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Chapter 12. Shortness ofBreath
Heart failure
261
HFpEF
Treat comorbidity
• HTN
• CAD
• DM
• Lipid
• CKD
• Smoking
cessation
Stage AStage B
Treat comorbidity
• HTN
• CAD
• DM
• AFib
• CKD
• Hyperthyroidism
• Anemia
• Sleep apnea
+
Life style modification
• Exercise
• Obesity management
• Smoking cessation
• Alcohol, illicit drug
• Salt restriction
+
Avoid
• NSAIDs
• Thiazolidinediones
• Most antiarrhythmics
• verapamil, diltiazem
HFrEF
Stage CStage D
ACEI or ARB
+
or ARNI
beta blockers
Diuretics
SGLT
Aldosterone
antagonist
Digitalis in select
patients
ACEI or ARB
+
beta blockers
Cardiology Consultation
• Revascularization
• Valve repair
• Biventricular pacing
• Arrhythmia treatment/Ablation/ICD
• LVAD/transplant
+
+
+
inhibitor
2
+
ACEI or ARB or
ARNI
+
beta blockers
+
Aldosterone
antagonist
+
SGLT
inhibitor
2
+
Diuretics
Consider inotropes
Consider palliative care
F . Heart failure management. Stage A: Patients at high
risk for heart failure but without structural disease or symptoms.
Stage B: Patients with structural heart disease but without signs or
symptoms. Stage C: Patients with structural heart disease with prior
or current symptoms. Stage D: Patients with refractory heart failure
requiring specialized interventions. (1) HFpEF heart failure with
preserved ejection fraction (EF ≥50%). (2) HFrEF heart failure
with reduced ejection fraction (EF ≤40%). (3) HTN hypertension,
CAD coronary artery disease, DM diabetes mellitus, CKD chronic
kidney disease. (4) ACEI angiotensin-converting enzyme inhibitor,
ARB angiotensin receptor blocker. (5) ICD implantable cardio-
verter defibrillator. (6) LVAD left ventricular assist device. (7)
NSAIDs nonsteroidal anti- inflammatory drugs (8) ARNI angioten-
sin receptor-neprilysin inhibitor. (Heidenreich PA, Bozkurt B,
Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. J AmColl Cardiol. 2022;79(17):e263–e421.)
262
K. Kinjo
Clinical Pearls
• When the routine history and physical examination are not
revealing, carefully watch how the patient walks and with
what pace while monitoring pulse rate and oxygen satura-
tion by pulse oximetry. This way the provider can get a
sense of the patient’s exercise capacity.
Don’t Miss This!
• Viral myocarditis may present with malaise, low-grade
fever, and nausea with little classical CHF symptoms; it can
be misdiagnosed as viral gastroenteritis, but the patient’s
general appearance is usually very ill and vital signs are
quite abnormal.
• Patients with angina may describe vague chest symptoms
as dyspnea on exertion. Careful attention to the symptoms
of chest tightness (which may or may not be typical
squeezing in nature), nausea, and diaphoresis is important
especially in patients with cardiovascular risk factors. If
acute coronary syndrome is deemed likely, patients would
be best evaluated in the emergency room.
References
1. DeVos E, Jacobson L. Approach to adult patients with acute
dyspnea. Emerg Med Clin North Am. 2016;34:129–49.
2. Budhwar N, Syed Z.Chronic dyspnea: diagnosis and evaluation.
Am Fam Physician. 2020;101:542–8.
3. Duffett L, Castellucci LA, Forgie MA. Pulmonary embolism:
update on management and controversies. BMJ. 2020;270:m2177.
4. Berliner D, Schneider N, Welte T, Bauersachs J.The differential
diagnosis of dyspnea. Dtsch Arztebl Int. 2016;113:834–45.
5. Prina E, Ranzani OT, Torres A.Community-acquired pneumonia. Lancet. 2015;386:1097–108.
6. Metlay JP, Schultz R, Li YH, etal. Influence of age on symptoms
at presentation in patients with community-acquired pneumonia. Arch Intern Med. 1997;157:1453–9.
7. Messerli FH, Bangalore S, Makani H, et al. Flash pulmonary
oedema and bilateral renal artery stenosis: the Pickering syndrome. Eur Heart J. 2011;32:2231–5.
Chapter 12. Shortness ofBreath
8. Parshall MB, Schwartzstein RM, Adams L, et al. An official
American thoracic society statement: update on the mechanisms,
assessment, and management of dyspnea. Am J Respir Crit Care
Med. 2012;185:435–52.
9. Global Initiative for Asthma. Global strategy for asthma management and prevention. 2022. www.ginasthma.org
10. Global Initiative for Chronic Obstructive Lung Disease
(GOLD). Global strategy for the diagnosis, management and
prevention of COPD. 2022. www.goldcopd.org.
11. Mahler DA, O’Donnell D.Recent advances in dyspnea. Chest.
2015;147:232–41.
263
Chapter 13
Sinusitis or Rhinosinusitis
ShuchitaKhasnavis
Abbreviations
ABRS Acute bacterial rhinosinusitis
ARS Acute rhinosinusitis
Introduction
Sinusitis affects about one in seven people in the USA, and
nearly always occurs with inflammation of the nasal
mucosa [1].
The vast majority of the cases are viral in origin, and only
a small percentage is bacterial. Most of the cases resolve
with conservative treatment, and a few require antimicrobials [2].
S. Khasnavis (*)
Department of Medicine, Jacob North Central Bronx Hospital,
Bronx, NY, USA
e-mail: Shuchita.Khasnavis@nychhc.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_13
265
266
S. Khasnavis
The four sinus cavities and their locations are detailed below:
• Frontal sinuses: behind the forehead and part of the fron-
tal bones
• Maxillary sinuses: behind the cheek bone
• Ethmoid sinuses: behind the nasal passages
• Sphenoid sinuses: near the optic nerve and part of the
orbits (Fig.13.1)
Sinusitis occurs if obstruction or congestion blocks the
paranasal sinus opening thereby causing mucus to build up in
the chamber. This blockage allows bacteria and viruses to
multiply leading to infection and inflammation.
Symptoms of sinusitis include the following:
• Thick nasal discharge
• Facial pain or pressure
• Fever
• Reduced sense of smell
Frontal
sinus
Ethmoid
sinus
Maxillary
sinus
Opening of the
maxillaru sinus
F . Paranasal sinus anatomy
Side view
Sphenoid
sinus
Chapter 13. Sinusitis or Rhinosinusitis
267
Depending on how long these symptoms last, sinusitis is
classified as acute, subacute, chronic, or recurrent [3, 4].
• Acute sinusitis: inflammation of sinuses lasting less than
4weeks.
• Subacute Sinusitis: inflammation and infection of the
sinuses lasting between 4 and 12weeks.
• Chronic sinusitis: infection of the sinuses lasting at least
12weeks or recurrence of infection.
• Recurrent sinusitis: four or more episodes of ARS/year
with interim symptom resolution.
Acute <4 weeks
Classification of
sinusitis
Subacute 4-12 weeks
Chronic >12 weeks
Recurrent:4 or more episodes of ARS/year
Acute Sinusitis
Etiology of ARS [4, 5]:
• Ninety to ninety-eight percent of sinusitis is secondary to
viral infection. In the vast majority of cases, the cause is a
viral upper respiratory tract infection such as the common
cold.
• Bacterial sinusitis occurs in 0.5–2% of episodes of ARS.
The most common organisms are as follows:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella
• Staph aureus
• Anaerobes
268
S. Khasnavis
• Other rare causes of ARS are fungi, allergies, or autoim-
mune reactions. Fungal rhinosinusitis, the majority of
which are Aspergillus, tend to occur in people who are
immunosuppressed.
ARS is divided into uncomplicated and complicated [3, 6]:
Uncomplicated: when infection and inflammation occur
without extension beyond the paranasal sinuses.
Complicated: when infection extends beyond the paranasal sinuses leading to involvement of surrounding structures
and causing one of the following:
• Preseptal cellulitis
• Orbital cellulitis
• Subperiosteal abscess
• Meningitis
• Intracranial abscess, epidural abscess
• Osteomyelitis
• Septic cavernous sinus thrombosis
Chronic/Recurrent Sinusitis
Allergies and asthma are two of the conditions most commonly
seen in patients with chronic or recurrent sinusitis. Seasonal
allergies and rhinitis may cause blockage and predispose to
sinusitis. The risk of sinusitis is higher with severe asthma.
People with a combination of polyps in the nose and sensitivity
to aspirin are at high risk for recurrent or chronic sinusitis.
Chronic sinusitis and recurrent sinusitis are also associated with
disorders that weaken the immune system such as diabetes,
AIDS, cystic fibrosis, and Wegener’s granulomatosis. Structural
abnormalities of the nose such as polyps, enlarged adenoids,
cleft palate, tumors, and deviated septum can lead to the blockage of nasal passages and mucous drainage. Some hospitalized
patients with head injuries, nasal tubes, mechanical ventilators,
and weakened immune systems are at higher risk for sinusitis.
Chapter 13. Sinusitis or Rhinosinusitis
269
Other medical conditions affecting sinuses include gastroesophageal reflux, oral or intravenous steroid treatment,
hypothyroidism, and Kartagener’s syndrome. Miscellaneous
risk factors are dental problems, change in pressure while flying, high altitudes, swimming, smoking, and air pollution.
Uncomplicated
Infection within paranasal sinuses
Acute
sinusitis
Infection beyond paranasal sinuses causing pre-septal cellulitis, orbital
cellulitis, meningitis, intracranial abscess, septic cavernous sinus
Complicated
thrombosis and osteomyelitis
Chronic
/recurrent
sinusitis
More common with allergies, asthma, polyps in nose, sensitivity to
Aspirin, adenoids deviated septum, cleft palate, cystic fibrosis, weak
immune system like diabetes, AIDS
Wegener’s granulomatosis
Symptoms ofAcute Sinusitis
General symptoms of acute sinusitis (both viral and bacterial) [7] include the following:
• Purulent anterior and posterior nasal discharge
• Nasal congestion or obstruction
• Facial congestion, fullness and pain
• Anosmia
• Fever
• Headache
• Ear pain, pressure, and fullness
• Halitosis
• Dental pain
• Fatigue
270
S. Khasnavis
In general, viral sinusitis symptoms last 7–10days.
• Covid-19 infection may present with symptoms of acute
sinusitis. Overlapping symptoms can make it difficult to
determine the nature of infection. While both can cause
fever, headache, nasal congestion, and sore throat, there
are some differences between the two. Covid-19 causes
more of a dry cough and loss of taste and smell, typically
more respiratory symptoms, and fatigue.
Symptoms ofChronic Sinusitis
Symptoms of chronic sinusitis are more vague. The fever may
be low grade or absent. The symptoms last at least 12weeks
or are intermittent throughout the year [8, 9].
Physical Findings
Patient with sinusitis usually present with erythema, edema,
or tenderness over the involved sinus [10].
• Maxillary sinusitis: The cheek is tender, or the patient may
present with jaw pain and tooth sensitivity.
• Frontal sinusitis: Pain on palpation of the forehead.
• Ethmoid sinusitis: Swelling and tenderness in the eyelids
and surrounding tissue.
• With any sinusitis the pain and tenderness may be found in
several locations. Purulent nasal discharge may be evident
on examination. Diffuse mucosal edema and inferior tur-
binate hypertrophy may be found.
Chapter 13. Sinusitis or Rhinosinusitis
271
Diagnosis
In the primary care setting, a thorough history and physical
examination can provide reliable diagnosis of acute sinusitis
[11]. Differentiation from common viral upper respiratory
tract infection is important where nasal congestion is predominant without head congestion and facial pains. The presence of purulent secretions has the highest positive predictive
value for clinically diagnosing sinusitis (Fig.13.2).
Diagnoses of Acute
sinusitis
Thorough exam
Viral URI:
Predominant nasal
congestion
Diagnoses confirmed
Diagnoses confirmed
Predominant Head congestion,
Facial pains and purulent nasal
Diagnoses not confirmed then do
Diagnoses not confirmed refer to
Sinusitis:
discharge
Nasal endoscopy
CT sinuses
MRI
specialist
F . Diagnostic algorithm for acute sinusitis