Health Care Guideline Diagnosis and Treatment of Respiratory Illness in Children and Adults How to Cite this Document Short S, Bashir H, Marshall P, Miller N, Olmschenk D, Prigge K, Solyntjes L. Institute for Clinical Systems Improvement. Diagnosis and Treatment of Respiratory Illness in Children and Adults. Updated September 2017. ICSI Members, Sponsors and organizations delivering care within Minnesota borders, may use ICSI documents in the following ways: • ICSI Health Care Guidelines and related products (hereinafter “Guidelines”) may be used and distributed by ICSI Member and Sponsor organizations as well as organizations delivering care within Minnesota borders. The guidelines can be used and distributed within the organization, to employees and anyone involved in the organization’s process for developing and implementing clinical guidelines. • ICSI Sponsor organizations can distribute the Guidelines to their enrollees and those care delivery organizations a sponsor holds insurance contracts with. • Guidelines may not be distributed outside of the organization, for any other purpose, without prior written consent from ICSI. • The Guidelines may be used only for the purpose of improving the health and health care of Member’s or Sponsor’s own enrollees and/or patients. • Only ICSI Members and Sponsors may adopt or adapt the Guidelines for use within their organizations. • Consent must be obtained from ICSI to prepare derivative works based on the Guidelines. • Appropriate attribution must be given to ICSI on any and all print or electronic documents that reference the Guidelines. All other copyright rights for ICSI Health Care Guidelines are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any use, adaptations, revisions or modifications made to ICSI Health Care Guidelines by the user or others. www.icsi.org Copyright © 2017 by Institute for Clinical Systems Improvement Health Care Guideline: Diagnosis and Treatment of Respiratory Illness in Children and Adults Main Algorithm Fifth Edition September 2017 Text in blue in this algorithm indicates a linked corresponding annotation. Patient reports some combination of symptoms: • Sore throat • Rhinorrhea • Cough • Fever • Hoarseness • Headache yes Are symptoms See immediately emergent? no Signs/symptoms of viral Signs/symptoms of strep Signs/symptoms of Signs/symptoms of acute upper-respiratory infection* pharyngitis* non-infectious rhinitis* bacterial sinusitis* • Rhinorrhea • Sudden onset of sore throat • Pruritis of the eyes, nose, • One or more of the following • Fever • Exudative tonsillitis palate, ears factors present at a point of • Cough • Tender anterior cervical • Watery rhinorrhea > 10 days after onset: • Hoarseness adenopathy • Sneezing - Facial pain or sinus pain, • Fever • Nasal congestion particularly aggravated by • Absence of rhinorrhea, • Postnasal drip postural changes or by cough, hoarseness valsalva maneuver Treatment options - Purulent nasal drainage • Comfort measures - Fever • Over-the-counter medications - Nasal congestion Do not give antibiotics See Acute Pharyngitis See Non-Infectious algorithm Rhinitis algorithm See Acute Sinusitis algorithm *See the relevant section for detailed description. Return to Table of Contents 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 Text in blue in this algorithm Patient presents with indicates a linked corresponding symptoms of GAS* annotation. 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 Return to Table of Contents 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 Text in blue in this algorithm Patient presents with indicates a linked corresponding symptoms of non-infectious annotation. 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 Return to Table of Contents 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 Text in blue in this algorithm indicates a linked corresponding Patient presents with annotation. 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 Return to Table of Contents 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