Pharyngitis and Bronchitis

Question 1

Define upper respiratory tract infections. Type?

Answer 1

Acute infections, typically viral and sometimes bacterial or rarely fungal, cause mild, self limiting symptoms e.g. congestion, sore throat and occasional fever

Acute rhinopharyngitis - Inflammation of the nasopharynx

Acute Pharyngitis - Inflammation of the pharynx, commonly caused by a virus or less commonly group A streptococcus

Question 2

Define lower respiratory tract infection

Answer 2

Acute Bronchitis

Inflammation of the bronchi, usually from viral infection but sometimes bacterial or due to irritant exposure (e.g. smoke)

Viral acute bronhcitis is the most common

Question 3

Describe the anatomy of the respiratory tract. Difference in LRTI

Answer 3

Bronchitis: Inflammation of the bronchus

Bronchiolitis: Inflammation of the bronchioles

Pneumonia: Inflammation/infx of the pulmonary parenchyma (the functional, gas-exchanging tissue of the lungs, primarily composed of millions of thin-walled alveoli)

Question 4

Describe the risk factors for pharyngitis/bronchitis

Answer 4

Exposure to other with infections

Inadequate hand hygiene

Crowded environments

Exposure to lung irritants that compromise respiratory tract ciliary: chemicals, smoking

Question 5

Describe the pathogenesis of pharyngitis/bronchitis

Answer 5

Colonization of pathogens in URT

Aspiration to bronchae

Bronchial irritation and ciliary dysfunction

Clogged airways, mucus secretion and cough

Question 6

Differential Diagnosis of Pharyngitis/bronchitis

Answer 6

Allergies, asthma, cystic fibrosis, COPD (acute exacerbation)

Irritants causing throat inflammation (e.g. smoking)

Sinusitis, pneumonia, pertussis (whooping cough), tuberculosis

Primary influenza infection and secondary influenza complication

GERD

Question 7

What are some drug related causes of drug-related symptoms of bronchitis

Answer 7

Cough (ACEi) - ACE breaks down bradykinin and substance P. Bradykinin sensitizes the airways leading to cough reflex. Usually occurs within the first month of intiation. After stopping the medication, the cough generally resolves within 1 to 4 weeks, though in some cases it may persist for up to 3 months.

SOB (beta-blockers) - Higher risk non-selective beta-blockers (Nadalol, Pindolol, Propranalol, Sotalol, Timolol), Non-selective beta and alpha-1 blockade (Carvedilol and Labetalol)

Flu-like symptoms: vaccines, monoclonal antibodies, missed doses of antidepressants (withdrawal sx)

Question 8

Drug induced esophagitis examples

Answer 8

Antibiotics: One of the most common causes of drug-induced esophagitis. These include tetracyclines, especially doxycycline.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Bisphosphonates

Ascorbic acid
Potassium chloride and ferrous sulfate

Chemotherapeutic regimens: dactinomycin, daunorubicin, bleomycin, methotrexate, 5-fluorouracil, cytarabine, and vincristine cause esophagitis perhaps due to oropharyngeal mucositis.

Question 9

Describe the clinical presentation of acute pharyngitis

Answer 9

Most cases of acute pharyngitis are viral and self limiting

Symptoms can include: Low grade fever, coughing, rhinorrhea, rash, headache, conjuctivitis

GAS (strep throat; CENTOR Score) - Sympt0oms can include sudden onset of sore throat, fever, absence of cough, palatal petechiae, tonsillar exudate, lymphadenopathy, and possible scarllet fever (rare - body rash that starts with face and then goes to trunk, snad paper feel, rednes sin skin, itchiness, peels off)

• Rare complications include invasive GAS (e.g. nefcroizinf fascitis), rheumatic fever, rheumatic heart disease, neck space infection and glormerulonephritis

Question 10

Describe the clinical presentation of acute bronchitis (chest cold)

Answer 10

Usually follows a viral URTi, adult symptoms are self-limiting (10-14 days) and can include: Cougghing (+/- sputum production), URTi symptoms (e.g. nasal congestion, runny nose, watery eyes)

** Cough can last 3-4 weeks (bronchitis often suspected following > 5 days of coughong)

Purulent sputum is not an indication of bacterial infection and raather the presence of leukocytes and inflammation

Symptoms in children can include: Wheezing, chills, chest congestion, vomitting, tachypnea, respiratory distress, hypoxemia (rare)

Question 11

Clinical symptoms of non-specific URTi

Answer 11

Early: rhinitis, coryza (Inflammation of the mucous membrane lining the nose), sore or scratchy throat, malaise, conjuctivitis

Delayed: Nasal congestion, mild cough, nasal discharge

Uncommon: Fever (sometimes presen tin children), nauseua, vomitting

Question 12

Diagnosis of non-specific URTi

Answer 12

presence of signs and symptoms without any sever or systemic symptoms

Question 13

Clinical symptoms of bacterial pharyngitis

Answer 13

ABSENCE OF COUGH

Early: Sudden onset of severe sore throat, fever, headache, swollen cervical lymph nodes, tonsillar exudate, nauseua and vomitting

Delayed: Scarlet skin rash, glomerulonephritis

Uncommon: COugh, coryza, nasal congestion

Question 14

Diganosis of bacterial pharyngitis

Answer 14

Rapid antigen test (RAT) or throat culture
RAT ok to rule out adults, need culture for children

Question 15

ACute Bronchitis Clinical SYmptoms and Timeline

Answer 15

Usually self-limiting and resolves in 10-14 days (in some cases up to 3-4 weeks)

Early: rhinitis, coryza, sore or scratchy throat, malaise, conjuctivitis

Delayed: persistent cough sputum production, wheezing (sputum increases with duration)

Uncokmmon: Fever, nauseua, vomitting

Early symptoms of acute bronchitis and URTI are the same

Question 16

Diagnosis of acute bronchitis. Referall?

Answer 16

Eliminate suspicion of pneumonia and influenza

Presence of high fever and systemic signs sch as increased breathing rate and tachycardia should prompt referral

Question 17

Acute Pharyngitis Etiology

Answer 17

Non-bacterial organisms: Viral (rhinovirus, coronavirus, adenocvirus) cokmmon

Bacterial:
Streptococcus pyogenes (Group A beta-hemolytic streptococci) which is also known as strep throat

Rarely: Fusobacterium, Nesseria

Question 18

Acute bronchitis etiology

Answer 18

VIRAL IS THE MOST COMMON
- Viral causes account for > 90% of cases - pathogens include rhinovirus, influenza A and B, parainfluenza, respiratory syntical virus (RSV), coronavirus 1 to 3, enterovirus and adenovirus

Bacterial - Uncommon causes of bronchitis cases

Bacterial sources include:

Strep Pneumo
Haemophilus Influenzae
Moraxella Catarhhalis
Mycoplasma pneumonjair
Chlamydiophilia pneumonaie
Bordetella pertussis
Bordetella parapertussis

Question 19

Non-pharmacological measures for bronchitis

Answer 19

Education:
- Likely viral cause of URTi/bronchitis/pharyngitis
- No benefit from antibiotics except in the cases of pertussis or acute pharyngitis secondary to bacterial pathogen. Risk of antibio resistance id antibiotics are used
- Limiting spread of infection through proper hand washing
- Avoiding environmental irritants such as toxin/allergen exposure (tobacco, smoke, pollen)

OTC:
LOzenges and lidocaine/menthol can be used to provide mild pain releief of sore throat (only sx relief)

Humidity
- Increase humidity to reduce cough

Fluids:
- Use fluids to prevent dehydration in children and reduce visocsity of respiratory seceretions (decraesed visocsity = incraesed mucosal flow)

Comfort:
- Improve patients comfort by rest, activity as tolerated

Question 20

Natural Remedies for Bronchitis

Answer 20

Echinacea: no conclusive evidence showing that it reduces duration or severity

Honey: no evidence that it reduces the duration but may help with symptomatic treatment of cough or sore throat
- Use pasturized honey for symptom management
- Use in children > 1 year (C.I. in children less than 1 year old due to the risk of botulism)

Vitamin C: No conclusive evidence that it reduces the duration or severity of URTi

Nasal Saline Spray: Helps with symptomatic treatment of nasal congestion and discomfort

Zinc: Often available as lozenges. There is some evidence that zinc shortens the duration and severity of a cold. Intranasal zinc has the side effect of permenant anosmia, Lozenges can also cause mouth irritation - avoid in aphthous ulcers

Question 21

Pharmacological Measures for Bronchitis Symptom relief

Answer 21

Analgesics and antipyretics
- Acetaminophen: Max dose of 1000 mg, 4 g/day and if exceeded, increased risk of hepatotoxicity
- MOA: Unknown, COX 2 inhibition in hypothalmus leading to decraesed PG E2

• Acetaminophen and ibuprofen can be used for fever, headache and pain
• Avoid ASA in children and adolescents due to risk of Reyes Syndrome

Anti-tussives:
-Dextromethorphan are not reccomended for productive coughs
- Works centrally to increase coughing threshold thereby requiring more stimulation to cough
- Avoid in children < 6 years of age: lack of evidence for efficacy and risk of adverse effects
- As per Health Canada: reccomended not to use opiod-containing products < 18 years of age
- Both have risk for abuse

Bronchodilators, inhaled corticosteroids
- Used in patieents with wheezing; no evidence of efficacy unless airway obstruction is present

Antihistamines
- Avoid antihistamines as thjey can cause drying of mucous secretions, which prevents effective clearence

Mucolytics (guaifenesin)
- Increase the volume of mucous, decraese the viscosity of mucous so its easier to expel
- No evidence of efficacy

Question 22

Bacterial Pharyngitis Diagnosis Tool and when to treat with antibiotics

Answer 22

Question 23

Pharmacological Measures for Bronchitis

Answer 23

Routine antibiotic treatment is recommended for acute bronchitis, since virus account for up to 95% of cases

Consider further investigation: symptoms greater than 14 days without improvement or worsening, if linked to PERTUSSIS CASE OR if Immunocompromised (refer)

Question 24

Bacterial pharyngitis pharmacological measures

Answer 24

Antibiotic therapy aimed at eradicating GAS is reccomended for cases of bacterial pharyngitis confirmed by throat culture or antigen testing

Concurrent use of corticosteroids with antibiotics is not reccomended

Question 25

First Line Therapy Bacterial Pharyngitis Adults and Peds

Answer 25

Question 26

Bacterial Pharyngitis Penicillin Allergy Pediatrics

Answer 26

Answer 27

Question 28

Bacterial Pharyngitis Therapy if Refractory Infection

Answer 28

Refractory infections to first-line agents: Amox-Clav for 3 days Clindamycin for 3 days - Take with meals to reduce GI symptoms

Question 29

Monitoring parameters for bacterial pharyngitis and viral bronchitis

Answer 29

Symptoms - Improvement Bacterial Pharyngitis: Fever < 48 h Pain and fatigue in 48-72 hours Symptomatic resolution is usually seen in 4-5 days, but 10 day therapy is used to prevent acute rheumatic fever (ARF) Viral Bronchitis: Improvement over 5-7 days Resolution of cough within 10-14 days, but up to 21-28 days or more in some cases Drug Side zEffects - Minimize - Through0out drug therapy and manage adverse drug reactions from antibiotics

Question 30

Timing to start antibiotics in bacterial pharyngitis for Peds

Answer 30

Start within 9 days, ABx duration should be 10 days to eradiczate GAS

Question 31

Are antibiotics required in acute bronchitis?

Answer 31

Antibiotics are not reccomended as predominately viral

Question 32

Acute Bronchitis Management TSrategies

Answer 32

Advise on treatments that will provide symptomatic relief: Maintaining hydration and increased humidity. Cough supression mabe considered for managing cough and inhaled bronchodilators if wheezing is presnet. Honey in children.

Question 33

Acute Bronchitis: When to refer?

Answer 33

Symptoms worsen New symptoms develop (e.g. dyspnea, fever, vomitting) Cough > 1 month > 3 episodes/year

Question 34

Acute Bronchitisi cough timeline

Answer 34

Self limiting. Cough usually persists for 1-3 weeks, aolthough up to 50% of viral cases have a cough beyond 3 weeks

Question 35

Define Acute Complicated Bronchitis

Answer 35

Acute complicated bronchitis (e.g. history of smoking, impaired lung function, chronic herat disease, immunocompromised) may require further investigation

Question 36

What to rule out in acute bronchitis?

Answer 36

Rule out pneumonia if: HR > 100 bpm, RR > 24-30 breathes/min, oral temp > 38C, or findings of local consolidation Also consider Covid-19 Fever is uncommon and may be indicative of influenza or pneumonia

Question 37

Non-pharm Management Strategies and Evidence/SUggestions

Answer 37

Increase/maintain hydration Increase humiditiy (PRN humidifier to maintain 30-50% humiditiy) - Caution hydration in HF and CKD Humidifier: clean frequently to decrease bacteria/fungi growth Honey: 2.5-10 mL po HS (Not in children < 1 due to concerns with ifnant botulism) (Often 1/2 tsp for ages 2-5)

Question 38

Acute vs Chronic Cough

Answer 38

Acute < 3 weeks usually due to self-limiting viral infection Chronic cough > 8 weeks - Usually sx of underlying cause (e.g. allergy, GERD, asthma, drugs (ACEi persists < 4 weeks after d/c), COPD (esp smokers), psot-nasal drip,pertussisis often prolonged

Question 39

OTC COugh and Cold Products Health Canada

Answer 39

Avoid anti-tussives, expetcorants and deocngestants in children < 6 years of age for tx of cold

Question 40

Decongestants in Acute Bronchitis

Answer 40

Often only need PO or topical; combo not often reccomended PO phenylephrine is not effective Nasal saline drops, sprays, irrigation soothes nasal tissue, may imrpove sx and decraese medication use; lubricants soothing if added by the manufacturer

Question 41

Pseudoephedrine Dosing

Answer 41

60 mg po q4-6h or 120 mg q12h MAx: 240 mg/day 6-11 years: 30 mg q4-6h; 120 mg max/day

Question 42

Phenylephrine OTC Dosieng

Answer 42

10 mg po q4h; 60 mg/day 6-11: 5 mg q4h; 30 mg/max

Question 43

Saline Dosing

Answer 43

1 spray 2-6x/day PRN (< 2 years: 4 drops 1-6x/day)

Question 44

Oxymetazoline and Xylometazoline Dosing

Answer 44

Greater than or equal to 12: Oxymetazoline: 2-3 sprays up to BID Xylo: 1-3 drops/sprays up to TID Limit nasal spray prep use to approx.7 days to avoid rebound congestion (less than or equal to 3 days with PE) - NAsal PE not reccomended due to short duration and likely rebound congetsion

Question 45

AE's Decongestants

Answer 45

CNS stimulation (insomnia, tremor, irirtability, tachycardia), headache, incraesed BP, incraesed BG

Question 46

Pseudoephedrine MOA

Answer 46

Alpha/beta AGonist Directly stimulates alpha-adrenergic receptors of respiratory mucosa causing vasoconstriction; directly stimulates beta-adrenergic receptors causing bronchial relaxation, increased heart rate and contractility

Question 47

Pseudoephedrine Cautiopn and CI

Answer 47

Caution: Patients with HTN, heart dx, diebetes, narrow angle glaucoma, BPH, on Beta blockers C>I>: MAOI use

Question 48

Dextromethorphan Dosing

Answer 48

Greate rthan or equal to 12: 10-20 mg po q4h or 30 mg q6-8h , 120 mg/day max 6-11: 5-10 mg q4-6h; max of 60 mg/day

Question 49

Gaufenisien DOsing

Answer 49

Greate rthan or equal to 12: 200-400 mg po q4-6h; 2.4 g/day 6-11 years old: 100-200 mg q4-6h; 1.2 g/day

Question 50

Oxymetazoline/Xylometazoline MOA

Answer 50

Xylo: Stimulates alpha-adrenergic receptors in the arterioles of the conjunctiva and the nasal mucosa to produce vasoconstriction Oxy: Stimulates alpha-adrenergic receptors in the arterioles of the nasal mucosa to produce vasoconstriction

Question 51

Codeine DOsing

Answer 51

C.I> less than 18 years old Effective Dose: 10-20 mg po q4h; 120 mg/day

Question 52

Hydrocodone Dosing

Answer 52

CI < 18 years old Effective Dose: 5 mg po q4-6h PRN

Question 53

DM product Formulation

Answer 53

Sugar and alcohol in some products, but minimal cocnern in diabetes abd kids (typically less than 15 kcal/dose)

Question 54

DM COncerns

Answer 54

ABuse concerns. False positive with opiate urine drug screens Use alcohol free options in pregnanacy and lactation

Question 55

Guafensien efficacy

Answer 55

Questionable effecrs in decraesed sputum viscosity abd incraesed expectoration

Question 56

Codeine Adverse Effects

Answer 56

Drowsiness, nauseua, constipation

Question 57

C.I. opioids for acute bronchitis

Answer 57

< 18 years old, asthma/COPD, CNS depression, pregnanacy/lactation, acute alcoholism

Question 58

Acetaminopehnn and NSAID in Pregnancy and Lacatation

Answer 58

Acetaminophen < or = < 4 grams/day - SFA Ein P/L NSAIDs: Caution in 1/2, C.I. in 3rd trimester, Safe L

Question 59

Hepatoxicitiy Acetaminophen

Answer 59

Adults/Adolescents at 7.5-10 g in < 8 hours Fatalities rare with ODs < 15 grams Peds: overdose concenrn if 150-200 mg/kg ingested

Question 60

NSAIDs and Health Canada Pregnaancy

Answer 60

Avoid NSAIDs 20 weeks or later as they can result in low amniotic fluid - IBu: Cause spremature closure of ductus arteriosus and increased bleeding risk at term Cat C up to 30 weeks and Category D at greater than 30 weeks

Question 61

Dosing Ibuprofen and Naproxen OTC

Answer 61

Acet: Up to 4 grams/day (3.2 g/day in elderly or chronic use) IBU: 300 mg QID or 400 mg TID (Macx of 1200 mg/day) Naproxen 220 mg BID (Max 440 mg) ASA: up to 4 g/day

Question 62

Salbutamol and Ipratropium DOsing Acute Bronchitis

Answer 62

Salbutamol: 100 mcg 2 puffs inhaled QID Iprat: 20 mcg 4 puffs QID

Question 63

When should patients se a prescribe for bacterial pharyngitis?

Answer 63

Symptoms worsen Symptoms take longer than 3-5 days to resolve Unilateral neck swelling develops

Question 64

Exceptions to Centor Score

Answer 64

AMay not accurately predict risk during epidemics or in high-risk groups e.g. hx of rheumatic fever, valvular heart disease, immunosupression an

Question 65

When is Diagnostic testing for bacterial pharungitis not reccomended:

Answer 65

A modfieied cnetro score less than or equal to 1 Sxs of vital infection rhinorhhea, cough, oral ulcers, hoarsness < 3 years old, unles sother risk factors (e.g. outbreak, sibling with GAS) Asx contact of pts with GAS pharyngitis

Question 66

Systemic ANalgesiscs for Sx Managemrnt in Bacterial Pharungitis

Answer 66

Ibuprofen Peds: 5-10 mg/kg/dose po q6-8h PRN (MAx of 40 mg/kg/day) Adults: 400 mg q6-8h PRN (Max: OTC: 1.2 g/day, RX may see 2.4-3.2 g/day) Naproxen: Peds > 2: 5-7 mg/kg/dose q8-12 h (Max: 1 g./day RX) Adults: OTC: 220 mg po BID (MAx of 440 mg, RX max 1-1.5 g/day) Acet: Peds: 10-15 mg/kg po q4-6h PRN (max of 75 mg/kg/day) Adults: 1000 mg q4-6h PRN; max of 4 g/day

Question 67

Other Sx Relief in Pharungitis

Answer 67

Benzocaine 10 mg lozenge q2h PRN - ALleviates throat pain if used frequently Avoid in children due to choking and methemoglobinemia concerns Phenol (Chloraspetic) 5 sprays q2h PRN - No evidence Gargling or drinking warm liquids (e.g. warm salt water rinse, tea), Little evidence Benzydamine 15 mL gargle or rinse q-1.5-3hr PRN