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9: RESPIRATORY GUIDELINES
E. Percuss:
1. Chest/lungs for hyperresonance.
F. Perform neurologic examination:
1. Assess for irritability and lethargy.
DIAGNOSTIC TESTS
A. Diagnosis is made based on age and seasonal occurrence,
tachypnea, and the presence of profuse coryza and ne rales,
wheezes, or both on auscultation.
B. Viral isolation from nasopharyngeal secretions or rapid
antigen detection (enzyme-linked immunosorbent assay
[ELISA], immunouorescence) for RSV can conrm the
diagnosis.
C. Consider pulse oximetry.
D. Routine use of chest radiograph is not recommended by
the American Academy of Pediatrics (AAP).
DIFFERENTIAL DIAGNOSES
A. Viral bronchiolitis.
B. Asthma.
C. Viral or bacterial pneumonia.
D. Aspiration syndromes.
E. Pertussis.
F. Cystic brosis (CF).
G. Cardiac disease.
H. Reux.
I. Aspiration.
J. Tracheoesophageal stula.
K. Foreign body.
PLAN
A. General interventions:
1. Treatment foundation is supportive care with attention
to adequate oxygenation and hydration.
a. Use a humidier in the client’s bedroom.
b. Clear stuffy nose with saline solution drops and suc-
tion out nares with bulb syringe.
c. Infants should not be exposed to secondhand
smoking.
d. Monitor respiratory pattern.
e. Use good hygiene practices: handwashing.
B. Client teaching: See Client Teaching Guide for this chapter,
“Bronchiolitis: Child.”
C. Pharmaceutical therapy:
1. Bronchodilators should not be routinely used. They
do not shorten the duration of illness or lessen the risk of
hospitalization.
2. Corticosteroids should not be routinely used. They
do not shorten the duration of illness or lessen the risk of
hospitalization.
3. Antibacterials should be used only with proven coexis-
tence of a bacterial infection.
4. There is no vaccine against bronchiolitis. Premature
infants and infants with CLD may benet from vaccination
with palivizumab (Synagis) prophylaxis against HMPV if
they are born during theRSV season. Palivizumab should
be administered to high-risk children following the AAP
guidelines. HMPV has a worldwide distribution and is
responsible for the majority of viral URIs in children and
adults.
5. Use of montelukast (Singulair) has not proven bene-
cial in resolution of symptoms.
D. Dietary management:
1. Encourage uids, such as juice and water. Dilute juice
for younger infants.
2. Offer small, frequent feedings.
3. Breastfeeding should continue.
E. Medical/surgical management:
1. Clients may require only supportive care. Clients with
respiratory distress require hospitalization.
2. Hypoxemic clients need oxygen therapy and possibly
mechanical ventilation.
3. Chest physiotherapy is not recommended.
FOLLOW-UP
A. Contact the client within 12 to 24 hours for evaluation.
CONSULTATION/REFERRAL
A. Notify a doctor if the client’s breathing becomes labored,
their wheezing becomes worse, and/or respiratory distress is
suspected.
B. Refer clients with RSV to the ED if moderate respiratory
distress, dehydration, or hypoxemia occurs.
C. Hospitalization isrecommended for:
1. Younger clients in moderate to severe respiratory
distress.
2. Infants less than 3 months of age.
3. Clients with pulmonary hypertension, CLD (formerly
bronchopulmonary dysplasia), or CF if their respiratory
rate is greater than 60 breaths/min, their pulse oximetry is
less than 92%, or they eat poorly.
INDIVIDUAL CONSIDERATIONS
A. High-risk chronic conditions:
1. Clients with pulmonary hypertension, bronchopulmo-
nary dysplasia, or CF may have prolonged courses with
high morbidity and mortality. Some may have reactive airway diseases in the future.
B. Pediatrics:
1. Young children are most susceptible to HMPV infec-
tion. The majority of children are seropositive for HMPV
infection by age 5. History of prematurity and asthma
increase the risk of hospitalization of children.
C. Adults:
1. Human pneumovirus was identied in 8% of adults
requiring hospitalization for lower respiratory infections.
D. Geriatrics:
1. Geriatric clients are most susceptible to HMPV
infection.
BIBLIOGRAPHY
Barr, F., & Graham, B. (2020). Immunoprophyl actic agents: Palivizumab.
UpToDate. https://www.uptodate.com/contents/respiratorysyncytial-virus-infection-prevention
Piedra, P. A. (2019, January). Bronchiolitis in infants and children: Clinical
features and diagnosis. UpToDate. http://www.uptodate.com/contents
/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis
Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley,
J. E., Gadomski, A. M., Johnson, D. W., Light, M. G., Marqa, N. F.,
Mondonca, E. A., Phelan, K. J., Zorc, J. J., Stanko-Lopp, D., Brown,
M. A., Nathanson, I., Rosenblum, E., Sayles, S., & Hernandez-Cancio,
S. (n.d). Clinical Practice Guidelines: The diagnosis, management and
Prevention of Bronchiolitis. Pediatrics. https://pubmed.ncbi.nlm.nih.
gov/25349312
BRONCHITIS, ACUTE
DEFINITION
A. Acute bronchitis is inammation of the tracheobronchial
tree. Bronchitis is nearly always self-limited in the otherwise
healthy individual. Generally, the clinical course of acute
bronchitis lasts 10 to 14 days. The cause is usually infectious,
BRONCHITIS, ACUTE
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219
but allergens and irritants may also produce a similar clinical
prole. Asthma can be mistaken as acute bronchitis if the client has no history of asthma.
INCIDENCE
A. Bronchitis is more common in fall and winter in relation to
the common cold or other respiratory illness. It occurs in both
children (younger than 5 years of age) and adults and is diagnosed in males more frequently than in females. Fewer than
5% of clients with bronchitis develop pneumonia. Bronchitis
ranks as the sixth leading cause of ofce visits to a medical
provider.
PATHOGENESIS
A. Most attacks are caused by viral agents, such as adenovi-
rus, inuenza, parainuenza viruses, and respiratory syncytial virus.
B. Bacterial causes include Bordetella pertussis, Mycobacterium
tuberculosis, Corynebacterium diphtheriae, and M. pneumoniae.
B. pertussis should be considered in children who are incom-
pletely vaccinated.
PREDISPOSING FACTORS
A. Viral infection.
B. Upper respiratory infection (URI).
C. Smoking.
D. Exposure to cigarette smoke.
E. Exposure to other irritants.
F. Allergens.
G. Chronic aspiration/gastroesophageal reux disease
(GERD).
COMMON COMPLAINT
A. The most common symptom is cough with or without
sputum.
OTHER SIGNS AND SYMPTOMS
A. Headache.
B. Dyspnea.
C. Rhonchi during respiration.
D. Low-grade fever.
E. Malaise.
F. Retrosternal pain during deep breathing and coughing.
G. Decreased/lack of appetite.
SUBJECTIVE DATA
A. Ask about the onset, duration, and course of symptoms.
Note duration of cough symptoms.
B. Is the cough productive?
C. Is there substernal discomfort?
D. Is there malaise or fatigue?
E. Has the client had a fever?
F. Does the client smoke, including e-cigarettes? (Smoking
aggravates bronchitis.)
G. A review of occupational history may be important in
determining whether irritants play a role in symptoms.
H. Assess for symptoms of gastroesophageal reux.
I. Recent cold symptoms.
PHYSICAL EXAMINATION
A. Examinations of children may best be completed with the
child sitting on the parent’s lap.
B. Check temperature, pulse, and blood pressure. Always
check a pulse oximeter.
C. Inspect:
1. Observe overall appearance.
2. Inspect the eyes, ears, nose, and throat (the pharynx
may be injected).
3. Transilluminate the sinuses.
D. Palpate:
1. Lymph nodes.
2. Maxillary and frontal sinuses.
E. Auscultate:
1. Lung elds for crackles, wheezing, and rhonchi.
DIAGNOSTIC TEST
A. Consider chest x-ray to exclude pneumonia for fever,
tachycardia, tachypnea.
DIFFERENTIAL DIAGNOSES
A. Pneumonia.
B. URI.
C. Asthma.
D. Sinusitis.
E. Cystic brosis.
F. Aspiration.
G. Respiratory tract anomalies.
H. Foreign-body aspiration.
I. Pneumonia.
J. Chronic obstructive pulmonary diseaseand emphysema.
K. Pediatrics and adults with persistent cough: pertussis.
L. Postnasal drip.
M. Heart failure.
N. Medications (angiotensin-converting enzyme inhibitors).
O. GERD.
P. Lung carcinoma.
PLAN
A. General interventions:
1. Primarily supportive care and ensuring the client is
adequately oxygenated.
2. Instruct the client to increase uid intake.
3. Suggest cool mist humidity and mist therapy.
4. Avoid irritants, such as smoke.
B. Client teaching: See Client Teaching Guide for this chapter,
“Bronchitis, Acute.”
C. Pharmaceutical therapy:
1. Acetaminophen (Tylenol) for fever and malaise:
a. Adults: 500 to 1,000 mg orally Q6H; not to exceed 4
g/d.
b. Pediatrics: for those younger than 12 years, 10 to
15mg/kg/dose PO every 4 to 6 hours, maximum of
75mg/kg/d and up to 4 g/d; for children older than
12 years, 325 to 650mg PO every 4 to 6 hours, not to
exceed 4 g/d.
2. Expectorants, such as guaifenesin with dextrometho-
rphan (Robitussin DM, Humibid DM, Mytussin), can be
used to treat minor cough from bronchial/throat irritation.
a. Adults and children older than 12 years: 10mL PO
Q4H.
b. The American Academy of Pediatrics recommends
that children younger than 6 years should not use
cough and cold medications.
c. Children 6 to 12 years: 5 mL PO Q4H as needed.
d. Among otherwise healthy individuals, antibiotics
have not demonstrated benet in acute bronchitis, as
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9: RESPIRATORY GUIDELINES
the etiology is usually viral. However, oral antibiotics
should be considered if symptoms persist for 2 weeks
with treatment (indicates bacterial infection).
i. Erythromycin (EES, E-Mycin, Ery-Tab):
1) Adults: 250 to 500mg PO QID or 333 mg
PO TID.
2) Pediatrics: 30 to 50 mg/kg/d PO divided
QID.
ii. Clarithromycin (Biaxin):
1) Adults: 250 to 500mg PO BID.
2) Pediatrics: 7.5 mg/kg PO BID.
iii. Azithromycin (Zithromax):
1) Adults: on day 1, 500mg PO, then 250mg
PO on days 2 to 5.
2) Pediatrics: 12mg/kg PO every day; do not
exceed 500mg/dose.
3. Albuterol (Ventolin) for clients with wheezes or rhon-
chi, or for clients with a history of bronchoconstriction:
a. Adults: two puffs every 4 to 6 hours or 2 to 4 mg PO
for three to four times a day.
b. Pediatrics: 0.1 to 2 mg/kg PO TID.
FOLLOW-UP
A. Follow up if client does not improve in 48 hours.
B. Recommend yearly inuenza vaccinations.
CONSULTATION/REFERRAL
A. In uncomplicated cases, mucus production decreases and
cough disappears in 7 to 10 days. If symptoms persist, refer
the client to a physician.
B. Refer the client if you note respiratory distress or if they
appear ill and you suspect pneumonia.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Children who have repeated episodes of bronchitis
should be evaluated for congenital defects of the respiratory system.
2. Instruct clients regarding the need for immuniza-
tion against pertussis, diphtheria, and inuenza, which
reduces the risk of bronchitis.
3. Children may attend school or day care without restric-
tions except during acute bronchitis with fever.
B. Geriatrics:
1. Monitor elderly clients for complications such as pneu-
monia. The elderly have a greater morbidity and mortality
rate.
BIBLIOGRAPHY
American Academy of Pediatrics. (2018, June). Cough and cold
medicine: Not for children. http://www.choosingwisely.org/
clinician-lists/american-academy-pediatrics-cough-and-coldmedicines-for-children-under-four/
Centers for Disease Control and Prevention. (n.d). Bronchitis (chest cold).
https://www.cdc.gov/getsmart/antibiotic-use/url/bronchitis.html
Centers for Disease Control and Prevention. (2017b, August 7). Pertussis
(whooping cough) surveillance & reporting. https://www.cdc.gov/pertu
ssis/surv-reporting.html
Chang, A., Oppenheimer, J., Weinberger, M., Rubin, B. K., Grant, C.
C., Weir, K., Irwin, R. S., &CHEST Expert Cough Panel. (2017).
Management of children with chronic wet cough and protracted bacterial bronchitis. Chest, 151(4), 884–890. https://doi/10.1016/j.chest.
2017.01.025
File, T. M. (2018, November). Acute bronchitis in adults. UpToDate. http://
www.uptodate.com/contents/acute-bronchitis-in-adults
Smith, M. P., Lown, M., Singh, S., Ireland, B., Hill, A. T., Linder, J. A.,
Irwin, R. S., &CHEST Expert Cough Panel. (2020). Acutre cough due
to acute bronchitis in immunocompetent adult outpatients: CHEST
expert panel report. CHEST, 157(5), 1256–1265. https://doi.org/10.1
016./j.chest.2020.01.044
BRONCHITIS, CHRONIC
DEFINITION
A. Chronic bronchitis is excessive mucus secretion with
chronic or recurrent productive cough occurring inthree successive months a year for two consecutive years.
B. Others limit the denition to a productive cough that lasts
more than 2 weeks despite therapy.
C. Clients with chronic bronchitis have more mucus than nor-
mal due to either increased production or decreased clearance.
Coughing is the mechanism for clearing excess secretion.
INCIDENCE
A. The incidence of chronic bronchitis is uncertain secondary
to underreporting of symptoms; many clients remain undiagnosed. There is a lack of denitive diagnostic criteria, as well
as considerable overlap with asthma. Visits for bronchitis are
second only to visits for otitis media and are slightly more
common than visits for asthma.
PATHOGENESIS
A. Mucociliary clearance is delayed due to excess mucus
production and loss of ciliated cells, leading to a productive
cough. This is usually secondary to the number of years of
cigarette smoke–induced damage. In children, chronic bronchitis follows either an endogenous response to an acute airway injury or continuous exposure to noxious environmental
agents such as allergens or irritants.
B. Bacteria most often implicated are Streptococcus pneu-
moniae, Haemophilus inuenzae, Mycoplasma pneumoniae, and
Moraxella catarrhalis. The most common causes of chronic bron-
chitis in the pediatric population include viral infections such
as adenovirus, respiratory syncytial virus, rhinovirus, and
human bocavirus.
C. Specic occupational exposures are associated with symp-
toms of chronic bronchitis, including coal, cement, welding
fumes, organic dusts, engine exhausts, re smoke, and secondhand smoke.
PREDISPOSING FACTORS
A. Cigarette smoking.
B. Cold weather.
C. Acute viral infection.
D. Chronic obstructive pulmonary disease (COPD)/
emphysema.
E. Occupational exposure to other airborne irritants.
F. Chronic, recurrent aspiration or gastroesophageal reux.
G. Allergies.
COMMON COMPLAINTS
A. Worsening cough: hacking, harsh, or raspy sounding.
B. Changes in color (yellow, white, or greenish), amount, and
viscosity of sputum.
C. Children younger than 5 years rarely expectorate, and
sputum is usually seen in vomitus.
D. “Rattling” sound in chest.
E. Dyspnea/breathlessness.
F. Wheezing.
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OTHER SIGNS AND SYMPTOMS
A. Difculty breathingand retrosternal pain during a deep
breath or cough.
B. Rapid respirations.
C. Fatigue.
D. Headache.
E. Loss of appetite.
F. Fever.
G. Myalgias.
H. Arthralgias.
SUBJECTIVE DATA
A. Determine the onset, course, and duration of illness.
B. Is the client having trouble breathing?
C. Has there been a fever?
D. How is the client’s appetite? Is the client drinking enough
uids?
E. Does the client smoke, use vapor cigarettes (vaping), or is
the client exposed to secondhand smoke?
Chronic bronchitis has a long history of a productive cough and
late-onset wheezing. Clients with asthma with a chronic obstruction
have a long history of wheezing with a late-onset of productive cough.
F. Review occupational history to evaluate exposure to
irritants.
G. Does the client have a history of asthma?
H. How often is the client currently using their short-acting
beta-2 agonists inhaler? Assess the severity of symptoms
using modied Medical Research Council (mMRC) Dyspnea
Scale or COPD Assessment Test (CAT) or the Rened ABCD
Assessment Tool.
I. Review medications: There is mixed evidence on the safety
of beta-blockers and gabapentinoids as each may increase the
risk of breathlessness.
PHYSICAL EXAMINATION
A. Examinations of children may best be started with the
child sitting on the parent’s lap.
B. Check temperature, pulse, blood pressure, and pulse
oximetry.
C. Inspect:
1. Observe overall appearance/mentation/ease of respi-
rations. Note nutritional status as cachexia may be noted
in advanced disease.
2. Inspect the eyes, ears, nose, and throat:
a. The pharynx may be injected.
b. Conjunctivitis suggests adenovirus.
3. Transilluminate the sinuses.
D. Auscultate:
1. Lungs in all elds; lung sounds may sound normal to
scattered, rhonchi, or large airway wheezing.
2. Heart.
E. Percuss:
1. Chest.
F. Palpate:
1. Lymph nodes.
2. Maxillary and frontal sinuses.
DIAGNOSTIC TESTS
A. Clients with uncomplicated respiratory illness need little,
if any, laboratory evaluation.
B. Pulse oximetry can help diagnose the issue.
C. Sputum culture is used to identify bacteria.
D. Chest radiograph may help exclude other diseases or
complications.
E. Pulmonary function studies may be indicated.
F. EKG and pulmonary function tests (PFTs) may be required
for clients with COPD.
G. Sweat test may be necessary to rule out cystic brosis (CF).
DIFFERENTIAL DIAGNOSES
A. Acute bronchitis.
B. Pneumonia.
C. Asthma.
D. Sinusitis.
E. CF.
F. Bronchiectasis.
G. Central airway obstruction.
H. Lung cancer.
I. Aspiration syndrome.
J. Gastroesophageal reux.
K. Tuberculosis.
L. Foreign body.
M. Heart failure.
PLAN
A. General interventions:
1. Rest during early phase of illness.
2. Encourage smoking cessation and staying away from
secondhand smoke.
3. Suggest exercise for clients with COPD.
4. The client’s goal is to improve symptoms and to reduce
cough and production of sputum.
5. Inform clients that increased sputum production may
occur after smoking cessation and that they may have airway reactivity (wheezing), which is especially seen in clients with asthma.
B. Client teaching: See Client Teaching Guide for this chapter,
“Bronchitis, Chronic.”
C. Pharmaceutical therapy:
1. Bronchodilators should be considered for
bronchospasm:
a. Albuterol sulfate (Proventil, Ventolin, ProAir):
i. Adults: metered-dose inhaler (MDI)-2 actua-
tions (90 mcg/actuation) inhaled every 4 to 6 hours.
ii. Pediatrics: MDI or nebulizer:
1) Younger than 1 year: 0.05 to 0.15 mg/kg
dose every 4 to 6 hours.
2) 1 to 5 years old: 1.25 to 2.5 mg/kg dose
every 4 to 6 hours.
3) 5 to 12 years old: 2.5 mg/kg dose every 4 to
6 hours.
4) Older than 12 years: 2.5 to 5 mg/kg dose
Q6H.
2. Analgesics and antipyretics are used to control fever,
myalgias, and arthralgias.
3. Consider oral steroids to reduce inammation:
a. Adults: 5 to 60mg/d PO.
b. Pediatrics: 1 to 2 mg/kg PO daily or in twice a day
divided dosing; do not exceed 80mg/d.
c. Tapering steroids is not necessary with steroid
courses of 10 days’ duration or less.
4. Inhaled corticosteroidmay be effective, although not
recommended without bronchodilator or other medications for symptom control.
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9: RESPIRATORY GUIDELINES
a. Budesonide (Pulmicort) is available as an MDI that
delivers 90 or 180 mcg/actuation:
i. Adult MDI: 90 to 180 mcg inhaled PO BID, not
to exceed 1440 mcg/d. Use the lowest effective
dosage.
ii. Pediatric MDI: 90 mcg inhaled PO BID, not to
exceed 720 mcg/d.
b. Fluticasone (Flovent HFA, Flovent Diskus)is avail-
able as MDI (44 mcg, 110 mcg, or 220 mcg per actuation) and Diskus powder for inhalation (50 mcg, 100
mcg, or 250 mcg per actuation).
i. Adults:
1) MDI: 88 mcg inhaled PO BID; dosage not to
exceed 440 mcg BID.
2) Diskus: 100 mcg inhaled PO BID; dosage
not to exceed 500 mcg BID.
ii. Pediatrics:
1) MDI: ages 4 to 11 years: 88 mcg inhaled PO
BID; older than 11 years: administer as inadults.
2) Diskus: ages 4 to 11 years: 50 mcg inhaled
PO BID; older than 11 years: administer as
inadults.
5. Antibiotics for bacterial infection:
a. Erythromycin (EES, E-Mycin, Ery-Tab):
i. Adults: 250 to 500mg PO QID or 333 mg PO
TID.
ii. Pediatrics: 30 to 50mg/kg/d PO divided QID;
do not exceed 2 g/d.
b. Clarithromycin (Biaxin):
i. Adults: 250 to 500mg PO BID.
ii. Pediatrics: 7.5 mg/kg PO BID.
c. Azithromycin (Zithromax):
i. Adults: 500mg PO on day 1, then 250mg PO on
days 2 to 5.
ii. Pediatrics: 10 mg/kg/d PO on day 1, then 5
mg/kg on days 2 to 5; do not exceed adult dose.
d. Amoxicillin-clavulanic acid (Augmentin):
i. Adults: 250 to 500mg PO Q8H.
ii. Pediatrics:
1) Younger than 3 months: 30 mg/kg/d PO
divided to Q12H.
2) 3 months or older: 40 to 80 mg/kg/d PO
divided to Q12H.
6. Over-the-counter cold and cough products: The
American Academy of Pediatrics does not recommend use
of cold and cough products in children 6 years of age or
younger. These products have been associated with serious adverse effects.
D. Dietary management:
1. Increase uids.
2. Eat nutritious food.
FOLLOW-UP
A. Follow up if there is no improvement in 3 to 4 days after
starting therapy.
B. Recommend yearly inuenza vaccinations.
C. Recommend pneumococcal vaccines.
D. Review the need for updated Tdap and tetanus toxoid.
CONSULTATION/REFERRAL
A. Refer clients with respiratory distress to a physician.
If respiratory failure occurs (rare), hospitalization may be
needed.
B. Refer clients with COPD to a physician or pulmonary
specialist.
C. Referral to a pediatric pulmonologist should be considered
when symptoms persist and do not respond to initial therapy.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Recurrent acute or chronic bronchitis should alert the
clinician to the diagnosis of asthma.
2. Recurrent episodes of acute or chronic bronchitis may
also be associated with immunodeciencies.
3. Discuss the need for immunization against pertus-
sis, diphtheria, and inuenza, which reduces the risk of
bronchitis.
4. Children may attend school or day care without restric-
tions except during fever.
5. In children, a foreign body needs to be ruled out either
radiographically or by bronchoscopy.
B. Geriatrics:
1. Age-specic changes in theelderly include changes in
airway size due to connective tissue changes, including
shallow alveolar sacs.
2. Chest wall compliance is reduced, with diaphragmatic
strength reduction of 25%.
3. Older adults may adjust their lifestyle to compensate
due to declining lung function.
4. Dyspnea should be addressed and not associated only
with deconditioning with age.
BIBLIOGRAPHY
Centers for Disease Control and Prevention. (n.d). Bronchitis (chest cold).
https://www.cdc.gov/getsmart/antibiotic-use/url/bronchitis.html
Centers for Disease Control and Prevention. (2017b, August 7). Pertussis
(whooping cough) surveillance & reporting. https://www.cdc.gov/pertu
ssis/surv-reporting.html
COPD DynaMed. EBSCO Information Services. Https://www-dynamed-
com.frontier.idm.oclc.org/condition/copd.
Epocrates Online. (2019). Pulmicort exhaler. https://online.epocrates.
com/drugs/464802/Pulmicort-Flexhaler/Peds-Dosing
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DEFINITION
A. Chronic obstructive pulmonary disease (COPD) is pro-
gressive, chronic, expiratory airway obstruction due to
chronic bronchitis or emphysema. The relief of bronchoconstriction due to inammation has some reversibility. Chronic
bronchitis is a chronic productive cough lasting 3 months
during two consecutive years, after all causes of chronic
cough have been excluded. Emphysema is an abnormal,
permanent enlargement (hyperination) and destruction of
the alveoli air sacs, as well as the destruction of the elastic
recoil. Many clients have both types of air restriction symptoms of chronic bronchitis and emphysematous destruction leading to COPD. Clients with asthma whose airow
obstruction is completely reversible are not considered to
have COPD. When asthmatic clients do not have complete
reversible airow obstruction, they are considered to have
COPD.
B. Irreversible airow obstruction is a key factor in the cli-
ent’s disability. The goal of COPD management is to improve
daily quality of life (QOL) and the recurrence of exacerbations. Smoking cessation continues to be the most important
therapeutic intervention.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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C. The following are the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) staging criteria:
1. Stage I: mild obstruction: forced expiratory volume in
1 second (FEV1) greater than 80% of predicted value, some
sputum, and chronic cough.
2. Stage II: moderate obstruction: FEV
between 50% and
1
80% of predicted value, shortness of breathon exertion,
and chronic symptoms.
3. Stage III: severe obstruction: FEV
between 30% and
1
50% of predicted value, dyspnea, reduced exercise tolerance, and exacerbations affecting QOL.
4. Stage IV: very severe obstruction chronic respiratory
failure: FEV1 less than 30% of predicted value or moderate obstruction FEV1 less than 50% of the predicted value,
dyspnea at rest, and chronic respiratory failure. Of clients
admitted for COPD exacerbation, 14% die within 3 months
of admission.
D. Comorbidities commonly seen with COPD include
hypertension; cardiac disorders, including atrial fibrillation and heart failure; diabetes/metabolic syndrome;
gastrointestinal disorders; lung cancer; depression; and
osteoporosis.
INCIDENCE
A. The National Heart, Lung, and Blood Institute reported
that 16 million Americans are affected with COPD and millions more do not know they have it. COPD is still an underrecognized diagnosis, although it is the third leading cause
of death in the United States. COPD is more commonly seen
in males than females, but gender differences are lessening
as more females are smoking. The Global Burden of Disease
Study reported a prevalence of 251 million cases of COPD
globally and that number is predicted to increase annually
secondary to higher smoking prevalence (tobacco, vaping,
and marijuana) in many countries.
PATHOGENESIS
A. Chronic bronchitis leads to the narrowing of the airway
caliber and increase in airway resistance. Mucous gland
enlargement is the histologic hallmark of chronic bronchitis.
B. In emphysema, loss of the air sac’s elastic recoil and alve-
oli destruction cause air limitation. Emphysema caused by
smoking is the most severe in the upper lobes. Most clients
with COPD have smoked one pack of cigarettes a day for 20
or more years before the symptomatic dyspnea, cough, and
sputum appear.
PREDISPOSING FACTORS
A. Cigarette smoking.
B. Occupational, environmental, or atmospheric pollutants:
1. Dust.
2. Chemical fumes.
3. Secondhand smoke.
4. Air pollution.
C. Genetic factor: alpha-1 antitrypsin (AAT) deciency.
D. Recurrent or chronic lower respiratory infections or
disease.
E. Age (most common in fth decade of life).
COMMON COMPLAINTS
A. Chronic cough and colorless sputum, usually worse in
morning.
B. Dyspnea with exertion, progressing to dyspnea at rest.
C. Wheezing.
D. Difculty speaking or performing tasks.
E. Weight loss (decrease in fat-free mass).
OTHER SIGNS AND SYMPTOMS
A. Pursed-lip breathing: induces auto-peeping and hence
helps keep alveoli open.
B. Use of accessory muscles.
C. Tripod position.
D. Barrel chest.
E. Cyanosis (ngertips, tip of nose, around lips).
F. Tachypnea.
G. Tachycardia.
H. Difculty speaking or performing tasks.
I. Distended neck veins.
J. Abnormal, diminished, or absent lung sounds.
K. Mental status changes.
L. Anxiety and depression.
M. Pulmonary hypertension.
N. Cor pulmonale.
O. Left-sided heart failure.
SUBJECTIVE DATA
A. Ask the client about past respiratory problems and infec-
tions. Do they currently have fever, chills, or other signs of
infection?
B. Ask about the onset of cough and characteristics of spu-
tum (amount, color, and presence of blood).
C. Determine cigar use and cigarette pack-year history (pack/
day × number of years smoked).
D. Inquire about exposure to occupational or environmental
irritants.
E. How far can the client walk before becoming breathless?
Is there more breathlessness when the client walks on a slight
incline?
F. Does the client become breathless or tired when perform-
ing activities of daily living (ADLs)?
G. Ask about insomnia, anxiety, restlessness, edema, and
weight change.
H. How many pillows does the client sleep on? Do they have
to sleep in a recliner or sitting up?
I. Assess the client’s ability to perform ADLs and instrumen-
tal activities of daily living (IADLs), including grooming and
personal hygiene, performing chores around the house, shopping, cooking, and driving.
J. Ask about alcohol use.
K. Review all medications, including over-the-counter and
herbal products.
L. Review further assessment questions based on existing
comorbidities.
PHYSICAL EXAMINATION
A. Record temperature, blood pressure, pulse, respirations,
and pulse oximetry.
1. The respiratory rate increases proportionally to disease
severity.
2. Take height and weight to calculate the body mass
index. Note nutritional status particularly muscle wasting
or cachexia.
3. The client may have a fairly normal examination early
in the disease course.
B. Inspect:
1. Observe general appearance: skin color, affect, pos-
ture, gait, amount of respiratory effort when walking; note
increased anterior–posterior chest diameter.
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2. Examine sputum: Frothy pink signals pulmonary
edema. Hemoptysis is as seen in tuberculosis (TB).
3. Examine the lips, ngertips, and nose for cyanosis (n-
ger clubbing is not characteristic of COPD).
4. Observe the neck for distended veins and peripheral
edema (advanced disease).
5. Check for pursed-lip breathing and use of accessory
muscles.
C. Auscultate:
1. Auscultate the heart.
2. Auscultate the lungs for wheezes, crackles, decreased
breath sounds, and prolonged forced expiratory rate.
3. Assess for vocal fremitus (vibration) and egophony
(increased resonance and high-pitched bleating quality).
Air trapping causes air pockets that do not transmit sound
well. Absent vesicular lung sounds are a distinctive characteristic of COPD.
4. Auscultate the carotid arteries and the abdomen for
bruits.
D. Percuss:
1. Chest for the presence of hyperresonance and for signs
of consolidation.
E. Palpate:
1. Palpate the neck for lymphadenopathy.
2. Palpate the chest.
3. Evaluate the abdomen for organomegaly.
4. Evaluate pedal edema.
F. Mental status:
1. Assess for decreased level of consciousness.
G. Six-minute walking distance (6MWD) test:
1. This test evaluates desaturation. A medical 6MWD may
be found at www.mdcalc.com/6-minute-walk-distance.
H. Further physical examinations are dependent on
comorbidities.
DIAGNOSTIC TESTS
A. Spirometry is the gold standard for diagnosing COPD.
Pulmonary function tests (PFTs) are used to diagnose,
determine severity, and follow the disease progression of
COPD. Perform spirometry before and after the client uses a
bronchodilator.
1. FEV
is used as an index to airow obstruction and
1
evaluates the prognosis in emphysema.
2. Forced vital capacity (FVC).
3. FEV
B. Chest radiograph (CXR) is not required to diagnose COPD
/FVC ratio less than 0.70.
1
but rules out other diagnoses.
C. Complete blood count: Evaluate polycythemia due to
chronic hypoxia.
D. Sputum specimen for culture.
E. If the client is younger than 40 years or has a family history
of early onset of emphysema, measure AAT levels. Clients
with a family history of AAT deciencies are at risk of lung
damage early in life, as AAT serves to protect lower lung tissue from damage by proteolytic enzymes.
F. Arterial blood gas (ABG).
G. EKG: Note sinus tachycardia, atrial arrhythmias.
H. Two-dimensional echocardiogram is used to evaluate sec-
ondary pulmonary hypertension.
I. Chest CT is an alternative imaging study for emphysema;
however, it is not required as a diagnostic tool.
J. Perform a puried protein derivative (PPD) skin test or
Quantiferon TB Gold blood test if TB is suspected.
K. Brain natriuretic peptide (BNP).
L. Theophylline level (if applicable).
DIFFERENTIAL DIAGNOSES
A. Asthma.
B. Heart failure.
C. Bronchiectasis.
D. Pulmonary edema.
E. TB.
F. AAT deciency.
G. Pneumonia.
H. Pulmonary embolism.
I. Cystic brosis.
J. Cancer.
PLAN
A. General interventions:
1. A smoking-cessation plan is an essential part of a com-
prehensive treatment plan. Develop a smoking-cessation
plan; assess readiness to quit. Set a quit date; encourage a group smoking-cessation program. Discuss smoking at every subsequent visit (see Client Teaching Guide for
Chapter22, “Nicotine Dependence”).
2. Advise client to stay away from secondhand smoke
and limit exposure to other pulmonary irritants, including
extreme temperature changes.
3. Advise exercise including lung exercises/pulmonary
rehabilitation.
4. Consider pulmonary rehabilitation for all stages of COPD.
5. The selection of inhalers is dependent on the client’s
age and ability to use the inhaler. Clients should be evaluated as to their coordination and inspiration abilities necessary to use inhalers; otherwise, aerosol medication via
nebulizer is the best delivery method.
6. Have clients bring in their medication/spacers to dem-
onstrate correct use.
B. Client teaching: See Client Teaching Guide for this chapter,
“Chronic Obstructive Pulmonary Disease.”
1. Educate and encourage active participation in the plan
of care, including medication adherence.
2. Educate and counsel clients regarding advance
directives.
3. Consider group visits for teaching sessions.
C. Dietary management:
1. About 25% of clients with COPD are malnourished due
to coexisting medical conditions, depression, and inability
to shop for or prepare food.
2. Suggest a low-carbohydrate diet. High-carbohydrate
intake may increase respiratory work by increasing CO2
production.
D. Pharmaceutical therapy: Treatment guidelines are based
on spirometry.
1. Stage I (mild FEV
80% or greater): The client may be
1
unaware that they have COPD. Give inuenza vaccine
and use short-acting beta-2 agonists (SABA) bronchodilators as needed.
2. Stage II (moderate FEV
between 50% and 79%): Give
1
inuenza vaccine, plus SABA bronchodilators, as needed,
plus long-acting bronchodilator(s) plus cardiopulmonary
rehabilitation.
3. Stage III (severe FEV
between 30% and 49%): Give
1
inuenza vaccine, plus SABA bronchodilators as needed,
plus long-acting bronchodilator(s)—for example, a
long-acting antimuscarinic antagonist (LAMA), plus cardiopulmonary rehabilitation, plus inhaled glucocorticoid
steroids if client has repeated exacerbations.
4. Stage IV (very severe FEV
less than 30%): Give inu-
1
enza vaccine, plus SABA bronchodilator, as needed, plus
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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225
long-acting bronchodilator(s) (e.g., LAMA), plus cardiopulmonary rehabilitation, plus inhaled glucocorticoid
steroids if repeated exacerbations plus long-term oxygen
therapy (if the client meets the criteria for O2). Medicare
guidelines require a client’s PaO2 (partial pressure of oxygen) to be less than 55 mmHg or the resting oxygen saturation to be less than 88% on room air.
5. Encourage utilization of a spacer/holding chamber for
inhalers.
6. Administer pneumonia vaccines for clients 65 years
and older. Prevnar 13 or Pneumovax 23 should be administered according to theCenters for Disease Control and
Prevention (CDC) recommendations and based on the
individual client’s vaccine history. See the CDC website
for current recommendations.
7. Administer yearly u vaccine. Quadrivalent inuenza
vaccine is essential for all COPD clients. Give the vaccine
each year as soon as it is available.
8. Prescribe pharmacologic agents/nicotine replacement
therapy for smoking cessation.
a. Nicotine chewing gum produces better quit rates
than counseling alone.
b. Transdermal nicotine patches have a long-term suc-
cess rate of 22% to 42%.
c. Use of an antidepressant such as Zyban (150 mg
BID) has been shown to be effective in smoking cessation and may be used in combination with nicotine
replacement therapy.
d. Varenicline is a partial agonist selective for alpha-4,
beta-2 nicotinic acetylcholine receptors.
9. Antibiotics are not recommended in clients with
COPD except with acute exacerbation; with symptoms
of increased dyspnea, increased sputum volume, and
increased sputum purulence; or with changes in cough,
fever, or other evidence of an infection such as an inltrate
on CXR. Antibiotics are prescribed in clients with COPD
on mechanical ventilation.
10. Consider phosphodiesterase-4 (PDE4) inhibitors
(roumilast or cilomilast) as needed when necessary.
11. Mucolytic agents have small benets and are not usu-
ally recommended.
12. Antitussives are not recommended.
13. Long-term oxygen has been shown to increase survival
in clients with severe resting hypoxemia. Target oxygen
saturation is 88% to 92% (Long-Term Oxygen Treatment
Trial Research Group, 2016).
14. Cardioselective beta-blockers are not contraindi-
cated in COPD. Cardioselective beta-blockers at low
dosages do not cause bronchospasm. A noncardioselective beta-blocker or a cardioselective beta-blocker
(B1-blocker) at higher dosages may contribute to
bronchospasm.
15. Methylxanthines (e.g., theophylline) have a risk for
toxicity in all clients; this risk is higher in elderly populations. Although methylxanthines have many drug-todrug interactions, adding theophylline to salmeterol has
suggested improvements in FEV1. Adverse effects could
include cardiac arrhythmias and seizure activity.
FOLLOW-UP
A. For acute exacerbations, follow up on the same day or the
following day.
B. Reassess stable, chronic COPD every 1 to 2 months,
depending on the client’s needs.
C. Serial PFTs may help guide therapy and offer prognostic
information.
D. Monitor serum theophylline levels. Theophylline has a nar-
row therapeutic window and the potential for toxicity. Nausea
and nervousness are the most common adverse effects. Other
adverse effects include abdominal pain with cramps, anorexia,
tremors, insomnia, cardiac arrhythmias, and seizures.
E. Reevaluate clients on oxygen therapy 1 to 3 months after
starting oxygen.
F. Evaluate for osteoporosis; bone mineral density is lower in
clients with COPD and they are at risk of vertebral fractures.
G. Monitor the client’s body weight.
CONSULTATION/REFERRAL
A. Consult with a physician if the client has acute respiratory
decompensation or severe cor pulmonale (distended neck
veins, hepatomegaly, dependent peripheral edema, ascites,
and pleural effusion).
B. Refer the client to a pulmonary specialist for rehabilitation,
if available:
1. Outpatient education for the client and the family.
2. Exercise training.
3. Breathing retraining—that is, pursed-lip breathingand
huff coughing.
4. Correct administration of medications.
C. Refer to a registered dietitian (RD) to provide medical
nutrition therapy (MNT). RDs focus on the prevention and
treatment of weight loss associated with COPD and other
comorbidities.
D. Send to a pulmonologist for evaluation for continuous
positive airway pressure (CPAP) or bilevel positive airway
pressure (BiPAP).
E. Send to a pulmonologist to evaluate for surgical interven-
tion such as bullectomy, lung volume reduction surgery, or
lung transplantation.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. In pregnancy, COPD is rare except in AAT deciency.
2. Monitor drug treatment for potential teratogenic effects.
B. Adults:
1. Sexual dysfunction is common in clients with COPD;
encourage other ways to display affection.
C. Geriatrics:
1. Presentation may be atypical.
2. Clients should have annual u vaccinations and pneu-
mococcal vaccination every 5 years.
3. Clients may not have the ability to use inhaler devices
due to tremors, muscle weakness, poor hand–eye coordination, and/or poor memory.
4. Theophylline is on the Beers list of drugs to use with
caution in the geriatric population related to cardiovascular, renal, and hepatic concerns, insomnia, and peptic
ulcers.
5. Discuss the course of disease, living wills, advance
directives, and resuscitation status early, before a crisis
occurs.
RESOURCE
Global Initiative for Chronic Obstructive Lung Disease (GOLD) guide-
lines: www.goldcopd.org
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9: RESPIRATORY GUIDELINES
BIBLIOGRAPHY
COPD Foundation. (2019). COPD across America: How does your state compare?
https://www.copdfoundation.org/What-is-COPD/UnderstandingCOPD/Statistics.aspx
Ferguson, E., & Make, B. (2019, January 21). Management of stable chronic
obstructive pulmonary disease. UpToDate. http://www.uptodate.com/
contents/management-of-stable-chronic-obstructive-pulmonary-dise
ase
Global Initiative for Chronic Obstructive Lung Disease. (2019). Global
strategy for the diagnosis, management, and prevention of COPD. https://
goldcopd.org/
GOLD 2020 pocket guide-goldcopd.org.www.goldcopd.org. (n.d). htt
ps://goldcopd.org/wp-content/uploads/2020/03/GOLD-2020POCKET-GUIDE.1.0_FINAL-WMV.pdf
Rains, S. G. (2020). Fifteen-to-eighteen-month visit. In B. Richardson (Ed.),
Pediatric primary care: Practice guidelines for nurses (2nd ed., pp. 117–
127). Jones & Bartlett Learning.
Terry, E. G. (2020). Seven-to-ten-year visit (school age). In B. Richardson
(Ed.), Pediatric primary care: Practice guidelines for nurses (3rd ed., pp.
147–162). Jones & Bartlett Learning.
COMMON COLD/UPPER RESPIRATORY INFECTION
DEFINITION
A. The common cold is a self-limiting acute respiratory
tract infection (ARTI) resulting from viral infection of the
upper respiratory tract. It is also called acute nasopharyngitis.
Symptoms of ARTI include mild coryzal symptoms, rhinorrhea, nasal obstruction, headache, sore throat, myalgia, and
sneezing.
INCIDENCE
A. ARTIs are among the most frequent reasons for ofce vis-
its. However, the true incidence is not known because clients
treat themselves with over-the-counter (OTC) and home rem-
edies, as well as due to seasonal and locational variability.
Most children have six to eight colds a year; most adults have
two to four.
PATHOGENESIS
A. More than 25% to 80% of ARTIs are caused by a rhinovi-
rus (greater than 100 antigenic serotypes). Other viral agents
include coronavirus (10%–20%), respiratory syncytial virus,
adenoviruses (5%), inuenza viruses (10%–15%), and parainuenza viruses. The incubation period is 1 to 5 days, with
viral shedding lasting up to 2 weeks.
B. Rhinoviral infections are chiey limited to the upper respi-
ratory tract but may cause otitis media and sinusitis.
PREDISPOSING FACTORS
A. Exposure to airborne droplets.
B. Direct contact with virus by touching hands or skin of
infected people, or by touching surfaces they touched, and
then touching eyes or nose.
C. Very young or old ages.
D. Smoking, which increases risk by 50%.
E. Crowded conditions such as day-care centers and schools.
COMMON COMPLAINTS
A. Low-grade fever.
B. Generalized malaise.
C. Nasal congestion and discharge (initially clear, then yel-
low and thick).
D. Sneezing.
E. Sore throat or hoarseness.
F. Watery and/or inamed eyes.
OTHER SIGNS AND SYMPTOMS
A. Headache.
B. Cough.
SUBJECTIVE DATA
A. Elicit the onset, course, and duration of symptoms.
B. Inquire about color and other characteristics of nasal dis-
charge and sputum. Purulent nasal discharge after 14 days
signals bacterial sinusitis.
C. Inquire about other discomforts and exposure to people
with similar symptoms.
D. Review allergens, seasonal problems, and exposure to irri-
tants and smoke.
E. Review history for other respiratory problems, such as
asthma, chronic bronchitis, and emphysema.
F. Note symptoms that may indicate more signicant com-
peting diagnosis (respiratory distress, altered mental status,
vomiting, dehydration, rash, stiff neck).
G. Ask about immune compromise.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pres-
sure (BP). Carry out pulse oximetry if difcult respiratory
symptoms are noted.
B. Inspect:
1. Observe general appearance.
2. Inspect eyes. Note “allergic shiners,” tearing, and eye-
lid swelling.
3. Observe ears, throat, and mouth. Otitis media is indi-
cated by redness and bulging of tympanic membrane, or
by membrane perforation with drainage.
4. Inspect nose for nasal redness, swelling, polyps,
enlarged turbinates, septal deviation, and foreign bodies.
5. Transilluminate the sinuses:
a. Group A Streptococcus: tonsillar enlargement, exu-
date, petechiae.
b. Allergies: “cobblestoned” pharyngeal mucosa.
c. Mononucleosis: About half of clients with mononu-
cleosis develop tonsillar exudates and about one-third
develop petechiae at the junction of the hard and soft
palates, which is highly suggestive of the disease.
C. Auscultate:
1. All lung elds; note decreased breath sounds, rales, or
wheezing.
2. Heart.
D. Percuss:
1. Sinus cavities and mastoid process of temporal bone to
rule out otitis media.
2. Chest for consolidation.
E. Palpate:
1. Palpate face for sinus tenderness.
2. Examine head and neck for enlarged, tender lymph
nodes.
DIAGNOSTIC TESTS
A. Diagnosis may be made from history and physical exami-
nation. Because common cold manifestations are so prevalent,
an aggressive workup is rarely necessary.
B. Consider rapid strep test if the client has symptoms or was
exposed to group A Streptococcus.
C. Consider throat culture if rapid strep test is negativeand
client is symptomatic.
D. Consider rapid antigen testing for inuenza if indicated.
COMMON COLD/UPPER RESPIRATORY INFECTION
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E. Chest x-ray is not usually indicated in the absence of phys-
ical ndings consistent with pneumonia, with comorbid conditions, or for symptoms greater than 3 weeks.
DIFFERENTIAL DIAGNOSES
A. Upper respiratory infection.
B. Allergic rhinitis.
C. Foreign body.
D. Sinusitis.
E. Inuenza.
F. Group A strep pharyngitis.
G. Otitis media.
H. Pneumonia.
I. Acute bronchitis.
J. Asthma.
PLAN
A. General interventions:
1. Controlled trials reveal minimal therapeutic benets of
vitamin C for treatment and prevention of colds.
2. Zinc has no proven benet. Echinacea has not shown
any differences in rates of infection or severity of symptoms when compared with placebo.
3. Validation and standardization of herbal products
have not been completed.
B. Client teaching: See Client Teaching Guide for this chapter,
“Common Cold.
C. Pharmaceutical therapy:
1. In a report by Irwin et al. (2018), the American College
of Chest Physicians updated the 2006 clinical practice
guidelines with management algorithms for management of cough in adults. Healthcare providers should
refrain from recommending cough suppressants and
OTC cough medicines to young children due to the associated morbidity and mortality. The American Academy
of Pediatrics reminds consumers to avoid the use of
OTC cough and cold products in children younger than
4 years.
2. Antibiotics are ineffective in treating viral infection.
3. Corticosteroids may actually increase viral replication
and have no impact on cold symptoms.
4. Topical decongestants for rhinorrhea and nasal
congestion:
a. Adults and children older than 6 years: pseudo-
ephedrine (Afrin) nasal spray 0.05% two to three sprays
per nostril BID, or phenylephrine (Neo-Synephrine)
nasal spray 0.25% to 1% two to three sprays per nostril
Q4H as needed. Using decongestant-type nasal sprays
longer than 2 to 3 days can result in rebound congestion and abuse of the drug.
b. Children younger than 6 years: saline nasal drops
two to three drops per nostril two to three times daily.
c. As an alternative to pseudoephedrine and other
nasal decongestants, consider clearing nasal congestion in infants with a rubber suction bulb; secretions
can be softened with saline nose drops or a cool-mist
humidier.
5. Oral decongestants such as pseudoephedrine
(Sudafed)are available. Side effects include tachycardia,
palpitations, and elevated BP.
a. Adults: pseudoephedrine (Sudafed) 60mg every 4
to 6 hours or 120mg Q12H.
b. Children older than 12 years: pseudoephedrine
(Sudafed) liquid 5 mL every 4 to 6 hours or pseudoephedrine (Sudafed) 30mg every 4 to 6 hours.
6. Analgesics, such as acetaminophen (Tylenol) and ibu-
profen (Advil), may be used for headache relief.
a. Ibuprofen: adults:
i. 200 to 400mg PO while symptoms persist; not
to exceed 3.2 g/d.
b. Ibuprofen: pediatrics:
i. Younger than 6 months: not established.
ii. 6 months to 12 years: 4 to 10mg/kg/dose PO
three to four times a day.
iii. Children older than 12 years: administered as
adults.
7. Cough suppressants, if necessary: dextromethorphan
(Benylin DM, Robitussin, Vicks Formula 44 pediatric
formula):
a. Adults and children older than 12 years: 10 to
20 mg orally Q4H, or 30 mg every 6 to 8 hours, or
60mg extended-release liquid BID, to a maximum of
120mg/d.
b. Elderly: Anticholinergic effects from antihista-
mines may be associated with side effects including confusion, cognitive impairment, delirium, dry
mouth, constipation, urinary retention, and sedation.
Diphenhydramine may be appropriate in acute treatment of severe allergic reactions.
8. Colds have no allergic mechanism, so antihistamines
are ineffective. The atropine-like drying effect from antihistamines may exacerbate congestion and obstruct the
upper airway by impairing mucus ow.
FOLLOW-UP
A. None recommended unless symptoms persist longer than
7 days from onset.
B. Parents should return to the doctor’s ofce if their child’s
fever exceeds 102°F, if respiratory symptoms increase, or if
symptoms do not resolve in 10 to 14 days.
CONSULTATION/REFERRAL
A. Consult a physician if the client has been reevaluated and
given a new treatment plan but still has symptoms.
B. Refer the client to an otolaryngologist if tonsillar abscess is
suspected.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Oral decongestants are not recommended for children
younger than 6 years of age.
2. The most common calls to poison control centers that
involve OTC medications concern the ingestion of acetaminophen and cough and cold preparations.
a. Accidental pediatric toxic ingestion is reported in
children younger than 6 years; intentional toxic ingestion is more common in adolescents aged 13 to 19
years.
b. Adolescents have used dextromethorphan as a rec-
reational drug.
B. Geriatrics:
1. Use of antihistamines with anticholinergic properties
may cause side effects of confusion and delirium as listed
earlier, along with increased rates of hospitalization.
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