Common Respiratory Tract InfectionsCARTI: The Usual Suspects

Dr. Anthony Ciavarella BA MA MD MCFP

The Ontario College of Family Physicians OCFP:  51st Annual Scientific Assembly

November 29 2013,  Toronto Ontario

Faculty/Presenter Disclosure

• Faculty: Dr. Anthony Ciavarella MD• Program: 51st Annual Scientific Assembly, OCFP• Topic : Community Acquired Respiratory Tract Infections:

The usual suspects

• Relationships with commercial interests:– Speakers Bureau/Honoraria: Merck Frosst, Pfizer, Bayer.– Consulting Fees: Merck Frosst, Boehringer Ingelheim

Disclosure of Commercial SupportCommunity Acquired Respiratory Tract Infections: The usual suspects

Statement :

This program has received no commercial financial support.

Potential for conflict(s) of interest:Dr. Anthony Ciavarella MD has received honoraria from:

Merck Frosst, Pfizer, Bayer, and Boehringer Ingelheim.

• None of these organizations are supporting this program. • No associated product is being discussed in this program.

Mitigating Potential BiasCommunity Acquired Respiratory Tract Infections: The usual suspects

1. The content of this talk is not about products or services of any company or group or organization with outside or commercial interest.

2. The information presented is explicitly ‘‘evidence-based’’.3. Sufficient time will be allowed for the audience to read and

comprehend the information being shared. 4. There will be opportunity for the audience to ask questions about

the disclosure should they arise.

Common Respiratory Tract InfectionsCARTI: The Usual Suspects

Dr. Anthony Ciavarella BA MA MD MCFP

The Ontario College of Family Physicians OCFP:  51st Annual Scientific Assembly

November 29 2013,  Toronto Ontario

Evidence based medicine: what it is and what it isn't;

David L Sackett, OC, MD, FRSC, FRCP

Evidence based medicine: what it is and what it isn't; It's about integrating individual clinical expertise and the best external evidenceDAVID L SACKEIT; Professor NHS Research and Development Centre for Evidence Based Medicine, Oxford Radcliffe NHS Trust, Oxford OX3 9DUWILLIAMM C ROSENBERG; Clinical tutor in medicine Nuffield Department of Clinical Medicine, University of Oxford, OxfordJ A MUIR GRAY; Director of research and development Anglia and Oxford Regional Health Authority, Milton KeynesR BRIAN HAYNES; Professor of medicine and clinical epidemiology McMaster University, Hamilton, Ontario CanadaW SCOTT7 RICHARDSON; Clinical associate professor of medicine University of Rochester School of Medicine and Dentistry, Rochester, NY, USABMJ VOLUME 312 13 January1996 p. 71 - 72

Evidence based medicine is not "cookbook" medicine.Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice…

Evidence based medicine: what it is and what it isn't;

Evidence based medicine: what it is and what it isn't; It's about integrating individual clinical expertise and the best external evidenceDAVID L SACKEIT; Professor NHS Research and Development Centre for Evidence Based Medicine, Oxford Radcliffe NHS Trust, Oxford OX3 9DUWILLIAMM C ROSENBERG; Clinical tutor in medicine Nuffield Department of Clinical Medicine, University of Oxford, OxfordJ A MUIR GRAY; Director of research and development Anglia and Oxford Regional Health Authority, Milton KeynesR BRIAN HAYNES; Professor of medicine and clinical epidemiology McMaster University, Hamilton, Ontario CanadaW SCOTT7 RICHARDSON; Clinical associate professor of medicine University of Rochester School of Medicine and Dentistry, Rochester, NY, USABMJ VOLUME 312 13 January1996 p. 71 - 72

Evidence based medicine is not "cookbook" medicine.Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice…

David L Sackett, OC, MD, FRSC, FRCP

Dr. Anthony Ciavarella BA MA MD Gimli Glider Pilot School

Common Respiratory Tract Infections: CARTI: The Usual Suspects

Acute Bacterial Rhino Sinusitis

Influenza

Group A Strep throat

‘Common cold’

Allergic Rhinitis

Bronchitis

Acute Otitis Media

Common Respiratory Tract Infections: CARTI: The Usual Suspects

Acute Bacterial Rhino Sinusitis

Influenza

Group A Strep throat

‘Common cold’

Allergic Rhinitis

Bronchitis

Acute Otitis Media

ABRS

the ‘Flu’

GAS

the ‘cold’

AR

Bronchitis

AOM

Dr. Anthony Ciavarella BA MA MD Gimli Glider Pilot School

Dr. Anthony Ciavarella BA MA MD Gimli Glider Pilot School

Common Respiratory Tract Infections: CARTI: The Unusual Suspects

Acute frontal Bacterial Rhino Sinusitis

Community Acquired Pneumonia

Mononucleosis 

Pertussis

Asthma worsening

Acute Exacerbation COPD

Tuberculosis

Dr. Anthony Ciavarella BA MA MD Gimli Glider Pilot School

Common Respiratory Tract Infections: CARTI: The Unusual Suspects

Acute frontal Bacterial Rhino Sinusitis

Community Acquired Pneumonia

Mononucleosis 

Pertussis

Asthma worsening

Acute Exacerbation COPD

Tuberculosis

ABRS

CAP

‘Mono’

AECOPD

TB

Dr. Anthony Ciavarella BA MA MD Gimli Glider Pilot School

CARTI:

frontal ABRS

CAP

‘Mono’

Pertussis

Asthma worsening

AECOPD

TB

ABRS

the ‘Flu’

GAS

the ‘cold’

AR

Bronchitis

AOM

Usual Suspects Unusual Suspects

CARTI:

frontal ABRS

CAP

‘Mono’

Pertussis

Asthma worsening

AECOPD

TB

ABRS

the ‘Flu’

GAS

the ‘cold’

AR

Bronchitis

AOM

Usual Suspects Unusual Suspects

Evidence based …approach that integrates the best external evidence with individual clinical expertise and patients' choice…

David L Sackett BMJ VOLUME 312 13 January1996 p. 71 - 72

Who are the

experts?

CARTI: The Usual Suspects

ABRS2 ‘Cold’ 3

Fever+Cough >38°C

Myalgia

Rapid Onset < 48 hrs

Chills or Sweating

‘Flu’ 4

1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.

2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;

3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html

4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62

5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht adapted by Dr. A. Ciavarella MD

‘Strep’ 5Allergic Rhinitis1

1. Fever >38°C

2. Tender ant. cervical Adenopathy

3. Tonsillar swelling or exudate

4. Age 3 to 14

5. No cough

Facial Pain/pressure/fullness

Nasal Obstruction

Nasal Purulence/ discoloured postnasal Discharge

hyposmia/anosmia (Smell)

[Acute Frontal Sinusitis requires urgent care]

PODSFAT And No cough

Sneezing

Nasal Obstruction

Nasal Itch (pruritus)

Nasal Rhinorrhea

+ Itchy watery Eyes (conjunctivits)

SOIRE

Sore throat sneezing

Cough

Nasal Obstruction

Nasal Rhinorrhea

Ill feeling Everywhere

SCORE

Flu Can Make Rapid

Chills or Sweating

CARTI: The Usual Suspects

ABRS2 ‘Cold’ 3 ‘Flu’ 4 ‘Strep’ 5Allergic Rhinitis1

Flu + CanMakeRapidChills or Sweating

1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.

2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;

3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html

4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62

5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.htm adapted by Dr. A. Ciavarella MD

SOIRE SCOREPODS FAT

And

No cough

Acute Bacterial RhinoSinusitis

P O D S

Facial Pain/Pressure/

Fullness

Nasal Obstruction

Nasal Purulence/Discolored Postnasal Discharge

Hyposmia/Anosmia (Smell)

Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J, Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91

1. Worsening after 5 to 7 days (biphasic illness) with similar symptoms2. Symptoms persist more than 7 days without improvement3. Presence of purulence for 3 to 4 days with high fever

ABRS diagnosis requires the presence of at least 2 major PODS symptoms; 1 symptom must be nasal Obstruction

or nasal purulence/discoloured postnasal Discharge

Group A Strep throat

FAT And No cough Point

Fever; temperature >38°C 1

AdenopathyTender Anterior cervical 1

Tonsillar swelling or exudate 1

Age 3–14 year 1

No cough 1

Age 15–44 year 0

Age ≥45 year -1

5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.htm

Allergic Rhinitis

1. Small P, Frnkiel S, Becker A, et al. Rhinitis: A practical and comprehensive approach to assessment and therapy. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.

● The previous classification of seasonal or perennial Allergic Rhinitis is being replaced with intermittent and persistent Allergic Rhinitis1

● Intermittent episode = symptoms last <6 weeks

● Persistent episode = symptoms last >6 weeks

S O I R

Sneezing

E

Nasal Obstruction

Nasal Itch (pruritus)

Nasal Rhinorrhea

+ Itchy Watery Eyes

(conjunctivits)

Allergic Rhinitis Diagnosis: 2 or More of ‘S O I R E’ Symptoms for More Than 1 Hour on Most Days

Common Cold• Early signs of a cold are a:

– Sore, Scratchy throat

– Sneezing

– Runny nose

• Other symptoms that may occur later include:– Headache

– Stuffy nose (Obstruction)

– Watering eyes

– Hacking Cough

– ill-feeling Everywhere: Chills, muscle aches, and general malaise

Symptoms Usually Show Up About Two Days After a Person Becomes Infected. Duration is 2 to 7 Days; Some Cases May Last for 2 Weeks

SCORE

Canadian Centre for Occupational Health and Safety; http://www.ccohs.ca/oshanswers/diseases/common_cold.html#_1_2 accessed 17 April 2013

Canadian Centre for Occupational Health and Safety

Diagnosis of Influenza

Ebell M.H. et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. J Am Board Fam Med. January-February 2012 vol. 25 no. 1 55-62

4 - 6 points = 59%

Fever + CoughMyalgiaRapid Onset < 48 hrsChills or Sweats

= 2 points = 2 points = 1 points = 1 point

Fever + Cough Onset < 48 hours

Myalgia

Chills or Sweating

High risk

Clinical Decision Rule helps but Influenza is still a diagnosis of Exclusion

Flu Can Make Rapid Chills or Sweating

CARTI: Symptoms Rapid onset with fever

ABRS2

Fever+Cough >38°C

Myalgia

Rapid Onset < 48 hrs

Chills or Sweating

‘Flu’ 4

2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;

4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62

5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.htm

6. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712.

adapted by Dr. A. Ciavarella MD

‘Strep’ 5

CAP6

CoughFeverPleuritic chest painPhysical ExaminationSputum probableCXR necessary CURB - 65 helpful

Facial Pain/pressure/fullness

Nasal Obstruction

Nasal Purulence/ discoloured postnasal Discharge

hyposmia/anosmia (Smell)

1. Fever >38°C

2. Tender ant. cervical Adenopathy

3. Tonsillar swelling or exudate

4. Age 3 to 14

5. No cough

Frontal Sinusitis FeverRapid onsetChills & sweatingFrontal sinus painPOSSIBLESystemic symptoms Neurological symptoms Occular symptomsRequires urgent care

AECOPD3 Asthma Worsening4

1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 216617122. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A.. 4 Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012 adapted by Dr. A. Ciavarella MD

CAP1

CoughFeverPleuritic chest painPhysical ExaminationSputum probableCXR necessary

Common Respiratory Tract Infections (CARTI):The Unusual Suspects

1. Asthma symptoms Day > 4 days / wk 2. Any Night time Asthma symptoms3. Any interference with Usual Activities

or exercise 4. Flow < 80% of personal best5. Reliever medication > 4 doses / wk

(including exercise) 6. Sputum Eosinophils > 3%.7. Employment or school - any days

lost8. Exacerbation frequent within the past

year or any not mild exacerbations.

CURB -65

DNA FREE E

CoughPhlegmSOB

Worsening &More Medicine

sustained Worsening of dyspnea (SOB), Cough or Phlegm production leading to an increase in the use of Maintenance Medications and/or supplemental withAdditional Medications

Frontal Sinusitis2

Facial Pain/pressure/fullness.

Nasal Obstruction Nasal Purulence/ discoloured postnasal Dischargehyposmia/anosmia (Smell)

PODSFever; Rapid onsetChills & sweatingFrontal sinus painPOSSIBLESystemic symptomsNeurological symptoms Occular symptoms

Pertussis: Clinical PhasesTypical Course of Pertussis*

ParoxysmalCough Cough Paroxysmal Cough Whooping Vomiting Cyanosis Apnea

*The illness can be milder and the typical "whoop" absent in children, teens, and adults who have been vaccinated with a pertussis vaccine.

Catarrhal:Mild coughRunny noseMild feverApnea in infants

Convalescent:Cough less paroxysmal disappears in weeks

Tozzi A.E.; Diagnosis and management of pertussis; CMAJ 2005;172(4):509-15http://www.cdc.gov/vaccines/pubs/pinkbook/pert.html 2013 October 02 adapted by Dr. A. Ciavarella MD

Incubation 7-10 days 0500 weeks to months01 02 03 04

Positive culture rates are highest

01 02 03 0500

most contagious

0404 05 06 07 08

Paroxysmal Cough + whoop or vomiting > 2 weeks

04

CAP: CURB – 65

C U R B

Confusion Urea >7 m mol/l

Resp rate ≥30/min

BP: Systolic

≤90 mm HgDiastolic

≤60 mm Hg

Developed by Mark H. Ebell, MD, MS. Copyright 2006 American Academy of Family Physicians. Physicians may photocopyⓒor adapt for use in their own practices; all other rights reserved. “Outpatient vs. Inpatient Treatment of Community Acquired Pneumonia.” Ebell MH. Family Practice Management. April 2006:41-44; http://www.aafp.org/fpm/20060400/41outp.html

Score 3 to 5 = Severe pneumonia; hospitalize and consider admitting to intensive care

65 – Age ≥ 65 Years

Evidence based medicine: what it is and what it isn't;

Evidence based medicine: what it is and what it isn't; It's about integrating individual clinical expertise and the best external evidenceDAVID L SACKEIT; Professor NHS Research and Development Centre for Evidence Based Medicine, Oxford Radcliffe NHS Trust, Oxford OX3 9DUWILLIAMM C ROSENBERG; Clinical tutor in medicine Nuffield Department of Clinical Medicine, University of Oxford, OxfordJ A MUIR GRAY; Director of research and development Anglia and Oxford Regional Health Authority, Milton KeynesR BRIAN HAYNES; Professor of medicine and clinical epidemiology McMaster University, Hamilton, Ontario CanadaW SCOTT7 RICHARDSON; Clinical associate professor of medicine University of Rochester School of Medicine and Dentistry, Rochester, NY, USABMJ VOLUME 312 13 January1996 p. 71 - 72

Evidence based medicine is not "cookbook" medicine.Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice…

CARTI: Who are the experts?