ASSAULT ON THE AIRWAY
From An Intensive Review in Family Medicine, sponsored by the Medical University of South Carolina, Charleston
| COLDS, COUGHS, AND “BAD SINUSES” —William J. Hueston, MD, Professor and Chair, Department of Family Medicine,
Medical University of South Carolina, Charleston
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| Main points: upper respiratory tract infections (URIs; “colds”)—decongestants only agents proven effective; avoid
antibiotics; avoid echinacea; sedative antihistamines effective in helping to induce sleep; antiviral agents soon available
(pleconaril in safety studies)
|
 | Influenza: reserve diagnostic testing for “shoulder seasons” (ie, early and late in influenza season); short courses of antivirals
best (avoid extra courses of oseltamivir [Tamiflu]); resistance rates 93% to 95% for amantadine and rimantadine,
≈2% for oseltamivir (neuramindase inhibitor); chemoprophylaxis with oseltamivir indicated for those who cannot receive
influenza vaccines; consider use of both influenza vaccine and oseltamivir in high-risk patients
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| Sinusitis: predictive factors include poor or no transillumination of sinuses, maxillary toothache, and poor response to decongestants
(reserve antibiotics for patients with these problems); 3-day course of antibiotics just as effective as 14-day
course
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| Acute bronchitis: antibiotics often provide little benefit; advise patient that clinical manifestations (particularly cough)
often persist >14 days; albuterol inhaler may improve cough
|
| Upper respiratory tract infections: >800 over-the-counter (OTC) products available for treating colds; ≈30% of
children and ≈60% of adults unnecessarily treated with antibiotics; color of secretions—many patients mistakenly
believe clear nasal discharge indicates cold, while green or yellow discharge indicates more serious condition for
which they should see physician for antibiotic; many pharmacists and physicians also have this misconception; many
physicians prescribe antibiotics in belief this will prevent patients from coming back (in one study, return rate 13% for
those on antibiotics and 15% for those not on them)
|
| Evaluation of various agents promoted for treating colds: intranasal saline—ineffective; intranasal hypertonic saline
(3%)—appears to reduce symptoms quicker; intranasal ipratropium (Atrovent)—decreases nasal discharge by
≈26%, (compared to saline) and 34% (compared to controls); appears to lighten weight of discharge; zinc—2 placebo-
controlled studies have shown zinc lozenges improve sore throats in adults, but not in children; 90% of patients taking
zinc experience gastrointestinal side effects, including nausea and vomiting; vitamin C—new Finnish studies indicate
that using high-dose vitamin C prophylactically and early on in colds may have some benefit; echinacea —in 1998,
meta-analysis of 16 studies showed some benefit for relieving cold symptoms; however, 3 more recent randomized studies
show no benefit, compared to placebo; excessive use can cause liver toxicity (limit to 2-3 wk); intercellular adhesion
molecule (ICAM) 1 blockers—appear to reduce cold severity; agents include tremacamra (not on market);
broad-spectrum anti-picornavirus agents—include pleconaril; effective against all common viruses that cause common
cold; reduce upper respiratory tract symptoms by ≈24 hr; pleconaril still awaiting approval
|
| Influenza: highest attack rates in children; highest mortality rates in elderly and those with debilitating illnesses; producing
herd immunity one of main reasons for immunizing children; highest morbidity in those with other comorbidities
|
| Influenza vaccines: available agents include trivalent inactivated vaccine (“flu shot”) and live-attenuated vaccine (Flu Mist);
both grown in eggs, and both effective in children and adults; immunized people who still develop influenza generally
have less-severe episodes; inactivated vaccine—some people who receive it develop local reactions, persisting for 1 to 2
days; some people concerned about thimerosal in this vaccine; live-attenuated vaccine—replicates in nose, but not in
lungs; given intranasally; expensive; safety and adverse reactions similar to those of flu shot; efficacy in children better
than inactivated vaccine; in children, virus shed for 7 to 8 days; side effects include nasal congestion, headache, and sore
throat from postnasal drip; much more expensive than flu shot
|
| Antiviral drugs: important to begin use within first 2 days of influenza (encourage patients with high fever and muscle
aches to see physician immediately); best used for short periods; neuraminidase inhibitors—act against influenza A
and B, generally shorten symptoms by 1.5 days, and help prevent influenza complications in high-risk people; agents
include oseltamivir and zanamivir (Relenza); oseltamivir given orally, approved for use in children, costs ≈$53 for 5
days, and can be used prophylactically; zanamivir given by inhaler within 30 hr of onset of symptoms, not associated
with neurotoxicity (but may cause bronchospasm), and slightly less expensive than oseltamivir; amantanes—include
amantadine and rimantadine; effective only against influenza A; limit use to 3 to 5 days to minimize resistance; in
2006, 92% of influenza strains resistant to amantanes (Centers for Disease Control and Prevention [CDC] recommends
against use); both agents shorten symptoms by ≈1 day; rimantadine safer for people who have had seizures; amantadine
less expensive ($1.80 for 5 days); cleared renally, so use with caution in patients with renal disease
|
| Resistance issues: amantanes no longer recommended by CDC because of high resistance levels; resistance now developing
for neuraminidase inhibitors (current resistance rate for influenza A, 5% to 18%)
|
| Prophylaxis with neuraminidase inhibitors: effective; consider use in patients who receive influenza vaccine during
height of flu season, while waiting for antibodies from vaccine to develop; also indicated for immunocompromised patients
who respond poorly to influenza vaccine, those in whom influenza vaccine contraindicated, and “super high-risk
patients” who have already received influenza vaccine
|
| Tests for influenza: rapid test available, but sensitivity and specificity poor; best time to use them when chances of having
influenza ≈50% (ie, beginning and end of flu season)
|
| Sinusitis: definitive diagnosis made by aspirating sinuses; most cases viral in etiology; ≈50% of people with colds develop
evidence of sinus inflammation; only ≈1% of cases bacterial in etiology; also associated with allergies
|
| Predictors of sinusitis: Williams criteria—maxillary toothache; poor response to decongestants; discolored nasal discharge
on history; abnormal transillumination; Lindboek criteria (from Belgium)—“double sickening” (ie, patient
has cold, gets better, then gets worse); more recent finding (2006)— patients with red streak in back of throat more
likely to have sinusitis
|
| What to do: 83% of patients get better with antibiotics, but 75% improve even without them; consider imaging studies or
otolaryngologic referral if patient fails to improve on antibiotic; 3 days of antibiotic therapy generally just as effective
as 14 days; what speaker does—prescribes 10- to 14- day course of trimethoprim–sulfamethoxazole and tells patient
to take it for 3 days, stop if he or she feels better, continue if symptoms still present
|
| Acute bronchitis: common problem; etiology almost always viral, but Mycoplasma pneumoniae sometimes plays role
in younger population; patients with M pneumoniae often do not improve any faster if treated with macrolide than
with placebo; symptoms usually persist from onset of infection until healing process completed (symptoms characteristically
persist several weeks)
|
| Chlamydia pneumoniae: those with acute bronchitis due to Chlamydia more likely to develop adult-onset asthma; still
unknown whether macrolides helpful for asthma in these patients
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| Cough: 50% of patients with acute bronchitis still coughing at 2 wk; some cough for months, especially those who exert
themselves or get exposed to cold environment
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| Comments: on spirometry, people with acute bronchitis resemble those with mild asthma; however, over time, spirometry
findings revert to normal; use of antibiotics not beneficial because symptoms due to results of infection rather than
to causative organism; consider treating symptoms with antiasthma drugs (eg, albuterol); 2 studies found that use of albuterol
helped to reduce length of symptoms, particularly cough; adding macrolide to albuterol did not appear to help;
if albuterol prescribed, tell patient to discontinue use when improvement noted
|
| Questions and answers: treating acute bronchitis in patients with chronic obstructive pulmonary disease
(COPD)—in these patients, bouts of “acute bronchitis” really exacerbations of chronic bronchitis; antibiotics (eg,
amoxicillin, tetracycline, sulfonamides) often helpful for these exacerbations; tell patient to start taking antibiotic when
exacerbation begins; nasal corticosteroids for sinusitis—indicated only for allergic sinusitis; data lacking for bacterial
or viral sinusitis
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| OBSTRUCTIVE SLEEP APNEA (OSA)—William M. Simpson, Jr, Professor of Family Medicine, Medical University of
South Carolina, Charleston
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| Key manifestations: loud snoring; frequent arousals; nonrestorative sleep; excessive daytime sleepiness (sometimes results
in impaired function, injury, and impaired job performance)
|
| Associated conditions: obesity (primary association); angina pectoris; increased incidence of nocturnal cardiac arrhythmias;
myocardial infarction; stroke; motor vehicle accidents
|
| Pathophysiology: related to narrowing of respiratory passages during sleep; obesity (leads to peripharyngeal infiltration
of fat and/or increased size of soft palate and tongue); diminutive or receding jaw; natural loss of muscle tone during
sleep (allows gravity to pull jaw backward in supine position, increasing obstructive potential); partial airway obstruction
leads to snoring (often from back of throat); more severe airway obstruction results in hypopnea (low rate of breathing
from working against obstruction) or apnea (total obstruction); remarks—patients often have only partial arousals that
cannot be recalled and daytime somnolence (due to nonrestorative sleep); with arousal, muscle tone of tongue and airway
improves, and obstruction resolves; cycle repeated many times during night
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| Sites of obstruction: nasopharynx—nasal polyps and septal deviation may contribute; partial or total nasal obstruction
may lead to apnea; oropharynx—associated with redundant peripharyngeal tissue, enlongated soft palate, and enlarged
uvula; hypopharynx—large tongue; receding jaw
|
| Prevalence: ≈2% of women and 4% of men >50 yr of age have symptomatic OSA; prevalence higher in primary care setting
|
| Indications to screen for OSA: history of snoring or daytime somnolence; report by bed partner of struggles to
breathe, accompanied by stopping and resumption of breathing; presence of obesity, hypertension, receding jaw, and/or
large neck circumference (>16" in women, >17" in men); crowded posterior airway (eg, large uvula, redundant soft palate,
large tongue)
|
| Diagnostic work-up: check nose for polyps, significant nasal septal deviation, or allergic rhinitis with edema of mucous
membrane; perform polysomnography (gold standard for evaluating patients)
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| Polysomnography: evaluates rapid eye movement (REM) sleep, and includes electroencephalography (EEG), chest wall
monitoring (looking for muscle movements), nasal and oral airflow measurements, electrocardiography (ECG), electromyography
(EMG), and oximetry; provides score (respiratory disturbance index) based on calculated number of respiratory
events per hour, sometimes called apnea-hypopnea index (graded as mild, moderate, or severe) and
information on oxygen (O2 ) desaturation
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| Severity of OSA: based on 3 components—respiratory disturbance index, sleepiness, and O2 desaturation
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| Sleepiness scale: mild—sleepiness occurs only when individual sedentary or when little attention required;
moderate—sleepiness occurs when patient minimally active or when moderate attention required; severe—sleepiness
occurs while doing active tasks that require significant attention; social or occupational function impaired
|
| Diagnostic points: polysomnography not always required to make diagnosis, but most insurance companies require it;
empiric use of continuous positive airway pressure (CPAP) and autotitration may be adequate if polysomnography not
readily available; research study—participants designated as high probability of having sleep apnea on basis of sleep
questionnaire and clinical score, based on neck circumference, hypertension, and measurements from home oximetry;
randomized to polysomnography or home CPAP autotitration; after 3 mo, sleep apnea same in both groups;
recommendation—treatment indicated if patient has ≥20 respiratory events/hr because long-term mortality increases
above that level
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| Treatment: sleep hygiene—includes adequate time in bed, maximization of nasal airflow; avoidance of alcohol and
sedatives; elevation of head of bed; sleeping on side (place tennis ball in pocket in middle of back to thwart sleeping on
back); weight loss; CPAP—major intervention available; warn patient about noise and possible complications (eg,
compression ulceration from poorly fitted mask); someone should watch for nasal symptoms and help with humidification;
respiratory therapist needed to closely follow patient and provide encouragement; oral appliance—particularly
helpful in patients with large tongues and receding jaws; used to move tongue and mandible forward; generally used
for those with mild apnea; usually fitted by dentist; costs $500 to $1000
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| Surgical alternatives: uvulopalatopharyngoplasty (UPPP)— done surgically or with laser; removes most of soft palate
and uvula; somnoplasty—radiofrequency modality for reducing palatal soft tissue; palatal stents (pillar
procedure)—relatively new; involves insertion of rods to hold soft palate up; decreases snoring; 40% to 50% of people
undergoing this procedure get substantially better; maxillomandibular advancement surgery—indicated for patients
with significant receding jaws; 95% effective; tracheostomy—last resort
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| Questions and answers: effectiveness of UPPP surgery—fairly effective for mild-to-moderate sleep apnea; painful
postoperative course; OTC sleep aids—aimed at making soft palate less redundant, so snoring less likely; no controlled
trials; probably as effective as using tennis ball
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Suggested Reading
Abad VC, Guilleminault C: Pharmacologic management of sleep apnea. Expert Opin Pharmacother 7:11, 2006;
Arroll B, Kenealy T: Are antibiotics effective for acute purulent rhinitis? Systemic review and meta-analysis of placebo
controlled randomized trials. BMJ 333:279, 2006; Benumof JL: Obesity, sleep apnea, the airway, and anesthesia.
Curr Opin Anesthesiol 17:21, 2004; Boyd EL, Philpot EE: Obstructive sleep apnea, nasal congestion and snoring:
their systemic effects and impact on quality of life. Allergy Asthma Proc 25:43, 2004; Burleson GR, Burleson FG:
Influenza virus host resistance model. Methods 41:31, 2007; Call SA et al: Does this patient have influenza? JAMA
23:293, 2005; Cintra OA, Rey LC: Safety, immunogenicity, and efficacy of influenza vaccine in children. J Pediatr
(Rio J) 82(3 Suppl):S83, 2006; Fendrick AM et al: Diagnosis and treatment of upper respiratory tract infections in the
primary care setting. Clin Ther 23:1683, 2001; Ferguson KA et al: Oral appliances for snoring and obstructive sleep
apnea: a review. Sleep 29:244, 2006; Giles TL et al: Continuous positive airway pressure for obstructive sleep apnea in
adults. Cochrane Database Syst Rev (3):CD001106; 2006; He J et al: Mortality and apnea index in obstructive sleep apnea:
experience in 385 male patients. Chest 94:9, 1998; Ibiapina CC et al: Rhinitis, sinusitis, and asthma: hard to disassociate?
J Bras Pneumol 32:357, 2006; Jefferson T et al: Amantadine and rimantadine for influenza A in adults.
Cochrane Database Syst Rev (2):CD001169, 2006; Lim DJ et al: Treatment of primary snoring using radiofrequency-
assisted uvulopalatoplasty. Eur Arch Otorhinolaryngol 264:761, 2007; Lin CC et al: Effect of uvulopalatopharyngoplasty
on work of breathing during wakefulness in obstructive sleep apnea syndrome. Ann Otol Rhino Laryngol 116:271,
2007; Lindbaek M, Hjortdahl P: The clinical diagnosis of acute purulent sinusitis in general practice—a review. Br
J Gen Prac 52:491, 2002; Linder JA, Sim I: Antibiotic treatment of acute bronchitis in smokers: a systematic review. J
Gen Intern Med 17:320, 2002; Matheson NJ et al: Neuraminidase inhibitors for preventing influenza in children. Cochrane
Database Syst Rev (1):CD002744, 2007; Monto AS et al: Respiratory illness caused by piconavirus infection: a
review of clinical outcomes. Clin Ther 23:1615, 2001; Morris P, Leach A: Antibiotics for persistent nasal discharge
(rhinosinusitis) in children. Cochrane Database Syst Rev (4):CD001094; Nagai T et al: Obstructive sleep apnea syndrome
accompanied by diabetes mellitus. J Med 34:23, 2003; Pevear DC et al: Relationship of pleconaril susceptibility
and clinical outcomes in treatment of common colds caused by rhinoviruses. Antimicrob Agents Chemother 49:4492, 2005;
Saunamaki T, Jehkonen M: A review of executive functions in obstructive sleep apnea syndrome. Acta Neurol
Scand 115:1, 2007; Singh M: Heated, humidified air for the common cold. Cochrane Database Syst Rev (3):CD001728,
2006; Smucny J et al: Antibiotics for acute bronchitis. Cochrane Database Syst Rev (4):CD000245, 2004; Stierer T,
Punjabi NM: Demographics and diagnosis of obstructive sleep apnea. Anesth Clin North Am 23:405, 2005;
Sundaram S et al: Surgery for sleep apnea. Cochrane Database Syst Rev (4):CD001004, 2005; Verse T et al: Recent
developments in the treatment of obstructive sleep apnea. Am J Respir Med 2:157, 2003; Victor LD: Treatment of
obstructive sleep apnea in primary care. Am Fam Physician 68:561, 2005; Zimmerman ME, Aloia MS: A review of
neuroimaging in obstructive sleep apnea. J Clin Sleep Med 15:461, 2006.
Educational Objectives
The goal of this program is to improve the management of upper respiratory tract infections (“colds”), influenza, sinusitis,
acute bronchitis, and sleep apnea. After hearing and assimilating this program, the clinician will be better able to:
| 1. Evaluate the efficacy of various agents that have been proposed for treating and preventing the common cold.
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| 2. Immunize patients against influenza, and prescribe antiviral drugs for treating it.
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| 3. Care for patients with sinusitis, and recognize the limitations of antibiotics for treating this condition.
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| 4. Consider the use of bronchodilators (rather than antibiotics) for patients with acute bronchitis.
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| 5. Diagnose and treat patients with sleep apnea.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Hueston and Simpson were recorded June 19, 2007, at An Intensive Review of Family Medicine, sponsored by the
Medical University of South Carolina, Charleston. The Audio-Digest Foundation thanks the speakers and the Medical University
for their cooperation in the production of this program.
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