Karen Rance, DNP, APRN, CPNP, AE-C

Most patients experience respiratory distress symptoms at some point in their lives, and at times, those symptoms will drive them to seek a health care provider’s diagnosis at a retail clinic. Even though cutting-edge imaging techniques exist to assess these patients, auscultation remains the first-line and fundamental method of evaluating lung sounds. Without question, accurately identifying auscultating breath sounds and then aligning those findings with a general exam and history are keys to true diagnosis. To optimize the health outcomes of patients with respiratory distress symptoms, this article reviews the auscultation of breath sounds in a routine clinical examination.

“Breath sounds” refer to the movement of air through the respiratory system and can be evaluated through auscultation of the lung fields. Auscultation, a technique that requires both clinical experience and a good stethoscope, dates back to the early 1800s. René Théophile-Hyacinthe Laënnec established the link between a breath sound and an identifiable pathological change in the lungs. During this process, Laënnec invented the stethoscope.

Breath sounds are categorized as normal or abnormal and have 3 characteristics: intensity (soft, medium, loud, very loud), pitch (low, medium, high), and duration. There is often confusion between breath and voice sounds; breath sounds generate in the lungs whereas voice sounds generated in the larynx.

Normal breath sounds can be heard throughout the lung fields in a healthy patient and are most often classified as 1 of 4 types: vesicular, tracheal, bron- chosvesicular, and bronchial. In airfilled lungs, vesicular breath sounds are commonly heard over the majority of the lung fields. Tracheal sounds are heard best over the trachea and typically are louder and have a higher pitch than vesicular sounds. Bronchovesicular breath sounds are best heard between the first and second intercostal spaces of the anterior chest. Bronchial sounds are best heard over the body of the sternum.

Abnormal breath sounds are often indicators of pathology in the airways and include wheezing, crackle, rhonchi, stridor, and plural rub. Because each of these adventitious breath sounds may be present with one or more diagnoses, it is important to make note of the abnormality in context with the patient’s history and clinical exam.

is often described as a musical note. The fluctuation of opposing airway walls being tightened nearly to a point of contact generates the sound. A wheeze may occur during either, or both, of the inspiratory and expiratory phases of the respiratory cycle. The timing of an adventitious sound within the respiratory cycle is a diagnostic identifier and should be noted during an exam. Wheezing may be a single sound or a multitude of sounds, and although its presence may be diagnostic for airflow obstruction, its absence does not rule anything out.

Conditions associated with wheezing include viral illnesses such as bronchiolitis, croup, and whooping cough; asthma; chronic obstructive pulmonary disease (COPD); cystic fibrosis; bronchiectasis; pulmonary edema; foreign body aspiration; or tracheal or laryngeal tumors. Of note, healthy patients can often produce a benign wheeze during forced expiration.

is an explosive short sound. Unlike a wheeze, it is not musical in nature. Crackles can be categorized as coarse or fine and may occur during either, or both, inspiration and expiration. These sounds are most often heard at the base of the lungs. A fine crackle has an increased frequency rate and quicker duration than a course crackle. Whereas the sudden opening of closed airways triggers a fine crackle, a coarse crackle is associated with the presence of secretions. Conditions associated with crackles include cardiac disease, fibrotic lung disease, COPD, and pneumonia. Regardless of the diagnosis, research has been unable to link disease severity with the quantity of crackles heard on exam.

are low-pitched, continuous, rattling breath sounds that often sound like snoring. They are associated with the presence of secretions, whether increased production or reduced clearance. Typically, rhonchi are cleared when a patient coughs.

is a high-pitched, unremitting sound heard over the trachea. It tends to occur when the upper airways are narrowed to 5 mm or less and is associated with any condition that leads to narrowing of the extra-thoracic airway. Stridor is louder on inspiration than expiration and much louder than wheezing.

is a harsh, high-pitched sound, such as that which occurs when opposing surfaces are being moved against one another. Some describe the sound as being similar to walking over fresh snow. It is often mistaken for a coarse crackle and occurs when the pleural lining is inflamed and has a deficit of lubrication; such as in pneu- monia, pleurisy, or pulmonary embo- lism. A pleural rub can be localized to a specific area of the lung.

Respiratory exams comprise 5 parts, with auscultation being the final com- ponent. A popular pneumonic to re- member this process is

2. Inspection of the patient and his or her respiratory efforts

3. Palpation of the patient’s chest, both anterior and posterior

4. Percussion of the patient’s chest wall

5. Auscultation of the patient’s chest, both anterior and posterior.

A quiet room and a stethoscope are needed when examining the patient with the intent of auscultating their breath sounds. The diaphragm of the stethoscope should be used for the assessment, and the exam should focus on listening to the anterior, posterior, and mid-axillary regions of the lungs (see Figure 1). The exam should not be conducted over clothing of any kind, regardless of how thin that clothing may be; it should be done in such a manner that the stethoscope has direct contact with the skin.

For the purposes of the exam, the anterior, posterior, and mid-axillary regions can be divided into 4 horizontal sections, and the anterior and posterior regions can be further divided into 2 lateral sections (right and left). There are a total of 8 assessment sites on each of the anterior and posterior regions and 4 on each of the mid-axillary regions. For the anterior and posterior exam, the patient’s lungs should be assessed from top to bottom, going left to right in a zigzag manner (see Figure 2). For the mid-axillary assessment, going from top to bottom at each of the 4 sites is recommended. The goal of auscultation is to listen to 1 complete respiratory cycle at each of the sites while paying particular attention to the duration, pitch, and intensity of the breath sounds and comparing them symmetrically.

For the exam, place the patient in an upright, seated position or in a supine position where they can be rolled from one side to another for assessment of the posterior lung fields. The patient should first take a normal breath through their mouth and then a deep breath for the exam.

Auscultating breath sounds may be more difficult to detect in obese patients due to excess adipose tissue diffusing breath sounds. In these cases, correctly positioning the patient will optimize the exam. If decreased or absent breath sounds are identified and the patient is correctly positioned for quality auscultation, a differential diagnosis may include pleural effusion, emphysema, restriction, or obstruction.

Depending on the outcome of the patient’s exam, abnormal breath sounds may require further testing, such as chest x-ray, chest computerized tomography scan, pulmonary function tests, or sputum sample analysis. Referral to a pulmonary specialist may be warranted if symptoms are severe, chronic, unresponsive to treatment, or not well defined. Encourage the patient to quickly communicate any discomfort they experience during the exam and take immediate note of cyanosis, nasal flaring, difficulty breathing, and acute shortness of breath, as these symptoms may indicate a medical emergency.

1. Scherer JR. Before cardiac MRI: Rene Laennec (1781-1826) and the invention of the stethoscope.

2. Sengupta N, Sahidullah M, Saha G. Lung sound classification using cepstral-based statistical features.

2016:75:118-129. doi: 10.1016/j .compbiomed.2016.05.013.

4. Mason RJ, Broaddus VC, Murray JF, Nadel JA. History and physical examinations. In: David JL, Murray JF, eds.

Murray and Nadel’s Textbook of Respiratory Medicine

. 4th ed. Philadelphia, PA: Elsevier Saunders; 2005:493-510.

Karen Rance DNP, APRN, CPNP, AE-C, is an allergy, asthma, and immunology specialty nurse practitioner. She is the US Clinical Affairs and Education Liaison with Thermo Fisher Scientific and an adjunct faculty member at Indian Wesleyan University Graduate School of Nursing. Dr. Rance has served on the board of directors of the National Association of Certified Asthma Educators and is on the National Heart, Lung, and Blood Institute’s National Asthma Education Prevention Program Expert Panel workgroup. She is the founding chair of the National Association of Pediatric Nurse Practitioners’ (NAPNAP) Asthma and Allergy Special Interest Group and is on NAPNAP’s Clinical Expert Panel for Asthma.

Articles

Most patients experience respiratory distress symptoms at some point in their lives, and at times, those symptoms will drive them to seek a health care providerâ€™s diagnosis at a retail clinic.

Ascultating Breath Sounds: What the Retail Clinician Should Know

For many of our patients, the season means walks in the park, evenings by the shore, backyard barbecues, and outdoor sports. However, with the warm days and beautiful evenings comes the increased incidence of insect bites, stings, and skin rashes. Because of their commonality, retail clinicians are sure to encounter patients with these skin ailments before the next change of season. Optimizing health outcomes for patients depends on clinicians teaching the keys of self-care and helping them set their expectations for symptom resolution appropriately. This article reviews common summer bites, stings, hives, and rashes, and also provides counseling points to share with patients.

Insect bites are more than just a bothersome part of summer; on rare occasions, they may lead to more serious conditions, such as Lyme disease (caused by a tick bite) or the West Nile or Zika virus (caused by mosquito bites). Insect bites are puncture wounds or lacerations made by insects such as mosquitos, ticks, gnats, fleas, horseflies, bed bugs, and spiders. An insect may bite when it is agitated and defends itself or when it wants to feed. An insect releases its saliva when it bites the skin, triggering erythema, inflammation, pain, and pruritus at the puncture site. The bites can range in size from a very small papule to a massive welt.

Patients will have varying degrees of reactivity at the site of the bite, depending on skin type and known sensitivities. Bite marks may become infected because of excoriation and rubbing, and they may exhibit signs of infection, such as pus inside or around the bite, swollen glands, fever, and/or flu-like symptoms. Typically, bite marks do not last more than a few hours. However, some patients may have a hyper reaction when the same type of insect bites them for a second time. Once this occurs, the patient becomes sensitized to the insect’s saliva, and a pruritic wheal or papule may develop and last for several days. Because there is no correlation between the size or appearance of the bite mark and the type of biting insect, patient history is critical to diagnosis.

In the majority of cases, reactions to insect bites are mild, local, and straight forward to treat. Patients may find that placing a cold compress over the bite area, applying a topical corticosteroid or anesthetic cream, or taking a non-steroidal anti-inflammatory drug or paracetamol (eg, acetaminophen) may help. In more severe cases, or when the bites are near the eyes, a short course of oral corticosteroids may be needed. Patients should be advised that if an insect bite is uncommonly pruritic, acutely swollen, painful, warm to the touch, or presents with an unusual rash or systemic symptoms (eg, fever, vomiting, nausea, or musculoskeletal complaints), then further evaluation and testing is warranted.

There are 2 major reasons why an insect will bite a particular person: (1) the presence of carbon dioxide production, and (2) the lipid mix on the surface of the skin. For example, mosquitos find humans by determining where carbon dioxide is being produced. Although humans manufacturing carbon dioxide is a given, each individual’s lipid mixture varies and is made up of cholesterol, triglycerides, ceramides, and other fats. Certain lipid mixtures are more appealing to insects than others, which explains why some patients report feeling that they are often a “target” for insect bites.

Since a patient’s skin lipid mix is based on genetics, and knowing that an individual cannot change his or her DNA, the CDC recommends that adults use bug repellents that contain diethyltoluamide (DEET), picaridin, or oil of lemon eucalyptus. Insect repellents containing DEET should not be used on children younger than 2 months, while oil of lemon eucalyptus products should not be used on chil dren younger than 3 years.

When an insect stings an individual and injects its venom into the skin, that patient’s reaction at the site is painful, erythematous, inflamed, and pruritic. However, some patients are allergic to the venom, and these symptoms progress to anaphylaxis in quick order. It is normal for a bee, hornet, yellow jacket, fire ant, or wasp sting to cause a minor rash and localized swelling; however, a more serious systemic reaction leading to anaphylaxis presents with widespread pruritus, urticaria, shortness of breath, swelling of the tongue/throat,nausea, vomiting, or diarrhea.

For mild to moderate reactions, treatment involves removing the stinger as soon as possible, washing the area with soap and water, and applying cold compresses or ice. When removing the insect stinger, a quick scrape with a fingernail is often sufficient. It is important not to pinch the sting or use tweezers, as this can inject more venom into the site. Patients may find relief by applying topical creams (eg, hydrocortisone, aloe, antihistamine) to the affected area.

For anaphylactic reactions, prompt emergency treatment with epinephrine is required. When the patients report experiencing anaphylaxis from an insect sting without prior history of a venom allergy, they should be referred to an allergist for further evaluation. An allergist will perform allergen skin testing as a part of the assessment. Patients who demonstrate sensitivity (positive results) to the skin tests and receive a diagnosis of venom allergy will be considered as candidates for allergy immunotherapy injections. There is no sublingual alternative when desensitizing a patient with a venom allergy.

Patients with a history of venom allergy who have been evaluated by an allergist will know to always carry a 2-pack epinephrine injector set with them and have a plan for emergency action in place. If the epinephrine injector is used, the patient should call 9-1-1, contact his or her health care provider, or go to the nearest emergency department for evaluation of a possible biphasic reaction. A biphasic reaction is a second episode or wave of anaphylaxis, and it occurs without additional exposure to the allergen. It is estimated that biphasic reactions happen in up to 20% of anaphylaxis cases.

Patients should know that if stinging insects are close by, they should remain calm and move slowly away. Because these insects are drawn to brightly colored clothing and perfume, it is best to avoid those when outdoors for a long period of time. The smell of food attracts insects, so awareness is necessary when cooking, eating, or drinking sweet drinks like soda or juice (particularly when drinking from straws or cans, which are common places for stinging insects to hide). At-risk patients should wear closed-toe shoes outdoors, avoid going barefoot, and avoid loose-fitting garments that can trap insects between material and skin.

Urticaria, also known as hives, is a rash with pale red, raised, and pruritic lesions that can appear anywhere on the body and may change shape, location, and vary in intensity over short periods of time. Urticaria is common year round, but in some patients, the summer season makes everything worse. Rising body tempratures in the summer months, whether caused by direct sunlight or increased outdoor activity, increase blood flow to the skin and provoke mast cells (within the dermis) to release histamine, thereby causing an urticarial exacerbation. Regardless of the cause of the urticaria, the summer season may cause a flare of symptoms.

Urticaria often appears suddenly and dissipates just as rapidly. For diagnostic purposes, applying pressure to the center of the hive should make it instantaneously turn white, a process called blanching.

Mild urticaria often disappears spontaneously after a few hours, while a moderate case necessitates first-line treatment with an oral antihistamine and will last days to weeks, or beyond. Patients often prefer the non-sedating, second-generation antihistamines to the sedating first-generation antihistamines for first-line treatment. When needed, subsequent first-line therapy may include the addition of histamine blockers. If the hives encompass the face, approach the eyes, or are acutely pruritic, adding an oral corticosteroid may be necessary. Patients should see a health care provider for further evaluation if hives last more than 3 to 4 days. If patients additionally develop angioedema or anaphylaxis, they should be advised to seek medical attention immediately.

When heat is a known aggravator, patients should try to avoid being outdoors on warm days for a long period of time. Patients should have a complete allergy work-up to properly diagnose their urticaria and learn how to manage avoidance of their triggers.

The high rainfall, humidity, and temperatures of the summer season, combined with the increased carbon dioxide levels of the past few years, promise to yield a potent crop of ivy-related plants this year. Hiking, camping, and playing outdoors are perfect summer activities; however, developing a rash from poison ivy, oak, or sumac while doing so can interrupt your patient’s day.

Poison ivy, oak, and sumac rashes are a form of allergic contact dermatitis and are caused by oils found in the leaves, stems, and roots of the plants called urushiol. Poison ivy is the most recognized form of the 3 plants and is similar in appearance to poison oak and sumac. The rash is erythematous and very pruritic, involving inflammation and blistering. According to the American Dermatology Association, 85% of individuals develop a rash when they get urushiol on their skin. The rash often does not start until 12 to 72 hours after the patient comes into contact with the oil. For most, the rash resolves within a few weeks.

The initial treatment for poison ivy, oak, or sumac is to use a cold compress, calamine lotion, hydrocortisone cream, or antihistamine to relieve itching. However, if the rash is more severe or encompasses the face (specifically the eye), a short burst of oral corticosteroids may be necessary. Inflammation is a sign of a serious reaction and necessitates an immediate evaluation by a health care provider. If the patient is having respiratory or swallowing difficulties, they should call 9-1-1 or go to an emergency department immediately.

It is often comforting for patients to know that the rash is not contagious and only spreads when the oil touches other parts of the body. It is not possible to get this rash from merely touching someone who has the rash, as the skin absorbs the oil too quickly. It is also not possible to get this rash from touching the fluid in the blisters of the rash. An individual must come into contact with the plant oil to develop the rash. Interestingly, dogs and other animals do not develop this type of rash, yet if the plant oil is on their fur, it is feasible for patients to develop the rash after touching the animal.

It is important to share with patients that the only way to prevent plant-induced contact rashes is to be hypervigilant of their surroundings when outdoors. Patients should be familiar with the appearance of their rash-provoking plant and avoid walking through tall grasses when possible. A simple reminder to share with patients is: “Leaves of 3, let them be.”

Summer often presents the perfect scenario for the development or exacerbation of all that itches. The increased number of insects and plants in the environment, along with longer, hotter days and spending more time outdoors, contributes to an increase in incidents of rashes, hives, bites, and stings during this season. Most of these skin ailments are self-limiting and will resolve spontaneously after a few hours or days. However, those with severe symptoms may require further evaluation, referral to an allergist, or emergency treatment. Regardless, retail clinicians are in a prime position to educate their patients on the primary prevention and avoidance measures of summer rashes,hives, bites, and stings

For many of our patients, the season means walks in the park, evenings by the shore, backyard barbecues, and outdoor sports. 

Summer Bites, Stings, Hives, and Rashes

Acute respiratory infections—specifically rhinosinusitis (RS), bronchitis, and pharyngitis&mdash;are among the most common reasons why patients in the United States seek medical care. With acute respiratory infections accounting for approximately 60% of all retail clinic,

nurse practitioners and physician assistants play a key role in diagnosing these illnesses and treating these patients. This article presents an overview and case study of RS and discusses its management in the retail clinic.

RS affects approximately 14% of the US population.

According to a recent analysis of National Health Interview Survey data, RS caused a similar number of missed workdays as acute asthma.

In the literature, the term “rhinosinusitis” is used synonymously with “sinusitis”; however, RS is a more appropriate term because the nasal middle turbinate extends directly into the ethmoid sinuses, and sinus inflammation rarely occurs without concomitant inflammation of the contiguous nasal mucosa. The subtypes of RS are acute RS (viral or bacterial), chronic RS with and without nasal polyps, and allergic fungal RS.

Acute RS is most commonly viral, with an average frequency of 8 to 10 times per year in children and 2 to 5 times per year in adults. In the current climate of antibiotic stewardship, the judicious use of antibiotics has come into sharp focus because of patients’ growing resistance to commonly used antibiotics. Although the impression is much higher, bacterial infections complicate viral RS in less than 3% of cases.

Antibiotics are prescribed for 80% to 90% of acute respiratory infection cases, even though 60% of cases resolve on their own.

It is theorized that the overuse of antibiotics is linked to the underdiagnosis of allergic or viral infections. This topic has gained national attention as an area of necessary education for health care providers.

During the past decade, a number of expert panels—including the Joint Task Force (consisting of members from the American Academy of Allergy, Asthma, & Immunology; American College of Allergy Asthma and Immunology; and Joint Council of Allergy, Asthma, and Immunology) and the American Academy of Otolaryngology-Head and Neck Surgery Foundation&mdash;have put forth evidence-based guidelines for the diagnosis and management of RS. Although the guidelines have distinct yet subtle differences, they are comparable in the guidance they offer health care providers.

Felicia is a 31-year-old graduate student who presents to the retail clinic with a 2-day history of congestion, colored nasal discharge, headache, sneezing, and overall fatigue. She is taking acetaminophen for her headache and has no significant medical history or known drug allergies. She does not take any medicines regularly except multivitamins and a calcium supplement. Felicia’s final exams start in 12 days, and she feels that a course of antibiotics will help her recover more quickly.

What additional information would you want to know about Felicia’s history and current illness?

Additional questions to aid the diagnostic process include whether Felicia has had any recent viral or bacterial exposures, if she has any past medical history of environmental allergies, if there is any repeated pattern of similar presentations, or if she has taken any medications to remedy symptoms.

Acute RS is a clinical diagnosis, and understanding its presentation is important in differentiating its etiology as viral, bacterial, or allergic. No specific diagnostic tests or absolute clinical signs or symptoms for acute RS exist, so the overall clinical impression should be used to guide diagnosis and management.

Acute viral RS symptoms typically peak within 2 to 3 days of onset, decline gradually, and disappear within 10 to 14 days. Symptoms that persist for 10 or more days, support a pattern of initial improvement followed by worsening, or include unilateral facial or tooth pain suggest acute bacterial RS.

It is a myth that the presence of fever or the color of nasal mucus alone can distinguish between viral and bacterial etiologies. Although the sole presentation of purulence cannot differentiate between viral and bacterial infection, a diagnosis of acute bacterial RS is unlikely in its absence.

After taking a thorough history, you begin your examination of Felicia and find pale, boggy nasal turbinates; scant purulent mucus discharge; a slightly erythematous oropharynx; and postnasal drip. All other findings are normal.

What is your initial diagnosis for Felicia’s presentation?

Based on Felicia’s history and exam, she is diagnosed with acute viral RS. A viral RS disease process involves 2 steps, the first of which is a viral infection of the nasal cells and the second of which is activation of inflammatory mediators that directly cause symptoms.

Treatment options you initially consider for Felicia include the following:

•   Nonsteroidal anti-inflammatory drugs

•   Intranasal decongestants (patients should avoid using topical decongestants for more than 3 days to reduce the likelihood of rebound congestion)

•   Intranasal corticosteroids (the only intranasal corticosteroid currently indicated for the treatment of RS is mometasone furoate)

•   Complementary medications such as zinc, echinacea, and vitamin C

What key educational messages would you share with Felicia regarding treatment?

The best strategy for treating acute viral RS is to start treatment as soon as symptoms present (the first 3 days are the most important) and to continue it until symptoms resolve (7 to 10 days on average). The suggestion for prompt and continuous treatment is based on the known timeline of viral courses from the nasal passages into the sinuses. Acute viral RS symptoms may appear as early as 10 hours after inoculation and may increase in severity for 48 to 72 hours, after which symptoms usually begin to dissipate in keeping with the natural course of the virus.

Felicia returns 10 days later and presents with worsening nasal congestion and drainage, unilateral facial pain, worsening headache, increased purulent nasal drainage, and fever. Upon exam, you find that Felicia has bilateral erythematous and inflamed turbinates, copious purulent drainage, and right frontal/maxillary sinus tenderness. The remainder of her exam is unremarkable.

Felicia is now diagnosed with acute bacterial RS. When considering whether further workup would be of value, all guidelines agree that plain radiography (eg, Waters’ view) is not useful or cost-effective. Computed tomography is not typically recommended for routine evaluation but is the imaging method of choice should it be warranted. Nasal cultures are not recommended for routine workup. Sinus puncture is a standard method for confirming bacterial pathogens in maxillary sinuses, but it is costly, inconvenient, and uncomfortable for the patient. Nasal endoscopy is reserved for pharmacotherapy failure.

The treatment goal for bacterial RS is to address the likely causative bacterial pathogens, such as

. Nurse practitioners and physician assistants should be aware of the probability of bacterial resistance within their community. Typically, the state health department is a resource for information on antibiotic resistance within a metropolitan or rural health area.

Multiple factors should be considered when choosing an antibiotic for treatment, including the likely causative organisms, given the clinical picture, and likelihood of resistant strains within a community. If amoxicillin is chosen, it should be given at double the standard dose (eg, 80 mg/kg/day to 90 mg/kg/day), especially in areas with known

resistance. The course of treatment is usually 10 to 14 days. Of note, the Infectious Diseases Society of America recommends amoxicillin/clavulanate over amoxicillin alone as empiric antibiotic therapy in children and adults with acute bacterial RS.

In patients who are allergic to penicillin, the first-line therapy is a macrolide antibiotic because of its low cost, ease of administration, and low toxicity. If patients reside in a locality with a high incidence of resistant organisms or fail to show initial improvement in symptoms within 72 hours of starting an antibiotic, consideration should be given to prescribing a second-line antibiotic such as a cephalosporin or quinolone.

What key educational messages would you share with Felicia regarding symptomatic care of her acute bacterial RS?

In addition to adhering to the prescribed antibiotic treatment, options for symptomatic care may include the following:

•     Warm compresses to address facial pain

Acute RS is among the most prevailing reasons patients seek medical care, and many of those visits occur in the retail clinic setting. Far too frequently, health care providers misdiagnose viral or allergic RS as a bacterial illness—a misstep that is believed to contribute to the overprescribing of antibiotics.

In this case, Felicia was initially diagnosed with acute viral RS. After being given appropriate viral treatment, her symptoms worsened. Felicia was diagnosed subsequently with bacterial RS and treated with a course of amoxicillin/clavulanate for 10 days.

Although patients like Felicia who present to the retail clinic with acute viral RS may expect to be prescribed an antibiotic, the time invested in patient education about appropriate viral treatment, the typical course of the disease, and antibiotic stewardship will go a long way toward improving their health outcomes.

is an allergy, asthma, and immunology specialty nurse practitioner. She is a medical science liaison with Meda Pharmaceuticals and an adjunct faculty member at Indiana Wesleyan University Graduate School of Nursing. Dr. Rance has served on the board of directors of the National Association of Certified Asthma Educators and is on the National Heart, Lung, and Blood Institute’s National Asthma Education Prevention Program Expert Panel workgroup. She is the founding chair of the National Association of Pediatric Nurse Practitioners’ (NAPNAP) Asthma and Allergy Special Interest Group and is on NAPNAP’s Clinical Expert Panel for Asthma.

Mehrotra A, Gidengil C, Setodji C, Burns R, Linder J. Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments.

Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines.

2011;88(5):427-443. doi: 10.4065/mcp.2010.0392.

Bhattacharyya N. Contemporary assessment of the disease burden of sinusitis.

2009;23(4):392-395. doi: 10.2500/ajra.2009.23.3355.

Chow A, Benninger M, Brook I, et al; Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.

2012;54(8):e72-e112. doi: 10.1093/cid/cir1043.

Acute respiratory infections are among the most common reasons why patients in the United States seek medical care. 

Acute Rhinosinusitis Management in the Retail Clinic

One of the most common diagnoses in the United States, allergic rhinitis is often misdiagnosed and/or undertreated.

Allergic rhinitis (AR) is one of the most common diagnoses in the United States, affecting an estimated 10% to 30% of adults and up to 40% of children.

Research estimates that AR is the reason for 13 million medical office visits annually,

many of which are to retail clinics. Each year, 25% of US households have at least 1 member with AR symptoms.

It is common for patients to have tried multiple OTC allergy medicines before they seek professional medical care for their AR symptoms. The financial and societal burdens of AR are significant and have been referred to by some as “massive.”

Studies show AR also has a negative impact on a patient’s quality of life, affecting emotional function, activities, sleep, and comorbid conditions.

In 2006, a landmark study, “Allergies in America,” surveyed 2500 adults who had been diagnosed with either AR or nonallergic rhinitis and who had taken prescription allergy medication in the previous 12 months. The survey results demonstrated the most commonly reported symptom was nasal congestion. Nearly 40% of patients said that their related discomfort was intolerable without some sort of relief measures. Survey results also demonstrated an average productivity decline of 25% among employees on days when they had significant allergy symptoms and 30% of employees losing workdays due to uncontrolled allergy symptoms in the past year.

AR is often misdiagnosed and/ or undertreated.

Patients with AR often present to medical practitioners requesting antibiotics for what they think is a sinus infection when what they need is appropriate treatment for AR. The misdiagnosis of AR contributes to and perpetuates the overuse of oral antibiotics. Retail clinic nurse practitioners (NPs) and physician assistants (PAs) are at the front line of patient care and have a great opportunity to educate patients regarding the commonality and characteristics of AR and offer an evidence-based treatment plan.

This article will review a case study of a patient with AR. The diagnosis and management of AR will be discussed along with evidence-based options for treatment.

Brooke is a 16-year-old girl, accompanied by her father, who presents to your clinic for the first time with the chief complaint of a flare of her allergy symptoms this fall. She states that since her school year started 2 months ago in early August, her “allergies have been terrible.” Brooke has had seasonal allergies since she was 9 years old, and her father states that they have typically controlled Brooke’s symptoms over the past several years with OTC antihistamines and OTC eye drops. He states that he typically sees a spike in Brooke’s allergy symptoms each spring when the trees start blooming, but that her symptoms are much better by July. Brooke reports having difficulty staying awake during her school day, and she is not sure if it is due to the allergy pill she takes in the morning or because her nasal congestion is keeping her awake at night. She is complaining of sneezing, an itchy nose, itchy eyes, clear runny nose, and postnasal drip. Brooke’s father states that the last time she had similar symptoms she was prescribed a 5-day course of antibiotics and wonders if she is getting more antibiotics today.

Brooke recently tried an OTC corticosteroid (fluticasone propionate) nasal spray after she and her father saw a poster about the medicine at her pharmacy. Typically, she only uses her nasal spray when her symptoms are “really bad,” but her current symptoms necessitated her using the nasal spray twice daily for the past 6 weeks. She states she doesn’t like nasal sprays very much because the medication “runs down” the back of her throat. She recently added a second-generation oral antihistamine to her daily medications, but her symptoms persist. She has also tried OTC allergy eye drops as needed and reports her eye symptoms have somewhat improved. When questioned, Brooke states she is adherent with her medications.

DISCUSSION QUESTION: What additional information would you want to know about Brooke’s history and current illness?

A patient’s medical history is critical to an accurate diagnosis. You decide that you need a more detailed medical history from Brooke and proceed to ask her additional questions that elicit the following information:

Brooke complains of sneezing, and itchy nose, itchy eyes, clear runny nose, and postnasal drip. She denies any discolored nasal mucus, fever, sore throat, or headaches, and does not have coughing, shortness of breath, or nocturnal cough.

Brooke has no history of other medical problems or known drug allergies.

Brooke and her family live in the Midwest in a home surrounded by trees on 1 acre of land. She has no pets, although she wants to adopt a cat. No one smokes around her. She redecorated her bedroom last year and, at that time, got a new mattress and pillow.

Brooke’s mother has similar seasonal allergy symptoms that she treats with alternating OTC loratadine and cetirizine.

Brooke is in 11th grade and has always been an excellent student; this school year, however, she has gotten off to a rough academic start. She is in choir and on the debate team, and her nasal congestion and postnasal drip have impacted her voice and ability to sing. She has upcoming tryouts for show choir, and it is very important that she is able to sing to the best of her ability.

DISCUSSION QUESTION: What is your initial impression of Brooke’s presentation?

Based on her history, you initially suspect AR. Brooke’s father again asks if she will be prescribed an antibiotic for treatment. You share that without evidence (on exam and/ or radiological imaging) of Brooke having a bacterial infection, there is no indication for antibiotics and that if antibiotics were prescribed in such a scenario, they wouldn’t be beneficial for symptom relief. Brooke’s father is satisfied with your answer. You then move on to Brooke’s physical exam and find the following:

She is a well-developed, well-nourished teenager who has been sneezing periodically and appears congested. Allergic shiners present bilaterally.

: Mucosa is pale and boggy with acutely edematous inferior nasal turbinates; clear rhinorrhea present. Nasal crease noted.

: Bilateral breath sounds are clear to auscultation. No wheezing, rhonchi, or rales noted.

DISCUSSION QUESTION: What would you recommend and/or prescribe for Brooke’s treatment plan?

: After Brooke’s exam, you conclude that her symptoms are consistent with seasonal AR and there is no evidence that supports a diagnosis of sinusitis. You review the Joint Task Force Allergic Rhinitis guidelines:

In 2008, a joint task force (JTF), representing the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology developed practice parameters for the diagnosis and treatment of rhinitis.

This evidence-based document provides NPs, PAs, and all medical providers a template by which they can make optimal choices for their patient’s treatment. Nasal corticosteroids are considered to be the most effective medication for controlling AR symptoms and, therefore, are considered first-line treatment for AR.

Nasal antihistamines may also be considered for use as first-line AR treatment.

The JTF ascribes to a stepwise approach for AR treatment (see Figure

According to the practice parameters, AR is controlled if nasal symptoms do not interfere with a patient’s normal daily routine and sneezing, nasal itching, congestion, and eye symptoms occur on fewer than 2 days per week. When this is the case, treatment should remain the same or stepped down as defined in the Figure. Alternatively, if a patient has mild interference with activities and is sneezing or has nasal itching, congestion, or eye symptoms 2 to 6 days per week, treatment should be increased by 1 step. If the patient has severe interference with activities and is sneezing or has nasal itching, congestion, or eye symptoms daily, treatment should be increased by 2 steps.

Patients with moderate to severe persistent AR are considered candidates for immunotherapy if they fail pharmacotherapy and have evidence of specific immunoglobulin-E antibodies to clinically relevant allergens.

The Rhinitis Control Assessment Test (RCAT) was published in 2013 and provides a validated means to subjectively assess a patient’s nasal allergy symptoms. The RCAT is a simple 6-item patient-completed questionnaire designed to reveal any issues of rhinitis symptom control.

1. During the past week, how often did you have nasal congestion?

2. During the past week, how often did you sneeze?

3. During the past week, how often did you have watery eyes?

4. During the past week, to what extent did your nasal or other allergy symptoms interfere with your sleep?

5. During the past week, how often did you avoid any activities (eg, visiting a house with a dog or cat, gardening) because of your nasal or other allergy symptoms?

6. During the past week, how well were your allergy symptoms controlled?

RCAT scores range from 6 to 30, with higher scores indicating better rhinitis control. RCAT scores equal to or less than 21 are consistent with patients who have uncontrolled allergy symptoms, and scores greater than 21 are consistent with patients whose symptoms are controlled. When using the RCAT on consecutive visits, a change of at least 3 points is considered clinically meaningful in the context of a patient’s treatment plan. The RCAT can be used to rapidly screen for patients with rhinitis symptom control problems and can help patients communicate with their providers about their symptoms.

Prior to discussing pharmacotherapy, you review allergen avoidance measures with Brooke and her father, which include minimizing her exposure to spring and fall pollens. Brooke asks your opinion regarding her interest in adopting a cat and you share that because of her atopic history, she would be a great candidate for allergy skin testing to best determine her related risks, if any.

Because Brooke has previously tried and failed treatment with a corticosteroid nasal spray and oral second-generation antihistamine, you decide to step up her treatment by adding an antihistamine nasal spray. Since the publication of JTF’s practice parameters in 2008, a prescription-only combination corticosteroid/ antihistamine nasal spray has become available (fluticasone proprionate / azelastine HCL). Remembering that Brooke complained of her previous nasal spray “running down” the back of her throat, you choose to minimize the volume of nasal spray that she will be taking daily by starting her on the combination corticosteroid/antihistamine spray. The combination product has a quick onset of action that should help her adhere to the treatment plan because she will be able to realize the benefits of the medication in short order. Additionally, the nasal sprays have minimal somnolence adverse effects. Brooke’s father asks you to review the best way for her to take a nasal spray medication and you review the proper steps with both of them (see Table). You discontinue Brooke’s daily use of cetirizine in hopes that any contribution it made to her being sleepy during the school day would stop. You tell Brooke that she can try an alternative second-generation antihistamine (fexofenadine) at bedtime, if needed. You also share with Brooke the benefits of using a nasal rinse, particularly about 20 minutes prior to taking her prescribed nasal spray. You ask Brooke to start taking her allergy eye drops on a consistent daily basis.

Brooke and her father are well pleased with their visit and believe the treatment plan sets them up for success. Brooke is to follow up in 1 month to reassess her symptoms and determine the effectiveness of her treatment plan. You explain to Brooke that she will be asked to complete the RCAT at her next visit to provide a basis for comparison.

It is widely accepted that the most effective treatment plan for a patient is one that they will follow, is evidence-based, and is created with a patient-centered approach. This case study presents the many aspects of a typical conversation that presents to a retail clinic for a very common diagnosis. Using the JTF’s practice parameters when treating AR while actively listening to the patient will provide a great platform for an effective treatment plan that will optimize the patient’s health outcome.

Karen S. Rance, DNP, RN, CPNP, AE-C, is an allergy, asthma, and immunology specialty nurse practitioner. She is a medical science liaison with Meda Pharmaceuticals and an adjunct faculty member at Indiana Wesleyan University Graduate School of Nursing. Dr. Rance has served on the Board of Directors of the National Association of Certified Asthma Educators and is on the National Heart, Lung, and Blood Institute’s National Asthma Education Prevention Program Expert Panel workgroup. She is the founding chair of the National Association of Pediatric Nurse Practitioners’ (NAPNAP) Asthma and Allergy Special Interest Group and is on NAPNAP’s Clinical Expert Panel for Asthma.

Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: An updated practice parameter

. 2008;122 (2 suppl):S1-S84. doi: 10.1016/j.jaci.2008.06.003. â€¨

Schappert SM Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007.

Marple BF, Fornadley JA, Patel AA, et al. Keys to successful management of patients with allergic rhinitis: focus on patient confidence, compliance, and satisfaction.

Hoyte FC, Meltzer EO, Ostrom NK, et al. Recommendations for the pharmacologic management of allergic rhinitis.

Allergies in America: A Landmark Survey of Nasal Allergy Sufferers.. Mahwah, NJ; HealthSTAR Communications, Inc. www.worldallergy.org/UserFiles/file/Allergies%20in%20America%20(AIA)%20-%20Adult%20Executive%20Summary.pdf.

Sur DK, Scandale S. Treatment of allergic rhinitis.

Schatz M, Meltzer EO, Nathan R, et al. Psychometric validation of the rhinitis control assessment test: a brief patient-completed instrument for evaluating rhinitis symptom control.

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Karen Rance, DNP, APRN, CPNP, AE-C

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