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Osteopathic Considerations in the Infections of the Respiratory Tract

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Osteopathic Considerations in the Infections of the Respiratory Tract Osteopathic Family Physician (2017) 17 - 25 17 REVIEW ARTICLE Osteopathic Considerations in the Infections of the Respiratory Tract Sheldon Yao, DO, Nardine Mikhail, OMS III, George Koutsouras, OMS III, Allison Coombs, OMS III, & Michael J. Terzella, DO New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York Keywords: Respiratory tract infections are a common reason for offce visits in primary care set- tings. Respiratory tract infections can often be managed in an outpatient setting, however Respiratory Infectons hospitalization may be necessary in some more emergent and life threatening cases. A Respiratory Tract thorough history and physical will often help guide physicians on the proper course and setting for management. Furthermore, a thorough osteopathic assessment will guide the Antbiotc Use physician in diagnosing and treating somatic dysfunctions caused by respiratory infection. Osteopathic manipulative treatment can aid in recovery by providing relief of symptoms, Disease Preventon & Wellness and restoring proper structure and function of the respiratory system. Osteopathic Manipulatve Medicine Community Acquired Pneumonia INTRODUCTION Acute respiratory infections (ARI) are currently the most common The upper respiratory tract humidifes inspired air, and offers pro- reason for seeking ambulatory care.1 Additionally ARI’s are the tective measures against entering microorganisms.3,4 Inspiration leading cause of seeking medical treatment in returning travelers.2 brings exogenous microorganisms, dust, gases, and smoke into the Because the realm of ARI’s is so broad, it is important to be able lungs.3 Because of this, the respiratory tract has to have a system to correctly differentiate between cases that can be adequately of fltration for removal of harmful inspired material. Cilia and mu- treated in an outpatient setting, and those that will require hos- cus entrap entering microorganisms, while tonsils and adenoids pitalization. Accounting for such a high number of offce visits, it provide immunologic defense against biologically active mate- is important for osteopathic family physicians to be knowledge- rial.3 Smaller particles that escape to the trachea and bronchial able and confdent in their approach to a patient with an (ARI). airways get trapped in the mucus which is ultimately removed by Understanding the interplay between the various components of mucociliary transport to the pharynx and mechanical expulsion the respiratory system, and the effect somatic dysfunctions have via coughing and sneezing.5 In the lower respiratory tract, alveolar on function is central to the proper management of a patient with macrophages engulf and destroy inhaled microorganisms and par- an ARI. ticles.5 Somatic dysfunctions disrupting structural and functional relationships of the face and thoracic cage can therefore impede STRUCTURAL & FUNCTIONAL host defenses against infection. CONSIDERATIONS OF THE RESPIRATORY TRACT EPIDEMIOLOGY The respiratory system is composed of the oropharynx, conduct- Infections of the upper and lower respiratory tract affect all indi- ing airways, lungs, muscles of respiration, and the chest wall.3 The viduals, but the probability of severe disease is observed in a bi- distinction between upper and lower respiratory infections is an modal distribution, as the young and the elderly are at greatest anatomical one. The nose, mouth, pharynx and larynx comprise risk. In the United States, respiratory infections are currently the the upper airway, which is also connected to the middle ear via the leading infectious cause of hospitalization and death among adults, 6,7 Eustachian tube.3 Infections in these areas are considered upper and are the overall leading cause of hospitalization in children. respiratory infections. Lower respiratory infections can potentially Acute respiratory infections are also one of the leading causes of 8,9 include infections that extend from the bronchus to the alveoli. death in children under 5 years of age. Risk factors that result in more severe illness include being male, inhalation of pollutants, malnutrition, and extremes of age.8 Upper respiratory tract infec- CORRESPONDENCE: tions, which are summarized in Table 1 (page 18), contribute to Sheldon Yao, DO | [email protected] disability and days lost from school or work.9 In 2016, just twelve 1877-5773X/$ - see front matter. © 2017 ACOFP. All rights reserved. 18 Osteopathic Family Physician | Volume 9, No. 1 | January/February, 2017 TABLE 1: Upper Respiratory Infections Common Physical Common Disease Etiology Common Symptoms Considerations Examination Findings Management Respiratory Distress Viral & Fever (>38ºC) Antimicrobial Cervical LAD Poor Feeding Pharyngitis33, 34,35 Bacterial Sore Throat therapy if high Pharyngeal Erythema Resistant to antibiotic (GAS) Myalgia Headahe bacterial suspicion Exudates therapy >2 sx: Sneezing Nasal Infamed Nasal Rule out non-allergic Nasal Allergic Viral pruritus Rhinorrhe turbinates Associated causes including drug decongestants 36,37 Rhinitis Congestion > 1 hour with sinusitis, asthma, induced, & infammatory Intranasal steroids for most days OM & conjunctivitis disorders, etc. Viral with IN THE NEWBORN: IN NEWBORNS: Nasal obstruction & Acute possible Sinus swelling poor feeding & focal Antibacterial 38,39,40 nasal secretions Sinusitis secondary Rhinorrhea signs of sinus therapy covers S. < 10 days bacterial involvement aureus, GAS & GBS ACUTE: ACUTE & CHRONIC: > 3 times/ year, Purulent nasal CRS: with > 2 sx: discharge Associated with Antibiotics are Viral with mucopurulent asthma, GERD, OM, controversial, with possible (not clear) drainage. immunodefciencies, potential use of a Rhinosinusitis41,42 CHRONIC: secondary Nasal obstruction, With or without nasal defects in mucociliary 10-14 day course bacterial Facial Pain, & Anosmia polyps seen on clearance (CF or PCD) with or without oral steroids. CHRONIC: rhinoscopic exam or sx> 12 weeks sinus CT scan. Fever (>38‐C), sore Unique posture of Posture & Stridor, throat, hoarseness, BSA & steroids; H.infuenza, the head & neck. Unstable vital dyspnea, inspiratory Emergency Epiglottitis43, 44,45 Streptococcus Gross appearance signs & distress stridor, with a intervention when spp., Virall of the pharynx may “hot potato” or ADULTS: stridor not appear normal necessary muffed voice as frequently seen Hoarseness & Aphonia If URT, consider Laryngitis46,47 Irritants Viral Benign examination Voice Rest ~3 - 4 days duration alternative diagnosis Viral (MC PRODROME: RADIOGRAPH: Conservative Parainfuenza) URT sx 12 - 48 hours AP neck flm with Rapid course, Management; Croup48,49,50 with possible before “barking” cough “steeple” or Drooling & High fever Emergent secondary with inspiratory stridor “hourglass” sign may be present intervention when necessary bacterial & hoarseness Westley Score < 3 years old are Unvaccinated children S.pneumonia, Fluid accumulation most susceptible: Signs of pharyngeal Antimicrobial Otitis Media H.infuenzae, in the middle ear & Fever, otalgia & irritation Recurrent & Therapy M.catarrhalis erythema of the TM impaired hearing persistent episodes ABBREVIATIONS: MC: most common, GAS: Group A Streptococcus, Sx: symptoms, LAD: Lymphadenopathy, GERD: Gastroesophageal reflux disease, OM: Otitis Media, BSA: Broad Spectrum Antibacterials; CRS: Chronic Rhinosinusitis, GBS: Group B Streptococcus, URT: Upper Respiratory Tract, AP: Anterior-Posterior, CF: Cystic Fibrosis, PCD: Primary Ciliary Dyskinesia, SX: symptoms, TM: tympanic membrane Yao, Mikhail, Koutsouras, Coombs, Terzella Osteopathic Considerations in the Infections of the Respiratory Tract 19 TABLE 2: Lower Respiratory Infections Common Physical Common Disease Etiology Common Symptoms Considerations Examination Findings Management Viral Cough suppressants, (Infuenza & RSV) Hospitalizations nasal decongestants, Upper & Lower Comorbidities Acute Bacteria Cough +/- sputum Respiratory signs expectorants, 51,52 Vomiting & > 4 weeks Bronchitis (Streptococcus 1-3 weeks without crackles beta agonists, duration: antihistamines, & spp, Atypical Consider B.pertussis Bacteria) Abx therapy. Conservative < 2 yrs old, MC Decreased lung Prematurity, management within 1st year Lower cord blood Viral sounds with crackles Consider Abx if Bronchiolitis Wheezing, MC is RSV Dyspnea antibody titers to bacterial 53,54,55,56,57,58,59,60,61 Fever, Cough, Chest retractions RSV, lower SES, superinfection Rhinorrhea smoke exposure. suspected BACTERIA: S. pneumonia, S. aureus, H.infuenzae Leukopenia Tachypnea Fever & Chills, Beta-lactam plus VIRAL Tachycardia Crackles Older age; Pneumonia Pleuritic chest pain, a macrolide or (CHILDREN): Signs of consolidation Unvaccinated; 6,7,62,,63,64,65,66,67,68,69 Productive cough furoquinolone RSV, Sputum: thick & Comorbidities 70,71,72,73 with purulent sputum Parainfuenza, purulent, possibly therapy Infuenza rust colored VIRAL (ADULTS): Infuenza & RSV ABBREVIATIONS: RSV: Respiratory Syncytial Virus, SES: Socioeconomic Status, Abx: antibiotics, MC: most common weeks into the year, infuenza-like illness had already accounted tiate between patients who can be managed conservatively, and for 2.9% of visits reported through the U.S Outpatient Infuenza- those who need emergent care. For example, in cases of upper like Illness Surveillance Network.10 respiratory infections that present with respiratory compromise, rapid disease progression, and symptoms of dyspnea, tachypnea, In adults, community-acquired lower respiratory tract infections tachycardia,
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