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Diagnosis and Treatment of Respiratory Illness in Children and Adults Non-Infectious Rhinitis Algorithm

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Diagnosis and Treatment of Respiratory Illness in Children and Adults Non-Infectious Rhinitis Algorithm Health Care Guideline: Diagnosis and Treatment of Respiratory Illness in Children and Adults Non-Infectious Rhinitis Algorithm Patient presents with symptoms of non-infectious rhinitis History/physical Consider RAST* and skin yes testing when definitive Signs and symptoms no Signs and symptoms Consider referral to diagnosis is needed suggest allergic suggest structural specialist etiology? etiology? yes no * Radioallergosorbent test Treatment options Non-allergic • Education on avoidance rhinitis • Medications - Intranasal corticosteroids - Intranasal antihistamines - Oral antihistamines Treatment options - Combination intranasal • Medications antihistamines/intranasal corticosteroids - Intranasal antihistamines - Leukotriene blockers - Decongestants - Anticholinergics - Intranasal corticosteroids - Decongestants - Intranasal ipraptropium bromide • Patient education Adequate yes • Patient education Adequate yes • Follow-up as response? • Follow-up as appropriate response? appropriate no no Consider referral • Consider testing to a specialist • Consider referral to a specialist www.icsi.org Copyright © 2017 by Institute for Clinical Systems Improvement 1 Diagnosis and Treatment of Respiratory Illness in Children and Adults Fifth Edition/September 2017 Acute Pharyngitis Algorithm Patient presents with symptoms of GAS* pharyngitis History/physical Shared decision-making Consider strep testing Do not routinely test if Centor (RADT**, throat culture, criteria < 3 or when viral features PCR***) based on clinical like rhinorrhea, cough, oral ulcers presentation and/or hoarseness are present Shared decision-making Treatment options Rapid test results yes • Symptomatic treatment show strep • Immediate antibiotics present? • Delayed antibiotics no • Symptomatic treatment Backup strep culture • Consider alternative for children Persistent no Follow-up as diagnoses infection/treatment needed failure? yes no Strep culture yes • Consider re-evaluation positive? for alternative diagnoses • Consider carrier state * Group A streptococcal ** Rapid antigen detection test *** Polymerase chain reaction www.icsi.org Institute for Clinical Systems Improvement 2 Diagnosis and Treatment of Respiratory Illness in Children and Adults Fifth Edition/September 2017 Non-Infectious Rhinitis Algorithm Patient presents with symptoms of non-infectious rhinitis History/physical Consider RAST* and skin yes testing when definitive Signs and symptoms no Signs and symptoms Consider referral to diagnosis is needed suggest allergic suggest structural specialist etiology? etiology? yes no * Radioallergosorbent test Treatment options Non-allergic • Education on avoidance rhinitis • Medications - Intranasal corticosteroids - Intranasal antihistamines - Oral antihistamines Treatment options - Combination intranasal • Medications antihistamines/intranasal corticosteroids - Intranasal antihistamines - Leukotriene blockers - Decongestants - Anticholinergics - Intranasal corticosteroids - Decongestants - Intranasal ipraptropium bromide • Patient education Adequate yes • Patient education Adequate yes • Follow-up as response? • Follow-up as appropriate response? appropriate no no Consider referral • Consider testing to a specialist • Consider referral to a specialist www.icsi.org Institute for Clinical Systems Improvement 3 Diagnosis and Treatment of Respiratory Illness in Children and Adults Fifth Edition/September 2017 Acute Sinusitis Algorithm Patient presents with symptoms suggestive of acute bacterial rhinosinusitis (ABRS) History/physical Diagnosis of ABRS Two clinical presentations where ABRS have a higher likelihood of being present: • Persistence of symptoms consistent with Does patient have no Consider alternative acute rhinosinusitis lasting 10 days or signs and symptoms diagnoses more without evidence of improvement of ABRS? • Symptoms are worsening – new onset of yes fever, headache or increase in nasal Shared discharge after a viral upper respiratory Treatment options decision-making infection that lasted 5-6 days and the patient • Symptomatic care was initially improving (double worsening - Comfort measures or double sickening) - Decongestants • Severe symptoms and high fever of 102ºF - Intranasal corticosteroids for at least 3-4 days from onset of illness • Consider immediate or delayed should not routinely be used as criteria to antibiotics based on the degree of diagnose ABRS. The diagnosis should be illness, comorbidities and after made on an individualized basis depending shared decision-making discussion on the entire clinical scenario. with patients who meet criteria for ABRS Re-evaluate • Start on antibiotic if not done Adequate • Consider changing an antibiotic no response to • Consider further evaluation and treatment? imaging yes • Consider alternative diagnoses • Consider referral to a specialist Continue plan of care and follow-up www.icsi.org Institute for Clinical Systems Improvement 4 Diagnosis and Treatment of Respiratory Illness in Children and Adults Fifth Edition/September 2017 Table of Contents Work Group Leader Algorithms and Annotations ........................................................................................ 1-48 Sonja Short, MD Algorithm – Main .................................................................................................................1 Internal Medicine and Algorithm – Acute Pharyngitis .............................................................................................2 Pediatrics, Fairview Health Algorithm – Non-Infectious Rhinitis ...................................................................................3 Services Algorithm – Acute Sinusitis .................................................................................................4 Work Group Members Evidence Grading .................................................................................................................7 Fairview Health Services Hiba Bashir, MD Recommendations Table .................................................................................................. 8-9 Allergy/Immunology Foreword Danielle Olmschenk, PharmD Pharmacy Introduction ...................................................................................................................10 HealthPartners Scope and Target Population .........................................................................................10 Peter Marshall, PharmD Aims ..............................................................................................................................10 Pharmacy Implementation Recommendation Highlights ..............................................................11 Mayo Clinic Annotations .................................................................................................................. 12-48 Nathaniel Miller, MD 1. Initial Presentation ............................................................................................. 12-13 Family Medicine 2. Viral Upper-Respiratory Infections .................................................................... 14-21 Kimberly Prigge, APRN, Causes ......................................................................................................................14 CNP Family Medicine History/Physical ................................................................................................ 14-15 Diagnosis .................................................................................................................15 South Lake Pediatrics Laura Solyntjes, MD Treatment ........................................................................................................... 16-20 Pediatrics Follow-Up ...............................................................................................................20 ICSI Prevention .......................................................................................................... 20-21 Jodie Dvorkin, MD, MPH 3. Acute Pharyngitis ............................................................................................... 21-29 Project Manager/Health Care Causes ......................................................................................................................21 Consultant History/Physical ......................................................................................................22 Senka Hadzic, MPH Diagnosis ........................................................................................................... 22-24 Clinical Systems Improvement Treatment ........................................................................................................... 24-27 Facilitator Re-Evaluation .................................................................................................... 27-28 Carrier State .............................................................................................................28 Complications of GAS ...................................................................................... 28-29 4. Non-Infectious Rhinitis ...................................................................................... 29-38 Causes ......................................................................................................................29 History/Physical ................................................................................................ 30-32 Diagnosis ........................................................................................................... 32-33 Treatment for Allergic Rhinitis
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