Respiratory conditions
J Dickinson
August 2015
Objectives
• Better understanding of respiratory
symptoms and their meaning
• Improve prescribing for
– Respiratory tract infections
– Allergic disease
• Become more aware of resources to assist
prescribing and care
• Apply Principles of Family Medicine
Outline
• Introduction:
– common clinical presentations
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Antibiotics for Respiratory infections
Allergic disease
Field trip
Answers to case examples
Putting it together
Case 1
Bus driver age 36 has a running nose and
cough 2 days. Temp 37.6. Sleeping
poorly - cough, difficulty driving,
because of sneezing and coughing.
Case 2
Child age 7 running nose, fever 38.1, sore
throat, mildly enlarged and tender
cervical nodes, left ear slightly red.
Mother asks does he need antibiotics?
His doctor always gives him antibiotics
for sore ears.
Case 3
Housewife aged 40, previously smoker,
had URTI last week that has improved,
but now has persistent cough, especially
at night. She says she coughs up
sputum, with difficulty, then swallows it.
Case 4
• Johnny 12yrs. Cold 3 weeks, initial fever,
persisting blocked runny nose
• green mucus, slight cough.
• Can you give him antibiotics?
• He has had 4 attacks/year.
• Decreased resistance to infection? Should
you investigate his immune system?
Case 5
• Tina 17yrs. Cough 4 weeks.
• fever 2 days originally.
• Now persisting cough, comes in bouts that
can be exhausting.
• ?bronchitis Can she have antibiotics?
Case 6
• Mr Mc Donald age 32. Cigarette smoker.
• Has severe frontal headache 4 days
• Tender to pressure over frontal areas
and Rt maxilla.
• Has chronic nasal blockage most of time
Good clinical practice
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Decide the diagnosis: know criteria
Decide the treatment: antibiotics or not
Discuss with patient
Reach agreement on the best solution
Use compliance aiding strategies to ensure the
patient takes the medication.
The Swamp of Primary Care
In the varied topography of professional
practice, there is a high hard ground
overlooking a swamp. On the high ground,
manageable problems lend themselves to
solution through the application of researchbased theory and technique. In the swampy
lowland, messy confusing problems defy
technical solutions.
Donald Schon: The Reflective Practitioner.
Jossey-Bass 1990
Why do doctors prescribe
antibiotics?
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Wanting to be nice
Giving something to patients
Avoiding conflict
The patient does not trust me
Uncertainty about diagnosis
Wanting to ensure that no risk
Veldhuis Wigersma and Okkes Br J Gen Pr 1998: 1833
Questions
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What do patients want?
What do patients need?
How can we give them what is good for them?
What is good antibiotic prescribing?
How do you learn about good prescribing?
How can you do everything in 10 minutes?
What do patients with sore throat want?
Belgium GPs (50% get antibiotic)
1 To be examined for the cause of sore throat
2 To get something for the pain*
3 Dr to explain the course of the problem
4 Dr to explain how serious the problem is
5 How soon will I recover?
6 Explain possible treatments
10 sick note for work or school
11 Antibiotics*
M L van Driel et al. Ann Fam Med 2007;4:494-499
Parents views
• Playgroups and kindergartens, Brisbane.
• Expectations when attending GP
• Had already tried painkillers, reached limit of
tolerance
• Expect antibiotics: previous experience, no
other alternatives offered
• Fear lasting hearing loss
MP Hansen, JP Howlett, C Del Mar T Hoffman.
BMC Family Pracite 2015;16:82
Reality of practice
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Diagnosis unclear
Patient has ideas of what they want
Antibiotics are not enough
Antibiotics often not recommended
Need symptom control!
Diagnosing Otitis Media?
Symptoms:
Ear Pain LR 3
Fever, upper resp symptoms, irritability
Signs:
Cloudy drum LR 34
Bulging LR 51
Immobile on pneumatic otoscopy LR31
Red membrane LR 8
Normal colour LR 0.2
Rational Clinical Examination JAMA 2003;290:1633
Otitis Media
• 1976 Dutch trial
– Myringotomy, antibiotics
• Succession of trials
– Change in criteria for entry
– Severity, age
• Europe vs US
• Delayed antibiotics?
• Retesting on “severe” population.
Rheumatic fever prevention
• Penicillin originally proven on high incidence
population: reduce rate by 70%
• Air force recruits, northern Michigan
• Siegel 1961: children up to 18yrs
Preventing Rheumatic fever
Anneliese Spinks, Paul P Glasziou, Chris B Del Mar
Antibiotics for sore throat. Cochrane Acute Respiratory
Infections Group. Published Online: 5 NOV 2013
DOI: 10.1002/14651858.CD000023.pub4
Rheumatic fever prevention
• Penicillin originally proven on high incidence
population: reduce rate by 70%
• Further trials less effective: only prior to 1970.
After that: no effect
• Rheumatic fever disappeared in developed
world: not developing
• Symptom relief: reduce by one day
• Canada?
Social Conditions!!
Carapetis NEJM 2007;357:439-441
Rheumatic Fever
Global Epidemiology
Rheumatic heart disease - Age-standardized disability-adjusted life years, 2004. Source: WHO
ARF in Canada
• Canadian Pediatric Surveillance
Program (2004-2007)
– 2.9 cases per million population <18
• Local case-studies - no data on rates
– Manitoba (1970-79) - 494 cases
– Montreal (1979-2005) - 98 cases
– Northern Ontario (2009) – 5 cases
C Gittens: Methods
• Pediatric hospitalizations, 2004-2011
• ICD-10 CA codes for ARF
• 93 health regions, 9 provinces
• Compared to census data
– Aboriginal population
– Crowded dwellings
Results
• 275 admissions over 7 years
• Rate: 5.58/million population <18
• Moderate correlation with
– Percent aboriginal population >18y
• IRR: 1.37(95%CI: 1.29-1.47)
– Percent of crowded dwellings
• IRR: 3.74(95%CI: 2.66-5.26)
Rheumatic Fever in Canada
• About 20 per year
• 60% Carditis (others chorea)
• 6-17 years
• Success of sore throat treatment: 70%?
• How many attended?
• Does medical ritual help?
ARF
Reduction in most Canadian areas due to:
Availability of antibiotics?
 Access to healthcare
 Patient education
Social circumstances?
 Better housing
 Clean water
 Better nutrition
Should Canadian Physicians
Continue to Swab Throats?
 ARF is
 Largely disease of social circumstance
 Almost non-existent in most of Canada
 No longer reason for widespread throat swabbing
 Goals of treating sore throat should be:
 Prevent complications: but focus on risk
 Decrease inappropriate antibiotic use: harm Rx > disease
 Decrease unnecessary testing: wasteful, causes dependence
 Teach self-care
The problem with TOP
(and many other guidelines)
• Start at the point of “needing antibiotics”
• NOT when we see the patients
• We need to assess who gets into the
algorithm.
• Rethink action and role of antibiotics
Recovery from “acute rhinosinusitis”
De Sutter et al. Ann
Fam Med 2006;4:486493
Effect of Antibiotic prescribing
Increased dependence on doctors for
diagnosis and treatment
• “Learned incompetence”
• Rush to see doctors immediately:
especially for children
• More prescribing
• Resistant bacteria
Resistance lags community prescribing
by one month
Sun L, Klein EY, Laxminarayan R. Clin Infect Diseases 2012
DOI: 10.1093/cid/cis509
Harm from antibiotics
• Antibiotics harmful for group
– Cause community resistance: pneumococci
– Iceland, erythromycin
• Harmful for Individual
– UTI: Within 2 months of previous antibiotic,
new infections twice as resistant to amoxycillin,
trimethoprim
Hay AD, Thomas M et al
J Antimicrob. Chemother. 2005;146-153
Harm from antibiotics
• Direct
– Allergy: rare
– Rash: common, unclear
– Diarrhea: 10-15%
– Toxicity: cardiac, connective tissues
• Indirect
– Asthma from administration under 1 year
Fig 2 Rate of cardiac death and number of excess cardiac deaths with clarithromycin and
roxithromycin, compared with penicillin V. *As calculated from unadjusted rate of cardiac
death. †Adjusted for propensity scores.
Svanström H et al. BMJ 2014;349:bmj.g4930
©2014 by British Medical Journal Publishing Group
Antibiotics in first year of life increase risk of
asthma?
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Meta-analysis
Different study designs
Prospective & database designs
405,000 children, 18,569+ asthma cases
Odds ratio for developing asthma: 1.25
That is: increases risk from 12% to 15%
Murk W et al Pediatrics 2011; 127:1125
Choosing the right antibiotic
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Know pharmacology: sensitivity patterns
Penicillin, Ampicillin/amoxycillin
Amoxycillin for sore throats?
Quinolones:
– side effects, resistance
• Long acting macrolides:
– cause resistance, Clarithromycin: interactions
• Lincosamines: -> C Difficile
• Tetracyclines
– Minocycline vs doxycycline
• Septra vs Trimethoprim
• Cost
• Rao GA1, Mann JR, Shoaibi A, Bennett CL,
Nahhas G, Sutton SS, Jacob S, Strayer SM.
Azithromycin and levofloxacin use and
increased risk of cardiac arrhythmia and
death. Ann Fam Med. 2014 MarApr;12(2):121-7. doi: 10.1370/afm.1601.
• McManus P, Iheanacho I. Don't use
minocycline as first line oral antibiotic in
acne. BMJ 2007; 334 doi:
http://dx.doi.org/10.1136/bmj.39048.540394.
BE (Published 18 January 2007) Cite this as:
BMJ 2007;334:154
Quinolones
• Tendon rupture
• Cardiac death: levofloxacin
• Retinal detachment: NNTH 2500
• Etminan M, Forooghian F, Brophy JM, Bird ST, Maberley D.
• Oral fluoroquinolones and the risk of retinal detachment.
• JAMA. 2012 Apr 4;307(13):1414-9.
How long to treat?
• Cystitis: 3, 5 days
• Strep 10 days?
• Based on expert opinion and convention, not
evidence.
• Long courses: for difficult sites eg biofilm on foreign
body, cardiac valve, urinary stone. (Surgical removal if
possible)
After empirical therapy, esp. for mild infections
STOP when bacterial infection excluded or resolved.
Gilbert GL Knowing when to stop antibiotic
therapy. Med J Aust 2015 202 (3) 121-122
The “medical model”
• Understand the pathology
• Treat the “cause”
• Using prescription drugs
• Is this appropriate?
• Is this sufficient?
What do patients want?
• Many doctors assume that patients want
antibiotics or they would not come
• Some patients do want antibiotics unnecessarily
• Most patients do not want them: They want
– Advice & Diagnosis
– Symptom relief: whatever works
– Certificates
Patients Need
• Problem-solving
– Naming not diagnosis
• Information & Prognosis
– Confidence that not serious
– Trust that immune system will work
• Coping with anxiety
– Delayed start to antibiotics
• Certificates: “Prescribing money”
• Relieving, symptomatic treatment
Antihistamines: OTC
• First generation: Dirty drugs
Sedating, decongestant, antinauseant, appetite stimulant
– diphenhydramine (Benadryl) GRAVOL?
– chlorpheniramine (Chlortripolon)
– brompheniramine
– hydroxyzine (Atarax)
– cetirizine (Reactine) 10mg OTC, 20mg prescription
• Second generation: “Non-sedating”
– loratadine (Claritin)
– desloratadine (Aereus)
– fexofenadine (Allegra)
Cold remedy?
• Multiple combination medications
– Hard to work out what they contain
– One name, many different combinations
• High prices for cheap ingredients
• Easy to overdose
– Cough medicine, decongestant, throat
Combinations
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Antihistamine
Codeine/DM
Decongestant
Acetaminophen
Expectorants
• Dangers: additive, esp. children.
– Now prohibited in N America
Decongestants: OTC
• Systemic
– pseudo-ephedrine 60mg bid-qid. Not hs, HTN
– phenylephrine
– (phenylpropanolamine PPA)
• Local sprays
– phenylephrine
– oxymetazoline, xylometazoline
• Aromatics
– menthol
– eucalyptus
Pharyngitis OTC
• aspirin gargles
• local anaesthetics
• benzdyamine
– (Tantum, Apo-benzdyamine)
• NSAIDs
Cough
• Codeine and related
– dextromethorphan (DM)
– codeine phosphate syrup, tablets
– pholcodeine
• Note
Narcotics
T3
Honey
Expectorants - mucolytics
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Ammonia, Iodide
Ipecacuahna
Bromhexine,
Guiaphenesin,
Ambroxol
Acetylcysteine
Do they work?
Allergic Disease
• Under-diagnosed, undertreated
• Allergic airways disease
– Long-term cough = asthma
• Allergic rhinitis.
Upper Airway Cough Syndrome
• Chronic cough and irritation
• Often blocked nose and feeling of something in
back of throat.
• Associated with “sinusitis”
• Stimulated by URTI
– Persists for weeks
• Related to asthma
Distinguish from (rare) Pertussis and related
Other common cause of chronic cough in adults?
Allergic Disease
• Under-diagnosed, undertreated
• Allergic airways disease
– Long-term cough = asthma
• Allergic rhinitis.
• Upper airway cough syndrome (UACS)
– Long-term runny nose, congestion, “sinusitis”
– 30% of population?
Pathology?
• Mucus seen, but not dripping!
• Allergic inflammation of
nasal/pharyngeal lymphoid tissue
• Extends to larynx
• Cough receptors mainly below larynx,
but some in pharynx
Under-diagnosis of allergy
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Many recurrent “colds and coughs”
Careful questioning and examination
Most have chronic symptoms
Look for signs: cobblestone, nasal edema
If it continues,
It’s allergic!
Therapeutic/diagnostic trial
Under-diagnosis of allergy
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Many “Migraines”
Careful questioning and examination
Most have chronic symptoms
Look for signs: cobblestone, nasal edema
If it continues,
It’s allergic!
Therapeutic/diagnostic trial
http://www.e-therapeutics.ca
Chronic symptoms > 3 weeks
Laryngeal symptoms
• Persistent cough without allergic signs
• Older, especially smokers
• Consider laryngeal cancer
Nasal blockage symptoms
• especially Southern, SE Asian Chinese M
• with any bleeding, ear pain or blockage
• Consider Nasopharyngeal cancer
Treatment of Allergic Rhinitis
by Symptom Class
Definition of Classes
Class I: Mild, intermittent
Class II:
Moderate-to-severe, intermittent
or mild persistent
Class III:
Moderate persistent
Class IV:
Moderate-to-severe to severe, persistent
Treatment of Allergic Rhinitis
by Symptom Class
Class I
Class II
Class III
Class IV
Immunotherapy
Immunotherapy
Oral Steroids
Oral Steroids
Leukotriene receptor antagonists
Leukotriene receptor antagonists
Intranasal corticosteroids
Intranasal corticosteroids
Oral H1 antihistamines
Oral H1 antihistamines
Allergen / irritant avoidance
Allergen / irritant avoidance
Local anti-allergics
For nose, eyes
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Steroids: beclomethasone, etc
Mast Cell stabilisers: cromoglycate OTC
Local antihistamine: levocabastine
Ocular antihistamine: olopatadine
Algorithm for allergy
1. Antihistamines
– Non-sedating: loratadine 10mg daytime
– Non-selective: chlorpheniramine 4mg at night
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Steroid nasal spray
Montelukast 10mg in evening (Blue Cross)
Cromoglycate spray Q6h (OTC)
Oral prednisone 25mg
Nasal saline (Neti-pot)
Principles of Prescribing
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Clear indication
Appropriate drug
Appropriate dose
Appropriate route
Appropriate interval
Will it do more good than harm?
Does Diagnosis Matter?
• Subversive thought
• Often, but not always
• Useful way-station on road to management
• No excuse for fuzzy thinking
Know your drugs
• Effects
• Spectrum of action
• Side effects
• COST
• Pharmacy pricing
– Reimbursed: Blue Cross and drug plans
– Out of pocket: OTC
Single drugs
• Allows separate adjustment of dose
• Change as syndrome changes
• Give people control
• Usually much cheaper since generic
• Less dangerous
What should we have at home?
• Aspirin, acetaminophen
• Antihistamines:
– sedating, non-sedating
• Cough syrup or codeine tablets
• Decongestant spray
• Pseudoephedrine
The most powerful drug
• The drug DOCTOR (Balint)
– Understanding
– Explanation
– Reassurance and prognosis
• Placebo effect
Bypass the argument
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I want antibiotics
No, not appropriate
I will not prescribe -> Argument!
BUT I can help you with symptom control
AND disease suppression
even better than antibiotics
Win – Win!
Principles of Prescribing
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Clear indication
Appropriate drug
Appropriate dose
Appropriate route
Appropriate interval
Will it do more good than harm?
Know your drugs
• Effects
• Spectrum of action
• Side effects
COST
How do I learn quality use of
medicines?
• Needs complete, comparative,
independent, source
• preferably considers price
• RxFiles. BNF, AMH, Dyna-Med
• On-line: UBC Therapeutics initiative
www.ti.ubc.ca, Bandolier, Clinical
Evidence (BMJ)
• Pharmacology text
Short consultations lead to:
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More prescribing
More investigation
Less prevention
Less effective communication
Less psychosocial content
More return visits
Less satisfied patients
Not necessarily bad practice: but limited
Even 5 minute consultations can be done
adequately or badly
How can you do everything in
10 minutes?
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Impossible, but not the only time
Repeated messages
Little at a time
Coordinated message
Informed patients
Informing patients
• Understand their anxiety:
– about what, why?
• Confidence
– Leave it alone, it will get better
– Backup available if needed
• Phone, immediate consult, after hours cover
• “How-to” information