Respiratory conditions

J DickinsonAugust 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

• 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

• 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 CareIn 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 research-based 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?

• 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

• 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 throat2 To get something for the pain*3 Dr to explain the course of the problem4 Dr to explain how serious the problem is5 How soon will I recover?6 Explain possible treatments

10 sick note for work or school11 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

• 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 3Fever, upper resp symptoms, irritability

Signs: Cloudy drum LR 34Bulging LR 51Immobile on pneumatic otoscopy LR31Red 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 MarAntibiotics for sore throat. Cochrane Acute Respiratory Infections Group. Published Online: 5 NOV 2013DOI: 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?

Carapetis NEJM 2007;357:439-441

Social Conditions!!

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;4:486-493

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, trimethoprimHay 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?

• 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

• 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

Diarrhea?

• 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 Mar-Apr;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 infectionsSTOP 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) Combination of

antihistamines

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

• 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

• NoteNarcotics

T3

Honey

Expectorants - mucolytics

• 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 relatedOther 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

• 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

• 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 cancerNasal 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

Allergen / irritant avoidance

Oral H1 antihistamines

Intranasal corticosteroids

Leukotriene receptor antagonists

Oral Steroids

Immunotherapy

Allergen / irritant avoidance

Oral H1 antihistamines

Intranasal corticosteroids

Leukotriene receptor antagonists

Oral Steroids

Immunotherapy

Class I Class II Class III Class IV

Local anti-allergicsFor nose, eyes

• 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

2. Steroid nasal spray3. Montelukast 10mg in evening (Blue Cross)4. Cromoglycate spray Q6h (OTC)5. Oral prednisone 25mg

Nasal saline (Neti-pot)

Principles of Prescribing

• 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

• 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

• 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:• 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?

• 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