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ARI management training

TOPIC 2. UNITED AIRWAY CONCEPT

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Contents
Respiratory physiology Medical problem common pattern United airway concept Rhinosinusitis Pharyngitis Rhinobronchitis

Respiratory physiology
External respiration

respiratory center neuromuscular system

blood

Internal respiration

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Involving organ system

The main Respiratory system Cardiovascular system The supporting Resp center Neuromuscular Blood, hematology

respiration

External

Respiratory system function

ventilation

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Respiration

Steps of respiration 1. Ventilation or gas exchange

between atmosphere & alveoli

2. Diffusion of O2 & CO2

between alveoli & the blood

3. Circulation (transport) of
O2 & CO2 between the lungs and the tissue

4. Exchange of O2 & CO2

between the blood and the tissues
Sherwood L, The Respiratory System, 2004

CRUCIAL POINT!

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External respiration - 1
FLOW in and out the respiratory tract

V - a VOLUME of air

L/mnt

alveoli & the blood crucial point

Diffusion of O2 & CO2 between

Q - a VOLUME of blood
FLOW through alveolar capillary

L/mnt

Sherwood L, The Respiratory System, 2004

External respiration - 2
ventilation

to take place, gas exchange (diffusion) from air to blood in alveolar capillary bed need an optimal ratio between VENTILATION & PERFUSION

V/Q = 4/5
perfusion

Q Q V

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Dyspnea pathophysiology
V/Q = 4/5
CRUCIAL POINT!

DYSPNEA
Resp system try to cope by increasing resp effort

Clinically

V/Q 4/5

V/Q mis-match, NOT optimal diffusion

Common pattern

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Common medical terms

Sign & symptoms Etiology Pathogenesis Pathophysiology Pathology Diagnosis Treatment Prognosis What is the definition of each terms? Is there any relation among each terms? Can we develop a common pattern?

Medical problem common pattern

Diagnosis & Treatment
symptomatology pathophysiology pathology pathogenesis adaptive responses insults

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Medical problem common pattern

Diagnosis & Treatment
symptomatology pathophysiology pathology pathogenesis adaptive responses insults

Insults
Medicine/Medical

a. an injury or trauma b. an agent that inflicts this

to affect offensively or damagingly

Any factor affecting the normal growth, development, process, or function of the cell, tissue, organ, system, or individu - DBS

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Medical problem common pattern

Diagnosis & Treatment
The ability to survive symptomatology by eliminate, terminate, defend, avoid, or adjust pathophysiology to anykind of insults (fight or flight, terjang atau terbang) pathology

pathogenesis

adaptive responses insults

Integumentary system (skin) Respiratory defense mechns Urinary def mechn Gastro-intestinal defense mechns Immune system Neuro-musculoskeletal system

Adaptive responses

Endocrine system Autonomic Nerve system

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Medical problem common pattern

Diagnosis & Treatment
symptomatology pathophysiology pathology pathogenesis adaptive responses insults

pathology
Gross pathology Histo-pathology Clinical pathology

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Levels of body organization

Chemical level Cellular level Tissue level Organ level Body system level Organism level
Clinical pathology Histo-pathology Gross pathology

What is INFLAMMATION?
symptom organism body system organ tissue cellular biochemical

pathophys

pathology adaptive response

Ongoing pathology

symptomatology

Insult

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The insults
Infection Allergy Mechanical trauma Injury: thermal, electrical, chemical, irradiation

symptom

pathophys

pathology adaptive response

Autoimmune Cancer
...

Insult

Acute inflammatory response

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4 cardinal signs Celsus, circa 6AD

United airway concept

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Historical separation of respiratory tract

(rhinitis) Upper resp tract Lower resp tract Otolaryngologist Pulmonologist

Sneeze

Wheeze
(asthma)

Separate management
Otolaryngologist Pulmonologist

ARIA EPOS

GINA GOLD

Anatomy based disease management

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Two concepts

The Old-one Separate Different entity

The New-one United One entity

United airway concept

Hypothesis: upper & lower airway disease manifestations of a single inflammatory process within the respiratory system Systemic links between upper & lower airways Same structure & function: mucosa, mucociliary system Both act as a transport system for air Both provide defense against inhaled foreign substance

Acute &/ chronic

The nose, part of lung that we can touch
Allergy Clin Immunol 2001; 108 (5 suppl):S147-334 J Manag Care Pharm 2004; 10:310-7 Med J Aust 2006; 185:565-71

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Synonims
Unified airways United airway disease Integrated airway disease Combined allergic respiratory syndrome Combined allergic rhinitis and asthma Chronic respiratory inflammation syndr (CRIS) (Allergic) rhino-bronchitis Med J Aust 2006; 185:565-71 Thorax 2000; 55 (Suppl 2):S26-7 One airway, one disease J Managed Care Pharm 2004; 10:310-7 J Allergy Clin Immunol 2001; 108 (5 suppl):S147-334 Rhino-sino-bronchitis
Combined asthma & rhinitis treatment, EPC, 2006

External insults
Pollutant Food Allergen Iritant Virus

Respiratory inflammation

Bacteria

Allergy Anatomical defect

Immunodeficiency Functional defect

Internal insults

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Unity, similarity, integration

Anatomy & physiology Common insults United defense mechanism Naso-bronchial interaction United inflammatory response Common pathology Similar pathophysiology & symptomatology Epidemiology of comorbidity United airway disease Integrated management symptom pathophys

pathology adaptive response

Insult

Respiratory inflammation syndrome

Rhinitis/CC (infection) Rhinitis (allergic) Allergic conjtvtis? Nasal polyp COPD Rhinosinusitis Asthma, bronchitis

Otitis media OSAS

UAD, Rhino-sino-bronchitis

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Selesma

Flu virus

Flu!
Rhino-sinusitis

Rhinovirus

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International guideline

Allergic rhinitis

Rhinosinusitis

Cold sinusitis = rhino-sinusitis

Pediatrics. 2003 May;111(5 Pt 1):e586-9.

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Epidemiology of ARS

Rhinology, EPOS 2012

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Ped acute rhinosinusitis (ARS)

Definition of ARS Sudden onset of >2 of:
o Discoloured nasal discharge o Nasal blockage / obstruction /congestion o Cough

Lasting <12 weeks If recurrent, symptom free intervals (+)

Rhinology, EPOS 2012

Diagnosis of ped ARS

The clinical diagnosis of ARS in children is challenging, overlap of symptoms with viral AURI, allergic rhinitis The symptoms are often subtle & the history is limited to the subjective observations by the parent Challenges related to physical examination Clinicians should rely on history and or imaging studies for appropriate diagnosis.
Rhinology, EPOS 2012

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Symptomatology of ped ARS

fever (50-60%), rhinorrhoea (71-80%), Rhinology. 2011 Sep;49(3):264-71. cough (50-80%), and pain (29-33%) purulent nasal drainage >7 days, and abnormal in the max sinuses on Waters, Int J Pediatr ORL. 2012 Jan;76(1):70-5. postnasal drip, nasal obstruction, and cough prolonged symptom duration, purulent rhinorrhoea, and nasal congestion Pediatrics. 2009 Feb;123(2):e193-8

Diff diagnosis of ped ARS

Rhinopharyngitis Allergic rhinitis Intranasal corpus alienum Unilateral choanal stenosis Adenoiditis Gastroesophageal reflux Nasal polyposis Immune deficiency ...

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Post nasal drip & cobblestone

Classification of ped ARS

C cold viral ARS: duration of symptoms <10 dys Post-viral ARS:
o Increase of symptoms after 5 days o Persistent symptoms after 10 days

Suggestive of acute bacterial RS, >3 of:

o o o o o o Discloured discharged, unilateral predominance Purulent secretion in cavum nasi Severe local pain, unilateral predominance Fever >38C ESR/CRP Double sickening
Rhinology, EPOS 2012

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Medical treatment of ARS

Most episodes of ARS are self-limited and will resolve spontaneously

Antibiotics, the most frequently used therapeutic agents Intranasal steroid Nasal irrigation Antihistamine Decongestant, oral or intrnasal Erdosteine
Rhinology, EPOS 2012

Uncomplicated viral CC / ARS

Pediatrics 2013;132:e262e280

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Daily practice
Upper resp symptoms

Signs of infection: source, fever, myalgia,

Common cold
Rhino-sinusitis acute, viral
Rhinology; EPOS 2012 IDSA 2012 gln Acute rhinosinusitis Pediatrics 2013;132:e262e280

Allergic rhinitis (non-infection) severe onset ie, >39C >5 days, worsening >10 days, persistence Rhino-sinusitis acute, bacterial

AB treatment of ARS
Antibiotics, Amoxicillin (+clavulanate) 40-80 mg/kgBW/day Cephalosporin Macrolide: clarithromycin, azitrhomycin
Antibiotic therapy seems to accelerate resolution, but whether an acceleration of improvement is worth the increased risk of antimicrobial resistance remains to be determined.
Rhinology, EPOS 2012

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Medical treatment of ARS

Intranasal steroid (INS)
o Mometasone furoate o Fluticasone furoate

Evidence for INS as additional treatment Evidence, high dose of INS (twice than AR dose) might be effective as monotherapy for ARS
Intranasal steroids might have a beneficial ancillary role in the treatment of ARS
Rhinology, EPOS 2012

Rhinology, EPOS 2007

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Rhinology, EPOS 2012

Pharyngitis (sore throat)

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Epidemiology
Children experience >5 ARIs / year and an average of one streptococcal infection every 4 yrs Mostly caused by respiratory viruses The most common viruses: rhinovirus & adenovirus The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes) Pharyngitis occurs with much greater frequency in the pediatric population. 15-30% of pharyngitis cases among school-aged children in the cooler months are due to GAS. 10% of adult cases of pharyngitis are due to GAS.
emedicine.medscape.com/article/764304-overview

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Epidemiology & clin features

Viral phrayngitis Conjunctivitis Coryza Cough Diarrhea Hoarseness Ulcerative stomatitis Viral exanthema
IDSA 2012 guidelines

Streptococ pharyngitis Sudden onset Age 515 years Fever Headache Nausea, vomiting, abd pain Tonsillopharyngeal inflammation Patchy exudates Palatal petechiae Anterior cervical adenitis

Streptococcal pharyngitis

patchy exudates

palatal ptechiae

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IDSA 2012 guidelines

IDSA 2012 recommendations D/.

Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers; strong, high). Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis Anti-streptococcal antibody titers are not recommended in the routine diagnosis

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IDSA 2012 recommendations T/.

Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration (usually 10 days). Penicillin or amoxicillin is the recommended drug of choice (strong, high) in penicillin-allergic individuals should include a 1st gen cephalosporin for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days (strong, moderate).

IDSA 2012 guidelines

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Rhino-bronchitis

Acute (rhino)bronchitis
a clinical syndrome produced by inflammation of the trachea, bronchi, and bronchioles. in children, acute bronchitis usually occurs in association with viral resp infection / C. cold acute bronchitis is rarely a primary bacterial infection in otherwise healthy children. self-limited, with complete healing and full return to function typically seen within 10-14 days following symptom onset
emedicine.medscape.com/article/1001332-overview

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Epidemiology
The incidence of acute bronchitis is equal in males and females prevalent throughout the world one of the top 5 reasons for childhood physician visits in countries that track such data incidence of bronchitis in British schoolchildren is reported to be 20.7% acute (typically wheezy) bronchitis occurs most commonly in children <2 years, with another peak seen in children aged 9-15 years
emedicine.medscape.com/article/1001332-overview

History, symptomatology
begins as a respiratory infection that manifests as the common cold. symptoms often include coryza, malaise, chills, slight fever, sore throat, back & muscle pain. cough is usually accompanied by a nasal discharge purulent nasal discharge is common with viral respiratory pathogens and does not imply bacterial infection rattling sound in the chest due to excessive mucous production
emedicine.medscape.com/article/1001332-overview

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Pathophysiology
upper respiratory tract spread to lower respiratory tract (United airway concept) the inflammatory response of the mucous membranes within the lungs bronchial passages Airway inflammation: oedema, mucous secretion, obstruction
emedicine.medscape.com/article/1001332-overview

Pathology
Goblet celss Squamous metaplasia Mucous glands Mucous in lumen

emedicine.medscape.com/article/1001332-overview

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Insults, etiology
Acute bronchitis is generally caused by acute resp infections; +90% are viral, 10% bacterial
o Adenovirus o Influenza o Parainfluenza o Respiratory syncytial virus o Rhinovirus o Human bocavirus o Coxsackievirus o Herpes simplex virus

emedicine.medscape.com/article/1001332-overview

Diagnosis
Clinical !!! natural history: preceded by common cold, rhinopharyngitis acute, not recurrent if recurrent: asthma !!! cough initially is dry & may be harsh or raspy sounding, then loosens & becomes productive lower resp sign: crackles, ronchi, wheezing of large airway Chest films generally appear normal in patients with uncomplicated bronchitis not needed

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Differential diagnoses
Aspiration syndrome Asthma Bacterial tracheitis Bronchiectasis Bronchiolitis GERD Inhalation injury Passive smoking Pneumonia Rhinosinusitis
emedicine.medscape.com/article/1001332-overview

Prognosis
Acute bronchitis is almost always a self-limited process in the otherwise healthy child it frequently results in absenteeism from school

emedicine.medscape.com/article/1001332-overview

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Treatment
Medical therapy generally targets symptoms and includes use of analgesics and antipyretics. Antitussives & expectorants are often prescribed but have not been demonstrated to be useful In healthy individuals, antibiotics has no benefit in relieving symptoms or improving the natural history Placebo-controlled studies using doxycycline, erythromycin, and trimethoprim-sulfamethoxazole have failed to show significant benefit in patients with acute bronchitis. Preliminary studies suggest a possible role for Pelargonium sidoides roots, in the treatment of pediatric patients (1-18 yrs) with acute bronchitis
emedicine.medscape.com/article/1001332-overview

Scheme
Rhinosinusitis ABRS Croup

Upper resp & infection symptoms

Common cold Rhinitis Nasopharyngitis Rhinopharyngitis Selesma

Pharyngitis GAS

Rhinobronchitis
Bronchiolitis

Need AB

Pneumonia

Lower resp symptomatology

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THANK YOU

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