Editorial
THINKING MORE CAREFULLY ABOUT RESPIRATORY INFECTIONS
James Arthur Dickinson, FRACGP PhD, Visiting Professor, International Medical University
Dickinson JA. Thinking more carefully about respiratory infections. Malaysian Family Physician. 2006;1(1):6-7
Among the commonest presentations to family physicians are upper respiratory infections and related symptoms such as cough. So we should treat these conditions well, just like any other illness. Most of the literature has focussed on whether to prescribe antibiotics, and now we all know that very few respiratory infections benefit from them, so we should be extremely sparing in their use. Many doctors take the attitude: it will resolve by itself, so don’t worry about it. But many people find the symptoms annoying or even distressing, and distract them from their activities. Symptom relieving drugs seem to be helpful, yet few doctors know the science of prescribing them, and this is often done badly, partly because it has been difficult to ascertain the science underlying treatment of these “trivial disorders”. Few medical schools or training programs teach about them.
How much of our workload these conditions comprise depends on the system in which we work: in countries such as Malaysia and Hong Kong they are a higher proportion than in countries like Australia and UK.1 This is a change: 50 years ago, respiratory infections were much more common presentations there also. Yet it is doubtful that there has been any change in the number of infections experienced by each individual, child or adult. More likely it is a different response. The difference appears to originate in social expectations, mediated by the payment systems for doctors and medications. Where doctors dispense, primary care medicine is seen as a shopkeeper’s role, and patients place greatest value on the medication rather than the consultation. In such countries, many patients perceive the number of drugs prescribed as a measure of the doctors’ worth. Consequently many doctors respond with multiple prescribing, often of compound drugs: what they think patients want rather than what they need. Most of these drugs are also available over the counter, and in developed countries that have separated the roles of prescriber and dispenser, doctors do not prescribe them, since advising about them is largely the responsibility of the pharmacist.
Understandably, lifesaving drugs for serious disease are emphasised in medical school and little attention is given to these “trivial” drugs. Yet they are important. Many patients take them several times a year. They cause side effects, and interfere with other treatments that we do prescribe, so
their effects are not trivial. Indeed on occasion children are poisoned and require hospitalisation.
Because they have been available for so long, much of the science about these drugs was developed long ago, before current standards for efficacy and safety were required, or even devised. Thus the literature at times contains inadequate background: for example on the efficacy of compound analgesics.2 At times absurd conclusions can be drawn, as shown by the report that a Cochrane review showed that codeine is not effective against cough, because there are no randomised trials to prove it.3 Narcotics were accepted as effective against cough long before randomised trials were invented, and they work, albeit with well-known side effects of constipation, and respiratory depression.
Fortunately, the American College of Chest Physicians has recently reviewed the literature about cough in great depth, and come up with thought-provoking Evidence-based Clinical Practice Guidelines, published as a supplement to Chest.4 Interestingly, the level of much of the evidence is rated as low, even as low as “expert opinion” or “case studies” and as Family Physicians; we may look at their priorities with some scepticism, since these authors are working from a filtered specialist viewpoint. Our expert opinion about the types of patients we deal with may be as good as theirs.
One of the most interesting recommendations is that postnasal drip should be renamed as Upper Airway Cough Syndrome (UACS). This new name is likely to gradually replace the old name, so as readers of this journal you can be ahead of most other sources! After an acute common cold, chronic cough may follow because the viral infection triggers an inflammatory response that persists long after the infection has gone. Such an inflammatory response may present in the lower airways as asthma or in the upper airway as UACS. Sadly, this is an indefinite syndrome, so it is difficult to diagnose, and there are no specific findings that diagnose it absolutely. It is most useful as a pointer to management strategies.
The Guidelines include useful algorithms for diagnosis of acute cough (less than 3 weeks), subacute cough (3 to 8 weeks) and chronic cough (over 8 weeks). For children < 15 years, chronic cough is defined as more than 4 weeks.
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