CHAPTER 5 - RESPIRATORY
THESE NOTES MUST BE READ
to use this chapter’s protocol revision materials successfully.
This does not substitute for a thorough reading of the introduction as well.
I have previously published three sets of protocols, specifically Nurse Practitioner Protocols, First Edition (1989), Second Edition (1994); Physician Assistant Protocols, First Edition (1989); Physician Assistant Protocols, Second Edition (1994); and Ambulatory Family Practice, First Edition (1989), Ambulatory Family Practice, Second Edition (1994); all of which were updated by the 1995 Supplement. At the time of publication of the Nurse Practitioner Protocols, Third Edition, hereafter NPP3 (2000), I published a much smaller printing run of Physician Assistant Protocols, Third Edition (2000) hereafter PAP3 (2000); and an even shorter run of Ambulatory Family PracticeThird Edition (2000), hereafter AFP3 (2000). The size of the runs reflected number of sales. I made this decision knowing I could use NPP3 as the single update for all three sets should the shorter runs sell out, since the distinctions between the three books were minor and easily noted by the clinician as the protocols were adapted in practice.
The protocols now being posted online are intended for users of all three prior sets. Ideally, however, a user of these updates will have in hand the NPP3 (2000), PAP3 (2000) or AFP3 (2000) Edition. Specific recommended changes in the text of the protocols are written as if they apply generally to all three 2000 texts, however for simplicity I will refer to NPP3 (2000) or just NPP3. If there is seeming specificity to NPP3 (2000); it should be easy for the clinician to make the transition to the other two books.
In publishing online these protocol revisions, I am providing three things: a thorough discussion of new developments in medicine and changes in medical practice since the publication of NPP3, PAP3, and AFP3; extensive references (primarily online with hyperlinks) to valuable resources for primary care clinicians, along with recommendations for the use of such resources; and in many instances, specific recommended changes to the language of the these 2000 protocols consistent with the changes in medicine and medical practice since its publication.
To use these protocol revisions properly and effectively, the clinician needs to be clear about what I am providing and when, and I have attempted to provide that clarity through the use of text formatting as illustrated here:
Practice notes are written in regular 12-point typeface and are not changes in protocol language.
Changes to the language of specific protocols are in 10-point bold typeface, and the layout of the change follows the layout of the former protocol.
Headings from the layout of NPP3 protocols are also in 10-point bold type, which distinguishes them from headings related to my own practice notes which are in regular 12-point type.
Within the discussion ofprotocols (original and changes to originals),
clinical notes are in bold type and centered,
and practice notes are left justified and in regular (not bolded) 12-point type.
Centered text in 14-point bold type
is used to emphasize issues which are critical for the clinician’s consideration.
Endnotes for all the protocols in a given chapter (e.g., “Gynecology”) are found at the end of that chapter. Hyperlinks (in blue type) to important online materials are embedded in the relevant text of the protocol revisions and also provided in a corresponding endnote. The clinician on our website can immediately access these hyperlinks and usually download useful materials. CAUTION: the hyperlinks are to websites current at the time the protocol is posted; it behooves the clinician to compliment the use of the hyperlinks I have provided with further relevant web searches. I also make note of websites which should be frequently consulted in practice as a matter of course (e.g., the links for Healthcare Providers and for immunization recommendations, the homepage, and the website of the Agency for Healthcare Research and Quality (AHRQ), the body which sets the standards for healthcare quality, at Clinicians should recognize that many references or sources of information can be found on multiple websites. I have tried to select for you the most helpful sites, though several others may be equally accessible and useful.
I have followed the AMA citation style, with some exceptions for simplification; information sufficient for further research is always provided in the citation. I will also be posting a blog on this website, and any suggestions for clarification of the text and its formatting will be welcomed.
MMC MD
AMBULATORY PRIMARY CARE PROTOCOLS SUPPLEMENT 2009
Copyright © 2009 by Matthew M. Cohen, M. D.
CHAPTER 5 - RESPIRATORY
NOTE: A number of the disorders covered by these protocols mayrequire antibiotics, but these disorders are ones in which inappropriatetreatment or over-treatment by antibiotics is tempting and frequent. Beadvised: the consequences of overuse can be severe for patients and for disease control.
CROUP & LARYNGOTRACHEOBRONCHITIS [5-1]
The protocol for croup as printed is reasonably current,although the clinician should be more aware of some areas. This is a common disorder in child from ages 6 to 36 months, and it peaks between ages 12- 24 months.
ASSESSMENT. Assessment remains the most important area and is accomplished mostly by physical exam and severity. It is directed at the likelihood that the patient has mild croup and can be treated as an outpatient at home.
Differential Diagnosis.Laryngeal/subglottic causes include: viral croup, spasmodic croup, foreign body, bacterial rachitic, laryngomalacia ± viral infection (in infants), congenital abnormality, diphtheria, thermal/chemical injury, intubation trauma, laryngospasm (associated with neurologic disorder, hypocalcaemia, or reflux). Supraglottic causes include:acute tonsillar enlargement (due to bacterial or viral infection), foreign body, retropharyngeal abscess, epiglottitis (rare), acute angioedema. Tracheal causes include; foreign body, bacterial tracheitis, tumor (e.g., anterior mediastinal lymphoma), trauma (e.g., hematoma), and trauma (e.g., hematoma).
Specific Measures. Practitioners should be aware that in emergency rooms and even in office settings, clinicians are using corticosteroids[1]more often as initial therapy in a single dose.This should be given consideration in office practice.Most commonly,the dose is dexamethasone 0.6 mg/kg intramuscularly, though oral dexamethasone and prednisone can be given very effectively to the older child. Similarly, nebulized racemic epinephrineor albuterol and budesonide are used as well. Reviewed literature suggestsdecreased inspiratory stridor and intercostal retractions are observed within 30 minutes of administering epinephrine, and the duration of action is about two hours.Common adverse effects include tachycardia and hypertension, so it should be used with caution in patients who have heart conditions or arrhythmias. Because the effect of epinephrine is brief, croup symptoms may reappear, demonstrating a rebound phenomenon. In the emergency department, children who have received nebulized epinephrine may be discharged if they have been observed for three to four hours and have no stridor at rest, normal air entry, good color, normal level of consciousness, and have received steroid therapy. Similar criteria can be used in the office setting.
The Physician Consultation and Immediate Transport sections should be revised. The original protocol covers two critical possibilities -- epiglottitis and foreign body aspiration – to which should be added retropharyngeal abscess and bacterial tracheitis. In addition,most children should be sent to the emergency room or directly admitted[2] and treated if they have one or more of the following circumstances: current significant respiratory distress (stridor at rest - low pulse oximetry), a history of severe obstruction before presentation, a history of previous severe croup or known structural airway anomaly (e.g., subglottic stenosis), poor fluid intake, less than 6 months of age, parental anxiety, poor response to initial treatment, re-presentation, or clinician uncertainty about the diagnosis.
INFLUENZA (CHILDREN AND ADULTS) [5-2]
NOTE: Protocol 5-2 should now be split into two protocols: INFLUENZA (CHILDREN)[5-2A] and INFLUENZA (ADULTS) [5-2B]. The clinician using this update should add the protocol text provided below to the language of 5-2 and create two new protocols, Protocol [5-2A] and Protocol [5-2B], consistent with the format in the 2000 edition. A blank format page which can be used for creating the new pages can be found atpage xviii of the Frontis section of the 2000 Edition. Text for new Protocols [5-2A] and [5-2B] is as follows:
INFLUENZA (CHILDREN) [5-2A]
NOTE: CDC has a site which contains complete information[3]for professionals covering every aspect of influenza.
Lab.Historically, lab tests were not used, particularly in communities with known outbreaks among adults and children, but with epidemiological uncertainty, one cannot clinically diagnose influenza virusinfections in children with confidence. Many respiratoryviruses (e.g., parainfluenza, respiratory syncytial virus, adenovirus,and Coxsackie virus) cause similar symptoms and signs. For influenza A and B, rapidenzyme-linked immunosorbent assay and polymerase chain reactiondiagnostic tests are available but havenot been widely used in the office setting.
General Measures. Revise last sentence to read: Acetaminophen or ibuprofen may be used as an antipyretic, but caution parents in the strongest of terms not to use aspirin; doses need to be appropriate for weight and age.
Specific Measures.
NOTE: Specific Measures are different for children who need immunization, children who need post-exposure prophylaxis, and children who need treatment.In the course of preparing this supplement, the recommendations for influenza immunizations for children have changed numerous times. Consult frequently the CDC Immunization Guidelines[4]for children.
Children who need post-exposure prophylaxis. For Influenza A, only three antiviral medications (amantidine, rimantadine, and oseltamivir) are approved for chemoprophylaxis in the United States. CDC encourages the use of amantidine or rimantadine for chemoprophylaxis and use of oseltamivir or zanamivir for treatment as supplies allow, in part to minimize the development of adamantine resistance among circulating influenza viruses. I expect this recommendation to change at some time as supply meets demand. Neuraminidase inhibitors (e.g., oseltamivir and zanamivar)are active against influenza A and B,[5]and are often used in other countries for adults.Their role in young children has not been clearly established,although authors of a recent Cochrane review of the evidenceconcluded that they were effective in shortening illness durationin previously healthy children aged 1–12 years with aclinical or laboratory diagnosis of influenza and that efficacyin children with asthma remains to be proven.[6]
Children who need treatment. In the United States, “four antiviral medications (amantidine, rimantadine, oseltamivir, and zanamivir) are approved for treatment of influenza. When used for treatment within the first two days of illness, all four antiviral medications are similarly effective in reducing the duration of illness by one or two days.”[7]
INFLUENZA (ADULT) [5-2B].
NOTE: CDC has a site which contains complete information[8] for professionals covering every aspect of influenza.
Lab. Lab tests were not used historically, particularly in communities with known outbreaks among adults and children. This standard may change, see [5-2A] Lab.
General Measures. Acetaminophen or ibuprofen may still be used as an antipyretic, but there are reports of older teens and young 20-year-olds having Reyes syndrome. I do not recommend using aspirin in patients under 21. (Clinicians, however, should remember that aspirin use has resulted in Reyes in older adults presenting with encephalopathy.)
Specific Measures. For adults who need prophylaxis, consult CDC Immunization Guidelines[9] for adults.
NOTE: Specific Measures are different for adults who need prophylaxis and adults who need treatment.
NOTE: Adults who need post-exposure prophylaxis. For Influenza A, only three antiviral medications (amantidine, rimantadine, and oseltamivir) are approved for chemoprophylaxis in the United States, but neuraminidase inhibitors (e.g., oseltamivir and zanamivar) are active against influenza A and B, and are often used in other countries for adults.[10] Their role in young children has not been clearly established,although authors of a recent Cochrane review of the evidenceconcluded that they were effective in shortening illness durationin previously healthy children aged 1–12 years with aclinical or laboratory diagnosis of influenza and that efficacyin children with asthma remains to be proven.[11]
NOTE: Treatment for adults also includes the same four drugs. The neuraminidase inhibitors (e.g., oseltamivir and zanamivar) should be used if it is not known whether the patient has influenza type A or type B.
NOTE: You may need to reduce the doses in the elderly.
NOTE: Doses should be individualized during pregnancy.
Additional Notes.
NOTE: CDC encourages the use of amantidine or rimantadine for chemoprophylaxis and use of oseltamivir or zanamivir for treatment as supplies allow, in part to minimize the development of amantadine resistance among circulating influenza viruses.
NOTE: Those in high risk populations and at high risk of serious complications who have been vaccinated but have not had time to mount an immune response to the vaccine need prophylaxis. In adults, chemoprophylaxis should occur for a period of 2 weeks after vaccination. Chemoprophylaxis should also be provided for the immune compromised who are not expected to mount a significant response to immunization. All four drugs discussed for use in children can be used for prophylaxis in adults.
BRONCHIOLITIS, CHILDREN [5-3]
The management of bronchiolitis[12]remains important. Bronchiolitis is “the most common serious lower respiratory tractinfection in infants. Among total hospitalizations for childrenyounger than 1 year, the proportion associated with bronchiolitisincreased from 5.4% in 1980 to 16.4% in 1996. It is the mostcommon cause of pediatric hospital admissions during the wintermonths and has been associated with 200 to 500 deaths in theUnited States annually.”[13] As written it is useful with the addition of slight changes. The changes may have big repercussions however, or at least that is the case in a national survey done by the AAP. “Since 1980, the rate of hospitalization for children with bronchiolitis has increased by nearly 250%, whereas mortality rates for the disease have remained constant.”[14]
Lab. Consideration should be given to the use of pulse oximetry. Low SpO2rates,i.e. those <95% and particularly those <92%, have increased the incidence of rising admission rates. Pulse oximetry’s availability has also impacted the frequency of ordering of other laboratory tests. In addition to thechest x-ray, the next most popular test is respiratory syncytialvirus (RSV) antigen detection. Other tests, including CBC, arterial blood gas, blood cultures, serum electrolytes are also being looked at more frequently for children in emergency room settings and for those already admitted, without clarity about whether they provide specificity and sensitivity toward predictive value in course and outcome for the patient.
General Measures. Add: The use of supportive measures in the outpatient setting has to be individualized.
Specific Measures. Many if not all infants – depending upon a clinician’s setting – may still require hospitalization for specific measures. The use of specific measures in the outpatient setting has to be individualized.
Physician Consultation,Referral, andImmediate Transfercriteria should be discussed thoroughly by the clinicians in a practice. All children under 3 months of age,as well as those already discussed in the protocol, should be referred to the emergency room or directly admitted. Pulse oximetric criteria warrant discussion, too.
Additional Notes. A good outpatient management protocol[15]has been developed by Denise M. Goodman, M.D.
ACUTE BRONCHITIS, CHILDREN [5-4]
NOTE: Acute bronchitis remains an appropriate clinical diagnosis where cough is the predominant symptom and other diagnostic possibilities have been excluded.
ASSESSMENT. Assessment is directed at severity of respiratory difficulty as previously written Etiologically, these are mostly viral infections. In patients younger than 1 year (see [5-3]preceding), respiratory syncytial virus, parainfluenza virus, and coronavirus are the most common isolates. In patients 1 to 10 years of age, parainfluenza virus, enterovirus, respiratory syncytial virus, and rhinovirus predominate. In patients older than 10 years, influenza virus, respiratory syncytial virus, and adenovirus are most frequent.
General Measures. Add: Emphasize to the parents that this can be a protracted illness lasting 10-14 days. And, more significantly, that these are overwhelmingly caused by viruses – therefore antibiotic therapy is not usually indicated.
Specific Measures. As written in 2000, the format inappropriately emphasizes antibiotic use, which should not be overused. Other measures widely used by clinicians, such as “protussive” therapy with products containing guaifenesin or antitussives, do not hold up in evidence-based analysis as being efficacious.
ACUTE BRONCHITIS, ADULTS [5-5]
Acute bronchitis is one of the top 10 conditions for adult patients who are seen for medical care.
ASSESSMENT. Assessment continues to be a clinical diagnosis. Often it is not necessary to sort among the infectious etiologic viral agents: adenovirus, coronavirus, coxsackievirus, enterovirus, influenza virus, parainfluenza virus, respiratory syncytial virus, rhinovirus. Viral infections are the most common causes of bronchitis in adults, with seasonal variations in the viruses. Parainfluenza virus, enterovirus, and rhinovirus infections most commonly occur in the fall. Influenza virus, respiratory syncytial virus, and coronavirus infections are most frequent in the winter and spring.[16]
Acute bronchitis can have a variety of bacterial causes,including Bordetella pertussis, Bordetella parapertussis, Branhamella catarrhalis, Haemophilus influenzae, Streptococcus pneumoniae, and atypical bacteria (e.g. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species), and a variety of other causes, such as yeast and fungi, including Blastomyces dermatitidis, Candida albicans, Candida tropicalis, Coccidioides immitis, Cryptococcus neoformans, Histoplasma capsulatum.
The noninfectious triggers, such as asthma, air pollutants and other chemical inhalants(e.g., ammonia), cannabis, tobacco, trace metals, etc.should also be considered.
General Measures. It is interesting to note that patient satisfaction with the treatment of acute bronchitis[17]has been found to be more related to the quality of the physician-patient interaction rather than to prescription of an antibiotic. An acute bronchitis patient information handoutcan also be found in this article on page 2036.[18]