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7/27/2019 COUGHING AND SHORTNESS OF BREATH IN CHILDREN.docx
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RESPIRATORY SYSTEM
PBL MODULE 2
COUGHING AND SHORTNESS OF BREATH IN CHILDREN
REPORT
BY GROUP B1
NAME:
MOHD ALIFF HALIMIE BIN MUSA C11108771
NAZIRUL MUNIR BIN ABU HASSAN C11108795
MUHAMMAD HAFIY BIN MOHD RUSLI C11108808
THIAGARAJAN A/L KANDAPAN C11108763
ELDIE RAHIM PRADANA C11108217
IIN BANISWARA C11108193
NEERMALADEVI PARAMASIVAM C11108755
NUR ADILAH BINTI SHAHARUDDIN C11108779
ZALIKHA BINTI MOHD NASIR C11108787
NURAYSHA BINTI NURULLAH C11108803
MEDICAL FACULTY
UNIVERSITAS HASANUDDIN
MAKASSAR 2010
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COUGHING AND SHORTNESS OF BREATH IN CHILDREN
Scenario
A 3 years old boy is taken to the hospital by his mother due to severe fever, the boy has not had
enough sleep since last night and getting very irritable. According to the mother, she has
frequently taken her boy to several doctors within the last 3 months for coughing and
unstoppable runny nose, sometimes even with difficulty in breathing. His last month recorded
body weight from POSYANDU was 10kgs. He is the third boy, the other two older brothers are
also experiencing similar problems, but as bad as this one.
Keyword
3 years old boy Severe fever Not had enough sleep and getting very irritable Coughing, unstoppable runny nose and difficulty in breathing for last 3 month Last month body weight is 10kgs Family history; elder brothers with similar symptoms
Clarification of Difficult Word
1. Irritable - Capable of reacting to stimulus/prone to excessive anger2. POSYANDU - Pos Layanan Terpadu3. Runny nose (Rhinorrhea) - Is any mucus-like material that comes out of the nose
Question
1. What is the appropriate weight for 3 years old boy?2. Why the boy getting very irritable?3. Classification of fever.4. What causes the unstoppable runny nose?5.
How comes only sometimes difficulty in breathing present?
6. How this case related with the brothers?7. What is the pathomechanism for all the symptoms?8. What is the relation between runny nose and difficulty in breathing?
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Differential Diagnosis
1. Allergic Rhinitis2. Common Cold3. Lung Tuberculosis4. Bronchitis
Answers
1. What is the appropriate weight for 3 years old boy?
According to WHO Child Growth Standards, the weight for 3 years old boy is between 12
- 16kg with mean weight of 14.343kg.
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2. Why this boy getting very irritable?
Irritable is a state of being overly sensitive to stimulation. The term irritable is used for
infants and young children. Children, who are irritable may, for example cry easily.
Irritability can be a very early sign of serious problems. Although irritability is not asymptom of any specific disease, it should arouse suspicion in the parent that something
might be wrong with the child, even though there not appear others symptoms yet.
The cause of irritability is hard to figure out in very young children who cannot talk.
Being overtired, hungry, teething, having soiled diapers and the need for attention may
cause mild irritable. Irritable may also as a response to pain, fright or discomfort. In
some cases, serious medical condition can cause irritability such as infection in any part
of body.
3. Classification of fever.
Normal body temperature: 36-37C Fever/ febrile : >37C Subfebrile : 37-38C Febris continue : >38C & fluctuate 38C & fluctuate >1C Febris intermittent : >38C & fluctuate >1C, tempt
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germ-fighting fluids will often be pushed into the nose - triggering the same kind of
mucus production that occurs during a cold. In many cases, however, parents can
identify the presence of a sinus infection by the length of time that mucus is being
produced in the child's nose. If the nasal discharge has been present for two weeks
without improvement, no matter what the color, the leakage could be the result of a
sinus infection a condition that may require a health care provider's attention and acourse of antibiotic treatment. A runny nose accompanied by severe sinus or facial
pressure or high fever also may signal a sinus infection.
Another major cause of runny nose in kids is allergic reaction, or "allergic rhinitis," in
which nasal tissues excrete mucus as an immunological response to antigenic particles
from plants, dust, pollen or other substances such as cat dander. Commonly known as
"hay fever," allergic rhinitis affects more than 15 percent of U.S. children. An allergy-
caused runny nose occurs in two basic modes: "seasonal" and "perennial." Seasonal
allergic rhinitis may attack a child's nasal passages during a particular season, usually
spring, summer or fall, in response to pollen or reproductive spores released by
vegetation. But some children are affected by allergic rhinitis regardless of the time of
year. For these victims of "perennial allergic rhinitis," the reason for the nasal discharge
may be household dust mites, mold or animal dander (dead skin and/or hair shed by
pets). In some cases, household irritants such as tobacco smoke or chemical-based
products may be responsible for a child's runny nose, and these substances should be
eliminated whenever possible.
5. How comes only sometimes difficulty in breathing present?
The episodes of difficulty of breathing or dyspneu happen because during the onset of
the inflammation process, for example in an allergic reaction, asthma or infection
attack, the airways become inflamed and narrower as the muscles surrounding them
constrict. The flow of air is blocked partially or completely as mucus produced by the
inflammation fills a narrower passageway. This mechanism is severe only at the onset of
inflammation reaction and has the restriction affect on the airway. That way this child
only has recurrent episodes of difficulty in breathing.
Increasing of nasal drips also can lead to obstruction of the airway. These happen whenthe mucus has move backflow to the pharynx or opening of larynx and then
accumulated there. This also will narrow the airway and cause difficulty in breathing or
dyspneu.
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6. How this case related with the brothers?
In disease that has suffered in the members of family, there are two possible etiologies
for that disease. Ether is because of infection or it related to the genetic factors.
In this case, the only possible factor is infection. This is because the infection of therespiratory track is very easy to transmit usually through air as droplet. So, the
possibility of one of family member to spread the disease to other members is very high.
According to the scenario, the patient is a youngest brother and affected most severely
compared with the others two older brothers. This is because in immunity defense
system of this boy is not yet well develops.
Besides that, the possibility for this child and two others brother suffered this disease
because of genetic factor is very low. This can be explaining by the mechanism of
recessive and dominant inheritance.
In recessive inheritance, both parents carry a normal gene (N), and a faulty,recessive gene (n). The parents, although carries are unaffected by the faultygene. Their offspring are affected, not affected or just carriers.
In dominant inheritance, one parent has a single, faulty dominant gene (D),which overpowers its normal counterpart (d), affecting that affecting that
parent. When the affected parent mates with an unaffected and non-carrier
mate (dd), the offspring are either affected or not affected, without the carriers.
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7. What is the pathomechanism for all the symptoms?
Dyspnea
Pathophysiology of Dyspnea
Dyspnea is the experience of shortness of breath. It may or may not be
associated with suffering. A runner in a race may be severely dyspneic and yet be
enjoying life. A dyspneic patient dying with lung cancer with very similar
physiologic parameters may be suffering greatly, as the meaning and context of
the dyspnea are entirely different.
Respiration as a bodily function is virtually unique in the degree to which it is
under both reflexive and volitional control. The survival advantage of such a
control is obvious. We continue to breath when deeply asleep (or in a coma),and yet we can hold our breath, if need be, to escape through smoke or water.
Perhaps because of this, the linkage between psychological states and breathing
is tighter and more complex than it is for other physical symptoms. Dyspnea is
often associated with panic and anxiety; panic may present as dyspnea, and
dyspnea may induce panic.
My education about dyspnea, brief as it was in medical school, stressed the
importance of blood gases. I learned that CO2 build-up and oxygen deprivation
were the critical factors that result in dyspnea. Although undoubtedly important
in keeping the body alive, their importance in the experience of dyspnea has
been exaggerated. If an oxygen saturation monitor is attached to a dyspneic
runner at the end of a race, it will register normal. This reveals an important
clinical pearl: oxygen saturation is insensitive in identifying patients with
dyspnea. That is, one cannot rely on the oxygen saturation to tell who is
dyspneic. Patients can be very dyspneic with normal saturations. Of course,
patients with low oxygen saturations (below 90%) are far more likely to be
dyspneic than are patients with normal saturations. However, oxygen saturation
also lacks specificity as a predictor of dyspnea; many patients with low oxygen
saturations (for example, patients with chronic lung disease or those who live at
high altitude) will not be dyspneic, especially at rest. Studies have suggested that
hypoxia correlates best with exertional dyspnea and poor exercise tolerance.Conversely, oxygen therapy has been shown to be a most helpful method to
relieve exertional dyspnea and improve exercise tolerance. Studies have been
mixed in testing the relief of rest dyspnea associated with hypoxia with oxygen
therapy.Oxygen levels are excellent indicators of changing pulmonary
physiology. The implications of the lack of sensitivity and specificity of oxygen
saturation in identifying dyspnea are profound. As with pain, we lack a "scanner"
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for dyspnea that can reliably identify who is short of breath. We have no choice
but to ask if dyspnea is present, or at least look for signs of distress that might
suggest dyspnea, such as rapid respirations or a look of panic. In fact, the oxygen
saturation meter can cause dyspnea by inducing panic and fear in patients,
family, and clinicians as the saturation number falls (often accompanied by an
ominously lower-pitched beeping tone).
Palliative Care Note
Oxygen saturation cannot be depended upon to identify dyspnea. Patient report
or signs of agitation or anxiety are the best means of identifying dyspnea.
Elevations in carbon dioxide levels appear to stimulate dyspnea more than do
low oxygen levels. Elevated partial pressure of arterial carbon dioxide (PaCO2)
levels have been found to be an independent stimulus of dyspnea.However,
increased respiratory drive does not necessarily result in dyspnea if it occurs
unimpeded. Patients with certain forms of increased respiratory drive, such as
diabetic ketoacidosis and pregnancy, may not experience dyspnea. What does
cause dyspnea is an imbalance between the perceived need to breathe and the
perceived ability to breathe. Elevated PaCO2 levels may be one among a number
of factors that contribute to the brain's perception of a need to breathe.
Palliative Care Note
Dyspnea results when there is an imbalance between the perceived need to
breathe and the perceived ability to breathe.
Recent studies have suggested that the body's ability to determine whether
breathing is occurring normally relies on considerably more than high CO2 levels
or low oxygen levels.64
Nerves in the nose sense the passage of air. Stretch
receptors in and about the lungs signal expansion and contraction of the lungs.
Thoracic muscles and ribs signal that they are moving, a good sign breathing is
occurring normally. These nerves tell the brain "all is well" and allow respirations
to continue automatically and largely unconsciously in the nondyspneic person.
The brain senses no imbalance between the ability to breathe and the need to
breathe. If there is a sudden cessation of airflow or respiratory muscle
movement, as measured by these nerves, the brain quickly goes into alarm
mode - before any measurable change in blood gases occurs.
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Imagine you are being held one foot below water. Go ahead - hold your breath.
Note how quickly there is a desire to breathe. You can suppress this need for a
while, although it will build rapidly. (Your oxygen saturation may fall slightly and
your CO2 saturation may rise slightly by the time you must breathe, contributing
a bit to the need to breathe.) If you were truly underwater, you would panic
almost immediately. This psychological state would result in a severe imbalancebetween the perceived need to breathe and the perceived ability to breathe.
You would desperately struggle to get to the surface. When you finally breathe
again, notice how quickly your dyspnea is relieved. Do you really believe it was
because your blood gases were so quickly normalized?
Patients more commonly are dyspneic while breathing. What is happening here?
The perception of respiratory fatigue is a key component. Although our
understanding of both peripheral and central receptor involvement in fatigue is
poor, it is clear that the brain is able to sense fatigue, much as you can sense any
overworked muscle. However, unlike wobbly leg muscles that signal you to stop
running, tired thoracic muscles must continue to work in an attempt to meet a
perceived need to breathe. The brain senses a mismatch: the need to breathe
continues, but the ability of the body to meet that need with tired muscles is in
doubt. Dyspnea is a wake-up call to this mismatch.
Short of altering lung physiology, how can this mismatch be addressed?
Decreasing the perceived need through energy conservation can help. Patients
with emphysema, who have minimal thoracic expansion, may ventilate
adequately but receive a signal from the thoracic muscles that they are not
moving enough, much as in the underwater example above. A number of studies
have demonstrated that fooling these muscles by activating vibrating devicesduring inspiration can lessen dyspnea.
65-67The perception that the body is not
able to meet this need can also be addressed by inhibiting the perception of
muscular fatigue with opioids and other drugs (see below).
As should have been apparent in the breath-holding experiment, perceived need
is also intimately connected to the psyche. Perceived need and perceived
inability to meet that need can quickly result in panic. Panic, in turn, can
stimulate increased ventilatory effort, which can result in more fatigue and
increased panic - a vicious cycle. Panic, fear, and anxiety are common affective
components of dyspnea. Beyond shear panic, dyspneic patients think about what
their dyspnea means. Does dyspnea reflect a good run, as it might to a jogger, or
impending death? If dyspnea occurs with increasingly mild exertion, the patient
is reminded of growing dependence on others. As with other symptoms, patients
monitor the trend of their dyspnea - is it getting better or worse? One reason the
runner does not suffer from dyspnea is that he or she knows it will end when the
running ends. The patient dying of COPD or lung cancer projects into a future
wherein dyspnea worsens. These cognitive processes commonly trigger affective
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responses. In addition to panic, fear, and anxiety, patients may become
depressed and angry.
Fever
Pathogenesis of Fever
Pyrogens
The term pyrogen is used to describe any substance that causes fever.
Exogenous pyrogens are derived from outside the patient; most are microbial
products, microbial toxins, or whole microorganisms. The classic example of an
exogenous pyrogen is the lipopolysaccharide (endotoxin) produced by all gram-
negative bacteria. Pyrogenic products of gram-positive organisms include the
enterotoxins of Staphylococcus aureus and the group A and B streptococcal
toxins, also called superantigens.
Pyrogenic Cytokines
Cytokines is a small proteins that regulate immune, inflammatory, and
hematopoietic processes. For example, the elevated leukocytosis seen in severalinfections with an absolute neutrophilia is the result of the cytokines interleukin
(IL) 1 and IL-6. Some cytokines also cause fever; formerly referred to as
endogenous pyrogens, they are now called pyrogenic cytokines. The pyrogenic
cytokines include IL-1, IL-6, tumor necrosis factor (TNF), ciliary neurotropic factor
(CNTF), and interferon (IFN). (IL-18, a member of the IL-1 family, does not appear
to be a pyrogenic cytokine.) Other pyrogenic cytokines probably exist
A wide spectrum of bacterial and fungal products induces the synthesis and
release of pyrogenic cytokines, as do viruses. However, fever can be a
manifestation of disease in the absence of microbial infection. For example,
inflammatory processes, trauma, tissue necrosis, or antigen-antibody complexes
can induce the production of IL-1, TNF, and/or IL-6, whichindividually or in
combinationtrigger the hypothalamus to raise the set point to febrile levels.
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Elevation of the Hypothalamic Set Point by Cytokines
During fever, levels of prostaglandin E2 (PGE2) are elevated in hypothalamic
tissue and the third cerebral ventricle. The concentrations of PGE2 are highest
near the circumventricular vascular organs (organum vasculosum of lamina
terminalis)networks of enlarged capillaries surrounding the hypothalamic
regulatory centers. Destruction of these organs reduces the ability of pyrogens
to produce fever. Thus, it appears that both exogenous and endogenous
pyrogens interact with the endothelium of these capillaries and that this
interaction is the first step in initiating feveri.e., in raising the set point to
febrile levels.
Pyrogenic cytokines such as IL-1, IL-6, and TNF are released from the cells and
enter the systemic circulation. Although the systemic effects of these circulating
cytokines lead to fever by inducing the synthesis of PGE2, they also induce PGE2
in peripheral tissues. The increase in PGE2 in the periphery accounts for the
nonspecific myalgias and arthralgias that often accompany fever. It is thought
that some systemic PGE2 escapes destruction by the lung and gains access to the
hypothalamus via the internal carotid. However, it is the elevation of PGE2 in the
brain that starts the process of raising the hypothalamic set point for core
temperature.
There are four receptors for PGE2, and each signals the cell in different ways. Ofthe four receptors, the third (EP-3) is essential for fever: when the gene for this
receptor is deleted in mice, no fever follows the injection of IL-1 or endotoxin.
Deletion of the other PGE2 receptor genes leaves the fever mechanism intact.
Although PGE2 is essential for fever, it is not a neurotransmitter. Rather, the
release of PGE2 from the brain side of the hypothalamic endothelium triggers the
PGE2 receptor on glial cells, and this stimulation results in the rapid release of
cyclic adenosine 5'-monophosphate (cyclic AMP), which is a neurotransmitter
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Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear
the large breathing passages from secretions, irritants, foreign particles and
microbes. The cough reflex consists of three phases: an inhalation, a forced
exhalation against a closed glottis, and a violent release of air from the lungs
following opening of the glottis, usually accompanied by a distinctive sound.
Coughing can happen voluntarily as well as involuntarily.
Frequent coughing usually indicates the presence of a disease. Many viruses and
bacteria benefit evolutionarily by causing the host to cough, which helps to
spread the disease to new hosts. Most of the time, coughing is caused by a
respiratory tract infection but can be triggered by choking, smoking, air pollution
asthma, gastroesophageal reflux disease, post-nasal drip, chronic bronchitis,
heart failure and medications such as ACE inhibitors.
Treatment should target the cause by for example smoking cessation or
discontinuing ACE inhibitors. Some people may be worried about serious
illnesses, and reassurance may suffice. Cough suppressants such as codeine or
dextromethorphan are frequently prescribed, but have been demonstrated to
have little effect. Other treatment options may target airway inflammation or
may promote mucus expectoration. As it is a natural protective reflex,
suppressing the cough reflex might have deleterious effects, especially if the
cough is productive.
Mechanism of productive cough
Cough is an important defence mechanism of the body. It serves to clear the
airway of excessive secretions and foreign matter. It can be either voluntary or
involuntary. As a reflex, it is activated when:
There is either inhaled particulate matter or irritant gases in the airway(certain gases such as ammonia, nitric acid and sulfuric acid and nitrogen
dioxide can irritate the airway)
There is a large amount of mucus in the airway (either because ofexcessive secretion or impaired clearance)
There is a large amount of edema or pus in the airway Thermal stimuli (very hot or very cold air can sometimes trigger the
cough reflex but, usually, this only occurs in people who already have
some pathology in the lungs)
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The cough reflex includes transmission of impulses via afferent (sensory)
neurons from specialized receptors located in respiratory tissue to a central
cough center, then transmission of nerve impulse from the central cough center
via efferent (motor) neurons back out to respiratory muscles. Cough receptors
are located within the epithelial layer of respiratory tissue. There are both
mechanical receptors and chemical receptors. The mechanical receptors aresensitive to touch and displacement and are located primarily in the larynx,
trachea, and carina. Chemical receptors are sensitive mostly to noxious gases
and fumes. These receptors are located more in the larynx and bronchi.
Receptors are found in respiratory bronchioles. but extend no further down the
respiratory tree then this. Cough receptors tend to become less sensitive when
continuously stimulated.
Cough receptors send their impulses to a central cough center via the vagus
nerve, the glossophayrngeal, trigeminal and phrenic nerves. The vagus may also
send messages to the cough center from higher centers of the brain. These
additional vagal afferents may be able to suppress the cough center. So, in one
respect, vagal afferents (directly from the receptors in respiratory tissue)
stimulate the cough center; in another respect, other vagal afferents (originating
from a higher center in the brain) can suppress the cough center.
There is much debate about where the central cough center in the brain is
located. Most likely it is not one single center, but rather is distributed
throughout the brain in a few locations spread out through the medulla
oblongata of the brainstem . The efferent nerves that carry impulses from the
cough center to the muscles that will result in a cough include the phrenic nerve
and the efferent branches of the vagal nerve.
An effective cough depends on an interaction between the volume of gas that is
inhaled and the properties of the mucus lining the airways. To begin with there is
an initial inspiration of air (ranging from 50% of tidal volume to 50% of vital
capacity). This volume of air stretches the expiratory muscles (like a rubber band
getting ready to snap back). When the muscles start to snap back (beginning of
expiratory phase), the glottis closes very briefly (this increases pressure in the
lungs even more so, so that when the glottis opens the air is expelled with a
greater force), then the glottis opens and the air is expelled (cough). The purpose
of the cough is to remove mucus, so the properties of the mucus also contribute
to the effectiveness of the cough. Mucus is most effectively dispersed in the
expelled volume of air if it contains a large amount of water.
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8. What is the relation between runny nose and difficulty in breathing?
Runny nose is a condition where there is mucus secretion from the nasal cavity. This
condition is usually caused by infections. Hence, if postnasal drip occurs, whereby the
mucus from the nasal cavity drops back into the posterior of the throat, there are great
chances of inflammation of the upper airways due to the blockade caused by the
mucus. Hence, this will cause the obstruction of the airway and further causes
disturbance in gaseous exchange. As a result, dyspnea might occur.
Differential Diagnosis
Allergic Rhinitis Primary TB Common ColdBoy
3 years old Severe fever and
worsening at night XCough for 3
months XRunny nose for 3
months X XDifficulty in
breathing XUnderweight Inherited /Contagious Inherited Contagious Contagious
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Allergic Rhinitis
Introduction
Allergic rhinitis is an allergic reaction that happens when your immune system overreact
to substances that you have inhaled, such as pollen. The two types of allergic rhinitis are
seasonal allergic rhinitis (hay fever) and perennial allergic rhinitis, which occurs year-
round. Hay fever is caused by outdoor allergens. Perennial allergic rhinitis is caused by
indoor allergens such as dust mites, pet dander, and mold.
Symptoms of allergic rhinitis resemble a cold, but they are not caused by a virus the way
a cold is. When patient breathe in an allergen, their immune system springs into action.
It releases substances known as IgEs into nasal passages, along with inflammatory
chemicals such as histamines. The nose, sinuses, or eyes may become itchy andcongested. Scientists aren't sure what causes your immune system to overreact to an
allergen.
Allergic rhinitis is common, affecting about 1 in 5 Americans. Symptoms can be mild or
severe. Many people who have allergic rhinitis also have asthma.
Signs and Symptoms
Allergic rhinitis can cause many symptoms, including the following:
Stuffy, runny nose Red, itchy, and watery eyes
tears from the lacrimal sac into the nasal cavity. Excess tears flow through
nasolacrimal duct which drains into the inferior nasal meatus. This is the
reason the nose starts to run when a person is crying or has watery eyes
from an allergy, and why one can sometimes taste eye drops
Post-nasal drip Swollen eyelids Itchy mouth, throat, ears, and face Sore throat Dry cough Headaches, facial pain or pressure Partial loss of hearing, smell, and taste
http://en.wikipedia.org/wiki/Tearshttp://en.wikipedia.org/wiki/Tearshttp://en.wikipedia.org/wiki/Lacrimal_sachttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Inferior_nasal_meatushttp://en.wikipedia.org/wiki/Inferior_nasal_meatushttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Lacrimal_sachttp://en.wikipedia.org/wiki/Tears7/27/2019 COUGHING AND SHORTNESS OF BREATH IN CHILDREN.docx
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Fatigue Dark circles under the eyes
Causes
The body's immune system is designed to fight harmful substances like bacteria and
viruses. But in allergic rhinitis, the immune system overresponds to harmless substances
-- like pollen, mold, and pet dander -- and launches an assault. This attack is called an
allergic reaction.
Seasonal allergic rhinitis is caused by an allergic reaction to pollens and spores
(depending on the season and area) as they are carried on the wind. Sources include:
Ragweed -- the most common seasonal allergen (fall) Grass pollen (late spring and summer) Tree pollen (spring) Fungus (mold growing on dead leaves, common in summer)
Year-round allergic rhinitis is caused by an allergic reaction to airborne particles from
the following:
Pet dander Dust and household mites Cockroaches Molds growing on wall paper, house plants, carpeting, and upholstery
Risk Factors
Family history of allergies Having other allergies, such as food allergies or eczema Exposure to secondhand cigarette smoke Male gender
Diagnosis
In anamnesis, the question that should be asked are:
Do symptoms change depending on the time of day or the season?
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Do you have a pet? Have you made changes to your diet? Are you taking any medications?
We will perform a physical exam and may also recommend a skin test to find out what
patient is allergic to. In a scratch test, for example, small amounts of suspected allergensare applied to the skin with a needle prick or scratch. If there is an allergy, a hive
(swollen reddened area) forms within about 20 minutes. Sometimes a blood test may be
used to find out which allergens they react to.
With young children, it can help to watch what they do. For example, a child with
allergic rhinitis may wiggle his nose and push it upward with the palm of the hand.
Prevention
Preventing them exposure to allergens is the best way to control symptoms. These steps
may help
If patient have hay fever, during days or seasons when airborne allergens are high:
Stay indoors, and if possible, close the windows. Use an air conditioner. Avoid using fans that draw in air from outdoors. Don't hang laundry outside to dry. Bath or shower and change the clothes after being outside. Use a HEPA air filter in the bedroom.
If patient have perennial allergic rhinitis:
Cover the pillows and mattress with dust mite covers. Remove carpet; install tile or hardwood floors. Use area rugs and wash them
often in very hot water.
Keep pets out of the bedroom.
Use a HEPA filter on the vacuum. Use an air purifier. Wash bedding and toys such as stuffed animals in very hot water once a week.
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Treatment
The best way to reduce symptoms is to prevent exposure to allergens.
Drugs (such as antihistamines, decongestants, and nasal corticosteroid sprays) may help
control allergy symptoms. Some complementary and alternative therapies may also beused to treat the symptoms of allergic rhinitis.
Patient may recommend immunotherapy ("allergy shots"). This treatment includes
regular injections of an allergen, with each dose being slightly larger than the previous
dose. The immune system should gradually get used to the allergen so that it no longer
reacts to it.
In addition, certain lifestyle and dietary changes may help prevent or improve symptoms
of allergic rhinitis.
Medications
Depending on the type of allergic rhinitis patient have. If they have perennial allergic
rhinitis, we may need to take medication daily. If they have seasonal allergic rhinitis (hay
fever) we may start medications a few weeks before the pollen season begins.
Nasal corticosteroids
These prescription sprays reduce inflammation of the nose and help relieve sneezing,
itching, and runny nose. They are most effective at reducing symptoms, although we
may not see improvement for a few days to a week after patient start using them.
Beclomethasone (Beconase) Fluticasone (Flonase) Mometasone (Nasonex) Triacinolone (Nasacort)
Antihistamines
Antihistamines are available in both oral and nasal spray forms, and as prescription
drugs and over-the-counter remedies. Over-the-counter antihistamines are short-acting
and can relieve mild-to-moderate symptoms. All work by blocking the release of
histamine in the body.
Over-the-counter antihistamines -- Include diphenhydramine (Benadryl),chlorpheniramine (Chlor-Trimeton), clemastine (Tavist). These older
antihistamines can cause sleepiness. Loratadine (Claritin) and cetrizine (Zyrtec)
do not cause as much drowsiness as older antihistamines.
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Prescription antihistamines -- These medications are longer-acting than over-the-counter antihistamines and are usually taken once a day. They include
fexofenadine (Allegra).
Decongestants
Many over-the-counter and prescription decongestants are available in tablet or nasal
spray form. They are often used with antihistamines.
Oral and nasal decongestants -- Include Sudafed, Actifed, Afrin, Neo-Synephrin.Some decongestants may contain pseudoephedrine, which can raise blood
pressure. People with high blood pressure or enlarged prostate should not take
drugs containing pseudoephedrine. Nasal decongestants can cause "rebound
congestion," where the nasal passages swell. Avoid using nasal decongestants
for more than 3 days in a row and do not use them if patient have emphysema
or chronic bronchitis.
Leukotreine modifiers
These prescription drugs block the production of leukotreines, which are inflammatory
chemicals produced by the body. They are taken once a day and do not cause
sleepiness, and are also used to treat allergic asthma. Leukotreine modifiers include
montelukast (Singulair) and zafirlukast (Accolate).
Cromolyn sodium (NasalCrom)
This over-the-counter nasal spray prevents the release of histamine and helps relieve
swelling and runny nose. It is most effective when taken before symptoms start and may
needed to be used several times a day.
Nasal atropine
Ipratropium bromide (Atrovent) is a prescription nasal spray that can help relieve a very
runny nose. People with glaucoma or an enlarged prostate should not use Atrovent.
Eye drops
Antihistamine eye drops -- relieve both nasal and eye symptoms; examplesinclude azelastine, olopatadine, ketotifen, and levocabastine
Decongestant eye drops -- such as phenylephrine and naphazolineEye drops may cause stinging or even headache.
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Other Treatments
Allergy shots (immunotherapy) are often recommended to anyone 7 years and older
who has severe allergy symptoms or who also has asthma. Immunotherapy accustoms
the immune system to allergens through regular injections of small doses of an allergen
over a long period of time.
Nasal irrigation or nasal lavage can help reduce symptoms of allergic rhinitis, studies
show. The technique uses a neti pot, bulb syringe, or squeeze bottle to flush out nasal
passages with saline solution (salt water).
Prognosis and Complications
Chances are your symptoms of allergic rhinitis can be treated, but they will appear eachtime you are exposed to an allergen.
Although perennial allergic rhinitis is not a serious condition, it can interfere with many
important aspects of life. Depending on how severe your symptoms are, allergic rhinitis
can lead you to miss school or work. Medication may cause drowsiness and other side
effects. Your allergies could also trigger other conditions, such as eczema, asthma,
sinusitis, and ear infection (called otitis media). Seasonal allergies may improve as you
get older.
Immunotherapy (allergy shots) may cause uncomfortable side effects (such as hives and
rash) and may have dangerous side effects such as anaphylaxis. It often requires years oftreatment and is effective in about two-thirds of cases.
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Common Cold
Introduction
The common cold (viral upper respiratory tract infection (VURI), acute viralrhinopharyngitis, acute coryza, or cold) is a contagious, viral infectious disease of the
upper respiratory system, caused primarily by rhinoviruses and coronaviruses.[1]
Common symptoms include a sore throat, runny nose, and fever. There is no cure;
however, symptoms usually resolve spontaneously in 7 to 10 days, with some symptoms
possibly lasting for up to three weeks.
Signs and symptoms
Symptoms are cough, sore throat, runny nose, and nasal congestion; sometimes thismay be accompanied by conjunctivitis (pink eye ), muscle aches, fatigue, headaches,
shivering, and loss of appetite. Fever is often present thus creating a symptom picture
which overlaps with influenza. The symptoms of influenza however are usually more
severe. The common cold usually resolves spontaneously in 7 to 10 days, but some
symptoms can last for up to three weeks. In children the coughs lasts for more than 10
days in 35-40% and continue for more than 25 days in 10%.
Those suffering from colds often report a sensation of chilliness even though the cold is
not generally accompanied by fever, and although chills are generally associated with
fever, the sensation may not always be caused by actual fever. In one study, 60% ofthose suffering from a sore throat and upper respiratory tract infection reported
headaches,often due to nasal congestion.
Complications
The common cold can lead to symptoms of acute bronchitis, bronchiolitis, croup,
pneumonia, sinusitis, otitis media, or strep throat. People with chronic lung diseases
such as asthma and COPD are especially vulnerable. Colds may cause acute
exacerbations of asthma, emphysema or chronic bronchitis.
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Causes
Viruses
The common cold is due to a viral infection of the upper respiratory tract. The most
commonly implicated virus is a rhinovirus (30-50%), a type of picornavirus with 99known serotypes. Others include: coronavirus (10-15%), influenza (5-15%)
[4], human
parainfluenza viruses.
Risk factors
Spending time in an enclosed area with an infected person or in close contact withan infected person. Common colds are droplet-borne infections, which means that
they are primarily transmitted through breathing in tiny particles that the infectedperson emits when he coughs, sneezes, or exhales.
Frequently touching eyes, nose, or mouth with contaminated fingers. A history of smoking extends the duration of illness by about three days. Getting fewer than seven hours of sleep per night has been associated with a risk
three times higher of developing an infection when exposed to a rhinovirus.
Low blood vitamin D levels are associated with an increased the risk of getting acommon cold. Whether this relation is causal has yet to be determined.
Common colds are seasonal, occurring more frequently during winter outside oftropical zones. This is believed to be partly due to a change in behaviors such as
increased time spent indoors, which puts infected people in close proximity to other
people, rather than to exposure to cold temperatures.
Low humidity increases viral transmission rates
Pathophysiology
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The common cold is a disease of the upper respiratory tract
The common cold virus is transmitted mainly from contact with the saliva or nasalsecretions of an infected person, either directly, when a healthy person breathes in the
virus-laden aerosol generated when an infected person coughs or sneezes, or by
touching a contaminated surface and then touching the nose or eyes.
Symptoms are not necessary for viral shedding or transmission, as a percentage of
asymptomatic subjects exhibit viruses in nasal swabs. It is generally not possible to
identify the virus type through symptoms, although influenza can be distinguished by its
sudden onset, fever, and cough.
The major entry point for the virus is normally the nose, but can also be the eyes (in this
case drainage into the nasopharynx would occur through the nasolacrimal duct). From
there, it is transported to the back of the nose and the adenoid area. The virus then
attaches to a receptor, ICAM-1, which is located on the surface of cells of the lining of
the nasopharynx. The receptor fits into a docking port on the surface of the virus. Large
amounts of virus receptor are present on cells of the adenoid. After attachment to the
receptor, virus is taken into the cell, where it starts an infection. Rhinovirus colds do not
generally cause damage to the nasal epithelium. Macrophages trigger the production of
cytokines, which in combination with mediators cause the symptoms. Cytokines cause
the systemic effects. The mediator bradykinin plays a major role in causing the local
symptoms such as sore throat and nasal irritation.[4]
The common cold is self-limiting, and the host's immune system effectively deals with
the infection. Within a few days, the body's humoral immune response begins
producing specific antibodies that can prevent the virus from infecting cells.
Additionally, as part of the cell-mediated immune response, leukocytes destroy the virus
through phagocytosis and destroy infected cells to prevent further viral replication. In
healthy, immunocompetent individuals, the common cold resolves in seven days on
average.
Prevention
The best prevention is staying away from people who are infected, because the
overwhelming majority of infections are acquired by inhaling virus-laden air that an
infected person has coughed, sneezed, or breathed out.
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Management
There are currently no medications or herbal remedies which have been conclusively
demonstrated to shorten the duration of illness. Treatment comprises symptomatic
support usually via analgesics for fever, headache, sore muscles, and sore throat.
Conservative
Treatments that help alleviate symptoms include simple analgesics and antipyretics such
as ibuprofen and acetaminophen / paracetamol. Evidence does not show that cold
medicines are any more effective than simple analgesic. and are not recommended for
use in children due to no evidence supporting their effectiveness and the potential of
harm.
Getting plenty of rest, drinking fluids to maintain hydration, and gargling with warm salt
water, are reasonable conservative measures. Evidence for encouraging the active
intake of fluids in acute respiratory infections is lacking as is the use of heated
humidified air. Saline nasal drops may help alleviate nasal congestion.
Antibiotics and antivirals
Antibiotics are not effective against the viruses that cause the common cold and due to
their side effects cause overall harm. There are no approved antiviral drugs for the
common cold even though some preliminary research has shown benefit.
Alternative treatments
Main article: Alternative treatments used for the common cold
Many alternative treatments are used to treat the common cold. However, there is
insufficient scientific evidence to support the use of any alternative medicine
treatments. Honey may be an effective treatment of cough and improved sleep
difficulty in children more than no treatment or dextromethorphan.
Prognosis
The common cold is generally mild and self-limiting.
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Epidemiology
Upper respiratory tract infections are the most common infectious diseases among
adults, who have two to four respiratory infections annually. Children may have six to
ten colds a year (and up to 12 colds a year for school children). In the United States, the
incidence of colds is higher in the fall (autumn) and winter, with most infectionsoccurring between September and April. The seasonality may be due to the start of the
school year, or due to people spending more time indoors (thus in closer proximity with
each other) increasing the chance of transmission of the virus.
Lung Tuberculosis
Introduction
Tuberculosis (TB) is another example of a lower respiratory tract infection. It is caused
by the microorganism Mycobacterium tuberculosis, which usually infects by inhalation
of droplets, person to person, and colonizes the respiratory bronchioles or alveoli. It can
also enter the body through the gastrointestinal tract, by means of ingestion of
contaminated unpasteurized milk, or, occasionally, through a skin lesion.
After nearly 30 years of decline, starting in the mid-1980s, the number of cases of
tuberculosis diagnosed in the United States began to climb. Reasons for this includedincreasing numbers of immigrants from areas where tuberculosis is endemic, increased
poverty and homelessness in this country, and the advent of HIV/AIDS and a surge of
immunocompromised persons. Although this increase has begun to taper off, the U.S.
Center for Disease Control and Prevention noted that despite a low TB rate reported in
2004 (4.9 cases per 100,000 population), the rate of decline for 2003 and 2004 were the
smallest since 1993.
If a significant amount of the mycobacterium bypasses the defense mechanisms of the
respiratory system and successfully implants in the lower respiratory tract, the host
mounts a vigorous immune and inflammatory response. Because of this vigorousresponse, which is primarily T-cell mediated, only approximately 5% of people exposed
to the bacillus develop active tuberculosis. Only those individuals who develop an active
tuberculin infection are contagious to others and only during the time of active
infection.
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Racial and Ethnic Implications
TB rates greater than the U.S. average were observed in certain racial/ethnic
populations in 2004: Hispanics, blacks, and Asians living in the U.S. have 7.5, 8.3, and
20.0 times higher frequency of infection than whites, respectively. In 2004, TB was
reported more frequently among Hispanics (an increase of 1.2% from 2003 to 2004)than among any other racial/ethnic population in the U.S. Slightly more than half
(53.7%) of U.S. cases were in foreign-born persons. To address the high rate of TB
among foreign-born persons living in the U.S., custom and immigration efforts are
directed to improve overseas screening of immigrants and refugees, strengthen the
current notification system about the arrival of those suspected of having TB, ensure
completion of treatment among TB patients who cross the border, test recent arrivals
from high-incidence countries for latent infection, and treat to completion. March 24 of
each year is being celebrated as World TB Day.
Risk Factors for Tuberculosis Exposure and Infection
Those most at risk of exposure to the bacillus are those living in close quarters with
someone who has an active infection. This includes homeless individuals living in
shelters where tuberculosis is present, as well as family members of infected individuals.
Children may be especially susceptible. Immigrants to this country from developing
nations frequently arrive with active or latent infection.
Also at risk of exposure to and development of tuberculosis are health care workers
caring for the infected, and those individuals using the same health care clinics or
hospital units as people who have active infection. Of those exposed to the bacillus,
individuals who have inadequate immune systems, including the undernourished, the
elderly and the young, individuals receiving immunosuppressant drugs, and those
infected with the human immunodeficiency virus (HIV), are most likely to become
infected. The virulence of the strain also affects transmission, with certain highly
infective strains identified. TB control is hindered by the emergence of multi-drug
resistance and the synergistic effect of HIV/AIDS. A significant number of TB cases in
Africa have been linked to HIV infection.
Immune Response to Tuberculosis
Because the tuberculosis bacillus is difficult to destroy once colonization of the lower
respiratory tract occurs, the goal of the immune response is to surround and seal off the
bacilli, rather than to kill them. The cell-mediated response involves T cells as well as
macrophages. Macrophages encircle the bacilli, after which T cells and fibrous tissue
wall off the bacilli and macrophage complex. This complex of bacilli, macrophages, T
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cells, and scar tissue is called a tubercle. The tubercle eventually becomes calcified and
is called Ghon's complex, which can be seen on chest radiograph. Before engulfment of
the bacteria is complete, the material liquefies. At this time, viable microorganisms can
gain access to the tracheobronchial system and spread airborne to infect others. Even
when adequately walled off, the bacillus may survive within the tubercle. It is believed
that because of this viability, approximately 5 to 10% of individuals who do not initiallydevelop tuberculosis may have a clinical demonstration of the disease at some other
time in their lives, perhaps when they have become immunocompromised by age, other
infection, or the need for anti-inflammatory medications. In fact, many if not most cases
of active tuberculosis occur in individuals whose primary infection occurred decades
earlier.
Among those infected, damage to the lung is caused by the bacilli as well as by a
vigorous immune and inflammatory reaction. Interstitial edema and permanent scarring
of the alveoli increase the distance for diffusion of oxygen and carbon dioxide,
decreasing gas exchange. Also, the deposition of scar tissue and production of tubercles
decrease surface area available for gas diffusion, decreasing diffusion capacity. If the
disease is extensive, abnormalities in the ventilation:perfusion ratio occur that can lead
to hypoxic vasoconstriction of pulmonary arterioles and pulmonary hypertension.
Decreased lung compliance occurs with scar tissue.
Multi-Drugs Resistant Tuberculosis
A recent worldwide and serious complication of tuberculosis is the development of
tuberculin bacilli resistant to many drug combinations. Resistance develops when
individuals do not complete the course of their therapy, and mutations of the bacillus
make it non-responsive to the antibiotics that were used for a short time. The tuberculin
bacillus mutates rapidly and often. Drug-resistant tuberculosis can also occur if an
individual cannot mount an effective immune response, for instance, as seen in AIDS
patients or in the malnourished. In these cases, antibiotic therapy is only partially
effective. Health care workers or others who are exposed to these strains of bacillus also
may develop drug-resistant tuberculosis, which can result in years of morbidity and
frequently even in death. Those who have multi-drug-resistant tuberculosis will need to
undergo more toxic and expensive treatments that are more likely to fail.
Clinical Manifestations
Clinical indications of tuberculosis may be absent with initial infection and may never be
present if active infection does not occur. If active tuberculosis develops, an individual
usually demonstrates the following:
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Fevers, especially in the afternoon. Malaise. Night sweats. Loss of appetite and weight loss. A productive, purulent cough accompanied by chest pain is common with active
infection.
Diagnostic Tools
A positive skin test for tuberculosis demonstrates cell-mediated immunity and isevidence only of previous exposure of the lower respiratory tract to the bacillus. It is
not evidence that active tuberculosis ever developed.
Active tuberculosis is diagnosed by collection of a sputum sample followed bymicroscopic examination for the presence of acid-fast bacilli or culturing of the cells
followed by identification and drug susceptibility testing of the isolates. Microscopysuffers from low sensitivity, especially in extrapulmonary tuberculosis and conditions
of low bacillus count, which are common among HIV-infected individuals. Sputum
culture of an actively infected individual will reveal the bacillus but takes a
significantly longer time to complete.
Drug-resistance testing is traditionally performed using conventional methods ineither solid or liquid media. More recently, molecular techniques based on PCR in
conjunction with electrophoresis, sequencing, or hybridization are being used to
detect gene mutations associated with the development of drug resistance. These
molecular techniques have been used to complement smear results and clinical
diagnosis.
Chest radiograph demonstrates current or previous tubercle formation.
Complications
Severe disease may lead to overwhelming sepsis, respiratory failure, and death. Multi-drug-resistant TB may develop. Passage to others of the drug-resistant strain
may occur.
Treatment
Treatment of individuals who have active tuberculosis is lengthy because the bacillusis resistant to most antibiotics and rapidly mutates when exposed to antibiotics to
which it is sensitive. Currently, treatment of individuals who have an active infection
includes a combination of four drugs and lasts at least 9 months or longer. If the
person does not respond to those drugs, other drugs will be tried and different
protocols will be followed.
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Individuals who develop a positive tuberculosis skin test after having beenpreviously negative, even if they show no symptoms of active disease, are usually
put on a 6- to 9-month antibiotic regimen to support their immune response and to
increase the likelihood that the bacillus will be eradicated completely.
If drug-resistant tuberculosis develops, more toxic drugs will be administered. Thepatient may be kept in the hospital or under some type of forced quarantine ifcompliance with the medical therapy is unlikely or impossible.
Bronchitis
Introduction
Bronchitis is an acute inflammation of the air passages within the lungs. It occurs when
the trachea (windpipe) and the large and small bronchi (airways) within the lungs
become inflamed because ofinfection or other causes.
The thin mucous lining of these airways can become irritated and swollen. The cells that make up this lining may leak fluids in response to the inflammation. Coughing is a reflex that works to clear secretions from the lungs. Often the
discomfort of a severe cough leads you to seek medical treatment.
Both adults and children can get bronchitis. Symptoms are similar for both. Infants usually get bronchiolitis, which involves the smaller airways and causessymptoms similar to asthma
Causes
Several viruses cause bronchitis, including influenza A and B, commonly referred to as
"the flu." A number ofbacteria are also known to cause bronchitis, such as Mycoplasma
pneumoniae, which causes so-called walking pneumonia. Bronchitis also can occur
when you inhale irritating fumes or dusts. Chemical solvents and smoke, including
tobacco smoke, have been linked to acute bronchitis. People at increased risk both of
getting bronchitis and of having more severe symptoms include the elderly, those withweakened immune systems, smokers, and anyone with repeated exposure to lung
irritants.
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Symptoms
Acute bronchitis most commonly occurs after an upper respiratory infection such as the
common cold or a sinus infection. You may see symptoms such as fever with chills,muscle aches, nasal congestion, and sore throat. Cough is a common symptom of
bronchitis. The cough may be dry or may produce phlegm. Significant phlegm
production suggests that the lower respiratory tract and the lung itself may be infected,
and you may have pneumonia. The cough may last for more than two weeks. Continued
forceful coughing may make your chest and abdominal muscles sore. Coughing can be
severe enough at times to injure the chest wall or even cause you to pass out. Wheezing
may occur because of the inflammation of the airways. This may leave you short of
breath.
Exams & Tests
Doctors diagnose bronchitis generally on the basis of symptoms and a physical
examination.
Usually no blood tests are necessary. If the doctor suspects the patient has pneumonia, a chest x-ray may be ordered. Doctors may measure the patient's oxygen saturation (how well oxygen is
reaching blood cells) using a sensor placed on a finger.
Sometimes a doctor may order an examination and/or culture of a sample ofphlegm coughed up to look for bacteria.
Treatment
By far, the majority of cases of bronchitis stem from viral infections. This means that
most cases of bronchitis are short-term and require nothing more than treatment of
symptoms to relieve discomfort.
Antibiotics will not cure a viral illness.o Experts in in the field of infectious disease have been warning for years that
overuse of antibiotics is allowing many bacteria to become resistant to the
antibiotics available.o Doctors often prescribe antibiotics because they feel pressured by people's
expectations to receive them. This expectation has been fueled by both
misinformation in the media and marketing by drug companies. Don't expect
to receive a prescription for an antibiotic if your infection is caused by a virus.
Acetaminophen (Feverall, Panadol, Tylenol), aspirin, or ibuprofen (Motrin, Nuprin,Advil) will help with fever and muscle aches.
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Drinking fluids is very important because fever causes the body to lose fluid faster.Lung secretions will be thinner and easier to clear when the patient is well
hydrated.
A cool mist vaporizer or humidifier can help decrease bronchial irritation. An over-the-counter cough suppressant may be helpful. Preparations with
guaifenesin (Robitussin, Breonesin, Mucinex) will loosen secretions;dextromethorphan-the "DM" in most over the counter medications (Benylin,
Pertussin, Trocal, Vicks 44) suppresses cough.
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