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03/10/2013 1 TOPIC 2. UNITED AIRWAY CONCEPT ARI management training

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Page 1: 13-10 Topic 2. United Airway Concept

03/10/2013

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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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THANK YOU