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UPPER RESPIRATORY TRACT

INFECTION
(Infesksi Saluran Pernafasan
Atas/ISPA)
By
Rara Merinda Puspitasari, M.
Farm., Apt

pper Respiratory System

The nose
Paranasal sinuses
Pharynx
Larynx
Trachea
bronchi

COMMON COLD
PATHOGENESIS
Viral families Acute Coryza
(common cold)
Mild, self-limited, inflamatory
syndrom
Pathogenesis: Viral Invasion
(rhinoviruses (30%cases),
parainfluenza viruses, enteroviruses,
coronaviruses, etc)
Several factor assosciated with

COMMON COLD
PATHOGENESIS
Incubation period: 48-72 hours
bodys defense mechanism
actifated inflamatory reaction
Complication secondary bacterial
infection; in children may progress to
pneumonia (cold caused by
parainfluenza and respiratory
syncytial virus)

COMMON COLD
CLINICAL CHARACTERISTIC AND DIAGNOSIS
Symptoms
Rhinorrhea
Nasal congestion (nasal quality tovoice)
Sneezing
Sore throat
Non productive cough
Nasal discharge may progress from watery to purulent
Lose in the sense of taste and smell
A feeling fullness in the ears or paranasal sinuses
Fever (lowgrade)
Headache,
Feeling of general malaise
Chills
conjungtivitis

TREATMENT
Symptomatic
Goal: symptoms relief, decreasing complication,
minimizing communicability
Non Pharmacology: bed rest, saline gargle, herbal
Pharmacology:
Antihistamine
Sympatomimetics
Anticholinergics
Analgesics
Antitusives
Expectorant
Antivirals
Vitamin C

ANTIHISTAMINE
Block the binding of antihistamine to
H1 receptor, preventing increased
capillary permeability and resultant
rhinorrhea.
Terapeutic benefit may depend on
the ability to blocking cholinergic
eseptor anticholinergic effect dry
up nasal and pharyngeal secretion as
well as worsen nasal blockage and
sinus kongestion

ANTIHISTAMINE
Selective H1 antihistamines that have
lower anticholinergic effect and sedation
have not demonstrated efficacy againrs
common cold symptoms
Side effects
Sedation
Tachycardia
Mucosal drying
Decreased GI motility
Urinary retention

SYMPATHOMIMETICS
Topical and systemic
sympathomimetics decongestants
for relief of nasal congestion
Most of nasal decongestant are from
the phenylethamine class:
pseudoephedrine, ephedrine
(stimulate alfa and beta receptor);
phenylpropanolamine, phenylephrin
(selective alfa adrenergic agonist)

SYMPATHOMIMETICS
Systemic side effect:
Restlessness
Tachycardia
Hypertension Phenylpropanolamine
>>> pseudoephedrin
Occasional nausea
Vomiting
anorexia

Antihistamine (by
chemical class)

Decongestants

Antitusives

Ethanolamines
Diphenhydramine
Doxylamine
Ethylendiamines
Pyrilamine
Thonzylamine
Alkylamines
Pheniramine
Brompheniramine
Chlorpheniramine
Tripolidine
Miscellaneous
Phenindamine

Topical
Ephedrine
Naphazoline
Oxymetazoline
Phenylephrine
Xylomethazoline
Oral
Phenylephrine

Codein
Dextromethorphan
Diphenhydramine

Phenylpropanolamine
Pseudoephedrine

ANTICHOLINERGIC
INTRANASAL IPRATROPIUM PRODUCE
A 40% REDUCTION OF MUCUS
WEIGHT.
Side effects : dry mouth, dry nasal
passages, epistaxis.
Clinical value of topical
anticholinergic agent appears
promising but requires further study.

ANALGESICS
Aspirin and acetaminofen analgesics and
antipyretics
Aspirin may reduce lung and tracheal
mucociliary clearance; Yeyes syndrome in
pediatric
Acetaminophen Drug of choise in pediatric
Other NSAID : Ibuprofen 200 mg decrease the
number of days of viral shedding by 44%
Caffeine, side effec: disturb sleep patterns, alter
mood and increases BP and gastric secretion..
May provoke cardiac arrhytmias

ANTITUSSIVE
Depress Cough reflex mediated in
the medulla:
Narcotics Agent : Codein,
Hydrocodone, Noscapine)
Dexthormethrophan (safest
antitussive for daytime cought relief
and pediatric)
Diphenhydramines

ANTITUSSIVE
If cough should become productive,
antitusive administration should strive for
supression of excessive coughing without
elimination of this important mechanism
for the clearance of bronchial secretion
Side effects :
Narcotics : sedation and consti[ation
Diphenhydramine : sedation
Dextromethorphan : GI distress

EXPECTORANTS
Decrease sputum viscosity
facilitating the expectoration of
bronchial secretions and for
antitussive effect
Expectorants: Guaifenesin,
ammonium chlorida, potassium
guaiacol sulfonat, potassium iodidal

ANTIVIRAL
Alpha Interferon prophylaxis, prevention
of rhinoviral and coronaviral
Enviroxime, a enzimidazoline derivative
inhibit in vitro rhinovirus replication

VITAMIN C
Linus Pauling : 1-5 g/day prevent cold; 15 g/day could
be curative
Potential adverse effects: Diarrhae, precipitation of
oxalate or urate renal stone, mobilization of Ca from
stone,

SINUSITIS
Inflammation of
one or more of
the four paired
structure that
make up the
paranasal
sinuses including
maxillary,
ethmoidal,
sphenoidal, and
frontal sinus

SINUSITIS
Clasification:
Acute : congestion, submucosal edema,
epithelial cellular debris lasting 2-4
weeks
Subacute : 2 weeks-3 months, severity
is lesser than acute sinusitis
Chronic : recurrent and uncured acute
sinusitis lasting more than 3 month,
result in change

SINUSITIS
Causes:
Acute Sinusitis
Streptococcus pneumonia
Haemophillus influenza
Moraxella catarrhalis 20% pediatric sinusitis
Staphylococcus aureus

Bacteroides anaerobic orgnsm in acute sinusitis in


adult
Chronic Sinusitis
Gram Negative and gram positive : S. Aureus, S. Viridans
(anaerobic); Bacteroides spp., fusobacterium spp., peptostreptococcus 88% cases, Pseudomonas aeruginosa

SINUSITIS
Clinical Characteristic and Diagnosis
Facial pain, headache, purulent nasal
discharge or nasal obstruction,
Concomitant symptoms include disorders of
sense of smell, nasal quality to the voice,
tenderness to palpitasion over the involved
sinus
Cough children.
Fever adult and pediatric for acute
maxillary sinusitis

SINUSITIS
Differential diagnosis:
Rhinitis alergy, prolonged cold, headache,
neoplasma.
Diagnosis: patients complaint and patient
history, Examination of the ears, nose,
throat, teeth, and sinuses.
Transillumination and radiologic diagnosis
limited in patient with chronic sinusitis
CT and MRI sensitive but costly for
visualization of the ethmoid sinus

TREATMENT
ANTIBIOTIC
Penicillin alergy amoxicillin and ampicillin
considered the drugs of choice
Penicillin-alergic patient erythromicin, cotrimoxazole and tetracycline (should not administered
to children or pregnant)
Filure to therapy within 72 hours suspicious betalactamase production co-trimoxazole, erythromycin,
cefachlor or co-amoxiclav
Chronic sinusitis 3-4 weeks course of broadened
antibiotic
Addition of clindamycin to infection of Bacteroides

SINUSITIS
Supportive therapy
Decongestant systemic topical decongestan reopening
blocked sinuses to promote drainage of purulent material
and provide symptomatic relief oxymethazoline,
xylomethazoline. 3-4 days to avoided rebound
phenomenon
Nasal Lavage saline nasal drops helps to clear
exudate
Antihistamine thicken purulent discharge if allergic
rhinitis is underlying causes.
Analgesics acethaminophen severe use short course
of codein
humidification,

OTITIS MEDIA
Inflamation of the middle ears
Classified depend on the presence
and duration of middle ear effusion,
presence of drainage adn recurrent
of pathology:
Acute OM: last less than 3 weeks
Subacute OM : last less than 3 months
Chronic OM : last longer than 3 months

OTITIS MEDIA

OTITIS MEDIA
Patogens:
S. Pneumonia, H. influenza, (50% cases in
children and adult); M. catarrhalis, hemolytic streptococci, Staphylococcus spp.
Respiratory syncitial virus, influenza virus,
enterovirus, rhinovirus
Chlamydia trachomatis (infants under 6
months)
E. Coli, Klebsiella sp (neonates under 6
weeks)

OTITIS MEDIA
Clinical Characterictic and Diagnosis
Symptoms of OM develop over munutes to hours and may occur as
new symptoms in association with an ongoing upper resp infection.
The tympanic membran can spontaneously tear and allow drainage of
purulent material and or blood
The presence of middle ear inflammation with effusion and acute
illness
Symptoms
Mild-severe ear pain
Otalgia
Hearing loss
Fever are common
Iritability and ear pulling (in infant)
Lest Frequent Manifestations:
Lethargy
Vomiting
Dizziness
nystagmus

OTITIS MEDIA
TREATMENTS
70-80% of episodes of OM resolve
spontaneously within 72 hours
Antimicrobial th/ is the standard care
of OMA
The duration of th/ has been 10-14
days, however short courses 3-7
days has been demonstrated
effectiveness

OTITIS MEDIA
EMPIRIC THERAPY
First line agents: Amoxicillin and ampicillin; if the
px has penicillin alergy subtitute by
erythomycin-ethylsuccinate-sulfisoxazole (EESSXZ)
In the presence of -lactamase producing
organism amoxicillin-clavulanate, EES-SXZ,
Cotrimoxazole, cefaclor, cefixime or cefuroxime
axetil.
Second line agent: cefaclor, cefuroxime, cefixime
(indicated for H. influenza and M. catarrhalis)

OTITIS MEDIA
TREATMENT
The microbiology of cronic OM is
varied, so middle ear fluid should be
obtained for culture and sensitivity.
Empiric th/ should be agent s
efficacious against P. Aeruginosa and
Staphylococcus sp.
Ceftazidime, ciprofloxacin

SIDE EFFECTS
Ampicillin causes diarrhea and rash
more than amoxicillin
Amoxicillin-clavulanate has high
incidence of GI advese effects
Cotrimoxazole may associated with rash
development and diarrhea
Erythromicin may induce hepatotoxicity
for longer than 14 days administration

OTITIS MEDIA

PHARYNGITIS
Sore ThroatAn acute inflammatory process involving the
pharynx,
May include otitis media, sinusitis or other upper respiratory
infections (in younger children and infant)
Causes:
environmental causes: cigarette smoke, air polution, alck
of humidity,
Viral: rhinovirus (20%), coronavirus (5%), herpes simplex
virus (4%)
Bacterial infection: Mycoplasma pneumonia (<1%),
Streptococcus pyogenes (15-30%), Group C. Streptococci
(20%) neisseria gonorrhoeae (<1%), Group A Betahaemolytic streptococci (GABHS)

PHARYNGITIS
Clinical Presentation and Diagnosis
Mild-moderate soreness, hoarseness and
irritation of the pharynx
Pharyngeal erythema, edema, and hyperemia
may accompanied by exudates, absesses and or
palatal petechiae.
Abdominal pain in children
Diagnostic goal: to differentiate between benign
viral pharyngitis (require palliative care) and
GABHS pharyngitis (requires antibiotic) and rare
viral or bacterial causes

PHARYNGITIS
TREATMENT
Penicillin drug of choice for GABHS
pharyngitis; rifampin short course to penicillin
regiment success to eradicating GABHS
Erythromycin is a suitable subtitute to
penicillin allergy
Amantadine Influenza A pharyngitis
Acyclovir Herpetic infection
Paliative care: analgesies, topical
anesthetics/anticeptis, demulcents, and liquid.

LARYNGITIS
AN ACUTE INFLAMMATORY PROCESS
OF THE LARYNX, IS COMMONLY
ASSOCIATED WITH VIRAL
SYNDROMES.
Characteristic
Hoarseness or aphonia (loss of voice)
Painless or mildly painful
Laryngitis lingering longer than 10
days requires laryngoscopic
examination

LARYNGITIS
CAUSES
Viral origin: influenza virus (22-37%),
rhinovirus (10-25%) and adenovirus (6-25%),
Bacterial infection: S. Pyogenes (10%), M.
cattarrhalis (55%)
TREATMENT
Self-limiting complaint consist of primarily of
voice rest and inhalation of moist air.
Antibiotic are recommended only for
laryngitis of bacterial etiology

SUPRAGLOTITIS
Epiglotitis, is an infection of the epligotis,
aryepiglottid fold and arytenoids.
Causes: H. influenza type B (HITB),
Streptococcus species, Staphylococcus
apecies and H. paraphropilus.
Clinical caracteristic: fever, dysphagia,
drooling result from the refusal swallow
because of sorethroat, hoarseness, hissing
sound may accompany tachypnea.
Diagnosis: cherry red and swollen epiglottis

SUPRAGLOTITIS
TREATMENT
Empiric i.v antibiotic ampicillin
200mg/kg/day and chloramphenicol
75 to 100 mg/kg/day every 6 hours
Initial therapy: cefotaxime 100-150
mg/kg/day in four doses; cefuroxime
200 mg/kg/day in three doses 7-10
days

ACUTE
LARYNGOTRANCHEOBRONCHITIS
Acute laryngotrancheobronchitis
(croup): viral process of the upper
and lower respiratory tract resulting
in inflammation in the subglottic
area.
Subglottic swelling produce dyspnea,
inspiratory cough
Usually self-limiting

ACUTE
LARYNGOTRANCHEOBRONCHITIS
PATHOGENESIS
Occurs most commonly in male
children 3monts-3years.
Causative agent:
parainfluenza type 1 (6-39%), type 2
(2-7%) type 3 (2-14%), rhinovirus,
adenovirus
Mycoplasma pneumoniae (secondary
bacterial infection)

ACUTE
LARYNGOTRANCHEOBRONCHITIS
Croup often appear one to several
days after acute upper respiratory
infection.
Symptoms: rhinorrhoe, sore throat,
mild cough and fever
Treatment: antibiotic th/ is not
indicated (viral infection).
Corticosteroid th/ remains
controversial

LATIHAN KASUS SOAL

FIRST CASE

QUESTION

SECOND CASE
Jacob Rodriguez is a 26-month-old boy who is
brought to his pediatrician by his mother on a
Monday morning in late January. Mom describes a
1-day history of tugging at his right ear and crying,
and a 2-day history of decreased appetite,
decreased playfulness, and difficulty sleeping. Mom
states that his temperature last night was normal
by electronic axial thermometer (37.0C). Jacob has
not been given any analgesics, as his mom states
she wanted to wait to hear what the pediatrician
had to say. When Jacob is asked if anything hurts,
he points to his right ear and says boo-boo.

Both TMs erythematous (with R > L);


right TM non-bulging and mobile with
copious cerumen and questionable
purulent fluid behind TM; both TMs
landmarks appear normal including the
pars flaccida, the malleus, and the light
reflex below the umbo. However, the left
TM landmarks are more clear than the
right landmarks.Throat is erythematous;
nares patent.

QUESTIONS
Problem Identification
1.a. Create a drug therapy problem list for this patient.
1.b. What subjective and objective data support the diagnosis of AOM, and is the
diagnosis certain or uncertain in this case?
1.d. How is the severity of otitis media determined?
1.e. What risk factors for AOM are present in this child?
Desired Outcome
2. What are the goals of pharmacotherapy for AOM in this child?
Therapeutic Alternatives
3.a. What organisms typically cause AOM?
3.b. What pharmacotherapeutic alternatives are available for treatment of AOM in this
patient?
3.c. Should this patient receive antibiotic therapy at this time, or should watchful waiting
(observation) be the course of action?Defend your answer.
Optimal Plan
4.a. If antibiotics are indicated, which of the alternatives would you recommend to treat
this childs AOM? Include the dose, duration of therapy, and rationale for your selection.
4.b. What other therapies could you recommend to treat this childs symptoms?

CLINICAL PRESENTATION
Acute otitis media presents as an acute onset of
signs and Symptoms of middle ear infection such
as otalgia, irritability, and tugging on the ear,
accompanied by signs such as a gray, bulging,
nonmotile tympanic membrane. These oftenfollow
cold symptoms of runny nose, nasal congestion, or
cough
Resolution of acute otitis media occurs over 1
week. Pain and fever tend to resolve over 2 to 3
days, with most children becoming asymptomatic
at 7 days. Effusions resolve slowly, 90% have
disappeared by 3 months.