Upper Respiratory Infections (URI) and Influenza Commonly viral in nature, colds and influenza pro- duce significant numbers of calls to any medical of- fice, with patients often asking for antibiotics that will not cure the problem. One study has found that 75 percent of antibiotic prescriptions written in the United States were for acute respiratory infections, of which URI is the most common [28]. Overtreatment as well as inappropriate treatment has led to a rapid increase in the presence of resistant Streptococcus pneumoniae, a problem with implications for the management of all respiratory disease, as S. pneumo- niae is the most common bacterial respiratory pathogen [29].
The diagnosis of URI is made based on the presence of nasal congestion and a clear or white discharge, as well as sore throat, muscle aches, headache, and cough. The symptoms of colds and influenza overlap, although high fever and dry cough are more typical of the “flu” than of a cold.
Symptomatic management with rest, increased hu- midity (hot showers, humidifiers), increased fluids, over-the-counter drugs—including antipyretics, analgesics, and cough suppressants or deconges- tants as needed—will reduce the severity of symp- toms. Ipratropium bromide (Atrovent), an anticholinergic nasal spray, has also been shown to relieve rhinorrhea, sneezing, and congestion. Initial use is two sprays in each nostril, three to four times daily [30]. Atrovent is also available in oral inhaler form as a therapy for obstructive pulmonary dis- Classification of LDL, Total, and HDL
Cholesterol (mg/dL) TABLE 7-9
LDL Cholesterol
<100 Optimal
100–129 Near optimal/above optimal 130–159 Borderline high
160–189 High
>190 Very high Total Cholesterol
<200 Desirable
200–239 Borderline high
>240 High HDL Cholesterol
<40 Low
>60 High
Source:National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).National Institutes of Health and National Heart, Lung, and Blood Institute, May 2001. Accessed at www.nhlbi.nih.gov/guidelines/index on 8/2/02.
ease. In contrast, the use of antihistamines has not been shown to reduce cold symptoms significantly.
Kinins, a group of vasoactive peptides, are impli- cated in rhinitis symptoms, while histamines are not [31]. Resolution of symptoms should be complete within a week.
Many upper respiratory infections can be avoided through the use of simple hygiene techniques, most particularly the practice of hand washing. The use of antibacterial soaps and environmental sprays are, by and large, not necessary in the home.
Several therapies for influenza are available, in- cluding rimantidine (Flumantidine) and the neur- aminidase inhibitors (Relenza, Tamiflu). When the winter influenza season is in progress, infections suspected of being influenza can be treated within 48 hours of the onset of symptoms to shorten the duration of infection by about one day. Vaccination has been shown to have a preventive benefit as well, although when influenza is defined only by clinical symptoms the benefit is slight [32]. The authors of the Cochrane database review concluded that while vaccination and treatment were beneficial, the most cost-effective approach to managing influenza in the healthy adult was to use supportive measures only [33]. Women with significant exposure risk such as health workers, immunocompromised pa-
tients, and older women may receive greater benefit from vaccination.
Sinusitis
Sinus infections are typically bacterial in nature and are frequently found as a superimposed infection when nasal swelling has blocked drainage from one or more sinus cavities. In addition to pain and pres- sure over the affected sinus, a change from the clear nasal drainage of rhinitis to a green or yellow dis- charge is commonly found. Toothache near the af- fected sinus is also predictive. Fever and a cough that worsens when lying down are also characteris- tic. Therapy includes supportive management with over-the-counter decongestants, increased humidity, and antibiotics. As with colds, antihistamines should not be used unless there is an allergic component to the congestion. Common pathogens in sinusitis in- cludeStreptococcusspecies,Staphylococcus aureus, andHaemophilus influenzae; these can generally be treated for ten days with any of a number of drugs, including mainstays such as ampicillin, trimetho- prim/sulfamethoxazole, the cephalosporins, and the macrolides [34]. Table 7-10 summarizes specific therapies.
Because antibiotic resistance is rising, some ex- perts are suggesting the use of symptomatic therapy
Examples of Antibiotics Commonly Used in the Treatment of Respiratory Infections TABLE 7-10
Class Dose Range/Duration Pregnancy Category
Cephalosporins
Cefaclor (Ceclor) 250 mg q8h ¥10 days B
Cefixime (Suprax) 400 mg po QD ¥10 days B
Cefuroxime Axetil (Ceftin) 250 mg po q12h ¥10 days B
Cephalexin (Keflex) 250 mg po q6h ¥10 days B
500 mg po q12h ¥10 days B
Macrolides
Azithromycin (Zithromax) 500 mg po ¥1, then B
250 mg po QD ¥4 days
Clarithromycin (Biaxin) 250–500 mg po q12h ¥10–14 days C
Penicillins
Amoxicillin (e.g., Amoxil) 500 mg po q8h ¥10 days B
500–875 mg q12h ¥10 days
Amoxicillin/Clavulanate (Augmentin) 500–875 mg po q12h ¥10 days B
(based on amoxicillin dose) Quinolones
Ciprofloxacin (Cipro) 500 mg po BID ¥10 days C
Levofloxacin (Levoquin) 500 mg po QD ¥10 days C
Trimethoprim/sulfamethoxazole (Bactrim) 160/800mg po BID ¥10 days C
only in newly presenting uncomplicated infections.
Unresolved symptoms after therapy, frequent recur- rences or infection, or a finding of periorbital edema require referral to a physician for further evaluation [35].
Bronchitis
Infections of the lower respiratory tract limited to the trachea and bronchi are termed bronchitis. It can appear as an inflammatory response to an oth- erwise uncomplicated URI. In healthy women of re- productive age, bronchitis is typically a viral syndrome of fever, malaise, fatigue, sore throat, chest pain, and cough. Worsening chest pain with shortness of breath or pain on inspiration suggests pneumonia. The cough may be productive or non- productive. On auscultation, lung sounds other than over the bronchi should be clear; a chest x-ray, if performed, should not show infiltrates.
In most cases, the infection will clear and the cough resolves within one to two weeks with sup- portive therapy, which should include the usual reg- imen of rest, increased fluids, and over-the-counter decongestants or cough suppressants. If cough is the primary symptom, the use of an albuterol in- haler (Proventil, Ventolin) may provide relief [36].
If an inhaler is prescribed, the directions should be for two puffs every four to six hours as needed to relieve symptoms. Greater frequency of use, or pro- longed use, suggests the need for referral to a physi- cian.
Antibiotics are not useful in the case of viral bronchitis, but under certain circumstances sus- pected bacterial infections of the bronchi may re- quire antibiotic therapy (see Table 7-10). Symptoms of such a condition include worsening cough with productive discolored sputum and chronic or recur- rent bronchitis with underlying respiratory disease.
If the diagnosis is unclear, pneumonia should be ruled out based on examination of the lungs and a chest x-ray. Consultation with the physician is war- ranted if the midwife is unable to exclude pneumo- nia.
Community-Acquired Pneumonias
Infections of the lungs are the leading infectious cause of death in the United States. Predisposing factors for pneumonia include damage to the cilia of the respiratory tract from chronic cough, viral in- fections, or smoking. The most common organisms found are Streptococcus pneumoniae,Haemophilus influenzae, and Staphylococcus aureus, with S.
pneumoniae causing up to two-thirds of all com- munity-acquired disease. Other bacteria and viruses can also produce pneumonia, as can chlamydia or mycoplasma. The onset of symptoms is usually abrupt, with fever, cough, chest pain, shortness of breath, sweats and chills, generalized aches, headache, and fatigue being common. When the cause is bacterial, high fever and a productive cough are more likely, whereas viral causes will pro- duce a more generalized malaise. Unlike most upper respiratory infections, increases in respiratory rate and pulse are common. The lung fields will have rales and occasional wheezing, and areas of consol- idation may produce diminished breath sounds on auscultation. Chest x-ray is indicated to confirm the diagnosis and to identify underlying complications.
When feasible, a sputum sample should be obtained to identify the etiologic agent.
Whether patients with pneumonia are treated on an outpatient basis or are hospitalized is a deci- sion with significant consequences in terms of treat- ment modalities, testing schemes, and costs. Fine and his colleagues reported on the development of a prediction rule that identified patients at low risk of dying or suffering major sequelae [37]. Adults under 50, without existing comorbidity such as liver, kidney, cardiac, cerebrovascular disease, or malignant disease are screened for physical abnor- malities: altered mental status, pulse greater than 125 bpm, increased respiratory rate greater than 30, systolic pressure less than 90 mm Hg, or tem- perature less than 35° C or greater than 40° C.
Patients who do not exhibit these signs of severe disease are at low risk of mortality. The authors went on to describe additional criteria for low-risk patients based on laboratory findings and other cri- teria. Using the findings described above produced a group of women who could be treated without further testing [37]. While uncomplicated pneumo- nia should be treated promptly with antibiotics and can safely be managed on an outpatient basis in healthy adults, the prudent midwife will consult with a physician if pneumonia is suspected.
Common first-line antibiotics for community- acquired pneumonia include the macrolides, doxy- cycline, and quinolones [38].
Asthma
Asthma is the chronic inflammation of airways—
associated with reversible obstruction from spasm, edema, and mucus production—and hyperrespon- siveness to stimuli. It is classified into four steps based on severity and frequency of symptoms: (1)
mild intermittent asthma, (2) mild persistent, (3) moderate persistent, and (4) severe persistent (Table 7-11) [41]. Over time, changes in the walls of the airways can lead to irreversible constriction. While most cases of asthma have childhood onset, adults can also develop new disease. Current data suggest that about 14 million U.S. adults have recent asthma symptoms. Being female and African American and having lower family income are all associated with increased risk of developing asthma [39]. An adult presenting with symptoms of wheez- ing, chest tightness, and shortness of breath should be evaluated for asthma; occasionally a dry noctur- nal cough will be the only presenting complaint.
The differential diagnosis includes chronic obstruc- tive disease (chronic bronchitis or emphysema), congestive heart failure, pulmonary embolism, drug-related cough, and other causes of airway ob- struction. Common triggers for adult asthma at- tacks include exercise, rhinitis (infectious or allergic), bronchitis, gastroesophageal reflux, and allergies to NSAIDs (such as Motrin), sulfites, or beta-blockers (such as Inderal). Women with asthma should be counseled to avoid triggers, which may also include inhaled allergens such as perfumes and irritants such as environmental
smoke or polluted air. Smoking cessation is key for decreasing the severity of the disease among women who smoke. The National Institutes of Health Expert Panel Report on asthma notes that under- diagnosis and undertreatment are the major con- tributors to morbidity and mortality from asthma [40].
In the office setting, a patient whose lung sounds and symptoms suggest asthma can be asked to use a peak flow meter that measures maximum expiratory breath force before and after the use of a short-acting bronchodilator to establish whether the respiratory difficulty responds to smooth mus- cle relaxation. Formal spirometry is necessary for an accurate diagnosis, but office evaluation can allow the immediate start of acute therapy.
Midwives practicing in areas of high asthma fre- quency may keep flow meters in their offices either to assist in the presumptive diagnosis of asthma or to assess lung function when asthmatic women present and are symptomatic.
Anyone with persistent asthmatic symptoms needs to be on daily medication, rather than relying solely on a rescue inhaler such as beta2-agonists like albuterol (Ventolin) or metaproterenol (Alupent).
Undertreatment limits physical activity, decreases
Classification of Asthma Severity: Clinical Features Before Treatment TABLE 7-11
Days with Nights with PEF or
Symptoms Symptoms FEV1* PEF Variability
Step 4 Continual Frequent ≤60% >30%
Severe Persistent
Step 3 Daily ≥5/month >60%–<80% >30%
Moderate Persistent
Step 2 3–6/week 3–4/month ≥80% 20–30%
Mild Persistent
Step 1 ≤2/week ≤2/month ≥80% <20%
Mild Intermittent
*Percent predicted values for forced expiratory volume in 1 second (FEV1) and percent of personal best for peak expiratory flow (PEF) (rele- vant for children 6 years old or older who can use these devices).
NOTES
• Patients should be assigned to the most severe step in which anyfeature occurs. Clinical features for individual patients may overlap across steps.
• An individual’s classification may change over time.
• Patients at any level of severity of chronic asthma can have mild, moderate, or severe exacerbations of asthma. Some patients with inter- mittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms.
• Patients with two or more asthma exacerbations per week (i.e., progressively worsening symptoms that may last hours or days) tend to have moderate-to-severe persistent asthma.
Source:Practical Guide for the Diagnosis and Management of Asthma. NIH Publication No. 97-4053. 10/97.
pulmonary function, and increases the risk of re- current attacks. The choice of medications is based on both the severity and persistence of symptoms.
The main categories of asthma drugs for long-term maintenance include (1) inhaled or systemic corti- costeroids (e.g., Vanceril, Flovent, prednisone), (2) cromolyn sodium (Intal) and nedocromil (Tilade), (3) long-acting beta2-agonists (e.g., Serevent), (4) methylxanthines such as theophylline, and leukotriene modifiers (e.g., Singulair). In addition to short-acting inhaled beta2-agonists, anticholiner- gics such as ipratropium bromide, or short courses of oral corticosteroids may offer relief [40]. The National Heart, Lung, and Blood Institute Web site (www.nhlbi.nih.gov) provides access to the most current guidelines on asthma management. In gen- eral, newly diagnosed asthma should be evaluated in consultation with or by referral to a physician ex- perienced in respiratory care.
During pregnancy, asthma symptoms may worsen as the lung space is compressed by the growing fetus. Women with moderate to severe asthma and recent exacerbations should be referred to a physician for evaluation. Liu and colleagues re- ported an increase in adverse pregnancy outcomes related to maternal asthma, including preterm labor and birth, preterm premature rupture of mem- branes (PPROM), and hypertensive disorders of pregnancy [42]. However, they could not identify severity of disease or level of asthma control in their retrospective cohort. Thus it is not clear that well- managed asthma with minimal exacerbations would have the same effect on pregnancy outcome.
If a woman’s condition is stable and she is not ex- periencing any limitations in physical activity, there is no reason why she should not receive prenatal care and give birth with a midwife.