13-10 topic 2. united airway concept
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TOPIC 2.UNITED AIRWAYCONCEPT
ARI management training
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Contents
• Respiratory physiology• Medical problem common pattern• United airway concept• Rhinosinusitis• Pharyngitis• Rhinobronchitis
Respiratory physiologyExternal
respiration
Internalrespiration
neuromuscularsystem
respiratorycenter blood
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Involving organ system
The main• Respiratory system• Cardiovascular system
The supporting• Resp center• Neuromuscular• Blood, hematology
External
respiration
ventilationRespiratory systemfunction
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Steps of respiration
1. Ventilation or gas exchangebetween atmosphere & alveoli
2. Diffusion of O2 & CO2between alveoli & the blood
3. Circulation (transport) ofO2 & CO2 between the lungsand the tissue
4. Exchange of O2 & CO2between the blood and thetissues
Sherwood L, The Respiratory System, 2004
Respiration
CRUCIALPOINT!
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Diffusion of O2 & CO2 betweenalveoli & the blood crucial point
Sherwood L, The Respiratory System, 2004
External respiration - 1
V - a VOLUME of airFLOW in and out
the respiratory tract
Q - a VOLUME of bloodFLOW through
alveolar capillary
L/mnt
L/mnt
External respiration - 2
ventilationV
perfusionQ
to take place, gas exchange(diffusion) from air to blood inalveolar capillary bed need an
optimal ratio betweenVENTILATION & PERFUSION
V/Q = 4/5
VQQ V
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Dyspnea pathophysiology
V/Q = 4/5
V/Q ≠ 4/5
Resp system try to copeby increasing resp effort
V/Q mis-match,NOT optimal diffusion
ClinicallyDYSPNEA
CRUCIALPOINT!
Common pattern
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Common medical terms
• Sign & symptoms• Etiology• Pathogenesis• Pathophysiology• Pathology• Diagnosis• Treatment• Prognosis
What is the definitionof each terms?
Is there any relationamong each terms?
Can we developa common pattern?
symptomatology
pathophysiology
pathology
insults
adaptiveresponses
Medical problem common pattern
Diagnosis &
Treatment
pathogenesis
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symptomatology
pathophysiology
pathology
insults
adaptiveresponses
Diagnosis &
Treatment
pathogenesis
Medical problem common pattern
Insults
Medicine/Medicala. an injury or traumab. an agent that inflicts
this
to affect offensively ordamagingly
Any factor affecting the normal growth,development, process, or function of the cell,
tissue, organ, system, or individu - DBS
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symptomatology
pathophysiology
pathology
insults
adaptiveresponses
Dia
gn
osis &Trea
tmen
t
pathogenesis
The ability to surviveby eliminate, terminate,defend, avoid, or adjust
to anykind of insults(fight or flight,
‘terjang atau terbang’)
Medical problem common pattern
Integumentarysystem (skin)
Adaptiveresponses
Immunesystem
Neuro-musculo-skeletal system
Gastro-intestinaldefense mechns
Respiratorydefense mechns
AutonomicNerve system
Urinarydef mechn
Endocrinesystem
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symptomatology
pathophysiology
pathology
insults
adaptiveresponses
Diagnosis &
Treatment
pathogenesis
Medical problem common pattern
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’?
Insult
adaptiveresponse
pathology
pathophys
symptom
symptomatology
Ongoing pathologybiochemical
cellulartissue
organbody system
organism
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The insults
• Infection• Allergy• Mechanical trauma• Injury: thermal, electrical,
chemical, irradiation
• Autoimmune• Cancer• ...
Insult
adaptiveresponse
pathology
pathophys
symptom
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
Upper resp tract
Lower resp tract
Sneeze(rhinitis)
Wheeze(asthma)
Otolaryngologist
Pulmonologist
Separate management
Otolaryngologist
ARIA
EPOS
Pulmonologist
GINA
GOLD
Anatomy based disease management
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Two concepts
The Old-oneSeparate
Different entity
The New-oneUnited
One entity
United airway concept
Hypothesis: upper & lower airway diseasemanifestationsof a single inflammatory process within the respiratorysystem
• 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):S147-334J 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• One airway, one disease• Rhino-sino-bronchitis
Med J Aust 2006; 185:565-71Thorax 2000; 55 (Suppl 2):S26-7
J Managed Care Pharm 2004; 10:310-7J Allergy Clin Immunol 2001; 108 (5 suppl):S147-334
Combined asthma & rhinitis treatment, EPC, 2006
Bacteria
Virus
Allergy
Pollutant
Allergen
Iritant
Immuno-deficiency
Anatomicaldefect Functional
defect
Respiratoryinflammation
Externalinsults
Internalinsults
Food
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Insult
adaptiveresponse
pathology
pathophys
symptom
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
Respiratory inflammation syndrome
Rhinitis/CC(infection)
Rhino-sinusitis
UAD, Rhino-sino-bronchitis
Otitismedia
Nasal polypOSAS
COPD
Rhinitis(allergic)
Asthma,bronchitis
Allergicconj’tvtis?
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Selesma
Flu!Flu virus Rhinovirus
Rhino-sinusitis
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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 dischargeo Nasal blockage / obstruction /congestiono Cough
• Lasting <12 weeks• If recurrent, symptom free intervals (+)
Rhinology, EPOS 2012
Diagnosis of ped ARS
• The clinical diagnosis of ARS in children ischallenging, overlap of symptoms with viralAURI, allergic rhinitis
• The symptoms are often subtle & thehistory is limited to the subjectiveobservations 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%),• cough (50-80%), and• pain (29-33%)• purulent nasal drainage >7 days, and• abnormal in the max sinuses on Water’s,• postnasal drip,• nasal obstruction, and cough• prolonged symptom duration,• purulent rhinorrhoea, and• nasal congestion
Rhinology. 2011 Sep;49(3):264-71.
Int J Pediatr ORL. 2012 Jan;76(1):70-5.
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 dayso Persistent symptoms after 10 days
• Suggestive of acute bacterial RS, >3 of:o Discloured discharged, unilateral predominanceo Purulent secretion in cavum nasio Severe local pain, unilateral predominanceo Fever >38ºCo ESR/CRPo Double sickening
Rhinology, EPOS 2012
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Medical treatment of ARS
• Antibiotics, the most frequently usedtherapeutic agents
• Intranasal steroid• Nasal irrigation• Antihistamine• Decongestant, oral or intrnasal• Erdosteine
Most episodes of ARS are self-limitedand will resolve spontaneously
Rhinology, EPOS 2012
Uncomplicated viral CC / ARS
Pediatrics 2013;132:e262–e280
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Daily practiceUpper resp symptoms
Signs of infection:source, fever, myalgia, …
Commoncold
Rhino-sinusitisacute, viral
Allergic rhinitis(non-infection)
Rhino-sinusitisacute, bacterial
• severe onset ie, >39C• >5 days, worsening• >10 days, persistence
-+
Rhinology; EPOS 2012IDSA 2012 gln Acute rhinosinusitisPediatrics 2013;132:e262–e280
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 resistanceremains to be determined.
Rhinology, EPOS 2012
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Medical treatment of ARS
• Intranasal steroid (INS)oMometasone furoateo Fluticasone furoate
• Evidence for INS as additional treatment• Evidence, high dose of INS (twice than AR
dose) might be effective as monotherapy forARS
Intranasal steroids might have a beneficialancillary 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 thepediatric population.
• 15-30% of pharyngitis cases among school-agedchildren 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 featuresViral phrayngitis• Conjunctivitis• Coryza• Cough• Diarrhea• Hoarseness• Ulcerative stomatitis• Viral exanthema
Streptococ pharyngitis• Sudden onset• Age 5–15 years• Fever• Headache• Nausea, vomiting, abd pain• Tonsillopharyngeal
inflammation• Patchy exudates• Palatal petechiae• Anterior cervical adenitis
IDSA 2012 guidelines
Streptococcal pharyngitis
palatal ptechiaepatchy exudates
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IDSA 2012 guidelines
IDSA 2012 recommendations – D/.
• Testing for GAS pharyngitis usually is notrecommended for children or adults with acutepharyngitis with clinical and epidemiological featuresthat strongly suggest a viral etiology (eg, cough,rhinorrhea, hoarseness, and oral ulcers; strong, high).
• Swabbing the throat and testing for GAS pharyngitis byrapid antigen detection test (RADT) and/or cultureshould be performed because the clinical featuresalone do not reliably discriminate between GAS andviral pharyngitis
• Anti-streptococcal antibody titers are notrecommended in the routine diagnosis
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IDSA 2012 recommendations – T/.
• Patients with acute GAS pharyngitis should betreated with an appropriate antibiotic at anappropriate dose for a duration (usually 10days). Penicillin or amoxicillin is therecommended drug of choice (strong, high)
• in penicillin-allergic individuals should includea 1st gen cephalosporin for 10 days,clindamycin or clarithromycin for 10 days, orazithromycin for 5 days (strong, moderate).
IDSA 2012 guidelines
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Rhino-bronchitis
Acute (rhino)bronchitis
• a clinical syndrome produced by inflammation ofthe trachea, bronchi, and bronchioles.
• in children, acute bronchitis usually occurs inassociation with viral resp infection / C. cold
• acute bronchitis is rarely a primary bacterialinfection in otherwise healthy children.
• self-limited, with complete healing and fullreturn to function typically seen within 10-14days following symptom onset
emedicine.medscape.com/article/1001332-overview
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Epidemiology
• The incidence of acute bronchitis is equal inmales 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 anotherpeak seen in children aged 9-15 years
emedicine.medscape.com/article/1001332-overview
History, symptomatology
• begins as a respiratory infection that manifests as thecommon cold.
• symptoms often include coryza, malaise, chills, slightfever, 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 bacterialinfection
• ‘rattling sound’ in the chest due to excessive mucousproduction
emedicine.medscape.com/article/1001332-overview
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Pathophysiology
• upper respiratory tract spread to lowerrespiratory tract (United airway concept)
• the inflammatory response of the mucousmembranes within the lung’s bronchialpassages
• Airway inflammation: oedema,mucoussecretion, 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 respinfections; +90% are viral, 10% bacterialo Adenoviruso Influenzao Parainfluenzao Respiratory syncytial viruso Rhinoviruso Human bocaviruso Coxsackieviruso 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 airwayChest 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-limitedprocess in the otherwise healthy child
• it frequently results in absenteeism fromschool
emedicine.medscape.com/article/1001332-overview
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Treatment
• Medical therapy generally targets symptoms and includesuse of analgesics and antipyretics.
• Antitussives & expectorants are often prescribed but havenot been demonstrated to be useful
• In healthy individuals, antibiotics has no benefit in relievingsymptoms or improving the natural history
• Placebo-controlled studies using doxycycline, erythromycin,and trimethoprim-sulfamethoxazole have failed to showsignificant benefit in patients with acute bronchitis.
• Preliminary studies suggest a possible role for Pelargoniumsidoides roots, in the treatment of pediatric patients (1-18yrs) with acute bronchitis
emedicine.medscape.com/article/1001332-overview
Scheme Upper resp & infection symptoms
Rhinosinusitis
PharyngitisCommon cold
RhinitisNasopharyngitis
RhinopharyngitisSelesma
Common coldRhinitis
NasopharyngitisRhinopharyngitis
SelesmaRhinobronchitis
Croup
PneumoniaLower resp symptomatology
ABRS
GAS
Need ABBronchiolitis
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