Acute Otitis Media—a Structured Approach

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This review is based on a selective literature search including previously published evidence-based recommendations, particularly those of the current American guidelines.

Learning goals

 · Shortness of breath and cough are common, disturbing symptoms in patients receiving palliative care. They arise in 10% to 70% of patients with advanced cancer and in 60% to nearly % of patients with non-malignant underlying diseases, depending on the type of designerscorner.pwon: Rockville Pike, Bethesda, MD.

In 10 of 22 studies involving patients with advanced disease and a survival time of less than six months, shortness of breath was found to be an indicator of shorter survival 7. In another study, cancer patients admitted to the hospital on an emergency basis because of shortness of breath were found to have a median survival time of twelve weeks 8.

Cancer patients report that shortness of breath arises suddenly, without warning, and that it causes them greater worry than pain does Patients should be instructed in self-management strategies, as the drugs given for shortness of breath often do not take effect till after the attack has subsided. Attacks of dyspnea can be triggered by a variety of factors, including physical stress walking, climbing stairs , emotional stress fear, panic, irritation , environmental influences dust, temperature , and concurrent medical conditions infections Shortness of breath is thus a multifactorial symptom that remains incompletely understood.

Recent studies have shown that the perception of shortness of breath is closely linked to the limbic system; this underscores the fact that it can be influenced by emotion 2. The experience of shortness of breath is the combined effect of multiple physiological, psychological, social, and environmental factors and can itself induce both physiological and behavioral reactions. Like pain, cough initially has a protective function, i.

Chronic cough, however, is physically exhausting, impairs social relationships, and worsens other symptoms including pain, shortness of breath, incontinence, and sleep disturbance. It can also cause rib fractures 3 , Studies involving the symptomatic treatment of refractory shortness of breath and cough in patients with advanced cancer and non-malignant disease e.

We use the term refractory shortness of breath to designate shortness of breath that persists despite optimal treatment of its underlying cause. The levels of evidence for the individual treatment options are given according to the grading scheme of the Scottish Intercollegiate Guidelines Network SIGN www.

Attacks of dyspnea can be triggered by various factors, including physical stress walking, climbing stairs , emotional stress fear, panic, irritation , environmental influences dust, temperature , and concurrent medical conditions infections. Both shortness of breath and cough are subjective sensations even though cough can also be observed. The subjective severity and intensity of these two symptoms should therefore be recorded regularly to evaluate the degree of suffering they cause and the effect of treatment.

As for cough, physicians should note the distinction between productive and nonproductive cough. Patients with productive cough should be asked about the type, color, and amount of sputum they produce. Aside from comprehensive history-taking and physical examination most importantly, auscultation and percussion of the lungs , other tests including a chest x-ray, ultrasound of the abdomen and pleural space, and measurement of the arterial blood oxygen saturation SaO 2 may be indicated to identify potentially reversible causes of shortness of breath and cough.

Ask about the intensity and quality of the symptom, its temporal onset, frequency, and course, precipitating, aggravating and alleviating factors, accompanying symptoms, and the resulting emotional stress on the patient and family. Both symptoms have multiple causes, most of which can cause either symptom. In patients with cancer, shortness of breath and cough can arise because of compression of the large airways, pulmonary metastases, or pleural effusion; further causes of shortness of breath include cachexia with weakness of the respiratory muscles, infection, and pulmonary embolism.

Patients with COPD, other chronic lung diseases, and severe congestive heart failure suffer from shortness of breath and cough as principal manifestations of the disease.

Nearly all patients with amyotrophic lateral sclerosis are severely short of breath in the last stage of their disease. It is very important to determine, for each patient, which of the suspected causes of shortness of breath and cough are reversible, and whether all options for causally directed treatment of the underlying disease have been exhausted.

Moreover, in patients with shortness of breath, feelings of fear, loneliness, tension, and sadness play a major role and often make shortness of breath worse. Shortness of breath is a complex symptom that generally cannot be satisfactorily relieved with a single measure alone.

Its treatment often requires a combination of general measures, non-pharmacological measures, and drugs. All of the treatment measures to be discussed here should be taken after, or in parallel with, the causally directed treatment of shortness of breath. They are particularly important, however, when shortness of breath persists despite appropriate treatment of the factors that induced it.

Reassurance, information, and an emergency plan promote individual initiative and self-management on the part of the patient and family. Multiple approaches are needed to relieve shortness of breath effectively and enable the patient to deal adequately with this symptom. The patient should be shown ways to gain control over the situation whenever shortness of breath arises.

The physician should inform the patient and family about the following:. It may also be helpful for the patient to practice specific rituals to be carried out when attacks of dyspnea arise.

Calming measures are an important part of the treatment of shortness of breath, which always has an emotional component 2 and is made much worse by fear and panic 2. The presence of persons who are emotionally near to the patient has a calming effect when acute shortness of breath arises.

Many patients fear death from suffocation during an acute attack of shortness of breath, but such events are actually very rare. The simple reassurance that an attack will come to an end and that normal breathing will be possible again lessens anxiety and helps the patient cope with shortness of breath.

Patients should always be encouraged to stay physically active and get adequate exercise to counteract progressive deconditioning and fatigue. Various non-pharmacological measures are available, some of which are supported by good evidence Fans generate a draft of air, which, when directed to the nose and central part of the face, can alleviate shortness of breath in many patients.

Either a table fan or a standing fan can be used for this purpose. There is also good evidence from a randomized trial LoE 1- supporting the use of a small, inexpensive, portable handheld fan The draft of air presumably activates trigeminal receptors and relieves shortness of breath via central trigeminal connections.

The use of a rollator or other walking aids not only prolongs the distance the patient can walk, but also relieves shortness of breath, presumably by stabilizing the thoracic outlet and thereby lessening the load on the auxiliary respiratory muscles LoE 1- Physiotherapists and respiratory therapists can show the patient useful exercises, positions, and breathing-control techniques to be performed at home, enabling the patient to take an active role in symptom control.

In addition, relaxation exercises alleviate fear and panic, and all patients should be given an opportunity to learn them Relaxation exercises that patients can perform themselves are an essential and effective component of treatment, especially in acute emergencies, and can improve the quality of life for patients and their families.

Table fans and handheld fans generate a draft of air, which, when directed to the nose and central part of the face, can alleviate shortness of breath, as can the use of a rollator. Stimulation increases muscle bulk and thereby relieves shortness of breath. This type of treatment is particularly useful for patients who can no longer actively participate in physical exercise. Its beneficial effect, however, appears only after four to six weeks of regular application 3—5 sessions per week for 15—30 minutes each.

One treatment option that is not yet widely known is neuromuscular electric stimulation NMES of the leg muscles; this was found to relieve shortness of breath significantly in three different randomized controlled trials on COPD patients. In a Cochrane review published ten years ago, a meta-analysis of nine clinical trials revealed a small, but statistically significant effect of oral and parenteral opioids Nonetheless, many physicians avoid giving opioids to patients in palliative care, fearing respiratory depression.

The current treatment recommendations of many different specialty societies unequivocally endorse the use of opioids to treat shortness of breath 2. Randomized controlled trials RCTs have shown a not just statistically significant, but also clinically relevant benefit of both oral and parenteral opioids on shortness of breath, and not only in cancer patients, but in those with COPD and chronic congestive heart failure as well 22 , Respiratory depression was not encountered in any of these trials and is not to be expected if opioids are properly used.

An opioid-induced lowering of the respiratory rate, from tachypnea which often accompanies dyspnea back to a normal respiratory rate, is expressly desired; it helps economize breathing and thereby raises the oxygen saturation of the blood. The efficacy and safety of the new fast-acting fentanyls buccal, nasal, and sublingual fentanyl preparations in treating attacks of pain have been well documented, and clinical trials of these drugs for attacks of dyspnea are now underway.

Of the thirteen published trials covered by a recent systematic review, only two were randomized controlled trials, one of which included only two patients The other RCT was a pilot study that revealed no statistically significant difference between fentanyl and placebo The following are important considerations for the treatment of shortness of breath with opioids:. Opioids are the drugs of choice for otherwise medically intractable dyspnea. Respiratory depression has not been observed in any clinical trial.

The dose needed to treat dyspnea is much lower than that needed to treat pain. Benzodiazepines— Benzodiazepines such as lorazepam and midazolam have long been used to treat shortness of breath in patients with advanced disease and are recommended in many treatment guidelines. A further important consideration is that benzodiazepines, if given over the long term, may worsen the respiratory situation through excessive muscle relaxation.

On the other hand, there is a close clinical relationship between shortness of breath and anxiety, and the successful treatment of anxiety often improves shortness of breath as well. This is further confirmed by the efficacy of relaxation techniques to treat attacks of dyspnea.

Many patients spontaneously report that shortness of breath and anxiety tend to reinforce each other. It may thus be useful to break the vicious circle by treating shortness of breath with opioids and anxiety with benzodiazepines at the same time. Steroids— Cancer patients with shortness of breath are often given steroids, such as dexamethasone, particularly when they suffer from tumor progression with tissue changes in the pleura, pulmonary interstitial space, or airways e.

No randomized trials of steroids for dyspnea in cancer patients have been published to date, so no definitive statement can be made as to their efficacy. Antidepressants— The little evidence now available LoE 3 on the use of antidepressants to treat shortness of breath comes mainly from a case series in which sertraline improved shortness of breath in seven patients with COPD Although there is not yet enough evidence to support the routine use of antidepressants against shortness of breath, dyspneic patients should always be evaluated for anxiety and depression as well and treated for these problems if present.

Oxygen— Oxygen administration can be useful in the long-term treatment of COPD and for patients with marked hypoxemia. Overall, however, supplemental oxygen is now still being given too widely and uncritically.

Stringent criteria should be used to determine the indication for treatment with supplemental oxygen, as such treatment may have adverse effects, including:. The authors of the randomized controlled trial referred to above therefore recommend that simpler and less burdensome treatments, such as the use of a fan, should be tried first and that oxygen treatment, if given, should be tested individually in every patient Very little evidence is available to date about the adminstration of antidepressants to treat shortness of breath.

Reduction of the rate of upper respiratory tract infections by lowering kindergarten group size e Use of xylitol chewing gum or xylitol lozenges several times a day during the time of year when common colds are prevalent Conclusion The criteria that have to be fulfilled before a diagnosis of AOM can be assigned are demonstration of a purulent tympanic effusion and, if applicable, demonstration of inflammatory changes of the tympanic membrane.

Question 1 Which antibiotic is considered the agent of choice in uncomplicated AOM? Amoxicillin; b azithromycin; c erythromycin; d cefuroxime; e cefpodoxime. A 1-year-old child with bulging of both tympanic membranes and a temperature of A 3-year-old child with reddening of the tympanic membrane, purulent tympanic effusion, and a temperature of A 6-year-old child with reddening of the tympanic membrane, purulent tympanic effusion, and severe earache.

The present CME unit can be accessed until 25 May Acknowledgments Translated from the original German by David Roseveare. Footnotes Conflict of interest statement Prof. Holstiege J, Garbe E. Systemic antibiotic use among children and adolescents in Germany: Therapy of acute otitis media: A double-blind study in children. The diagnosis and management of acute otitis media. Symptoms and otoscopic signs in bilateral and unilateral acute otitis media. A placebo-controlled trial of antimicrobial treatment for acute otitis media.

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Arch Otolaryngol Head Neck Surg. Clinical epidemiology of otitis media. Eine leistungsfähige und sehr gut skalierbare Speichereinheit. Der richtige Speicher für die richtigen Daten. Überblick - Business-centric Storage. Überblick - Storage Produkte engl. Media Portal Bilder, Veröffentlichungen und viel mehr. Analyst White Paper von Freeform Dynamics engl. Since its foundation in , KFMC has relied on a traditional client-server model for its user devices. Over 1, fully-featured PCs were spread across the facility for use by doctors, nurses and administration.

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