Pathophysiology

URIs involve direct invasion of the mucosa lining the upper airway. Person-to-person spread of viruses accounts for most URIs. Patients with bacterial infections may present in similar fashion, or they may present with a superinfection of a viral URI. Inoculation by bacteria or viruses begins when secretions are transferred by touching a hand exposed to pathogens to the nose or mouth or by directly inhaling respiratory droplets from an infected person who is coughing or sneezing. After inoculation, viruses and bacteria encounter several barriers, including physical, mechanical, humoral, and cellular immune defenses. Hair lining the nose filters and traps some pathogens. Mucus coats much of the upper respiratory tract, trapping potential invaders. The angle resulting from the junction of the posterior nose to the pharynx causes large particles to impinge on the back of the throat. Ciliated cells lower in the respiratory tract trap and transport pathogens up to the pharynx; from there they are swallowed into the stomach. Adenoids and tonsils contain immune cells that respond to pathogens. Humoral immunity (immunoglobulin A) and cellular immunity act to reduce infections throughout the entire respiratory tract. Resident and recruited macrophages, monocytes, neutrophils, and eosinophils coordinate to engulf and destroy invaders. A host of inflammatory cytokines mediates the immune response to invading pathogens. Normal nasopharyngeal flora, including various staphylococcal and streptococcal species, help defend against potential pathogens. Patients with suboptimal humoral and phagocytic immune function are at increased risk for contracting a URI, and they are at increased risk for a severe or prolonged course of disease. Viral agents include a vast number of serotypes, which undergo frequent changes in antigenicity, posing challenges to immune defense. Pathogens resist destruction by a variety of mechanisms, including the production of toxins, proteases, and bacterial adherence factors, as well as the formation of capsules that resist phagocytosis. Incubation times before the appearance of symptoms vary among pathogens. Rhinoviruses and group A streptococci may incubate for 1-5 days, influenza and parainfluenza may incubate for 1-4 days, and respiratory syncytial virus (RSV) may incubate for a week. Pertussis typically incubates for 7-10 days or even as long as 21 days before causing symptoms. Diphtheria incubates for 1-10 days. The incubation period of Epstein-Barr virus (EBV) is 4-6 weeks. Most symptoms of URIs, including local swelling, erythema, edema, secretions, and fever, result from the inflammatory response of the immune system to invading pathogens and from toxins produced by pathogens. An initial nasopharyngeal infection may spread to adjacent structures, resulting in sinusitis, otitis media, epiglottitis, laryngitis, tracheobronchitis, and pneumonia. Inflammatory narrowing at the level of the epiglottis and larynx may result in a dangerous compromise of airflow, especially in children, in whom a small reduction in the luminal diameter of the subglottic larynx and trachea may be critical. Beyond childhood, laryngotracheal inflammation may also pose serious threats to individuals with congenital or acquired subglottic stenosis.

The upper respiratory tract includes the sinuses, nasal passages, pharynx, and larynx. These structures direct the air we breath from the outside to the trachea and eventually to the lungs for respiration to take place. An upper respiratory tract infection, or upper respiratory infection, is an infectious process of any of the components of the upper airway. Infection of the specific areas of the upper respiratory tract can be named specifically. Examples of these may include rhinitis(inflammation of the nasal cavity),sinus infection (sinusitis or rhinosinusitis) - inflammation of the sinuses located around the nose, common cold(nasopharyngitis) - inflammation

of the nares, pharynx, hypopharynx, uvula, and tonsils, pharyngitis (inflammation of the pharynx, uvula, and tonsils), epiglottitis (inflammation of the upper portion of the larynx or the epiglottis), laryngitis(inflammation of the larynx), laryngotracheitis (inflammation of the larynx and the trachea), and tracheitis (inflammation of the trachea). Upper respiratory infections are one of the most frequent causes of doctors visits with varying symptoms ranging from runny nose, sore throat, cough, to breathing difficulty, and lethargy. In the United States, upper respiratory infections are the most common illness leading to missing school or work. Although upper respiratory infections can happen at any time, they are most common in the fall and winter months, from September until March. This may be explained because these are the usual school months when children and adolescents spend a lot of time in groups and inside closed doors. Furthermore, many viruses of upper respiratory infection thrive in the low humidity of the winter.

What are the causes of upper respiratory infection?

Upper respiratory infection is generally caused by the direct invasion of the inner lining (mucosa or mucus membrane) of the upper airway by the culprit virus or bacteria. In order for the pathogens (viruses and bacteria) to invade the mucus membrane of the upper airways, they have to fight through several physical and immunologic barriers. The hair in the lining of the nose acts as physical barrier and can potentially trap the invading organisms. Additionally, the wet mucus inside the nasal cavity can engulf the viruses and bacteria that enter the upper airways. There are also small hair-like structures (cilia) that line the trachea which constantly move any foreign invaders up towards the pharynx to be eventually swallowed into the digestive tract and into the stomach. In addition to these intense physical barriers in the upper respiratory tract, the immune system also does its part to fight the invasion of the pathogens or microbes entering the upper airway. Adenoids and tonsils located in the upper respiratory tract are a part of the immune system that help fight infections. Through the actions of the specialized cells, antibodies, and chemicals within these lymph nodes, invading microbes are engulfed within them and are eventually destroyed. Despite these defense processes, invading viruses and bacteria adapt various mechanisms to resist destruction. They can sometimes produce toxins to impair the body's defense system or change their shape or outer structural proteins to disguise from being recognized by the immune systems (change of antigenicity). Some bacteria may produce adhesion factors that allow them to stick to the mucus membrane and hinder their destruction. It is also important to note that different pathogens have varying ability to overcome the body's defense system and cause infections. Some viruses may infect by much fewer numbers than others. Furthermore, different organisms require varying time of onset from when they enter the body to when symptoms occur (incubation time). Some of the common pathogens for upper respiratory infection and their respective incubation times are the following:

y y y y y y y

rhinoviruses, 1-5 days; group A streptococci, 1-5 days; influenza and parainfluenza viruses, 1-4 days; respiratory syncytial virus (RSV), 7 days; pertussis (whooping cough), 7-21 days; diphtheria,1-10 days; and Epstein-Barr virus (EBV), 4-6 weeks.

What are the risk factors for upper respiratory infection?

Some common risk factors for upper respiratory infection are:
y y y y y y y

physical or close contact with someone with a upper respiratory infection; poor hand washing after contact with an individual with upper respiratory infection; close contact with children in a group setting, schools or daycare centers; contact with groups of individuals in a closed setting, such as, traveling, tours, cruises; smoking or second-hand smoking (may impair mucosal resistance and destroy the cilia); health care facilities, hospitals, nursing homes; immunocompromised state (compromised immune system) such as,HIV, organ transplant, congenital immune defects, long term steroid use; and anatomical abnormalities as in facial trauma, upper airway trauma, nasal polyps.

What are the symptoms of upper respiratory infection?

Generally, the symptoms of upper respiratory infection result from the toxins released by the pathogens as well as the inflammatory response mounted by the immune system to fight the infection. Common symptoms of upper respiratory infection generally include:
y

nasal congestion,

y y y y y y y y y

runny nose (rhinorrhea), nasal discharge (may change from clear to white to green) nasal breathing, sneezing, sore or scratchy throat, painful swallowing (odynophagia), cough (from laryngeal swelling and post nasal drip), malaise, and fever (more common in children).

Other less common symptoms may include foul breath, poor smelling sensation (hyposmia), headache, shortness of breath, sinus pain, itchy andwatery eye (conjunctivitis), nausea, vomiting diarrhea, and body aches. The symptoms of upper respiratory infection usually last between 3-14 days; if symptoms last longer than 14 days, an alternative diagnosis can be considered such as, sinusitis, allergy, pneumonia, or bronchitis. Bacterial pharyngitis (strep throat due to group A streptococcus) may be considered if symptoms continue to worsen after the first week in the absence of runny nose, cough, or conjunctivitis. Prompt testing and initiation of appropriate antibiotics is important due to the risk of developing rheumatic fever, especially in children. Epiglottitis is an upper respiratory infection in children that may have a more sudden onset of sore throat, feeling of a lump in the throat, muffled voice, dry cough, very painful swallowing, and drooling. Upper respiratory infections in the lower part of the upper respiratory tract, such as, laryngotracheitis, are more commonly featured with dry cough andhoarseness or loss of voice. Barking or whooping cough, gagging, rib pain (from severe cough) are other presenting features.

What is the treatment for upper respiratory infection?

As described above, most cases of upper respiratory infection are caused by viruses and therefore, require no specific treatment and are self-limited. People with upper respiratory infections typically diagnose themselves and treat their symptoms at home without requiring doctor's visit or prescription medications.

Rest is an important step in treating upper respiratory infections. Usual activities, such as, working and light exercising may be continued as much as tolerated. Increased intake of oral fluids are also generally advised to keep up with the fluid loss from runny nose, fevers, and poor appetite associated with upper respiratory infections. Treatment of the symptoms of upper respiratory infection are usually continued until the infection has resolved. Some of the most common upper respiratory infection or cold medications used to treat these symptoms are the following:
y y

Acetaminophen (Tylenol) can be used to reduce fever and body aches. Nonsteroidal antiinflammatory drugssuch as ibuprofen (Motrin, Advil) can be used for body aches and fever. Antihistamines such asdiphenhydramine (Benadryl) are helpful in decreasing nasal secretions and congestions. Nasal ipratropium (topical) can be used to diminish nasal secretions. Cough medications (antitussives) can be used to reduce cough. Many cough medications are commercially available such as dextromethorphan, guaifenesin (Robitussin), and codeine all have shown benefits in reducing cough in upper respiratory infections. Honey can be used in reducing cough. Steroids such as (dexamethasone (Decadron )and prednisone orally (and nasally) are sometimes used reduce inflammation of the airway passage and decrease swelling and congestion. Decongestants such as pseudoephedrine (Sudafed) Actifed oral, phenylephrine (Neo-synephrine nasal) can be used to reduce nasal congestion (generally not recommended in children less than 2 years of age and not recommended for individuals with high blood pressure). Oxymetazoline (Afrin) nasal solution is a decongestant, but should only be used for short-term. Combination medications containing many of these components are also widely available over the counter.

y y

y y

y y

Some cough and cold medicines can cause excessive drowsiness need to be used with caution in children younger than 4 years of age and the elderly. Antibiotics are sometimes used to treat upper respiratory infections if a bacterial infection is suspected or diagnosed. These conditions may include strep throat, bacterial sinusitis, or epiglottitis. Antivirals may occasionally be recommended by doctors in patients who are immunocompromised

(poor immune system). The treating doctor can determine which antibiotic would be the best option for a particular infection. Because antibiotics are associated with many side effects and can promote bacterial resistance and secondary infections, they need to be used very cautiously and only under the direction of a treating physician. Inhaled epinephrine is sometimes used in children with severe spasm of the airways (bronchospasm) and in croup to reduce spasm. Rarely, surgical procedures may be necessary in cases of complicated sinus infections, compromised airway with difficulty breathing, formation of abscesses behind the throat, or abscess formation of the tonsils (peritonsillar abscess).

IV. COMPUTATION OF AGE OF GESTATION (AOG) (TINAMBAN STYLE) For Example:Last menstrual period (LMP): September 7-12, 2008 Assessment date: April 21, 2009 LMP: September: 30 - 7 23 September : 23 October: 31 November : 30 December : 31 January: 31 February : 28 March: 31 April: 21 226 AOG: 32_r.2 7 226 21 16 14 2 _8_ 4 32 32 x AOG= 8 months 2weeks 0 day