Conditions of the lower respiratory tract.pptx

Upper respiratory tract infections (URTIs) can manifest with various conditions, including:

1. Common Cold: Runny nose, congestion, sneezing, coughing, and mild fatigue.

2. Pharyngitis (Sore Throat): Painful swallowing, redness, and swelling in the throat.

3. Laryngitis (Hoarseness): Inflammation of the vocal cords, leading to hoarseness or loss of voice.

4. Sinusitis: Infection or inflammation of the sinuses, causing facial pain, pressure, and nasal congestion.

5. Tonsillitis: Inflamm

1. Conditions of the lower respiratory tract. BY: MUTEGEKI ADOLF

2. 1. Asthma Definition: Asthma is a chronic inflammatory disorder of the airways characterized by episodes of reversible airway obstruction, bronchial hyper-responsiveness, and airway inflammation. This leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning Aetiology : Asthma's exact cause is not fully understood, but it is believed to result from a combination of genetic and environmental factors. Key contributors include: Genetic Predisposition: Family history of asthma or atopy (allergic conditions like eczema, allergic rhinitis). Specific genetic variants associated with immune response and airway function.

3. b) Environmental Factors: Allergens: House dust mites, pollen, mold, pet dander, and cockroach droppings. Irritants: Tobacco smoke, air pollution, strong odors, and chemical fumes. Infections: Respiratory viral infections, particularly in early childhood. Occupational Exposures: Certain chemicals, dusts, and gases in the workplace. Dietary Factors: Obesity and a diet low in antioxidants may increase risk . C) Other Contributing Factors: Exercise, particularly in cold air. Emotional stress. Gastroesophageal reflux disease (GERD).

4. Pathophysiology Asthma involves complex interactions between airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness : a) Airway Inflammation Inflammatory cells, including eosinophils , mast cells, T lymphocytes, and neutrophils, infiltrate the airway walls. Release of inflammatory mediators such as histamine, leukotrienes , and cytokines leads to airway edema and mucus hypersecretion . b) Airflow Obstruction Bronchoconstriction due to smooth muscle contraction. Airway edema and mucus plug formation further narrow the airways. This obstruction is typically reversible, either spontaneously or with treatment. c) Bronchial Hyperresponsiveness Increased sensitivity of the airways to various stimuli, leading to exaggerated bronchoconstriction. Chronic inflammation results in structural changes (airway remodeling), including thickening of the basement membrane and increased smooth muscle mass, which may contribute to persistent airflow limitation.

5. Clinical Presentations Asthma symptoms vary widely in frequency and severity. Wheezing: A high-pitched whistling sound, particularly during expiration. Shortness of Breath: Often worsens with physical activity, at night, or early in the morning. Chest Tightness: A sensation of pressure or constriction in the chest. Coughing: Typically dry, persistent, and may worsen at night or early morning. Increased Respiratory Rate and Use of Accessory Muscles: During an asthma attack. Note: Symptoms are often episodic, with symptom-free periods between attacks. However, in severe cases, symptoms may persist and lead to chronic breathlessness.

6. Differential diagnosis Heart failure Other causes of chronic cough Bronchiolitis Bronchiectasis

7. Investigations Spirometry : Measures lung function, including FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity). A reduced FEV1/FVC ratio that improves after bronchodilator administration suggests reversible airway obstruction. Peak Expiratory Flow (PEF): Simple tool for monitoring asthma control. Variability in PEF readings indicates poor control. Bronchoprovocation Tests: Methacholine or exercise challenge tests to assess airway hyperresponsiveness . Allergy Testing: Skin prick tests or serum IgE levels to identify specific allergens. Chest X-ray: Typically normal in asthma but can rule out other causes of symptoms (e.g., pneumonia, pneumothorax). Blood Tests: CBC mostly for Eosinophil count Serum IgE levels may be elevated in atopic asthma.

8. Management General principles of management The four essential components of Asthma Management: P atient education C ontrol of asthma triggers Monitoring for changes in symptoms or lung function and P harmacologic therapy. Inhalation route is always preferred as it delivers the medicines directly to the airways; the dose required is smaller, the side-effects are reduced Eg nebuliser solutions for acute severe asthma are given over 5-10 minutes, usually driven by oxygen in hospital

9. Parenteral route is used only in very severe cases when nebulisation is not adequate. Acute Asthma Asthma attack is a substantial worsening of asthma symptoms. The severity and duration of attacks are variable and unpredictable. Most attacks are triggered by viral infections. Not all features may be present. If the patient says they feel very unwell , listen to them !

10. Assessment of Severity Mild to moderate Able to talk Pulse < 110 bpm Respiratory rate < 25 P eak flow >50% of predicted or best SpO2 ≥ 92% Severe Cannot complete sentences in one breath Pulse 110 bpm Respiratory rate >25 Peak flow <50% of predicted or best SpO2 ≥ 92%

11. Life threatening (Adults and Children) Silent chest, feeble respiratory effort, cyanosis Hypotension , bradycardia or exhaustion, agitation Reduced level of consciousness Peak flow < 33% of predicted or best Arterial oxygen saturation < 92%

12. Management of asthma attacks A. Mild to moderate Treat as an out-patient Reassure patient; place him in a ½ sitting position Give salbutamol Inhaler 2-10 puffs via a large volume spacer, Or 5 mg (2.5 mg in children) nebulisation Repeat every 20-30 min if necessary Prednisolone 50 mg (1 mg/kg for children) Monitor response for 30-60 min. If not improving or relapse in 3-4 hours Refer to higher level

13. If improving, send home with Prednisolone 50 mg (1 mg/kg for children) once a day for 5 days (3 days for children) Institute or step up chronic treatment Follow up after 1-2 weeks Instruct the patients on self-treatment and when to come back Review in 48 hours Do not give routine antibiotics unless there are clear signs of bacterial infection

14. B. Severe Attack Patients with severe asthma need to be referred to HC4 or hospital after initial treatment. Admit patient; place him in a ½ sitting position Give high flow oxygen continuously, at least 5 litres /minute , to maintain the SpO2 ≥ 94 % if available Give salbutamol Inhaler 2-10 puffs via a large volume spacer, Or 5 mg (2.5 mg in children) nebulization. Repeat every 20-30 min if necessary during the 1 st hour

15. Prednisolone 50 mg or f Or hydrocortisone 100 mg (children 4 mg/kg max 100 mg) IV every 6 hours until patient can take oral prednisolone Monitor response after nebulisation If response poor, pratropium bromide nebuliser 500 micrograms every 20- 30 min for the first 2 hours then every 4-6 hours Or Aminophylline 250 mg slow IV bolus if patient is not taking an oral theophylline Alternatively, if symptoms have improved, respiration and pulse settling, and peak flow >50% Step up the usual treatment and continue with prednisolone to complete 5 days of treatment Review within 24 hours - Monitor symptoms and peak flow Arrange self-management plan

16. Life threatening Arrange for immediate hospital referral and admission First aid Admit patient; place him in a ½ sitting position Give high flow oxygen continuously, at least 5 litres /minute , to maintain the SpO2 ≥ 94% if available Give salbutamol Inhaler 2-10 puffs via a large volume spacer Or 5 nebulisation Repeat every 20 min for 1 hour

17. Hydrocortisone 100 mg IV stat or prednisolone 50 mg Ipratropium bromide nebuliser 500 micrograms every 20- 30 minutes for the first 2 hours then every 4-6 hours Monitor response for 15-30 minutes If response is poor, Give Aminophylline 250 mg slow IV bolus If patient is not taking an oral theophylline Note: The use of aminophylline and theophylline in the management of asthma exacerbations is discouraged because of their poor efficacy and poor safety profile

18. Chronic Asthma General principles of management Follow a stepped approach Before initiating a new drug, check that diagnosis is correct, compliance and inhaler technique are correct and eliminate trigger factors for acute exacerbations. Start at the step most appropriate to initial severity Rescue course Give a 3-5 days “rescue course” of prednisolone at any step and at any time as required to control acute exacerbations of asthma at a dose of 40-60 mg daily for up to 3-5 days .

19. Stepping down Review treatment every 3-6 months If control is achieved, stepwise reduction may be possible If treatment started recently at Step 4 (or contained corticosteroid tablets, reduction may take place after a short interval; In other patients 1-3 months or longer of stability may be needed before stepwise reduction can be done

20. STEP 1: Intermittent asthma Intermittent symptoms (< once/week) Night time symptoms < twice/month Normal physical activity Occasional relief bronchodilator: Inhaled short-acting beta2 agonist e.g. salbutamol inhaler, 1-2 puffs (100-200 micrograms ) Move to Step 2 if use of salbutamol needed more than twice a week or if there are night-time symptoms at least once a week.

21. STEP 2: Mild persistent asthma Symptoms > once/week, but < once/day Night time symptoms > twice/month Symptoms may affect activity Regular inhaled preventer therapy Salbutamol inhaler 1-2 puffs prn Plus regular standard-dose inhaled corticosteroid , e.g. beclomethasone 100-400 micrograms every 12 hours. Assess after 1 month and adjust the dose prn Higher dose may be needed initially to gain control Doubling of the regular dose may be useful to cover exacerbations

22. STEP 3: Moderate persistent asthma Daily symptoms Symptoms affect activity Night time symptoms > once/week Daily use of salbutamol Salbutamol inhaler 1-2 puffs prn up to 2-3 hourly Usually 4-12 hourly PLUS beclomethasone inhaler 400-1000 micrograms every 12 hours In adults, also consider 6-week trial with Aminophylline 200 mg every 12 hours

23. STEP 4: Severe persistent asthma Daily symptoms Frequent night time symptoms Daily use of salbutamol Regular corticosteroid tablets plus Regular high-dose beclomethasone (as in Step 3) Plus regular prednisolone 10-20 mg daily after breakfast Note: If inhaler not available, consider salbutamol tablets 4 mg every 8 hours

24. Prevention Primary Prevention: Avoid exposure to tobacco smoke and environmental pollutants during pregnancy and early childhood. Breastfeeding may reduce the risk of developing asthma. Secondary Prevention: Early identification and treatment of allergic conditions. Avoidance of known triggers in sensitized individuals. Regular use of controller medications to maintain control and prevent exacerbations. Tertiary Prevention: Educating patients on early recognition of worsening symptoms and adherence to treatment. Regular follow-up with healthcare providers to monitor asthma control and adjust treatment as needed.

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