-like (corona) appearance when viewed under an electron microscope.

 

The common cold is a viral infection of the upper respiratory tract. The most commonly implicated virus is a rhinovirus (30–80%), a type of picornavirus with 99 known serotypes. Others include: coronavirus (10–15%), human parainfluenza viruses, human respiratory syncytial virus, adenoviruses, enteroviruses, and metapneumovirus. Frequently more than one virus is present. In total over 200 different viral types are associated with colds.

 

Transmission

 

The common cold virus is typically transmitted via airborne droplets (aerosols), direct contact with infected nasal secretions, or fomites (contaminated objects). Which of these routes is of primary importance has not been determined. The viruses may survive for prolonged periods in the environment and can be picked up by people’s hands and subsequently carried to their eyes or nose where infection occurs. Transmission is common in daycare and at school due to the close proximity of many children with little immunity and frequently poor hygiene. These infections are then brought home to other members of the family. There is no evidence that recirculated air during commercial flight is a method of transmission. However, people sitting in close proximity appear at greater risk. Rhinovirus-caused colds are most infectious during the first three days of symptoms; they are much less infectious afterwards.

Weather

 

The traditional folk theory is that a cold can be “caught” by prolonged exposure to cold weather such as rain or winter conditions, which is how the disease got its name. The role of body cooling as a risk factor for the common cold is controversial. Some of the viruses that cause the common colds are seasonal, occurring more frequently during cold or wet weather. Some believe this to be due primarily to increased time spent indoors in close proximity; specifically children returning to school. However, it may also be related to changes in the respiratory system that result in greater susceptibility. Low humidity increases viral transmission rates potentially due to dry air allowing small viral droplets to disperse farther and stay in the air longer.

Other

 

Herd immunity, generated from previous exposure to cold viruses, plays an important role in limiting viral spread, as seen with younger populations that have greater rates of respiratory infections. Poor immune function is also a risk factor for disease. Insufficient sleep and malnutrition have been associated with a greater risk of developing infection following rhinovirus exposure; this is believed to be due to their effects on immune function.

 

Pathophysiology

The common cold is a disease of the upper respiratory tract.

 

The symptoms of the common cold are believed to be primarily related to the immune response to the virus. The mechanism of this immune response is virus specific. For example, the rhinovirus is typically acquired by direct contact; it binds to human ICAM-1 receptors through unknown mechanisms to trigger the release of inflammatory mediators. These inflammatory mediators then produce the symptoms. It does not generally cause damage to the nasal epithelium. The respiratory syncytial virus (RSV) on the other hand is contracted by both direct contact and air born droplets. It then replicates in the nose and throat before frequently spreading to the lower respiratory tract. RSV does cause epithelium damage. Human parainfluenza virus typically results in inflammation of the nose, throat, and bronchi. In young children when it affects the trachea it may produce the symptoms of croup due to the small size of their airway.

 

Diagnosis

 

The distinction between different viral upper respiratory tract infections is loosely based on the location of symptoms with the common cold affecting primarily the nose, pharyngitis the throat, and bronchitis the lungs. There however can be significant overlap and multiple areas can be affected. The common cold is frequently defined as nasal inflammation with varying amount of throat inflammation. Self-diagnosis is frequent. Isolation of the actual viral agent involved is rarely performed, and it is generally not possible to identify the virus type through symptoms.

 

Prevention

 

Physical measures to prevent the spread of cold viruses have been deemed the only potentially effective measures for prevention. These measures include primarily hand washing and face masks; in the health care environment, gowns and disposable gloves are also used. Efforts such as quarantine are not possible as the disease is so widespread and symptoms are non-specific. Vaccination has proved difficult as there are so many viruses involved and they change rapidly. Creation of a broadly effective vaccine is thus highly improbable.

 

Regular hand washing appears to be effective at reducing the transmission of cold viruses especially among children. Whether the addition of antivirals or antibacterials to normal hand washing provides greater benefit is unknown. Wearing face masks when around people who are infected may be beneficial; however, there is insufficient evidence for maintaining a greater social distance. Zinc supplementation may be effective at decreasing the rate of colds.[36] Routine vitamin C supplementation does not reduce the risk or severity of the common cold, though it may reduce its duration.

 

Management

 

There are currently no medications or herbal remedies which have been conclusively demonstrated to shorten the duration of infection. Treatment thus comprises symptomatic relief. Getting plenty of rest, drinking fluids to maintain hydration, and gargling with warm salt water, are reasonable conservative measures. Much of the benefit from treatment is however attributed to the placebo effect.

 

Symptomatic

 

Treatments that help alleviate symptoms include simple analgesics and antipyretics such as ibuprofen and acetaminophen/paracetamol. Evidence does not show that cough medicines are any more effective than simple analgesics and they are not recommended for use in children due to a lack of evidence supporting effectiveness and the potential for harm. In 2009, Canada restricted the use of over-the-counter cough and cold medication in children six years and under due to concerns regarding risks and unproven benefits. In adults there is insufficient evidence to support the use of cough medications in adults. The misuse of dextromethorphan (an over-the-counter cough medicine) has led to its ban in a number of countries.

 

In adults the symptoms of a runny nose can be reduced by first-generation antihistamines; however, they are associated with adverse effects such as drowsiness. Other decongestants such as pseudoephedrine are also effective in this population. Ipratropium nasal spray may reduce the symptoms of a runny nose but there is little effect on stuffiness. Second-generation antihistamines however do not appear to be effective.

 

Due to lack of studies, it is not known whether increased fluid intake improves symptoms or shortens respiratory illness and a similar lack of data exists for the use of heated humidified air. One study has found chest vapor rub to be effective at providing some symptomatic relief of nocturnal cough, congestion, and sleep difficulty.

 

Antibiotics and antivirals

 

Antibiotics have no effect against viral infections and thus have no effect against the viruses that cause the common cold. Due to their side effects they cause overall harm; however, they are still frequently prescribed. Some of the reasons that antibiotics are so commonly prescribed include: people’s expectations for them, physicians’ desire to do something, and the difficulty in excluding complications that may be amenable to antibiotics. There are no effective antiviral drugs for the common cold even though some preliminary research has shown benefit.

 

Alternative treatments

 

While there are many alternative treatments used for the common cold, there is insufficient scientific evidence to support the use of most. As of 2010 there is insufficient evidence to recommend for or against either honey or nasal irrigation. Studies suggested that zinc, if taken within 24 hours of the onset of symptoms, reduces the duration and severity of the common cold in healthy people. Due to wide differences between the studies, further research may be needed to determine how and when zinc may be effective. Vitamin C’s effect on the common cold while extensively researched is disappointing, except in limited circumstances, specifically, individuals exercising vigorously in cold environments. Evidence about the usefulness of echinacea is inconsistent. Different types of echinacea supplements may vary in their effectiveness. It is unknown if garlic is effective.[64] A single trial of vitamin D did not find benefit.

 

Prognosis

 

The common cold is generally mild and self-limiting with most symptoms generally improving in a week. Severe complications, if they occur, are usually in the very old, the very young or those who are immunosuppressed. Secondary bacterial infections may occur resulting in sinusitis, pharyngitis, or an ear infection. It is estimated that sinusitis occurs in 8% and an ear infection in 30% of cases.

 

Epidemiology

 

The common cold is the most common human disease and all peoples globally are affected. Adults typically have two to five infections annually and children may have six to ten colds a year (and up to twelve colds a year for school children). Rates of symptomatic infections increase in the elderly due to a worsening immune system.

 

History

 

While the cause of the common cold has only been identified since the 1950s the disease has been with humanity since antiquity. Its symptoms and treatment are described in the Egyptian Ebers papyrus, the oldest existing medical text, written before the 16th century BCE. The name “common cold” came into use in the 16th century, due to the similarity between its symptoms and those of exposure to cold weather.

 

In the United Kingdom, the Common Cold Unit was set up by the Medical Research Council in 1946 and it was here that the rhinovirus was discovered in 1956. In the 1970s, the CCU demonstrated that treatment with interferon during the incubation phase of rhinovirus infection protects somewhat against the disease, but no practical treatment could be developed. The unit was closed in 1989, two years after it completed research of zinc gluconate lozenges in the prophylaxis and treatment of rhinovirus colds, the only successful treatment in the history of the unit.

 

Research

 

A number of antivirals have been tested for effectiveness in the common cold; however as of 2009 none have been both found effective and licensed for use. There are ongoing trials of the anti-viral drug pleconaril which shows promise against picornaviruses as well as trials of BTA-798. The oral form of pleconaril had safety issues and an aerosol form is being studied.

 

DRACO, a broad-spectrum antiretroviral therapy being developed at the Massachusetts Institute of Technology, has shown preliminary effectiveness in treating rhinovirus, as well as a number of other infectious viruses.

 

Researchers from University of Maryland, College Park and University of Wisconsin–Madison have mapped the genome for all known virus strains that cause the common cold.

 

Lower respiratory tract infection

While often used as a synonym for pneumonia, the rubric of lower respiratory tract infection can also be applied to other types of infection including lung abscess, acute bronchitis, and emphysema.

Symptoms include shortness of breath, weakness, high fever, coughing and fatigue. Commonly known as the most prolific cause of death amongst all infectious diseases, with 3.9 million people killed in 2002 – accountable for 6.8% of worldwide human deaths for that year.

Lower respiratory tract infections place a considerable strain on the health budget and are generally more serious than upper respiratory infections. Since 1993 there has been a slight reduction in the total number of deaths from lower respiratory tract infection. However in 2002 they were still the leading cause of deaths among all infectious diseases accounting for 3.9 million deaths worldwide and 6.9% of all deaths that year.

There are a number of acute and chronic infections that can affect the lower respiratory tract, the focus of this paper is to look at the two most common infections, Bronchitis and Pneumonia, as identified by the Therapeutic guidelines.  Although influenza affects the lower respiratory tract, it also affects the upper respiratory tract (shown in figure 1) and hence it will not be discussed here. Antibiotics are often thought to be the first line treatment in lower respiratory tract infections however as discussed later these are not indicated in viral infections. It is important to use appropriate antibiotic selection based on the infecting organism and to ensure this therapy changes with the evolving nature of these infections and the emerging resistance to conventional therapies. H influenzae and M catarrhalis are of increasing importance in both community acquired pneumonia (CAP) and acute exacerbation of chronic bronchitis (AECB) while the importance of S pneumoniae is declining. It has also become apparent the importance of atypical pathogens such as C pneumoniae, M pneumoniae and L pneumophila, in CAP.

 

Bronchitis

Bronchitis Overview

 

 

Bronchitis is an acute inflammation of the air passages within the lungs. It occurs when the trachea (windpipe) and the large and small bronchi (airways) within the lungs become inflamed because of infection or other causes.

The thin mucous lining of these airways can become irritated and swollen.

The cells that make up this lining may leak fluids in response to the inflammation.

Coughing is a reflex that works to clear secretions from the lungs. Often the discomfort of a severe cough leads you to seek medical treatment.

Both adults and children can get bronchitis. Symptoms are similar for both.

Infants usually get bronchiolitis, which involves the smaller airways and causes symptoms similar to asthma.

Bronchitis can be classified as either acute or chronic. Acute bronchitis can be defined as acute bacterial or viral infection of the larger airways in healthy patients with no history of recurrent disease. It affects over 40 adults per 1000 each year and consists of transient inflammation of the major bronchi and trachea. Most often it is caused by viral infection and hence antibiotic therapy is not indicated in immunocompetent individuals.

Bronchitis Causes

Bronchitis occurs most often during the cold and flu season, usually coupled with an upper respiratory infection.

Several viruses cause bronchitis, including influenza A and B, commonly referred to as “the flu.”

A number of bacteria are also known to cause bronchitis, such as Mycoplasma pneumoniae, which causes so-called walking pneumonia.

Bronchitis also can occur when you inhale irritating fumes or dusts. Chemical solvents and smoke, including tobacco smoke, have been linked to acute bronchitis.

People at increased risk both of getting bronchitis and of having more severe symptoms include the elderly, those with weakened immune systems, smokers, and anyone with repeated exposure to lung irritants.

 

Bronchitis Symptoms

 

·        Acute bronchitis most commonly occurs after an upper respiratory infection such as the common cold or a sinus infection. You may see symptoms such as fever with chills, muscle aches, nasal congestion, and sore throat.

·        Cough is a common symptom of bronchitis. The cough may be dry or may produce phlegm. Significant phlegm production suggests that the lower respiratory tract and the lung itself may be infected, and you may have pneumonia.

·        The cough may last for more than two weeks. Continued forceful coughing may make your chest and abdominal muscles sore. Coughing can be severe enough at times to injure the chest wall or even cause you to pass out.

·        Wheezing may occur because of the inflammation of the airways. This may leave you short of breath.

 

When to Seek Medical Care

 

When to call the doctor

·        Although most cases of bronchitis clear up on their own, some people may have complications that their doctor can ease.

·        Severe coughing that interferes with rest or sleep can be reduced with prescription cough medications.

·        Wheezing may respond to an inhaler with albuterol (Proventil, Ventolin), which dilates the airways.

·        If fever continues beyond four to five days, see the doctor for a physical examination to rule out pneumonia.

·        See a doctor if the patient is coughing up blood, rust-colored sputum, or an increased amount of green phlegm.

 

When to go to the hospital

If the patient experiences difficulty breathing with or without wheezing and they cannot reach their doctor, go to a hospital’s emergency department for evaluation and treatment.

 

Exams and Tests

·        Doctors diagnose bronchitis generally on the basis of symptoms and a physical examination.

·        Usually no blood tests are necessary.

·        If the doctor suspects the patient has pneumonia, a chest x-ray may be ordered.

·        Doctors may measure the patient’s oxygen saturation (how well oxygen is reaching blood cells) using a sensor placed on a finger.

·        Sometimes a doctor may order an examination and/or culture of a sample of phlegm coughed up to look for bacteria.

 

Bronchitis Treatment

 

Self-Care at Home

 

·              By far, the majority of cases of bronchitis stem from viral infections. This means that most cases of bronchitis are short-term and require nothing more than treatment of symptoms to relieve discomfort.

 

·              Antibiotics will not cure a viral illness.

 

·              Experts in in the field of infectious disease have been warning for years that overuse of antibiotics is allowing many bacteria to become resistant to the antibiotics available.

 

·              Doctors often prescribe antibiotics because they feel pressured by people’s expectations to receive them. This expectation has been fueled by both misinformation in the media and marketing by drug companies. Don’t expect to receive a prescription for an antibiotic if your infection is caused by a virus.

 

·              Acetaminophen (Feverall, Panadol, Tylenol), aspirin, or ibuprofen (Motrin, Nuprin, Advil) will help with fever and muscle aches.

 

·              Drinking fluids is very important because fever causes the body to lose fluid faster. Lung secretions will be thinner and easier to clear when the patient is well hydrated.

 

·              A cool mist vaporizer or humidifier can help decrease bronchial irritation.

 

·              An over-the-counter cough suppressant may be helpful. Preparations with guaifenesin (Robitussin, Breonesin, Mucinex) will loosen secretions; dextromethorphan-the “DM” in most over the counter medications (Benylin, Pertussin, Trocal, Vicks 44) suppresses cough.

 

Medical Treatment

 

·              Treatment of bronchitis can differ depending on the suspected cause.

 

·              Medications to help suppress the cough or loosen and clear secretions may be helpful. If the patient has severe coughing spells they cannot control, see the doctor for prescription strength cough suppressants. In some cases only these stronger cough suppressants can stop a vicious cycle of coughing leading to more irritation of the bronchial tubes, which in turn causes more coughing.

 

·              Bronchodilator inhalers will help open airways and decrease wheezing.

 

·              Though antibiotics play a limited role in treating bronchitis, they become necessary in some situations.

 

·              In particular, if the doctor suspects a bacterial infection, antibiotics will be prescribed.

 

·              People with chronic lung problems also usually are treated with antibiotics.

 

·              In rare cases, the patient may be hospitalized if they experience breathing difficulty that doesn’t respond to treatment. This usually occurs because of a complication of bronchitis, not bronchitis itself.

Follow-up

 

The patient should follow up with their doctor within a week after treatment for bronchitis—sooner if your symptoms worsen or do not improve.

Call the doctor’s office if any new problems occur.

 

Pneumonia

Bacterial Pneumonia Overview

 

Pneumonia is an infection of the lungs. People with pneumonia usually complain of coughing, fever, shortness of breath, and chest pain.

 

·              Your body’s immune system usually keeps bacteria from infecting your lungs. In bacterial pneumonia, bacteria reproduce in your lungs, while your body tries to fight off the infection. This response to bacterial invaders is called inflammation.

 

·              When the inflammation occurs in the alveoli (microscopic air sacs in the lungs), they fill with fluid. Your lungs become less elastic and cannot take oxygen into the blood or remove carbon dioxide from the blood as efficiently as usual.

 

·              When the alveoli don’t work efficiently, your lungs have to work harder to satisfy your body’s need for oxygen. This causes the feeling of being short of breath, which is one of the most common symptoms of pneumonia. Inflammation causes many of the other symptoms, including fever and chest pain.

 

·              Pneumonia can be very serious, because it directly interferes with your body’s ability to exchange carbon dioxide and oxygen.

 

·              Pneumonia is different in this way from acute bronchitis, which is another disease that can cause fever, cough, chest pain, and shortness of breath. Bronchitis is caused by inflammation in the air passages (called bronchi) leading to the alveoli, not the alveoli themselves. Sometimes it is very difficult, even for a doctor, to tell pneumonia and bronchitis apart. The symptoms and physical examination can be identical. Sometimes a chest x-ray is the only way to tell pneumonia and bronchitis apart.

Bacterial Pneumonia Causes

·              Most pneumonia is caused by bacteria or a virus. Pneumonia from any cause can occur at any age, but people in certain age groups are at higher risk for certain types of pneumonia.

 

·              The most common cause of bacterial pneumonia is a type of bacteria known as Streptococcus pneumoniae. Haemophilus influenzae, Chlamydia trachomatis, Mycoplasma pneumoniae, and Legionella pneumophila are some other major bacteria that cause pneumonia.

 

·              If you inhale toxic materials, you can injure your lungs and cause chemical pneumonia.

 

·              Fungi can also cause pneumonia. In certain areas of the United States, specific fungi are well known. Coccidioidomycosis is a type of fungal infection that causes a pneumonia called “San Joaquin fever” or “Valley fever.” Histoplasmosis and blastomycosis are other fungal diseases that cause pneumonias.

 

·              The most common way you catch pneumonia is to breathe infected air droplets from someone who has pneumonia. Another cause is an improperly cleaned air conditioner. Yet another source of infection in your lungs is spread of an infection from somewhere else in your body, such as the kidney.

 

·              Your risk of catching pneumonia is determined by the specific bacteria, virus, or fungus, the number of organisms you inhale, and your body’s ability to fight infections.

 

·              You do not catch pneumonia by not dressing properly for cold weather or by being caught in the rain.

 

Bacterial Pneumonia Symptoms

·              Doctors often refer to typical and atypical pneumonias, based on the signs and symptoms of the condition. This can help to predict the type of bacteria causing the pneumonia, the duration of the illness, and the optimal treatment method.

·              Typical pneumonia comes on very quickly.

·              Typical pneumonia usually results in a high fever and shaking chills.

·              Typical pneumonia usually leads to the production of yellow or brown sputum when coughing.

·              There may be chest pain, which is usually worse with breathing or coughing. The chest also may be sore when you touch or press it.

·              Typical pneumonia can cause shortness of breath, especially if you have any chronic lung conditions such as asthma or emphysema.

·              Because chest pain also can be a sign of other serious medical conditions, do not try to diagnose yourself.

·              Older people can have confusion or a change in their mental abilities as a sign of pneumonia or other infection.

·              Atypical pneumonia has a gradual onset.

·              It is called “walking pneumonia.”

·              Sometimes it follows another illness in the days to weeks before the pneumonia.

·              The fever is usually lower, and shaking chills are less likely.

·              There may be headache, body aches, and joint pain.

·              Coughing may be dry or produce only a little sputum. You may not have any chest pain.

·              Abdominal pain may be present.

·              There may be other symptoms, such as feeling tired or weak.

 

Exams and Tests

 

·              Pneumonia can be diagnosed simply by a doctor listening to your lungs. Certain sounds heard through a stethoscope may indicate infection.

·              One of the easiest tests to perform is pulse oximetry, sometimes called “pulse ox.” A probe that looks like a clothespin is gently attached to your finger, toe, or ear. A special light shines through your skin to estimate how much oxygen you have in your bloodstream. If your oxygen level is lower than expected, it may mean you have pneumonia.

·              An x-ray of your chest can help identify which part of your lung is infected. An x-ray also can show abnormal fluid collections which also can help diagnose pneumonia.

·              You may have blood drawn. Laboratory tests can show that your immune system is working properly to fight off your infection. They also show whether you have enough red blood cells to carry oxygen or whether the bacteria have gotten into your bloodstream.

·              Occasionally your doctor may need to sample blood from one of your arteries (usually in your wrist) in order to get an exact measurement of how well you are exchanging oxygen and carbon dioxide. This test, called an arterial blood gas (“ABG” or “blood gas”), is very important, takes only a minute, and is done with a very small needle and syringe. This test cannot be run on the other blood that is sampled from your veins.

·              Sometimes your doctor will collect some of your sputum and look at it under a microscope. Certain stains, or dyes, help your doctor tell which specific bacterium is causing your pneumonia. Sputum cultures may also be performed. In these tests, your sputum is put on a plate to help it grow so a laboratory specialist can identify the specific bacteria.

·              If you are admitted to the hospital, your doctor will draw blood and send it to the laboratory so that it may also be cultured to determine whether bacteria are present in the bloodstream.

 

Bacterial Pneumonia Treatment

 

Self-Care at Home

If you suspect pneumonia based on the signs or symptoms, see your doctor as soon as possible. There is no home treatment for pneumonia. Although cough suppressants, expectorants, or fever-lowering drugs may be helpful, they should not be started without discussing their use with your doctor.

 

Medical Treatment

 

·              If you have a bacterial pneumonia, you will need to take an antibiotic. The antibiotic choice depends on your age, your chronic medical conditions, whether or not you smoke or drink alcohol, and other medications you are taking. Tell your doctor about allergies or bad reactions to any medicines you have taken before and bring a list of your current medicines with you.

 

·              Drink plenty of nonalcoholic fluids to stay hydrated. This helps your body fight the pneumonia. Anti-fever medicines such as acetaminophen (Tylenol) or ibuprofen (Advil) may also help you feel better.

 

·              Because coughing helps clear infection out of your lungs, your doctor may recommend that you not use a cough suppressant.

 

·              You must avoid cigarette or other tobacco smoke while you recover from pneumonia. Smoking hurts your body’s ability to fight infection and makes the healing process take a lot longer.

 

·              If you are severely short of breath or if you have significantly lowered oxygen levels in your bloodstream, you may need to be admitted to the hospital. You will get extra oxygen to help you breathe, and you may get your antibiotic by an IV catheter through your veins.

 

·              If your pneumonia is very severe, you may need a breathing tube in your windpipe so that a machine can do the work of breathing for you. If you need a breathing machine, you will be admitted to an intensive-care unit in the hospital.

 

Lobar pneumonia

 

Lobar pneumonia is an acute medical emergency, and specific therapeutic measures require the diagnosis to be made as soon as possible. Lobar pneumonia is a specific acute infectious disease which involves an entire lung or part of a lung. Sometimes both lungs are completely involved in the pneumonic process.

Etiology. Lobar pneumonia may occur at any time of the year, but it is most frequent in the months from December until May. It is a disease that spares no age group, though it is most likely to occur before the age of 10 and after the age of 50 years. Exposure to inclement weather, draughts, loss of sleep, and contact with patients who have infections, or healthy carriers are the chief predisposing factors. The causative agent of pneumonia is the pneumococcus. Formerly, four main types of pneumococci were recognized, but recently more than 40 kinds have been identified.

Signs and symptoms. Pneumonia does not always begin according to the classical textbook description with chills, fever, pain in the chest, and expectoration of bloody or rusty sputum, but it frequently does. It is well to remember that pneumonia is a disease that sets in abruptly. There may or may not be a preceding upper respiratory infection with a cough. Frequently the first evidence of pneumonia is a feeling of prostration which is due to the early bacteremia. Then coughing begins, and there may be bloody expectoration. Even at this early stage, the sputum may contain the pneumococcus. When the patient has a chill with a rapid, bounding pulse, fever, and pain in the side of the chest, the diagnosis is easily made.

Although pneumonia may be suspected when pleuritic pain, chill, fever, tachycardia, and bloody sputum occur, the physical signs of pneumonia may not be present for another 24 hours. The early recognition of pneumonia is accomplished by careful attention to the history of onset and by a skillful examination of the chest. Many physicians believe that an X-ray examination is more important in early diagnosis than a physical examination, and that it is a more positive means of diagnosing early pneumonia. This is not always true because proficient clinicians are able to determine the presence of pneumonia and clinch the diagnosis before the evidence is confirmed on the X-ray film.

Inspection usually reveals a patient with an anxious facial express­ion. Breathing may be rapid and the excursions of the chest may be limited. A cyanotic tinge about the lips or finger tips may help in the identification of the disease. Palpation reveals a hot, dry skin, and the pulse is not only rapid but bounding. The early diagnosis of pneumonia is established usually by the finding of an impaired percussioote over the diseased lung. The dullness to percussion is usually well marked even in the first stage of the disease.

Auscultation on the involved side of the chest may disclose altera­tion of the breath sounds. Typical bronchial breathing may not be present, but a muffled breathing is usually noted. The presence of fine crepitant rвles, especially if the patient coughs, associated with other signs, is practically always positive evidence of early pneumo­nia. Two or three days may elapse before the typical features of lobar consolidation appear.

Course. If lobar pneumonia remains uncomplicated, the disease runs its course in from 7 to 12 days. It usually terminates by crisis, when the temperature drops, and the pulse and respiratory rates suddenly approach normal.

Antibiotic Choice

With increased development of drug resistance, traditional empirical treatments are becoming less effective, hence it is important to base antibiotic choice on isolated bacteria and sensitivity tests. According to the Cochrane review of antibiotic use in CAP in adults, the current evidence from RCTs is insufficient in order to make evidenced based decisions on the antibiotic of choice. Further studies are required to make these decisions. For children they found amoxicillin or procaine penicillin to have greater effect than co-trimoxazole for the treatment of CAP. In hospital settings, penicillin and gentamycin was found to be more effective than chloramphenicol, with oral amoxicillin giving similar results to injectable penicillins. In another review of children with severe pneumonia oral antibiotics were found to be as effective as injectable ones without the side effects of pain risk of infection and high cost. Also in a Cochrane review azithromycin has been shown to be no better than Amoxycillin or Amoxycillin with clavulanic acid in the treatment of lower respiratory infections.  The AMH list Amoxycillin as first line of AECB and community acquired pneumonia where as IV azithromycin is first line if high risk of death. If severe hospital acquired pneumonia it recommends IV gentamicin and ticarcillin with clavulanic acid.

Non-Pharmacological Treatments

The main stay of non pharmacological treatment for many years has been rest and increased fluid intake. Although it is common for doctors and other health professional to recommend extra fluid intake a Cochrane systematic review could find no evidence for or against increased fluid intake. Although the idea of replacing fluids lost through fever and rapid breathing was sound, some observational studies reported harmful effects such as dilution of blood sodium concentration leading to headache, confusion or possibly seizures. Rest will allow the body to conserve energy to fight off the infection. Physiotherapy is indicated in some types of pneumonia and should be encouraged where appropriate.

Complementary Therapies

Chickweed taken orally has been used for many years to reduce fever and phlegm associated with bronchitis. It is believed to act as an expectorant and although the pharmacological actions of several constituents suggest it may be useful, controlled studies are not available to confirm its effectiveness.

A systematic review of Chinese herbs used in the treatment of acute bronchitis found that there was weak evidence for their use, but there was insufficient quality data to recommend them. The benefit found may be due to study design or publication bias. Hence they should be used carefully because their safety is largely unknown.

Thyme is approved by commission E in the treatment of bronchitis and there is encouraging data for its use in chronic bronchitis when used in combination with other herbs, however there is no stand-alone data.

The use of Vitamin C is commonly thought to act to prevent colds and other respiratory infections. However according to a recent Cochrane review the evidence is too weak to support its widespread use as a prophylactic in preventing pneumonia in the general population. It may be reasonable to use in high risk patients with low plasma levels of vitamin C due to its low cost and risk associated with is use.  Vitamin A has been successfully used to reduce the mortality and severity of respiratory infection with measles. However in a review of non-measles pneumonia it was not found to have any benefit or harmful effects.

For the treatment of pneumonia baical skullcap was shown to be as effective as piperacillin after one treatment. The piperacillin group resulted in 4 of 30 patients with fungal infections while there where none in the baical skullcap group.

The Future

It is likely that the future treatment of lower respiratory tract infections will consist of new antibiotics aimed at facing the problems associated with the constant emergence of antibiotic resistance. With resistance evolving so rapidly future treatments may include the use of vaccines to prevent these infections. Although a Cochrane systematic review of a polysaccharide pneumococcal vaccine didn’t reduce the pneumonia or there related deaths in adults, but was able to reduce incidence of more specific outcomes such as pneumococcal disease in the elderly. So it is hoped with further developments these will become more effective against pneumonia.

Vaccination of patients with AECB in the autumn months is thought to have a positive effect in reducing the severity and number of exacerbations over winter. The oral vaccine described in this review was able to decrease the carriage or non-typeable Haemophilus influenzae that is a common cause of exacerbations to chronic bronchitis. With good planing and further research these types of vaccines may reduce the burden associated with lower respiratory diseases.

There are few treatments available for viral forms of bronchitis and pneumonia. Respiratory syncytial virus (RSV), the main cause of these in children, could be potentially treated using a new monoclonal antibody (mAb) Motavizumab. In animal trials it reduced antibody titres 100 lower than the only drug currently available to treat the condition. This holds great promise for future treatments of LRTI.

Influenza (Grippe). TB

PULMONARY TUBERCULOSIS

Pulmonary tuberculosis is a specific communicable disease, usually chronic but occasionally acute, caused by the bacillus tuberculosis.

Dr. Robert Koch discovered the tuberculosis bacilli.

 

Dr. Robert Koch discovered the tuberculosis bacilli.

The bacillus causing tuberculosis, Mycobacterium tuberculosis, was identified and described on March 24, 1882 by Robert Koch. He received the Nobel Prize in physiology or medicine in 1905 for this discovery. Koch did not believe that bovine (cattle) and human tuberculosis were similar, which delayed the recognition of infected milk as a source of infection. Later, this source was eliminated by the pasteurization process. Koch announced a glycerin extract of the tubercle bacilli as a “remedy” for tuberculosis in 1890, calling it ‘tuberculin’. It was not effective, but was later adapted as a test for pre-symptomatic tuberculosis.

It is generally believed that the pathogenesis of the disease is as follows: first contact with the disease results in a lesion of the lung which is microscopic in size and usually produces no signs or symptoms by which it may be diagnosed clinically. Healing of this lesion takes place by the deposition of lime salts in and around it so that even­tually complete calcification takes place which is evident in X-ray examination of the lung. Inside this lesion, however,   are tubercle bacilli which may remain alive for many years.

   In the United States, most people will recover from primary TB infection without further evidence of the disease. The infection may stay asleep or nonactive (dormant) for years and then reactivate.

 

Most people who develop symptoms of a TB infection first became infected in the past. However, in some cases, the disease may become active within weeks after the primary infection.

 

The following people are at higher risk for active TB:

Elderly

Infants

People with weakened immune systems, for example due to AIDS, chemotherapy, or antirejection medicines given after an organ transplant

 

Your risk of contracting TB increases if you:

Are in frequent contact with people who have the disease

Have poor nutrition

Live in crowded or unsanitary living conditions

 

The following factors may increase the rate of TB infection in a population:

Increase in HIV infections

Increase iumber of homeless people (poor environment and nutrition)

The appearance of drug-resistant strains of TB

 

In the United States, there are approximately 10 cases of TB per 100,000 people. However, rates vary dramatically by area of residence and socioeconomic class.

 

 

Symptoms

 

The primary stage of the disease usually doesn’t have symptoms. When symptoms do occur, they may include:

Cough (sometimes producing phlegm)

Coughing up blood

Excessive sweating, especially at night

Fatigue

Fever

Unintentional weight loss

 

Other symptoms that may occur with this disease:

Breathing difficulty

Chest pain

Wheezing

 

Exams and Tests

 

Examination may show:

Clubbing of the fingers or toes (in people with advanced disease)

Enlarged or tender lymph nodes in the neck or other areas

Fluid around a lung

Unusual breath sounds (crackles)

 

Tests may include:

Biopsy of the affected tissue (rare)

Bronchoscopy

Chest CT scan

Chest x-ray

Interferon-gamma blood test such as the QFT-Gold test to test for TB infection

Sputum examination and cultures

Thoracentesis

Tuberculin skin test

 

 

Treatment

 

The goal of treatment is to cure the infection with drugs that fight the TB bacteria. Treatment of active pulmonary TB will always involve a combination of many drugs (usually four drugs). It is continued until lab tests show which medicines work best.

 

You may need to take many different pills at different times of the day. This may be difficult for some people. However, it is very important that you take the pills the way your health care provider instructed.

 

When people do not take their tuberculosis medications as recommended, the infection becomes much more difficult to treat. Sometimes, the drugs no longer help treat the infection.

 

Treatment usually lasts for 6 months, but longer courses may be needed for people with AIDS or who get better slowly.

 

You may need to be admitted to a hospital to avoid spreading the disease to others until you are no longer contagious.

 

Your doctor or nurse is required by law to report your TB illness to the local health department. Your health care team will be sure that you receive the best care for your TB.

 

Outlook (Prognosis)

 

Symptoms may improve in 2 – 3 weeks. A chest x-ray will not show this improvement until later. The outlook is excellent if pulmonary TB is diagnosed early and treatment is begun quickly.

Possible Complications

 

Pulmonary TB can cause permanent lung damage if not treated early.

 

Medicines used to treat TB may cause side effects, including liver problems. Other side effects include:

Changes in vision

Orange- or brown-colored tears and urine

Rash

When to Contact a Medical Professional

 

Call your health care provider if:

You have been exposed to TB

You develop symptoms of TB

Your symptoms continue despite treatment

New symptoms develop

 

Prevention

 

TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers.

 

A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative.

 

Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB.

 

Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States.

 

People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor.

Pathogenesis

Mycobacterium tuberculosis (stained red) in sputum

Mycobacterium tuberculosis (stained red) in sputum

Classification & external resources

Scanning electron micrograph of Mycobacterium tuberculosis

Bacterial species.  Scanning electron micrograph of Mycobacterium tuberculosis

 

Tuberculosis.  The disease is widespread. All ages are affected but the morta­lity is highest between 20 and 45 years. The disease may result from the inhaling of dust containing bacillus tuberculosis, from droplet infection, or from the contact with contaminated objects.

In the early stage of tuberculosis the patient usually complains of general malaise, fatigue, loss of appetite and weight. Cough may be dry or productive, i.e. with sputum discharge. Coughing becomes worse at night and in the morn­ing. In patients with cavities in the lungs coughing is accom­panied by a considerable sputum discharge.

Sputum is mucopurulent. Its microscopic examination reveals a large number of pus corpuscles, erythrocytes, and tuberculosis organisms. Blood in the sputum is sometimes the first sign of tuberculosis. When larger blood vessels become involved the discharge of blood may become profuse.

Fever is one of the permanent symptoms of pulmonary tuberculosis. In benign processes the body temperature is often subfebrile. In active forms it may range from 38 to 39° C. A considerable elevation of temperature is observed in pneu­monic forms, when fever persists at a level of 38° C and higher for several months.

Cold profuse perspiration at night is sometimes evidence of a severe form of tuberculosis. Loss of body weight is one of the typical signs of pulmonary tuberculosis. It is caused by tuberculous intoxication, a sharp increase in the metabol­ic rate and loss of appetite. It is particularly marked in progressive forms of the disease.

If the patient has TB bacilli in the sputum, then he stays in the hospital for no less than six to eight months. This is sufficient time for the doctors to put the disease into the so-called closed form. After that he is treated as an outpatient for 18 months. After the course of treatment is completed, the patient is kept under surveillance for three years. Every spring and autumn he has prophylactic vaccinations. Mem­bers of his family are also given medical check-ups.

TB prevention and control takes two parallel approaches. In the first, people with TB and their contacts are identified and then treated. Identification of infections often involves testing high-risk groups for TB. In the second approach, children are vaccinated to protect them from TB. Unfortunately, no vaccine is available that provides reliable protection for adults. However, in tropical areas where the incidence of atypical mycobacteria is high, exposure to nontuberculous mycobacteria gives some protection against TB.

The prophylaxis of TB starts as soon as a baby is born. Antituberculosis vaccinations are administered to all the babies in maternity homes. Every person over 12 years of age has his chest examined for TB once every year.

 

Mantoux tuberculin skin test

 

Mantoux tuberculin skin test

 

The scientists have elaborated new surgical methods of tuberculosis treatment, both independent and combined with modern anti-bacterial methods. The treatment of TB of bones and joints, including resto­ration of the affected joints and bones of the spine, is the most important problem.

 

Epidemiology

Annual number of new reported TB cases. Data from WHO.

 

Annual number of new reported TB cases. Data from WHO.

World TB incidence. Cases per 100,000; Red = >300, orange = 200-300; yellow = 100-200; green 50-100 and grey <50. Data from WHO, 2006.

 

World TB incidence. Cases per 100,000; Red = >300, orange = 200-300; yellow = 100-200; green 50-100 and grey <50. Data from WHO, 2006.

According to the World Health Organization (WHO), nearly 2 billion people—one–third of the world’s population—have tuberculosis. Annually, 8 million people become ill with tuberculosis, and 2 million people die from the disease worldwide. In 2004, around 14.6 million people had active TB disease with 9 millioew cases. The annual incidence rate varies from 356 per 100,000 in Africa to 41 per 100,000 in the Americas. Tuberculosis is the world’s greatest infectious killer of women of reproductive age and the leading cause of death among people with HIV/AIDS.

In 2004, the country with the highest incidence of TB was South Africa, with 718 cases per 100,000 people. India has the largest number of infections, with over 1.8 million cases. In developed countries, tuberculosis is less common and is mainly an urban disease. In the United Kingdom, TB incidences range from 40 per 100,000 in London to less than 5 per 100,000 in the rural South West of England; the national average is 13 per 100,000. The highest rates in Western Europe are in Portugal (42 per 100,000) and Spain (20 per 100,000). These rates compare with 113 per 100,000 in China and 64 per 100,000 in Brazil. In the United States, the overall tuberculosis case rate was 4.9 per 100,000 persons in 2004.

The incidence of TB varies with age. In Africa, TB primarily affects adolescents and young adults. However, in countries where TB has gone from high to low incidence, such as America, TB is mainly a disease of older people.

There are a number of known factors that make people more susceptible to TB infection: worldwide the most important of these is HIV. Co-infection with HIV is a particular problem in Sub-Saharan Africa, due to the high incidence of HIV in these countries. Smoking more than 20 cigarettes a day also increases the risk of TB by two- to four-times.

INFLUENZA (GRIPPE)

Influenza is an acute infectious disease occurring in ende­mic, epidemic or pandemic form. The cause of influenza is now definitely established. It is a filterable virus. The disease is contagious and spread directly from person to person by talking, coughing or sneezing. Healthy carries, as well as patients, probably spread the disease. The incubation period is from 1 to 3 days. The onset is sudden with chilly sensa­tions or a true chill, followed by fever. Common symptoms are severe frontal headache, pains in the back, limbs and eyeballs,   dizziness, conjunctivitis and   severe prostration. The temperature ranges between 37.7° and 40 °С and persists from two to five days. The   respiratory rate is moderately increased. The pulse is accelerated but usually not very high. Vomiting and diarrhea are frequent. Many patients also have respiratory symptoms, such as laryngitis, tracheitis and bronchitis. The tongue is dry and coated, the pharynx usual­ly reddened.

In some cases catarrhal symptoms are replaced by ner­vous symptoms or prostration, insomnia, mental depression, intense headache, general pains. There may be serious com­plications after the grippe. One of them is pneumonia, which usually follows rather than accompanies the disease. Influenza in which no complications arise usually lasts from 2 to 3 days, and even to 5 days. Convalescence may be prompt or protracted by weakness or mental depression. The mortality is low in the epidemic and endemic forma but may be high in pandemics.

Treatment of the patients is symptomatic and supportive. Fluids should be given freely, nutrition ma­intained by means of a bland diet, and constipation obviated by the use of mild laxatives. The headache and general pains are alleviated by the use of acetylsalicylic acid (aspirin) in doses of 0.3 g. Codeine sulfate in doses of t 5 or 30 mg. every 4 hours may be required for the cough.

 

What is the key to flu prevention?

 

Flu vaccine

 

Much of the illness and death caused by influenza can be prevented by annual influenza vaccination. Flu vaccine (influenza vaccine made from inactivated and sometimes attenuated [non-infective] virus) is specifically recommended for those who are at high risk for developing serious complications as a result of influenza infection. These high-risk groups for conventional flu include all people aged 65 years or older and people of any age with chronic diseases of the heart, lung, or kidneys; diabetes; immunosuppression; or severe forms of anemia. However, with the novel H1N1 flu, the CDC has listed these groups listed below as being at high risk and should obtain the novel H1N1 vaccine as soon as it is available to them:

pregnant women,

people who live with or care for children younger than 6 months of age,

health-care and emergency-services personnel,

people between the ages of 6 months through 24 years of age and children 5-18 years of age who have chronic medical problems, and

people from 25-64 years of age who are at higher risk for novel H1N1 because of chronic health disorders or compromised immune systems.

Other groups for whom conventional flu vaccine is specifically recommended are residents of nursing homes and other chronic care facilities housing patients of any age with chronic medical conditions and children and teenagers who are receiving long-term aspirin therapy and who may therefore be at risk for developing Reye syndrome after an influenza virus infection. Influenza vaccine is also recommended for people who are in close or frequent contact with anyone in the high-risk groups defined above. These people include health-care personnel and volunteers who work with high-risk patients and people who live in a household with a high-risk person.

 

Because the flu is easily spread among children and because many children require hospitalization with the flu, the CDC now advises that all children 6-59 months of age receive a yearly conventional flu vaccination.

 

What are some treatments an individual can do at home for the flu?

 

First, individuals should be sure they are not members of a high-risk group that is more susceptible to getting severe flu symptoms. Check with your physician if you are unsure if you are a higher risk person. Home care is recommended by the CDC if a person is normally healthy with no underlying diseases or conditions (for example, asthma, lung disease, pregnant, or immunosuppressed).

 

Increasing liquid intake, warm showers, and warm compresses, especially in the nasal area, can reduce the body aches and reduce nasal congestion. Nasal strips and humidifiers may help reduce congestion, especially while trying to sleep. Some physicians recommend nasal irrigation with saline to further reduces congestion; some recommend nonprescription decongestants. Fever can be treated with over-the counter acetaminophen (Tylenol) or ibuprofen (Motrin and others) (read labels for safe dosage). Cough can be suppressed by cough drops and over-the-counter cough syrup. If an individual’s symptoms at home get worse, their doctor should be notified.

 

When should a person go to the emergency department for the flu?

 

The CDC has recently published guidelines on who should go to the emergency department for flu symptoms and who should not go. The CDC published these guidelines to avoid a crush of people going to the emergency department during the H1N1 flu pandemic and utilizing limited resources needed for true emergency patients such as cardiac or trauma patients and to avoid transmitting the virus to high-risk patients. The CDC guidelines are as follows for children and adults. The CDC urges normally healthy people that get either the conventional or novel H1N1 swine flu to stay home as the large majority of infected individuals will recover without antiviral medications or other treatments.

 

 

Signs

• Fever or chills

• Cough or sore throat

• Sore or aching muscles

• Headache

• Vomiting

Diarrhea

• Runny or stuffy nose

• Earache

• Red, watery and sore eyes

• Feeling very tired

 

 

Your Care

Your care may include:

• Taking medicine to treat the virus, diarrhea, fever, body aches or cough

• Resting

• Drinking at least 8-10 glasses of liquids each day

• Avoiding alcohol and tobacco

• Using a humidifier to help you breathe easier

 

Preventing Influenza

• Wash your hands often, especially after blowing your nose.

• Cover your mouth with a tissue when you cough or sneeze. Then, wash

your hands.

• Avoid touching your eyes, nose or mouth.

Post-Text Assignments

I.  Skim through the text and find the key sentences.     

II. Write the key sentences out of the text and translate them.

III. Read the text closely and answer the following questions:

1.In what forms does Influenza occur? 2. What is the cause of Influenza? 3. How does Influenza spread? 4. Who spreads the disease?  5. What is the incubation period of Grippe? 6. What common symptoms of Influenza can you name? 7. How long do the active symptoms of the disease’ persist? 8.In which cases are nervous symptoms present? 9. What complications of Influenza are the most serious? 10. How long does the disease last? 11. When is the mortality high?

Respiratory disease is a medical term that encompasses pathological conditions affecting the organs and tissues that make gas exchange possible in higher organisms, and includes conditions of the upper respiratory tract, trachea, bronchi, bronchioles, alveoli, pleura and pleural cavity, and the nerves and muscles of breathing. Respiratory diseases range from mild and self-limiting, such as the common cold, to life-threatening entities like bacterial pneumonia, pulmonary embolism, and lung cancer.

The study of respiratory disease is known as pulmonology. A doctor who specializes in respiratory disease is known as a pulmonologist, a chest medicine specialist, a respiratory medicine specialist, a respirologist or a thoracic medicine specialist.

 

Classification

Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause (etiology) of the disease.

 

Inflammatory lung disease

Characterised by a high neutrophil count, e.g. asthma, cystic fibrosis, emphysema, chronic obstructive pulmonary disorder or acute respiratory distress syndrome.

 

Obstructive lung diseases

Obstructive lung diseases are diseases of the lung where the airways (i.e. bronchi, bronchioles, alveoli) become reduced in volume or have free flow of gas impeded, making it more difficult to move air in and out of the lung.

 

Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD), which includes emphysema an example of an obstructive lung disease, is where the alveolae rupture causing air to be retained in the lungs and limit the available space during inhalation.

Asthma is an example of an obstructive lung disease, (and of an inflammatory lung disease). It is a disease in which muscles of bronchi contract, making it difficult for air to reach the lungs. One treatment of asthma is to use an inhaler which contains a drug to relax muscles of bronchi. Asthma is a difficulty in breathing causing wheezing due to inflammation of bronchi and bronchioles, this causes a restriction in the airflow into the alveoli.

Asthma attacks can be brought on by triggers, such as air pollution, tobacco smoke, factory fumes, cleaning solvents, infections, pollens, foods, cold air, exercise, chemicals and medications. Triggers are highly individual and may not be related to allergens. Many asthmatics are not allergic to common allergens such as mold, ragweed, dust or pollens. It can also be caused by dust.

 

Restrictive lung diseases

Restrictive lung diseases (also known as interstitial lung diseases) are a category of respiratory disease characterized by a loss of lung compliance, causing incomplete lung expansion and increased lung stiffness, such as in infant respiratory distress syndrome.

 

Respiratory tract infections

Infections can affect any part of the respiratory system. They are traditionally divided into upper respiratory tract infections and lower respiratory tract infections.

 

Upper respiratory tract infection

The most common upper respiratory tract infection is the common cold however, infections of specific organs of the upper respiratory tract such as sinusitis, tonsillitis, otitis media, pharyngitis and laryngitis are also considered upper respiratory tract infections.

Sinusitis or rhinosinusitis is inflammation of the paranasal sinuses, which may be due to infection, allergy, or autoimmune issues. Most cases are due to a viral infection and resolve over the course of 10 days. It is a common condition; for example, in the United States more than 24 million cases occur annually.

Classification

Sinusitis (or rhinosinusitis) is defined as an inflammation of the mucous membrane that lines the paranasal sinuses and is classified chronologically into several categories:

·        acute rhinosinusitis — a new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe;

·        recurrent acute rhinosinusitis — four or more separate episodes of acute sinusitis that occur within one year;

·        subacute rhinosinusitis — an infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection;

·        chronic rhinosinusitis — when the signs and symptoms last for more than 12 weeks; and

·        acute exacerbation of chronic rhinosinusitis — when the signs and symptoms of chronic rhinosinusitis exacerbate, but return to baseline after treatment.

 

All these types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life.

 

Acute

Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin. If the infection is of bacterial origin, the most common three causative agents are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Until recently, Haemophilus influenzae was the most common bacterial agent to cause sinus infections. However, introduction of the H. influenza type B (Hib) vaccine has dramatically decreased H. influenza type B infections and now non-typable H. influenza (NTHI) are predominantly seen in clinics. Other sinusitis-causing bacterial pathogens include Staphylococcus aureus and other streptococci species, anaerobic bacteria and, less commonly, gram negative bacteria. Viral sinusitis typically lasts for 7 to 10 days, whereas bacterial sinusitis is more persistent. Approximately 0.5% to 2% of viral sinusitis results in subsequent bacterial sinusitis. It is thought that nasal irritation from nose blowing leads to the secondary bacterial infection.

 

Acute episodes of sinusitis can also result from fungal invasion. These infections are typically seen in patients with diabetes or other immune deficiencies (such as AIDS or transplant patients on immunosuppressive anti-rejection medications) and can be life threatening. In type I diabetics, ketoacidosis can be associated with sinusitis due to mucormycosis.

Chemical irritation can also trigger sinusitis, commonly from cigarette smoke and chlorine fumes. Rarely, it may be caused by a tooth infection.

 

Chronic

Chronic sinusitis, by definition, lasts longer than three months and can be caused by many different diseases that share chronic inflammation of the sinuses as a common symptom. Symptoms of chronic sinusitis may include any combination of the following: nasal congestion, facial pain, headache, night-time coughing, an increase in previously minor or controlled asthma symptoms, general malaise, thick green or yellow discharge, feeling of facial ‘fullness’ or ‘tightness’ that may worsen when bending over, dizziness, aching teeth, and/or halitosis. Each of these symptoms has multiple other possible causes, which should be considered and investigated as well. Unless complications occur, fever is not a feature of chronic sinusitis. Often chronic sinusitis can lead to anosmia, a reduced sense of smell. In a small number of cases, acute or chronic maxillary sinusitis is associated with a dental infection. Vertigo, lightheadedness, and blurred vision are not typical in chronic sinusitis and other causes should be investigated.

 

Chronic sinusitis cases are subdivided into cases with polyps and cases without polyps. When polyps are present, the condition is called chronic hyperplastic sinusitis; however, the causes are poorly understood and may include allergy, environmental factors such as dust or pollution, bacterial infection, or fungus (either allergic, infective, or reactive). Non-allergic factors, such as vasomotor rhinitis, can also cause chronic sinus problems. Abnormally narrow sinus passages, such as having a deviated septum, can impede drainage from the sinus cavities and be a contributing factor.

 

Chronic rhinosinusitis represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection. The medical management of chronic rhinosinusitis is now focused upon controlling the inflammation that predisposes patients to obstruction, reducing the incidence of infections. However, all forms of chronic rhinosinusitis are associated with impaired sinus drainage and secondary bacterial infections. Most individuals require initial antibiotics to clear any infection and intermittently afterwards to treat acute exacerbations of chronic rhinosinusitis.

A combination of anaerobic and aerobic bacteria, are detected in conjunction with chronic sinusitis. Also isolated are Staphylococcus aureus (including methicilin resistant S.aureus ) and coagulase-negative Staphylococci and Gram negative enteric organisms can be isolated. Typically antibiotic treatment provides only a temporary reduction in inflammation, although hyperresponsiveness of the immune system to bacteria has been proposed as a possible cause of sinusitis with polyps (chronic hyperplastic sinusitis).

Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. The presence of eosinophils in the mucous lining of the nose and paranasal sinuses has been demonstrated for many patients, and this has been termed eosinophilic mucin rhinosinusitis (EMRS). Cases of EMRS may be related to an allergic response, but allergy is not often documented, resulting in further subcategorization into allergic and non-allergic EMRS.

A more recent, and still debated, development in chronic sinusitis is the role that fungus plays in this disease. Fungus can be found in the nasal cavities and sinuses of most patients with sinusitis, but can also be found in healthy people as well. It remains unclear if fungus is a definite factor in the development of chronic sinusitis and if it is, what the difference may be between those who develop the disease and those who remain free of symptoms. Trials of antifungal treatments have had mixed results.

 

By location

There are several paired paranasal sinuses, including the frontal, ethmoid, maxillary and sphenoid sinuses. The ethmoid sinuses is further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the basal lamella of the middle turbinate. In addition to the severity of disease, discussed below, sinusitis can be classified by the sinus cavity which it affects:

Maxillary – can cause pain or pressure in the maxillary (cheek) area (e.g., toothache, headache) (J01.0/J32.0)

Frontal – can cause pain or pressure in the frontal sinus cavity (located above eyes), headache (J01.1/J32.1)

Ethmoid – can cause pain or pressure pain between/behind the eyes and headaches (J01.2/J32.2)

Sphenoid – can cause pain or pressure behind the eyes, but often refers to the vertex, or top of the head

 

Recent theories of sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the respiratory tract (i.e., the “one airway” theory) and is often linked to asthma. All forms of sinusitis may either result in, or be a part of, a generalized inflammation of the airway, so other airway symptoms, such as cough, may be associated with it.

 

Signs and symptoms

Headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is typically localized to the involved sinus and may worsen when the affected person bends over or when lying down. Pain often starts on one side of the head and progresses to both sides. Acute and chronic sinusitis may be accompanied by thick nasal discharge that is usually green in color and may contain pus (purulent) and/or blood. Often a localized headache or toothache is present, and it is these symptoms that distinguish a sinus-related headache from other types of headaches, such as tension and migraine headaches. Infection of the eye socket is possible, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is the infection of the bones (osteomyelitis) of the forehead and other facial bones – Pott’s puffy tumor.

 

Sinus infections can also cause inner ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, “a pressurized or heavy head”, or vibrating sensations in the head. Other symptoms of sinusitis include bad breath and Post-nasal drip.

 

Recent studies suggest that up to 90% of “sinus headaches” are actually migraines. The confusion occurs in part because migraine involves activation of the trigeminal nerves, which innervate both the sinus region and the meninges surrounding the brain. As a result, it is difficult to accurately determine the site from which the pain originates. Additionally, nasal congestion can be a common result of migraine headaches, due to the autonomic nerve stimulation that can also cause tearing (lacrimation) and a runny nose (rhinorrhea).[citation needed] A study found that patients with “sinus headaches” responded to triptan migraine medications, but stated dissatisfaction with their treatment when they are treated with decongestants or antibiotics. People with migraines do not typically have the thick nasal discharge that is a common symptom of a sinus infection.

 

The close proximity of the brain to the sinuses makes the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of anaerobic bacteria through the bones or blood vessels. Abscesses, meningitis, and other life-threatening conditions may result. In extreme cases the patient may experience mild personality changes, headache, altered consciousness, visual problems, seizures, coma, and possibly death.

 

Sinus infection can spread through anastomosing veins or by direct extension to close structures. Orbital complications were categorized by Chandler et al. into five stages according to their severity (see table). Contiguous spread to the orbit may result in periorbital cellulitis, subperiosteal abscess, orbital cellulitis, and abscess. Orbital cellulitis can complicate acute ethmoiditis if anterior and posterior ethmoidal veins thrombophlebitis enables the spread of the infection to the lateral or orbital side of the ethmoid labyrinth. Sinusitis may extend to the central nervous system, where it may cause cavernous sinus thrombosis, retrograde meningitis, and epidural, subdural, and brain abscesses. Orbital symptoms frequently precede intracranial spread of the infection . Other complications include sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis. Osteomyelitis of the frontal bone often originates from a spreading thrombo-phlebitis. A periostitis of the frontal sinus causes an osteitis and a periostitis of the outer membrane, which produces a tender, puffy swelling of the forehead.

 

The diagnosis of these complication can be assisted by noting local tenderness and dull pain, and can be confirmed by CT and nuclear isotope scanning. The most common microbial causes are anaerobic bacteria and S. aureus. Treatment includes performing surgical drainage and administration of antimicrobial therapy. Surgical debridement is rarely required after an extended course of parenteral antimicrobial therapy. Antibiotics should be administered for at least 6 weeks. Continuous monitoring of patients for possible intracranial complication is advised.

Causes

Factors which may predispose someone to developing sinusitis include: allergies; structural abnormalities, such as a deviated septum, small sinus ostia or a concha bullosa; nasal polyps; carrying the cystic fibrosis gene, though research is still tentative; and prior bouts of sinusitis, because each instance may result in increased inflammation of the nasal or sinus mucosa and potentially further narrow the nasal passageways.

Both smoking and second hand smoke are associated with chronic rhinosinusitis.

Maxillary sinusitis may also be of dental origin and constitutes a significant percentage, given the close proximity of the teeth and the sinus floor. Complementary tests based on conventional radiology techniques and modern technology are needed. Their indication is based on the clinical context.

Chronic sinusitis can also be caused indirectly through a common but slight abnormality within the auditory or Eustachian tube, which is connected to the sinus cavities and the throat. This tube is usually almost level with the eye sockets but when this sometimes hereditary abnormality is present, it is below this level and sometimes level with the vestibule or nasal entrance. This almost always causes some sort of blockage within the sinus cavities ending in infection and usually resulting in chronic sinusitis.

 

Pathophysiology

It has been hypothesized that biofilm bacterial infections may account for many cases of antibiotic-refractory chronic sinusitis. Biofilms are complex aggregates of extracellular matrix and inter-dependent microorganisms from multiple species, many of which may be difficult or impossible to isolate using standard clinical laboratory techniques. Bacteria found in biofilms have their antibiotic resistance increased up to 1000 times when compared to free-living bacteria of the same species. A recent study found that biofilms were present on the mucosa of 75% of patients undergoing surgery for chronic sinusitis.

 

Diagnosis

Acute

Bacterial and viral acute sinusitis are difficult to distinguish. However, if symptoms last less than 10 days, it is generally considered viral sinusitis. When symptoms last more than 10 days, it is considered bacterial sinusitis. At this point 30% to 50% of cases are bacterial.[citatioeeded] Imaging by either X-ray, CT or MRI is generally not recommended unless complications develop.

 

Chronic

For sinusitis lasting more than 12 weeks a CT scan is recommended. Nasal endoscopy, and clinical symptoms are also used to make a positive diagnosis. A tissue sample for histology and cultures can also be collected and tested. Allergic fungal sinusitis (AFS) is often seen in people with asthma and nasal polyps. In rare cases, sinusoscopy may be made.

Nasal endoscopy involves inserting a flexible fiber-optic tube with a light and camera at its tip into the nose to examine the nasal passages and sinuses. This is generally a completely painless (although uncomfortable) procedure which takes between five to ten minutes to complete.

 

Treatment

 

Conservative

Nasal irrigation may help with symptoms of chronic sinusitis. Decongestant nasal sprays containing for example oxymetazoline may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause rebound sinusitis. Other recommendations include applying a warm, moist cloth to the affected areas several times a day; drinking sufficient fluids in order to thin the mucus; and inhaling low temperature steam two to four times a day.

 

Antibiotics

The vast majority of cases of sinusitis are caused by viruses and will therefore resolve without antibiotics. However, if symptoms do not resolve within 10 days, amoxicillin is a reasonable antibiotic to use first for treatment with amoxicillin/clavulanate being indicated when the person’s symptoms do not improve after 7 days on amoxicillin alone. Antibiotics are specifically not recommended in those with mild / moderate disease during the first week of infection due to risk of adverse effects, antibiotic resistance, and cost.

Fluoroquinolones, and a newer macrolide antibiotic such as clarithromycin or a tetracycline like doxycycline, are used in those who have severe allergies to penicillins. Because of increasing resistance to amoxicillin the 2012 guideline of the Infectious Diseases Society of America recommends amoxicillin-clavulanate as the initial treatment of choice for bacterial sinusitis. The guidelines also recommend against other commonly used antibiotics, including azithromycin, clarithromycin and trimethoprim/sulfamethoxazole, because of growing drug resistance.

A short-course (3–7 days) of antibiotics seems to be just as effective as the typical longer-course (10–14 days) of antibiotics for those with clinically diagnosed acute-bacterial sinusitis without any other severe disease or complicating factors. The IDSA guideline suggest five to seven days of antibiotics is long enough to treat a bacterial infection without encouraging resistance. The guideline still do recommend children receive antibiotic treatment for 10 days to two weeks.

 

Corticosteroids

For unconfirmed acute sinusitis, intranasal corticosteroids have not been found to be better than placebo either alone or in combination with antibiotics. For cases confirmed by radiology or nasal endoscopy, treatment with corticosteroids alone or in combination with antibiotics is supported. The benefit however is small.

 

There is only limited evidence to support short treatment with oral corticosteroids for chronic rhinosinusitis with nasal polyps.

 

Surgery

For chronic or recurring sinusitis, referral to an otolaryngologist specialist may be indicated, and treatment options may include nasal surgery. Surgery should only be considered for those patients who do not experience sufficient relief from optimal medication.

Maxilliary antral washout involves puncturing the sinus and flushing with saline to clear the mucus. A 1996 study of patients with chronic sinusitis found that washout confers no additional benefits over antiobiotics alone.

A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal endoscopic ones. The benefit of FESS is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications.

Another recently developed treatment is balloon sinuplasty. This method, similar to balloon angioplasty used to “unclog” arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. The utility of this treatment for sinus disease is still under debate but appears promising.

For persistent symptoms and disease in patients who have failed medical and the functional endoscopic approaches, older techniques can be used to address the inflammation of the maxillary sinus, such as the Caldwell-Luc radical antrostomy. This surgery involves an incision in the upper gum, opening in the anterior wall of the antrum, removal of the entire diseased maxillary sinus mucosa and drainage is allowed into inferior or middle meatus by creating a large window in the lateral nasal wall.

 

Lower respiratory tract infectionThe most common lower respiratory tract infection is pneumonia, a lung infection. Pneumonia is usually caused by bacteria, particularly Streptococcus pneumoniae in Western countries. Worldwide, tuberculosis is an important cause of pneumonia. Other pathogens such as viruses and fungi can cause pneumonia for example severe acute respiratory syndrome and pneumocystis pneumonia. A pneumonia may develop complications such as a lung abscess, a round cavity in the lung caused by the infection, or may spread to the pleural cavity.

 

Malignant tumors

Malignant tumors of the respiratory system, particularly primary carcinomas of the lung, are a major health problem responsible for 15% of all cancer diagnoses and 29% of all cancer deaths.[3] The majority of respiratory system cancers are attributable to smoking tobacco.

The major histological types of respiratory system cancer are:

·        Small cell lung cancer

·        Non-small cell lung cancer

·        Adenocarcinoma of the lung

·        Squamous cell carcinoma of the lung

·        Large cell lung carcinoma

·        Other lung cancers (carcinoid, Kaposi’s sarcoma, melanoma)

·        Lymphoma

·        Head and neck cancer

·        Pleural Mesothelioma, almost always caused by exposure to asbestos dust.

 

In addition, since many cancers spread via the bloodstream and the entire cardiac output passes through the lungs, it is common for cancer metastases to occur within the lung. Breast cancer may invade directly through local spread, and through lymph node metastases. After metastasis to the liver, colon cancer frequently metastasizes to the lung. Prostate cancer, germ cell cancer and renal cell carcinoma may also metastasize to the lung.

 

Treatment of respiratory system cancer depends on the type of cancer. Surgical removal of part of a lung (lobectomy, segmentectomy, or wedge resection) or of an entire lung pneumonectomy), along with chemotherapy and radiotherapy, are all used. The chance of surviving lung cancer depends on the cancer stage at the time the cancer is diagnosed, and to some extent on the histology, and is only about 14-17% overall. In the case of metastases to the lung, treatment can occasionally be curative but only in certain, rare circumstances.

 

Benign tumors

Benign tumors are relatively rare causes of respiratory disease. Examples of benign tumors are:

·        Pulmonary hamartoma

·        Congenital malformations such as pulmonary sequestration and congenital cystic adenomatoid malformation (CCAM).

 

Pleural cavity diseases

A collection of fluid in the pleural cavity is known as a pleural effusion. This may be due to fluid shifting from the bloodstream into the pleural cavity due to conditions such as congestive heart failure and cirrhosis. It may also be due to inflammation of the pleura itself as can occur with infection, pulmonary embolus, tuberculosis, mesothelioma and other conditions.

A pneumothorax is a hole in the pleura covering the lung allowing air in the lung to escape into the pleural cavity. The affected lung “collapses” like a deflated balloon. A tension pneumothorax is a particularly severe form of this condition where the air in the pleural cavity cannot escape, so the pneumothorax keeps getting bigger until it compresses the heart and blood vessels, leading to a life threatening situation.

 

Pulmonary vascular diseases

Pulmonary vascular diseases are conditions that affect the pulmonary circulation. Examples are:

Pulmonary embolism, a blood clot that forms in a vein, breaks free, travels through the heart and lodges in the lungs (thromboembolism). Large pulmonary emboli are fatal, causing sudden death. A number of other substances can also embolise (travel through the blood stream) to the lungs but they are much more rare: fat embolism (particularly after bony injury), amniotic fluid embolism (with complications of labour and delivery), air embolism (iatrogenic – caused by invasive medical procedures).

Pulmonary arterial hypertension, elevated pressure in the pulmonary arteries. Most commonly it is idiopathic (i.e. of unknown cause) but it can be due to the effects of another disease, particularly COPD. This can lead to strain on the right side of the heart, a condition known as cor pulmonale.

Pulmonary edema, leakage of fluid from capillaries of the lung into the alveoli (or air spaces). It is usually due to congestive heart failure.

Pulmonary hemorrhage, inflammation and damage to capillaries in the lung resulting in blood leaking into the alveoli. This may cause blood to be coughed up. Pulmonary hemorrhage can be due to auto-immune disorders such as Wegener’s Granulomatosis and Goodpasture’s syndrome.

 

Neonatal diseases

Pulmonary diseases may also impact newborns, such as pulmonary hyperplasia.

Diagnosis

Respiratory diseases may be investigated by performing one or more of the following tests:

·        Chest x-ray

·        Pulmonary function test

·        Computed tomography scan

·        Culture of microorganisms from secretions such as sputum

·        Bronchoscopy

·        Biopsy of the lung or pleura

·        Ventilation – perfusion scan

·        blood investigation

·        Ultrasound scanning can be useful to detect fluid such as pleural effusion

Natural Healing Solutions

 

 Conscious breathing, which utilizes deep breathing, is excellent for helping manage respiratory illnesses. Deep breathing exercises will help to strengthen and revivify the lungs. It will also help to dissolve hardened mucus in the lungs, sinus cavities and nostrils. Conscious breathing exercises or yoga is highly ideal for overall respiratory health.

 

 There are a plethora of potent and effective herbs that are great for the lungs and the respiratory system. These are pulmonary, expectorant and demulcent herbs and include:

·        Mullein (leaf/flowers)

·        Lobelia

·        Fenugreek

·        Coltsfoot

·        Boneset

·        Comfrey

·        Marshmallow (Althea)

·        Licorice

·        Pleurisy

·        Slippery Elm bark

·        White Pine Bark

·        Hyssop

·        Eucalyptus

·        Yerba Santa

·        Elecampane

·        Ground Ivy, and

·        Horehound

 Essential oils are also effective for respiratory health and healing. Oils such as:

·        Eucalyptus

·        Pine Bark

·        Inula

·        Cajeput

·        Hyssop

·        Wintergreen

·        Peppermint

·        Spruce

·        White camphor, and

·        Spearmint

 These essential oils can be added to a diffuser or bath water. Inhaling the vaporized molecules of these oils in the air or hot water steam of a bath will dissolve hardened mucus, opeasal passages, and clear sinus and lung congestion.

 

 Some of these oils such as Eucalyptus and Peppermint can be rubbed in to the chest area (on top of a carrier oil) before bed which will greatly help to do the things mentioned above.

 

 Crystals such as Angelite, Pink Tourmaline, Aventurine, Blue Chalcedony, Emerald, Iron Pyrite, Amethyst, Peridot, Chrysocolla, Pietersite, Rose Quartz, and Prehnite help in healing all lung disorders. They can be placed directly on the Fourth Chakra (located at the thymus gland) situated between the chest area or added to drinking water.

 

 Any country area that is laced with trees is great for healing respiratory problems like asthma and bronchitis. Remember, trees help us by converting carbon monoxide into oxygen.

 

 Arizona is one of the best places to go to help eradicate respiratory illnesses and challenges. Arizona contains many pine trees. Pine trees (as well as Eucalyptus trees) can help improve breathing conditions.

 

Dietary Intervention

 

 A high alkaline diet consisting of plenty of raw and organic fruits and vegetables can improve respiratory problems. Green foods are high in alkalinity and also contain chlorophyll and will help to dissolve mucus throughout the body in general and the lungs and respiratory tract, in particular.

 

 Drinking alkaline water can also help in eradicating respiratory diseases. Alkaline water is highly alkaline and therefore counteracts acidity. This water greatly helps to dissolve mucus so that mucus can be expectorated from the body. It is very important to drink a lot of water period, but especially so if you suffer from bronchitis or asthma.

 

 Poor diet is the greatest physical cause of lungs and respiratory diseases. The worst offenders are:

·        Dairy

·        Meat

·        Refined, processed grains

·        Starches

·        Acidic beverages

 Dairy is greatly mucus forming. People battling respiratory illnesses should remove all dairy products from their diet. Dairy breaks down into LACTIC ACID, which creates mucus, especially in the lungs.

 

 Meat breaks down into URIC ACID, which creates mucus. All meats should be eliminated from the diet if you want to regulate respiratory issues.

 

 Refined, processed grains convert into starch and also break down in to mucus and saturate in the lungs.

 

 Starches too, the refined and processed ones, also break down into acid, CARBONIC ACID, and cause excess mucus production that may saturate in the lungs and other parts of the respiratory tract.

 

VIDEO

 

Diseases of the respiratory system

 

 REFERENCES:

  1. Maton, Anthea; Jean, Hopkins Susan, Johnson Charles William, McLaughlin Maryanna Quon Warner David, LaHart Wright, Jill (2010). Human Biology and Health. Englewood Cliffs: Prentice Hall. pp. 108–118. ISBN 0134234359.

  2. Wier LM, Hao Y, Owens P, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. Agency for Healthcare Research and Quality, Rockville, MD. May 2013.

  3. Michelle, Julia. “How Do Babies Breathe in the Womb?“. Retrieved 7 March 2011.

 

 

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