Unit - I: Upper Airway Infection

Upper airway infections —

Common cold, sinusitis, ethinitis, rhinitis, pharyngitis, tonsilitis and adenoiditis, peritonsilar abscess, laryngitis

Common cold

Common cold (viral upper respiratory tract infection, acute viral nasopharyngitis, acute viral rhinopharyngitis, or acute coryza) is a contagious, viral infectious disease of the upper respiratory  system, primarily caused by rhinovirus, coronaviruses or picornaviruses.

Colds last on average for 1 week. Mild cold may last only 2 or 3 days while severe colds may last for upto 2 weeks.

Etiology

• More than 200 different types of viruses are known to cause the common cold.

• Cold are a frequent and recurring problems.

• Cold is usually spread by direct hand to hand contact with infected secretion or from contaminated surface.

• A cold virus can live on objects such as pen, books, telephone, computer keyboard, and coffee cup for several hours and can be acquired from contact with these objects.

Pathophysiology

Clinical Manifestations

• Nasal stuffiness or drainage

• Nasal congestion

• Sore and scratchy throat

• Sneezing

• Hoarseness

• Cough

• Sometimes accompanied by pink eye

• Muscle aches and muscle weakness

• Fatigue

• Malaise

• Headache

• Mild fever

• Uncontrollable shivering

• Loss of appetite

• Rarely extreme exhaustion

• Symptoms of cold usually resolve after 1 week and may last up to 3 weeks.

Diagnosis

• history

• physical examination. 

• the health care practitioner (physician or mid-level practitioner) may perform a throat culture or blood test to rule out a secondary bacterial infection.

• An allergist can perform tests to determine if  the persistent cold-like symptoms are attributable to an  allergic reaction.

• Environmental irritants such as smoke, pollen, pollutants, pesticides, and perfumes may also trigger allergic rhinitis.

• Allergies are usually more persistent than the common cold. Also, some people get a runny nose when they go outside in winter and breathe cold air. This type of runny nose, called vasomotor rhinitis, is not a symptom of a cold.

Management

There is no cure for common cold. Most of the cold are due to viruses and are self limiting, so treatment with antibiotics are generally not required. Home treatment is directed at alleviating the symptoms and allowing this self limiting illness to run its course.

Supportive measures include:

• rest and drinking plenty of fluids

• Over-the-counter medications such as throat lozenges, throat spray, cough drops & cough syrup may be beneficial.

• Decongestants such as pseudoephedrine/antihistamines may be used for nasal symptom.

• Saline spray & humidifier may also be beneficial.

• Acetaminophen & ibuprofen can help with fever, sore throat & body aches.

• Aspirin is contraindicated in children or teenage because it may lead to Reye's syndrome.

Some ways also can helps ease cold discomfort include:

• Saltwater drop in nostrils to relief congestions

• A cool-mist humidifier may be used to increase air moisture

• Petroleum jelly on the skin under the nose soothes rawness

• Hard candy or cough drops to relieve sore throat

• A warm bath or heating pad to soothe aches and pain

• Steam from a hot shower helps to breath more easily 

Prevention

• Steer clear of anyone who smokes or who has a cold. Virus particles can travel upto 12 feet in air when someone sneeze or cold cough.

• Avoid contact with people for the first 2 to 4 days of cold to prevent spreading of cold.

• Wash hands thoroughly & frequently with soap & alcohol based sanitizer, specially after blowing nose.

• Cover nose and mouth when sneeze or cough.

• Avoid sharing towels or utensils if family member has a cold (use disposable cup).

• Life style modifications such as smoking cessation & stress management

Complications

• Opportunistic coinfections or superinfections such as acute bronchitis, bronchiolitis, croup, pneumonia, sinusitis, otitis media, or strep throat.

• Cold may exacerbate asthma, emphysema & chronic bronchitis.

SINUSITIS

Sinusitis is inflammation of the sinuses (paranasal sinuses). The maxillary sinus is affected most often. Newer classification of sinusitis refer to as rhinosinusitis, takes into account only when the inflammation of sinuses occur occur with the inflammation of nose as well (rhinitis). Sinusitis can lead to serious complications, such as infection of the middle ear or brain.

Nursing Management

• Encourage the patient to take bed rest in propped up position with pillow.

• Instruct the patient about methods to promote drainage such as steam inhalation, increase fluid intake and apply local heat.

• Instruct the patient to apply moist heat by holding a warm, wet towel against face to open up the sinus passage.

• Advice to avoid bending bending, lifting heavy objects and stooping.

• Advice to consult doctor before using over the counter drug (OTC), which may worse symptoms or cause other problems.

• Advice the patient not to use nasal spray with decongestant for more than 3 days as it may  get worse when stop using the medication.

Prevention

• Keep the nose as moist as possible with frequent use of saline spray (salt).

• Avoid upper respiratory infection & minimize contact with people who have colds.

• Wash hand frequently with soap and water especially before meals.

• Use a humidifier if necessary to add moisture in air.

• Avoid very dry indoor environment.

• Avoid exposure to allergens such as molds, house dust mites & cockroaches.

• Avoid exposure to irritants such as cigarette, cigarette smoke or strong odors chemicical.

• Avoid long term swimming in pools treated in chlorine.

• Avoid water diving which forces water into the sinuses.

Rhinitis

Rhinitis is the inflammation and swelling of the mucous membrane of the nose, characterized by a runny nose and stuffiness and usually caused by a common cold or an allergy.

The primary symptom of rhinitis is nasal dripping. It is the acute and chronic inflammation of the mucous membrane of the nose due to virus, bacteria or irritants.

Classification

1. Allergic Rhinitis

2. Non-allergic Rhinitis

Allergic Rhinitis

Allergic rhinitis is the inflammation of the nasal passage, usually associated with watery nasal discharge and itching of the nose and the eyes. The symptoms occurs in the eye and nose usually after the exposure to dust, danger, and seasonal pollens in people that are allergies to these substances.

Incidence:

• Two - third of the patients have symptoms of allergic rhinitis before the age of 30 years, but onset can occur at any age.

• There is no sex predilection, although boys upto the age of 10 are twice likely than girls.

• There is strong genetic predisposition (1 parent -30% ; 2 parent - 50% to offsprings)

Etiology

• • Seasonal allergens - pollens, grass, ragweed pollens & molds.

• Occupational - exposure to allergen in work place.

• Dust mites, cockroaches, molds and animal dander are all year around allergens.

Pathophysiology

Clinical Manifestations

• Early phase symptoms

  • It occurs within minutes of exposure and symptoms include-

  • Sneezing, rhinorrhea (runny nose), post-nasal drip, nasal congestion, pruritic eye (itchy), ear, nose & throat and generalized fatigue.

• Late phase symptoms

  • Late phase occurs 4- 8 hours later and may include one or more of the symptoms-

  • Nasal congestion, fatigue, wheezing, tearing from eye, dark circle under the eye, sore throat, puffy lower eyelids & decrease sense of smell.

  • Other symptoms include - decrease sense of taste, plugged ear, sinus headache, post nasal drip.

  • Mental changes can include irritability, decrease attention span, worsen memory & slower thinking

Diagnostic Evaluation

• History collection - exposure to allergen, occupational exposure

• Physical Examination

• Allergy skin testing

  • After withdrawing antihistamine for at least 12- 72 hours, small amount of suspected allergens are applied to the skin with a needle prick or scratchy or deep into the skin. If allergy is present a hive (redness area) forms within 20 minutes. 

• Test for IgE -

  • Blood test for IgE production may be performed. One test is Radioallergosorbent Test (RAST), used to detect increase allergen specific IgE in response to particular allergens.

• Total blood eosinophil count

• Radiography (structural abnormality, sinusitis, adenoiditis)

• CT scanning (sinusitis, polyps, turbinate swelling, bone & septal abnormalities)

• MRI (malignancies of upper airway)

• Nasal cytology

Management

The management of allergic rhinitis consist of 3 major categories of treatment:

1. Environmental control measures & allergen avoidance

   • Avoidance of exposure to allergens

   • Maintaining allergen free environment by covering pillow & mattresses with plastic covers, substituting synthetic materials for animal products (wool & horse hair) and removing dust collection fixures like carpet, drapes & bed spread.

   • Air purifiers and dust filters may help. 

2. Immunotherapy

   • It involves gradually increasing doses of allergens to which person is allergic. This works by making the immune system less sensitive to that substance, probably by causing production of blocking antibody when substance is encounter in future. Immunotherapy  has a risk of anaphylaxis and warrant caution.

3. Pharmacological management - avoidance of allergen is the best treatment

   • Antihistamines - diphenhydramine, clemastine (1st gen), loratadine & cetrizine(2nd)

   • Nasal corticosteroid - beclomethasone, flunisolide, budesonide, fluticasone propionate & fluticasone furoate.

   • Nasal decongestants - oxymetazoline, xylometazoline & phenylephrine.

   • Oral decongestants - Pseudoephidrine.

   • Intranasal cromolyns - Cromolyn sodium (Nasalcrom)

   • Intranasal anticholinergic agents - Ipratropium bromide

   • Mucus thinning agents - Guaifenesin

Non -Allergic Rhinitis

Non - allergic rhinitis is a syndrome resulting from nasal inflammation that encompasses several distinct diagnoses. Non-allergic rhinitis is a medical condition of unknown cause, leading to symptoms very similar to allergic rhinitis.

• Approximately half of people suffering from allergies also have a non-allergic component to their symptoms.

• Unlike allergies (which can be a seasonal problem) symptoms of non-allergic rhinitis are typically year-round.

• Non-allergic rhinitis also tends to be more common as people age, whereas allergic rhinitis tends to affect children and young adults.

Non-allergic rhinitis has 7 basic sub classifications, as follows:

1. Infectious Rhinitis

   • The most widespread form of infectious rhinitis is the common cold.

   • It is usually caused by upper respiratory tract infection, usually viral origin. The most common organism involve are rhinovirus, coronavirus, adenovirus, parainfluenza virus, respiratory syncytial virus, and enterovirus.

   • Viral infection are generally self-limiting and resolve within 7-10 days.

   • Patient with infectious rhinitis typically present with clear-to-mucopurulent nasal discharge rather than watery rhinorrhea, accompanied by facial pain & pressure, altered sense of smell and postnasal drainage & cough.

   • Persistent facial pain and edema, purulent drainage and fever suggest a secondary bacterial infection.

2. Vasomotor Rhinitis

   • It is believed to results from disturbed regulations of parasympathetic and sympathetic system in which parasympathetic system dominates, resulting in vasodilation and edema.

   • Symptoms of vasomotor rhinitis are rhinorrhea, sneezing and congestion.

   • Cold air, strong odors, stress, inhaled irritants may exacerbate symptoms.

3. Occupational Rhinitis

   • Patient with occupational rhinitis have symptoms of rhinitis only on workplace.

   • These symptoms are usually due to inhaled irritants such as metal salts, animal dander, latex, wood dusts and chemicals and patient frequently present with concurrent occupational asthma.

   • The diagnosis is based on the history or nasal provocation or skin test.

   • Nasal corticosteroids or 2nd generation antihistamines are beneficial.

   • Avoidance is a preventive measure.  

4. Hormonal Rhinitis

   • Rhinitis occurring during the period of known hormonal imbalance.

   • Most common cause are pregnancy, menstruation, puberty, use of estrogen and known hypothyroidism.

   • Hormonal rhinitis in pregnancy usually continues during pregnancy & ceases after delivery.

   • In patient with hypothyroidism, edema increases in turbinates as a result of thyrotropic hormone release.

   • Nasal congestion & rhinorrhea are the chief manifestations of hormonal rhinitis.

5. Drug-induced Rhinitis

   • Several medications are implemented in rhinitis, including ACE inhibitors, reserpine, methyldopa, beta-blockers, chlorpromazine, gabapentin, penicillamine, aspirin, NSAID, inhaled cocaine, exogenous estrogens & oral contraceptives.

   • Rhinitis medicamentosa is related to overuse of decongestant spray such as oxymetazoline, with symptoms of severe nasal congestion and runny nose.

6. Gustatory Rhinitis

   • This occurs after eating, particularly hot and spicy foods or alcohol intake.

   • The end results in profuse watery rhinorrhea secondary to nasal vasodilation, is vagally mediated and generally occurs within few hours of oral ingestion.

7. Non-allergic Rhinitis with Eosinophilia Syndrome (NARES)

   • NARES or eosinophilic rhinitis accounts for as many as 20% of rhinitis diagnoses.

   • It is believe that the condition may be precursor to aspirin triad of intrinsic asthma, nasal polyposis (lots of polyps) and aspirin intolerance.

   • Abnormal prostaglandin metabolism may be implicated as a cause of NARES.

   • Eosinophilia counts are elevated in approx 20% of nasal smear with nasal congestion, sneezing, rhinorrhea, nasal pruritis and hyposmia (reduce smell).

Etiology and risk factors

Non allergic rhinitis occurs when the blood vessels in the nose expand(dilate), filling the nasal lining with blood and fluids.

Many factors that triggers the nasal swelling in non allergic rhinitis are

• Environmental or occupational irritants: dust, smoke, secondhand smoke, strong odors, chemical fumes.

• Weather changes: Temperature & humidity.

• Infections: viral - cold / flu.

• Food and beverages: hot & spicy food, alcoholic beverages - beer, wine.

• Medications: NSAIDs (aspirin, ibuprofen), antihypertensive (beta-blockers), sedatives, antidepressants, oral contraceptives, erectile dysfunction drugs & overuse of nasal spray.

• Hormonal changes: pregnancy, menstruation, oral contraceptives, hypothyroidism.

• Certain health problems: asthma, lupus, cystic fibrosis, emotional & physical stress.

Diagnostic Evaluation

• History collection

• Physical examination - question about symptoms

1. Ruling out the allergic cause

   • Skin test: Skin is pricked and exposed to certain amounts of allergens such as dust mites, mold, pollen, cats and dogs. If allergic to the substance develop a raised bump (hive) at the test location.

   • Blood test: measuring the amount of antibodies like IgE and test the sensitivity to specific allergens.

2. Ruling out the sinus problems

   • DNS / polyps, Nasal endoscopy, CT scan

Management

For mild symptoms - home treatment and avoiding triggers

For major symptoms - Medications that provide relief include

• Oral decongestants - pseudoephidrine containing drugs - (Actifed) and phenylephrine.

• Saline Nasal Sprays - Nasal saline spray or home made salt water solution to flush the nose helps thin the mucus and shoothe the membranes.

• Antihistamine nasal sprays - azelastine

• Anti-drip anticholinergic nasal sprays - Ipratropium (Atrovent)

• Corticosteroid nasal sprays - fluticasone (Flonase), mometasone (Nasonex)

• Decongestants nasal sprays - oxymetazoline

Nursing Management

• Reduce exposure to allergen and irritants - dusts, molds, animal, fumes, odors, powders, sprays and tobacco smoke.

• Controlling the environment at home and work.

• Saline nasal or aerosol sprays to shoothe mucus membrane

• A review of the research shows that vitamin C modestly shortens the duration of a cold by less than 1 day per cold when daily intake is at least 1000 mg/day (the RDA is 75 mg/day for women and 90 mg/day for men). The placebo effect is credited for reducing the number of colds in people who thought they were taking vitamin C supplements but were actually receiving a placebo.

• Evidence on the effectiveness of zinc lozenges in shortening the duration of colds is inconclusive.

Home Management

Nasal wash

A nasal wash can be helpful for removing mucus from the nose. A saline solution or a home made nasal wash can be prepared by - 2 cup warm water, a teaspoon salt, a pinch of baking soda.

Client and Family Teaching 20-1 Treating Rhinitis

• For all types of rhinitis:

  • Rest as much as possible.

  • Increase fluid intake to assist in liquefying secretions.

  • Use a vaporizer to help liquefy secretions.

  • Blow nose with mouth open slightly to equalize pressure.

  • Wash hands frequently to avoid spreading infection.

  • Use over-the-counter medications as directed; be aware of possible side effects, especially interactions with food and alcohol.

• For allergic rhinitis:

  • Be tested for allergen sensitivity.

  • Avoid specific allergens.

  • Use antihistamines and decongestants as ordered.

Ethinitis

Ethmoditis - Inflammation of the ethamoid sinus

Pharyngitis

Pharyngitis is an inflammation of the pharynx (simple term - sore throat), thhe portion of the throat that lies just beyond the back at the roof of the mouth and stretches to the Adam's apple (pharynx).