Upper Respiratory Tract Infections | Jindal Chest Clinic

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Upper Respiratory Tract Infections

• Surinder K. Jindal
• (Emeritus Professor Ex-Head, Pulm Med, PGIMER,
  Chandigarh)
• Medical Director, Jindal Clinics, Chandigarh
• www.jindalchest.com

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Defense mechanisms of respiratory tract

• Anatomical site
• Conducting zone (Nose, Nasopharynx, Larynx,
  Tracheobronchial region excluding respir
  bronchioles)
• B. Gas exchange region Alveolar macrophages
• (Terminal or respir bronchioles and alveoli)
• NALT Nasopharynx-Associated Lymphoid Tissue
  BALT Bronchus-Associated Lymphoid Tissue

• Defense mechanism
• Mechanical barrier
• Lymphoid tissue adenoids, tonsils, Waldeyers
  ring
• NALT, BALT
• Mucociliary mechanism
• Secretory IgA
• Sneeze and cough reflex
• Immunoglobulins (humoral immunity)
• Cell-mediated immunity
• Polymorphonuclear granulocytes

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Risk factors for a URTI

• Close contact with children both day-cares and
  schools increase the risk fo URI
• Medical disorder People with asthma and allergic
  rhinitis are more likely to develop URI
• Smoking - a common risk factor for URI
• Immunocompromised individuals including those
  with cystic fibrosis, HIV, use of
  corticosteroids, transplantation, and
  post-splenectomy
• Anatomical anomalies including facial dysmorphic
  changes or nasal polyposis also increase the risk
  of URI

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Transmission

• URIs spread from one person to another through
  aerosol droplets and direct hand-to-hand contact.
  
• Risk is increased in these situations
• i. Sneezing or coughing without
  covering the nose mouth
• ii. In a closed-in area or crowded
  conditions
• iii. Hospitals, institutions, schools,
  and day care
• centers have increased risk -close
  contact.
• Touch of nose or eyes. Infection occurs when the
  infected secretions come in contact with nose or
  eyes. Viruses can live on objects, such as
  doorknobs.
• Seasonal when people are more likely to be
  inside.
• Indoor heating favors survival of many viruses
• Weakened immune system.

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Clinical Symptoms Symptoms
usually begins one to three days after exposure
lasts 710 days, and can persist up to 3 weeks

• Respiratory

• General Constitutional

• Cough Wet or dry
• Sore throat
• Sneezing
• Chest or nasal congestion
• Pressure in the ears and sinuses
• Runny nose
• Watery discharge from the nose thickens and turns
  yellow or green, mild

• Fatigue, Malaise, Myalgias
• Body aches.
• Headache
• Low-grade fever
• Facial pressure
• Burning eyes
• Chills
• Achy muscles and bones

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Microbial Causes of URTI Both viruses and
bacteria can cause acute URIs

• Viruses

• Bacteria

• Group A beta-hemolytic streptococci
• Group C beta-hemolytic streptococci
• Corynebacterium diphtheriae (diphtheria)
• Neisseria gonorrhoeae (gonorrhea)
• Chlamydia pneumoniae (chlamydia)

• Rhinovirus
• Adenovirus
• Corona virus
• Coxsackievirus
• Parainfluenza
• Respiratory Syncytial Virus
• Human metapneumovirus

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Diagnosis

• Tests of nasopharyngeal specimens for specific
  pathogens such as Rapid antigen detection/
  cultures
• i. When targeted therapy depends on the
  results (eg, group A streptococcal infection,
  gonococcus, pertussis).
• ii. When patients are immunocompromised
• iii. During outbreaks
• iv. To provide specific therapy to
  contacts.
• General hematological and biochemical tests
• Imaging Warranted in patients with suspected
  mass lesions (eg, peritonsillar abscess,
  intracranial suppurative lesions).
• Chest X-ray Neck X-ray (Lat. view) CT
  scan (PNS)
• Blood cultures are typically appropriate only in
  hospitalized patients with suspected systemic
  illness.

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Common Cold

• Responsible pathogens rhinovirus, adenovirus,
  parainfluenza virus, respiratory syncytial virus,
  enterovirus, and coronavirus.
• Rhinovirus is the most common cause
  in up to 80 of all respiratory infections
  Dozens of rhinovirus serotypes and frequent
  antigenic changes make identification,
  characterization, and eradication complex.
• Symptoms Appear as soon as 10 to 12 hours after
  inoculation.
• The mean duration of symptoms is 7 to
  10 days, but can persist
  for as long as 3 weeks.
• Vasodilation and increased vascular
  permeability
• Nasal obstruction and rhinorrhea
• Mucus production and sneezing due to
  cholinergic stimulation

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Common Cold -Differential Diagnosis

• Common cold- a clinical diagnosis
• i. Classical features for rhinovirus
• infection
• ii. absence of signs of bacterial
• infection or serious respiratory
• illness
• Diagnostic testing is not necessary. When
  testing for influenza obtain specimens as close
  to symptom onset as possible.
• Nasal aspirates and swabs are the best
  specimens. Rapid strep swabs can be used to rule
  out bacterial pharyngitis

• Common Cold
• Allergic rhinitis
• Sinusitis
• Tracheobronchitis
• Pneumonia
• Influenza
• Atypical Pneumonia
• Pertussis
• Epiglottitis
• Streptococcal Pharyngitis/Tonsillitis
• Infectious Mononucleosis

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Viral Nasopharyngitis

• Usually referred as the common cold
• Paucity of clinical findings despite notable
  subjective discomfort.
• Findings may include the following
• Nasal mucosal erythema and edema
• Nasal discharge Profuse
  discharge
• i. more characteristic of
  viral than bacterial
• infections
• ii. initially clear
  secretions typically become cloudy white,
• yellow, or green over
  several days
• Foul breath
• Fever Less common in adults may be present in
  children

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Influenza

• The incubation period for influenza1 to 4 days
• Time interval between symptom onset is estimated
  to be 3 to 4 days. Viral shedding can occur 1 day
  before the onset of symptoms.
• Influenza can be transferred among humans by
  direct contact, indirect contact, droplets, or
  aerosolization. Short distances (lt1 meter)
  are generally required for contact and droplet
  transmission to occur between the source person
  and the susceptible individual.
• Airborne transmission may occur over longer
  distances (gt1 m). Most evidence-based data
  suggest that direct contact and droplet transfer
  are the predominant modes of transmission for
  influenza. 

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Group A streptococcal infection

• Pharyngitis

• Laryngotracheitis and laryngotracheobronchitis

• Erythema, swelling, or exudates of the tonsils or
  pharynx
• Temperature of 38.3C (100.9F) or higher
• Tender anterior cervical nodes (1 cm)
• Absence of conjunctivitis, cough and rhinorrhea,
  which are symptoms that may suggest viral
  illness 

• Nasopharyngitis often precedes laryngitis and
  tracheitis by several days
• Swallowing may be difficult or painful
• Patients may experience a globus sensation of a
  lump in the throat
• Hoarseness or loss of voice is a key
  manifestation of laryngeal involvement

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Acute bacterial rhinosinusitis

• In children, acute bacterial sinusitis is defined
  as a URI with any of the following  
• Persistent nasal discharge (any type) or cough
  lasting 10 days or more without improvement
• Worsening course (new or worse nasal discharge,
  cough, fever) after initial improvement
• Severe onset (fever of 102 or greater with nasal
  discharge) for at least 3 consecutive days.
• In older children and adults, symptoms (eg, pain,
  pressure) tend to localize to the affected sinus.

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Acute Sinusitis

• The most common bacterial agents
• - Streptococcus pneumoniae
• - Haemophilus influenzae
• - Moraxella catarrhalis
• Other organisms Staphylococcus aureus,
  Streptococcus pyogenes, Gram-negative organisms
  and anaerobes
• Signs and symptoms
• - Nasal blockade, discharge
• - Fever, other constitutional symptoms
• - Facial pressure, pain
• - Headache

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Epiglottitis

• More often found in children aged 1-5 years, who
  present with a sudden onset of the following
  symptoms
• - Sore throat
• - Drooling, difficulty or pain during swallowing
• - Globus sensation of a lump in the throat
• - Muffled dysphonia or loss of voice
• - Dry cough or no cough, dyspnea
• Fever, fatigue or malaise (may be seen with any
  URI)
• Tripod or sniffing posture
• May sometimes prove to be fatal upper
  respiratory obstruction

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Whooping cough (Pertussis)

• The classic whoop sound - an inspiratory gasping
  squeak that rises in pitch, typically
  interspersed between hacking coughs
• The whoop is more common in children
• Coughing often comes in paroxysms of a dozen
  coughs or more at a time and is often worst at
  night
• The 3 classic phases of whooping cough
• - Catarrhal (7-10 days) predominantly URI
  symptoms
• - Paroxysmal (1-6 weeks) with episodic cough
• - Convalescent (7-10 days) of gradual
  recovery

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COVID-19

• Caused by novel corona virus (SARS-CoV2), which
  is currently responsible for a global pandemic.
• Starts with involvement of upper respiratory
  tract (nose, sinuses, pharynx and larynx).

• Most (around 80) starts with flu-like symptoms
• i. Fever
• ii. Headache
• iii. Cough, usually dry
• iv. Others myalgias
• (especially back pain),
• loss of smell, anorexia,
• fatigue, nausea (usually
• without vomiting)
• v. Abdominal discomfort
• Occasionally, diarrhoea.

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Diagnosis of specific disorders

• Group A streptococcal infection

• Acute bacterial rhinosinusitis

• Laboratory studies are generally not indicated
• Computed tomography scanning or other sinus
  imaging-
• i. if symptoms persist despite therapy
• ii. complications (eg, extension of disease
  into surrounding tissue

• Clinical findings or a history of exposure to a
  case
• Results of rapid-detection assays
• Cultures (positive rapid antigen detection tests
  do not necessitate a backup culture)

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Other specific infections

• Influenza Rapid tests have over 70 sensitivity
  and more than 90 specificity
• Mononucleosis Antibody testing (eg, Monospot)
• Herpes simplex virus infection Cell culture or
  polymerase chain reaction (PCR) assay
• Pertussis Rapid tests culture of a
  nasopharyngeal aspirate (criterion standard)
• Epiglottitis Direct visualization by
  laryngoscopy, performed by an otorhinolaryngologis
  t
• Gonococcal pharyngitis Throat culture
  for Neisseria gonorrhoeae
• Tubercular laryngitis

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COMPLICATIONSSpread to Lower Respiratory Tract

• Epiglottitis dangerous because it can block the
  flow of air into the trachea.
• Laryngitis inflammation of the larynx or voice
  box.
• Tracheitis
• Bronchitis Inflammation of the bronchi both
  central and peripheral
• Bronchiolitis
• Pneumonia Inflammation of the lung alveoli
• ARDS Respiratory Failure

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Secondary Bacterial Infection

• Warning signs that cold has progressed from a
  viral infection to a bacterial infection
• Symptoms lasting longer than 1014 days.
• A fever higher than 100.4 degrees.
• A fever that gets worse a couple of days into the
  illness, rather than getting better.
• White pus-filled spots on the tonsils
• Small amounts of white mucus may be coughed up if
  the bronchitis is viral. If the color of the
  mucus changes to green or yellow, it may be a
  sign that a bacterial infection has also set in.
  The cough is usually the last symptom to clear up
  and may last for weeks.

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Summary

• 1. URTI is the most common acute illness
  evaluated in the outpatient setting.
• 2. URTI commonly include Common cold typically
  a mild, self-limited, catarrhal syndrome of the
  nasopharynx, mild flu, tonsillitis, laryngitis,
  epiglottitis and sinusitis
• 3.Specific infections constitute a distinctly
  separate category
• 4. Most common causes Viral Bacterial
• 5. Progression can occur from a viral to a
  bacterial infection
• 6. Generally self-limiting can lead to serious
  complications such as pneumonias and respiratory
  failure
• 7. Diagnosis Mostly based on clinical features

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