Chapter 8: Pulmonary Disorders 97
Upper Respiratory Infections
General Characteristics
Theupperrespiratorysystemconsistsofthenasalcavity,
pharynx, and larynx. The nasal cavity is divided by the
septumandcontainsthreeturbinateswhosefunctionisto
warm,clean,andhumidifythenearly15,000litersofair
entering the external nares each day.
3,72
The surfaces of
the nasal passageways are lined with ciliated epithelial
cells containing many mucous and serous glands. This
mucousmembraneofthenasalcavityprotectsthelower
airway through two processes. First, it acts as a lter,
entrapping foreign particles from the air, and second, it
furtherhumidiesairenteringthe lungs. The entrapped
foreign particles are transported by the ciliated epithelial
cellsintothethroattobeswallowedorremovedwhenthe
nose isblown. These physiologic processes of removing
foreignparticlesfromtheairareveryefcientandrarely
allowparticlesgreaterthan3to5micronstopassthrough
thenoseintothelowerrespiratorybronchialsystem.
3
Thepharynx,orthroat,canbeseparatedintothreeparts:
the nasopharynx, oropharynx, and laryngopharynx. The
nasopharynxisthesuperiorportionofthepharynxthatcon-
nects with the nasal cavity. The oropharynx refers to the
portion of the oral cavity that is connected with the posterior
pharynx.Thelaryngopharynxistheinferiormostportionof
thepharynx,whichseparatesanteriorlyintothelarynxand
posteriorly into the esophagus. At this point, food is sepa-
ratedfromair.Airpassesthroughthelarynxintothetrachea,
eventually reaching the lungs. In contrast, food passes
through theesophagusinto thestomach. Thevocalcords,
housed within the larynx, vibrate to generate sound and
prevent aspiration of food into the lungs upon swallowing.
3
Thefrontal,sphenoid,ethmoid,andmaxillarysinuses
arefourpaired,hollowairspaceslocatedadjacenttothe
nasal cavity. They are lined with a ciliated epithelial
mucous membrane, which facilitates drainage of these
sinuses into the nasal cavity.
3
Upperrespiratoryinfectionsarehighlycommunicable
illnessesthataccountfornumerousvisitstoprimarycare
providers and many days of missed work and school.
Nearly 75 percent are due to viruses, with rhinovirus
beingthemostcommonpathogen.Othervirusesinclude
inuenza,parainuenza,coronavirus,adenovirus,respira-
torysyncytialvirus,andmanyothers.Althoughthemajor-
ity are due to viruses, their clinical picture is difficult to
differentiatefromthoseduetobacterialinfections,which
hasresultedinovertreatmentofviralinfectionswithanti-
biotics, contributing to resistance.
73
Signs, Symptoms, and Diagnosis
Clinically,patientspresentwithahistoryofvariableand
generalizedcomplaintsthatmayincluderhinorrhea,sore
throat,nasalcongestion,andcough.Theymayalsocom-
plainofafullfeelingintheirhead,fever,fatigue,sneezing,
conjunctivitis,andhoarseness.Thephysicalexamination
isoftennonspecicandmayrevealpostnasaldrainage,a
minimallyinjectedpharynx,orrhinorrhea;itcanalsobe
completelyunremarkable.Diagnosisismadewithobtain-
ing a thorough history of the full clinical course in
itoccursintherightbronchusmorefrequentlythanthe
left.
69,70
Themostseverecomplicationofaspirationisair-
way obstruction, which typically occurs with circular-
shaped foods, such as hot dog pieces or grapes.
69,70
Signs, Symptoms, and Diagnosis
Acarefulhistoryshouldbeelicitedfromthecareprovider
regarding anepisodeof violent coughingorchoking.In
thecaseofcompleteobstruction,symptomsmayprogress
tothevictimbeingunabletospeakorcough,whichisa
signofrespiratorydistress.Inothercases,theforeignbody
may become trapped and cause partialor little obstruc-
tion. In these cases, the patient can exhibit decreased
breathsounds,wheezing,orstridor;thepatientmayalso
beasymptomatic.Ifthepatientisasymptomatic,nofurther
investigationmay bedone, which canlead tocomplica-
tions such as atelectasis, pneumonia, lung abscess, or
other infections. When presenting with these complica-
tions, patients may exhibit fever, chills, cough, and
hemoptysis.
69,70
High clinical suspicion obtained during a thorough his-
tory warrants radiographic examination of the chest.
69,70
AchestX-raymaybenormaluptoone-thirdofthetime,
anditmayrevealanopaqueforeignbodyuptoone-fourth
ofthetime.Radiolucentobjectsmaybedifculttoappre-
ciate on a standardinspiratory PA chest radiograph and
expirationradiographs;CTormagneticreasonanceimag-
ingmaybehelpful.
69–71
Management
Inapatientwithanacuteairwayobstructionofthelarynx
ortracheaandrespiratorydistress,theHeimlichmaneu-
ver, abdominal thrusts, or back blows should be per-
formed immediately in an attempt to expel the foreign
body.
69,71
Treatment of a foreign body in the airway
requiresimmediateremovalupondiscoverywitharigid
bronchoscope.
69–71
Complicationsofforeignbodyaspira-
tion, such as atelectasis, pneumonia, or lung abscess,
should be treated accordingly.
69,70
Lifestyle Changes: Practical Tips for Your
Patients
Infantsandtoddlersshouldbemonitoredwhileeat-
ingandplaying.Foodshouldbecutintopiecessmall
enough to avoid risk of obstruction or aspiration.
Smalltoysandobjectsshouldbekeptoutofthereach
of children. In the elderly or those with difculty
swallowing, consultation with a speech therapist and
a subsequent swallow study may be warranted to
determineafoodconsistencythatwoulddecreasethe
risk of aspiration. Talking and eating concurren-
tly should be avoided because it poses a risk for
aspiration. Sedative use may also increase the risk
of aspiration and should be avoided. All individuals,
especially parents and caregivers, should learn how
toperformtheHeimlichmaneuverincaseofachok-
ingemergency.
69

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