Lower Respiratory Disorders 2021 updated.ppt

Medical surgical ppt for cooperensive nursing student
For other health science students

1. LOWR RESPIRATORY TRACT DISORDERS
by Amanuel.O 17/27/2022

2. Overview of RS Anatomy & Physiology
7/27/2022 by Amanuel.O 2

3. Overview of Anatomy & Physiology RS
Therespiratorysystemiscomposedoftheupperand
lowerrespiratorytracts.
TheUpperairwaystructuresconsistofthe:-
noseandnasalpassages
sinuses,
pharynx,
tonsilsandadenoids
larynxand
trachea.
URTwarmsandfiltersinspiredair
BY A.O 37/27/2022

4. Overview of Anatomy & Physiology of RS
•Thelowerrespiratorytractconsistsofthe
Lungs,whichcontainthebronchialandalveolar
structures.
•TheLRT(thelungs)canaccomplishgasexchange.
•BothURT&LRTareresponsibleforventilation.
TheRSworksinconcertwiththecardiovascularsystem.
TheRSisresponsibleforventilationanddiffusion&
TheCVSisresponsibleforperfusion.
BY A.O 47/27/2022

5. Overview of Anatomy & Physiology RS…
Thelungsandwallofthethoraxarelinedwithaserous
membranecalledthepleura.
Thepleuralfluidissmallamountoffluidfoundbetween
thesetwomembranesserveasalubricant.
Lobes:-
Theleftlungconsistsofanupperandlowerlobes
Therightlunghasanupper,middle,andlowerlobe.
BY A.O 57/27/2022

6. Overview of Anatomy & Physiology RS…
BronchiandBronchioles:
Thereareseveraldivisionsofthebronchiwithineach
lobeofthelung.
Firstarethelobarbronchi(3intherightlungand2in
theleftlung).
Thebronchiolesthenbranchintoterminalbronchioles.
Terminalbronchiolesthenbecomerespiratory
bronchioles
Therespiratorybronchiolesthenleadintoalveolar
ductsandalveolarsacsandthenalveoli.
Oxygenandcarbondioxideexchangetakesplaceinthe
alveoli.
BY A.O 67/27/2022

7. Overview of Anatomy & Physiology of RS
Alveoli: About 300 million alveoli are made the lung.
Three different types of cells are found in the alvioli:-
TypeIalveolarcellsareepithelialcellsthatform
thealveolarwalls.
TypeIIalveolarcellssecretesurfactantthatlines
theinnersurfaceandpreventsalveolarcollapse.
TypeIIIalveolarcellsarelargephagocyticcells
thatingestforeignmatter(e.g,mucus,bacteria)and
actasanimportantdefensemechanism.
7/27/2022 by Amanuel.O 7

8. LOWER RESPIRATORY TRACT INFECTIONS(LRTI)
I.Pneumonia
II.PTB
7/27/2022 by Amanuel.O 8

9. I.PNEUMONIA
Pneumoniaisaninflammationofthelungparenchyma
causedbyvariousmicroorganisms,includingbacteria,
fungi,parasites,andviruses.
Pneumonitisisamoregeneraltermthatdescribesan
inflammatoryprocessinthelungtissuethatmay
predisposeorplacethepatientatriskformicrobial
invasion.
by Amanuel.O 97/27/2022

10. Classification of Pneumonia
•Classically,therearefourcategoriesofpneumonia:
Bacterial(typical=ifs.pneumonie,H.influenzae,S.aureus)
Atypical(ifotherbacteriasandothercausitiveagents)
Anaerobic/cavitary,and
Opportunistic.
•However,Themorewidelyusedclassificationareas
follow:
Community-acquiredpneumonia(CAP),
Hospital-acquired(nosocomial)pneumonia(HAP),
PneumoniaintheImmunocompromisedhost,and
Aspirationpneumonia
by Amanuel.O 107/27/2022

11. 1. Community-Acquired Pneumonia
CAPoccurseitherinthecommunitysettingorwiththe
normalsocialcontact.
HospitalizationforCAPdependsonitsseverity.
Causativeagentsare:
S.pneumoniae,H.influenzae,Legionella,
Pseudomonasaeruginosa,andothergram-negativerods.
It is most prevalent during the winter andspring, when
URTIs are most frequent.
by Amanuel.O 117/27/2022

12. CAP
Streptococcalpneumonia(pneumococcal)
Highestoccurrenceinwintermonths
Incidencegreatestinthe:
Elderlyand
PatientswithCOPD,
Heartfailure,
Alcoholism,andafterinfluenza.
Deathoccursin14%ofhospitalizedadultswithinvasive
disease.
Abruptonset,toxicappearance,pleuriticchestpain
Bacteremiain15%to25%ofallpatients
by Amanuel.O 127/27/2022

13. CAP…
TheorganismcolonizestheURTandcancausethe
disseminatedinvasiveinfections:
URTIs-otitismediaandsinusitis
PneumoniaandotherLRTIs,and
Itmayoccurasa:
Lobaror
Bronchopneumonicformandmayfollowarecent
respiratoryillness.
by Amanuel.O
137/27/2022

14. CAP
Treatment
Penicillins
Alternative antibiotic therapy, such as
Cefotaxime or
Ceftriaxone;
Antipseudomonal fluoroquinolones
levofloxacin, gatifloxacin, moxifloxacin
by Amanuel.O 147/27/2022

15. CAP…
Mycoplasmapneumonia
ItisCAP,w/ciscausedbyM.pneumoniae
Itoccursmostoftenin:
Olderchildrenand
Youngadults
Itisspreadbyinfectedrespiratorydropletsthroughperson-to-
personcontact.
Itaffectsentirerespiratorytractandhasthecharacteristicsofa
bronchopneumonia.
by Amanuel.O 157/27/2022

16. CAP
Increase in fall and winter
Responsible for epidemics of respiratory illness
Most common type of atypical pneumonia
Accounts for 20% of CAP
Mortality rate:<0.1%
by Amanuel.O 167/27/2022

17. CAP
Onsetisusuallyinsidious
Patientsnotusuallyasillasinotherpneumonias
Sorethroat,nasalcongestion,earpain,
headache,low-gradefever,pleuriticpain,
Myalgias, diarrhea, Erythematous rash,
Pharyngitis
Interstitial infiltrates on chest x-ray.
by Amanuel.O 177/27/2022

18. CAP
Treatment of Mycoplasma pneumonia caused CAP
Doxycycline,
Macrolide : ERT,clarithromycin,azithromycin
Fluoroquinolone
by Amanuel.O 187/27/2022

19. CAP
H. influenzae .
Incidence greatest in:-
Alcoholics,
Elderly,
Pts with DM or COPD, and
children <5 years of age
Accounts for 5–20% of CAP
Mortality rate:30%
by Amanuel.O 197/27/2022

20. CAP
Frequentlyinsidious onset associated with URTI 2 to 6
weeks before onset of illness
low-grade fever, chills, productive cough
Usually involves one or more lobes
Bacteremia is common
Chestx-raysmayreveal:
Multilobar,
Patchybronchopneumoniaor
Consolidation(alveolitissueissolidified)
by Amanuel.O 207/27/2022

21. CAP
Treatment of H. influenzae caused CAP
Ampicillin,
Third Cephalosporin,
Macrolides (Azithromycin, Clarithromycin),
Fluoroquinolones
by Amanuel.O 217/27/2022

22. CAP
ViralpneumoniaisanothercauseofCAP
InfluenzavirusestypesA,B
Adenovirus,parainfluenza,CMV,Coronavirus
Incidencegreatestinwintermonths.
Epidemicsoccurevery2to3years.
Accountsfor20%ofCAP
Virusesarethemostcommoncauseofpneumoniain
infantsandchildren.
by Amanuel.O 227/27/2022

23. CAP
ThechiefcausesofviralpneumoniaInimmunocompetent
adults:-
InfluenzavirusestypesAandB,
Parainfluenzavirus,
Adenovirus,coronavirus,and
Varicella-zostervirus.
Thechiefcausesofviralpneumonia,Inimmuno
compromisedadults:
Cytomegalovirusistheleading
HSV,
Adenovirus,andrespiratorysyncytialvirus
by Amanuel.O 237/27/2022

24. CAP
ChestX-ray
Patchyinfiltrate,
small pleural effusion
Begins as an acute URTIs-in most patients
bronchitis,
pleurisy
by Amanuel.O 247/27/2022

25. CAP
TreatmentofviralCAP
TypeA:AmantadineandRimantadine
TypeA/B:zanamivir,oseltamivirphosphate
Treated symptomatically
Does not respond to treatment with currently available
antimicrobials
by Amanuel.O 257/27/2022

26. 2. Hospital-Acquired Pneumonia
HAP,alsoknownasnosocomialpneumonia,isdefinedas
theonsetofpneumoniasymptomsmorethan48hours
afteradmissioninpatientswithnoevidenceofinfection
atthetimeofadmission.
HAPaccountsfor15%ofhospital-acquiredinfectionsbut
isthemostlethalnosocomialinfection.
by Amanuel.O 267/27/2022

27. HAP
Ventilator-associatedpneumoniaisconsideredasatypeof
nosocomialpneumonia
Itisbacterialpneumoniathatdevelopsinpatientswith
acuterespiratoryfailurewhohavebeenreceiving:-
Mechanicalventilationforatleast48hoursor
Endotrachealintubation
Handsofhealthcarepersonnelisalsoanotherpotential
sourceofnosocomialinfection.
by Amanuel.O 277/27/2022

28. HAP…
HAPoccurswhenatleastoneofthreeconditionsexists:
Inoculum of organisms reaches the LRT and
overwhelms the host's defenses, or
Presence of highly virulent organism
Impaired host defenses
Immunocompromised patients are at particular risk.
by Amanuel.O 287/27/2022

29. HAP
PredisposingfactorstoHAPincludes:
Impairedhostdefenses(acuteorchronicillness),
Avarietyofco-morbidconditions
Supinepositioningandaspiration
Coma
Malnutrition
Prolongedhospitalization
Hypotension,and
Metabolicdisorders.
by Amanuel.O 297/27/2022

30. HAP
HAPisassociatedwithahighmortalityratebecauseof:
Thevirulenceoftheorganisms,
Theirresistancetoantibiotics,and
Thepatient'sunderlyingdisorder
ThecommonorganismsresponsibleforHAPinclude:
Enterobacterspecies,E.coli,H.influenzae,Klebsiella
species,Proteus,Serratiamarcescens,P.aeruginosa,
Methicillin-sensitive/resistant-S.aureus & S.
pneumoniae
by Amanuel.O 307/27/2022

31. HAP
Staphylococcalpneumoniaaccountsfor>30%casesofHAP
but<10%ofcasesofCAP.
•Itcanoccurthroughinhalationorhematogenousroute.
•Itisoftenaccompaniedbybacteremiaandpositive
bloodcultures.
•Itsmortalityrateishigh
•Specificstrainsofstaphylococciareresistanttoall
availableantimicrobialagentsexceptvancomycin.
by Amanuel.O 317/27/2022

32. HAP
Pseudomonalpneumoniaaccountsfor15%casesofHAP
andmortalityrate:40–60%.
Itoccurs:-
Indebilitatedpatients,
Alteredmentalstatus,and
Prolongedintubationorwithtracheotomy
by Amanuel.O 327/27/2022

33. Clinical manifestations of HAP…
Coughandsputumproduction
Generalmalaise
Fever,chills,productivecough,relativebradycardia,
Leukocytosis
Pleuraleffusion,
Diffuseconsolidationonchestx-ray.
•Evenwithtreatment,themortalityrateremainshigh(40-60%).
by Amanuel.O 337/27/2022

34. HAP
Treatments:
Aminoglycoside And
Antipseudomonal Pencillins (Ticarcillin, Piperacillin,
Mezlocillin)
Ceftazidine
by Amanuel.O 347/27/2022

35. 3. Pneumonia in Immune compromised Host
PneumoniainImmunocompromisedhostsincludes:
PCP,andotherFungalpneumonias
Mycobacteriumtuberculosis.
TheorganismthatcausesPCPisnowknownas
PneumocystisjiroveciinsteadofPneumocystiscarinii.
by Amanuel.O 357/27/2022

36. Pneumonia in the immunocompromised host occurs
with:
Immunosuppressive agents
Use of corticosteroids or
Chemotherapy
Nutritional depletion,
Use of broad-spectrum antimicrobial agents,
HIV/AIDS
long-term advanced life-support technology
(mechanical ventilation).
by Amanuel.O 367/27/2022

37. Pneumonia in an Immunocompromised…
ImmunecompromisedPatientscommonlydevelop
pneumoniafromorganismsoflowvirulence.
PatientswithimpaireddefensesdevelopHAPfromgram-
negativebacilli(Klebsiella,Pseudomonas,E.coli,
Enterobacteriaceae,Proteus,Serratia).
Whetherpatientsareimmunocompromisedorimmuno
competent,theclinicalpresentationofpneumoniais
similar.
by Amanuel.O 377/27/2022

38. Pneumonia in an Immunocompromised…
PCP/Pneumocystisjiroveci
Incidencegreatestinpatientswith:
AIDS and
Immunosuppressive therapy for cancer, organ
transplantation
Frequently seen with CMV infection
Mortalityrate15–20%inhospitalizedpatientsandfatalif
nottreated.
by Amanuel.O 387/27/2022

39. Pneumonia in an Immunocompromised…
Pulmonaryinfiltratesonchestx-ray
Non-productivecough,fever,dyspnea
Treatment
Trimethoprim/sulfamethoxazole(TMP-SMZ),
Primequineplusclindamycin
by Amanuel.O 397/27/2022

40. Pneumonia in an Immunocompromised…
Fungal Pneumonia
Incidence greatest in
Immunocompromised and
Neutropenic patients
Mortality rate:15–20%
Cough,hemoptysis,
Onchestx-ray-infiltratesandfungusball
by Amanuel.O 407/27/2022

41. Pneumonia in an Immunocompromised…
Treatment
Flucytosine with amphotericin B in non-neutropenic
patients,
Amphotericin B, Itraconazole, ketoconazole
Lobectomy for fungus ball
by Amanuel.O 417/27/2022

42. 4. Aspiration Pneumonia
Aspirationpneumoniareferstopneumoniaresultingfrom
entryofendogenousorexogenoussubstancesintothe
lowerairway.
Themostcommonformofaspirationpneumoniais
bacterialinfectionfromaspirationofbacteriathat
normallyresideintheupperairways.
CommonpathogensareS.pneumoniae,H.influenza,
andS.aureus.
by Amanuel.O 427/27/2022

43. Aspiration Pneumonia…
Substancesotherthanbacteriamaybeaspiratedintothe
lung,suchasgastriccontents,exogenouschemical
contents,orirritatinggases.
Thistypeofaspirationoringestionmay:-
Impairthelungdefenses,
Causeinflammatorychanges,and
Leadtobacterialgrowthandaresultingpneumonia.
by Amanuel.O 437/27/2022

44. Other Classification of Pneumonia
lobarpneumonia-Ifasubstantialportionofoneormore
lobesisinvolved.
Bronchopneumonia-isapneumoniathatisdistributedina
patchyfashion,andoriginatedinoneormorelocalized
areaswithinthebronchiandextendingtotheadjacent
surroundinglungparenchyma.
Bronchopneumoniaismorecommonthanlobar
pneumonia.
by Amanuel.O 447/27/2022

45. by Amanuel.O 45
.
Distributionoflunginvolvementinbronchialandlobar
pneumonia.
Inbronchopneumoniapatchyareasofconsolidationoccur.
Inlobarpneumonia,anentirelobeisconsolidated
7/27/2022

46. Clinical manifestation of pneumonia
Rapidlyrisingfever(38.5°to40.5°C)and
pleuriticchestpainthatisaggravatedbydeepbreathing
andcoughing.
Markedtachypnea(25to45breaths/min),
shortnessofbreath,
useofaccessorymusclesinrespiration
suddenonsetofshakingchillinpneumococcal.
by Amanuel.O 467/27/2022

47. Assessment and Diagnostic Findings
consolidation of lung tissue, including increased tactile
fremitus.
crackles
percussion dullness
Egophony (secondary to consolidation)
by Amanuel.O 477/27/2022

48. Assessment and Diagnostic Findings
History(recentRTI),
Physicalexamination,
Chestx-raystudies,
Bloodculture(bacteremia)
Sputumexamination.
by Amanuel.O 487/27/2022

49. Medical Management
Administrationoftheappropriateantibioticas
determinedbytheresultsoftheGramstain.
However,anetiologicagentisnotidentifiedin50%of
CAPcasesandempirictherapymustbeinitiated.
InsuspectedHAPpneumonia,empiricaltreatmentis
usuallyinitiatedwithabroad-spectrumIVantibioticand
Maybemonotherapyorcombinationtherapy
Cephalosporingroupsor
Antistaphylococcalpenicillincouldbeused.
Ifhypoxemiadevelops,oxygenisadministered.
Pulseoximetry-todeterminetheneedforoxygenand
evaluatetheeffectivenessofthetherapy.
by Amanuel.O 497/27/2022

50. Complications
Shock
respiratory failure
atelectasis and
pleural effusion
Super infection and etc
by Amanuel.O 507/27/2022

51. II. TUBERCULOSIS (TB)
Introduction:-
TBisaninfectiousdiseasethatprimarilyaffectsthelung
parenchyma
Italsomaybetransmittedtootherpartsofthebody,including
themeninges,kidneys,bones,andlymphnodes
TBiscausedbymycobacteriumtuberculosis,arod-shaped
‘acidfast’bacillus
Occasionally,thediseasecanalsobecausedbymycobacterium
bovisandafricanum
7/27/2022 by Amanuel.O 51

52. Introduction…
IfProperlytreated,tuberculosiscausedbydrug-
susceptiblestrainsiscurableinvirtuallyallcases.
IfUntreated,thediseasemaybefatal
Transmission:airbornespreadofdropletnucleiproduced
bypatientswithinfectiouspulmonarytuberculosis.
52BY: A.O7/27/2022

53. Routes of transmission
.
53
1)Byinhalationofinfecteddropletnuclei.Thisismost
commonMOT.
3000dropletnucleicanbeproducedduringasingle
cough
Dropletnucleiaresosmallthattheypassthedefenses
ofthebronchiand
multiplicationandinfectionbeginintotheterminal
alveoliofthelungs
BY: A.O7/27/2022

54. Routes of transmission…
54
2)ConsumptionofrawmilkcontainingM.bovine
Itismuchlessfrequent
Theriskofinfectionishighwithclose,prolonged,
indoor,exposuretoapersonwithsputumsmear-positive
pulmonaryTB.
BY: A.O7/27/2022

55. Risk Factors
55
Householdcontactwithanewlydiagnosedsmear
positivecase
Agelessthan5yearsandelders
Immunosuppressivetherapy
HIVinfection,Malnutrition,Overcrowding
Poorlivingcondition
Alcoholabuse&druguse
Comorbidcondition(DM,ChronicRenalFailure,Ca).
BY: A.O7/27/2022

56. Pathophysiology
Primaryinfection:occursinpeoplewhohavenothadany
previousexposuretotuberclebacilli.
Infectionbeginswhenpersoninhalesdropletnucleicontaining
tuberclebacillithatreachthealveoli(lungs).
Theyareingestedbyalveolimacrophagesandthemajorityof
bacilliareinhibited.
Asmallnumberofbacillimaymultiplyintracelulary&
releasedwhenmacrophagesdie.
Alocalizedgranulomatousinflammatoryprocessoccursinthe
lung&thisiscalledtheprimary(Ghon)focus.
56BY: A.O7/27/2022

57. Pathophysiology…
FromtheGhonfocus,bacillidrainvialymphatictothe
regionallymphnodes.
TheGhonfocusassociatedwithregionallymphadenopathy
formtheprimaryGhonComplex.
Ifalive,thebacillimayspreadbylymphaticchannelorvia
bloodstreamfromtheprimarycomplextodistanttissueor
organs.
Thenthefuturecoursedependsonthedynamicbalanceb/n
thehostimmunity&thepathogen.
Atthislevelmostofpatientsareasymptomatic.
57BY: A.O7/27/2022

58. Latent TB Infection (LTBI)
TheprocessofLTBIbeginswhenextracellularbacilliare
ingestedbymicrophages&presentedtootherWBCs.
Thistriggerstheimmuneresponseinw/cWBCskillor
encapsulatemostofbacilli,leadingtoformationofa
granuloma.
Atthispoint,LTBImaybedetectedbyusingthetuberculin
skintest(TST)orInterferongammareleaseassay(IGRA).
Itcantake2-8wksafterinitialinfectionforbody’simmune
systemtobeabletoreacttotuberculin&fortheinfectionto
detectedbyTST&IGRA.
58BY: A.O7/27/2022

59. Signs and symptoms…
ThecommonestsymptomsofpulmonaryTbare:
Coughwithorwithoutsputumproduction,
Chestpain,hemoptysisandmilddyspnea
Fever,nightsweats,anorexia,anddecreasedactivity
Someinfantsandyoungchildrenwithbronchialobstructionhave:
localizedwheezingor
decreasedbreathsoundsthatmaybeaccompaniedbytachypnea
or,
rarely,respiratorydistress
59BY: A.O7/27/2022

60. Signs and symptoms…
60
Thesepulmonarysymptomsandsignsareoccasionally
alleviatedbyantibiotics,suggestingbacterialsuper
infection.
SymptomofEPTB
•BoneTB;localizedpain,swelling,muscleweakness,paralyzing
andstiffnessofjoint.
•Intestinal;lossappetite,lossofweight,abdominalpain,diarrhea
andascites.
•TBmeningitis;headache,fever,neckstiffness,andvomiting.
BY: A.O7/27/2022

61. Classification of TB
1.Anatomicalsiteofdisease
2.Bacteriologicalresults(includingdrugresistance)
3.Historyofprevioustreatment
4.HIVstatusofthepatient
61BY: A.O7/27/2022

62. 1. Anatomical site of TB diseases
IngeneralrecommendedRxregimensaresimilar,
irrespectiveofsite.
A.PulmonaryTuberculosis(PTB)
RefertoacaseofTBinvolvingthelungparenchyma.
62BY: A.O7/27/2022

63. 1. Anatomical site of TB diseases…
B. Extra pulmonary tuberculosis(EPTB)
RefertoacaseofTBinvolvingorganotherthanlung
suchas:
Lymphnodes,Pleura,GUT,BonesandJoints,Meninges,
Peritoneum,andPericardium.
Virtuallyallorgansystemsmaybeaffected.
EPTBisseenmorecommonlyinHIV-infectedtodaythan
inthepast.
63BY: A.O7/27/2022

64. 2. Bacteriological classification
Refertothesmearstatusofpulmonarycaseandthe
identificationofMTBbycultureornewermethods.
A. Smear PTB+ If a pt With :
Atleasttwoinitialsputumsmear+veforAFBor
Oneinitialsmear+veforAFBandculture+veor
oneinitialsmear+veforAFBandradiographic
abnormalities
ConsistentwithactiveTBasdeterminedbyaclinician.
64BY: A.O7/27/2022

65. 2. Bacteriological classification …
B.Smear-NegativePTB/PTB-ve
1.AsuggestivesymptomsofTBwithatleast3initial-ve
forAFBandNoresponsetoacourseofbroadspectrum
antibiotic
2.AgainthreesmearAFB–veandRadiologicalabnormality
consistentwithpulmonaryTB.
65BY: A.O7/27/2022

66. 2. Bacteriological classification …
C.ExtrapulmonaryTB(EPTB)
TBinorganotherthanthelung,provenbyoneculture
+vespecimenfromanextra-pulmonarysiteorhisto-
pathologicalevidencefromabiopsyor
TBbasedonstrongclinicalevidencewithactiveEPTB
andthedecisionbyaphysiciantotreatwithafullcourse
ofantiTBtherapy.
66BY: A.O7/27/2022

67. 3. Hx of previous Rx pt registration group
Itisimportanttoidentifypreviouslytreatedpt.B/cthey
arehighriskfordrugresistanceincludingMDR-TB.
Newpatient:AwhoneverhadRxorhavetakenantiTB
forlessthan1month[Newcase(N)].
PreviouslyTreatedpatient:Apatientwhohavereceived
1monthormoreofantiTBdruginthepast&mayhave
+veor–vebacterlogicalandmaybeanydiseasesatan
anatomicalsite.
67BY: A.O7/27/2022

68. 3. Hx of previous Rx pt registration group…
Relapse(R): Rx completed but who report back is now
found to be AFB +ve
Rx after failure(F): pt while on Rx is smear +ve at end
of 5 month.
Return after default (D): a pt record as default from Rx
and return with smear +ve.
Transfer in (T): pt transfer into continue Rx after staring
Rx in to another Rx unit for at least 4 week.
Other (O):Smear –ve PTB who returned after default
,EPTB return after default.
68BY: A.O7/27/2022

69. 4. HIV Status in HIV+ve individuals
Smear+vePTB:
Onesputumsmear+ve&HIV+ve/strongclinicalevidenceofHIV
infection.
Smear-vePTB:
Threeseptumsmear-ve&radiologicalabnormality,or
HIV+ve/strongclinicalevidenceofHIVinfection&Decisionby
cliniciantoRxwithAntiTBor
AptwithAFB–ve&culture+ve.
EPTB:
ThedefinitionisthesameasHIV-veTBcases
69BY: A.O7/27/2022

70. Diagnosis of Tuberculosis
Thekeytothediagnosisoftuberculosisisahighindexof
suspicion.
Diagnosisisnotdifficultwithahigh-riskpatiente.g.,a
Homeless,alcoholicwhopresentswithtypical
symptomsand
Aclassicchestradiographshowingupper-lobe
infiltrateswithcavities.
70BY: A.O7/27/2022

71. Diagnostic Method
A.bacteriologicalmethod
1.Directlightsmearmicroscope/Conventional
microscope.
2.fluorescentmicroscope
-sensitivityby10%.
3.culture
7/27/2022 BY: A.O 71

72. Diagnostic Method…
B. Molecular test for TB Dx
1. Line probe Assay (LPA): show Rifampicin & INH drug
sensitivity & used for smear +ve only to check presence or
absence of a specific mutation.
2. Gene Xpert MTB/RIF :Shows Rifampicin resistance
only.
C. Histo-pathological examination
D. Radiological examination
72BY: A.O7/27/2022

73. Standard TB Case Definition
73
•Tuberculosissuspect
coughof2weeksormoredurationwithSOB,chest
pain,hemoptysis&constitutionalsymptomsisTB
suspect.
•Caseoftuberculosis
AdefinitecaseofTBoroneahealthworkerhas
diagnosedTBandhasdecidedtoRxwithafullcourse
ofTBRx.
•Adefinite/provencaseoftuberculosis
Aptwithtwosputumsmears+ve(onesputum+veis
enoughforHIV+vept)or
culture+veformycobacteriumtuberculosis.
BY: A.O7/27/2022

74. Treatment of TB
TheaimofTBtreatmentis:-
TocuretheTBpatientandrestoreQOLandproductivity.
TopreventdeathfromactiveTBoritslateeffects.
ToPreventrelapseofTB.
Topreventthedevelopmentandtransmissionofdrug
resistance.
TodecreaseTBtransmissiontoothers.
Toreducesthenumberofactivelymultiplyingbacteria.
74BY: A.O7/27/2022

75. Drugs-used For TB
The drugs used for the TB treatment are safe and effective if
properly used:
First line drugs for the treatment of TB in Ethiopia include:
Rifampicin (R)
Ethambutol (E)
Isoniazid (H)
Pyrazinamide (Z)
Streptomycin(S)
75BY: A.O7/27/2022

76. Drugs-used For TB…
The fixed dose combination(FDC) drugs available for
adult and adolescent:
RHZE 150/75/400/275mg
RHZ 150/75/400mg
RH 150/75mg
EH 400/150mg
76BY: A.O7/27/2022

77. Chemotherapy of TB
TBdrugsavailableaslooseform:
Ethambutol400mg
Isoniazid300mg
Streptomycinsulphatevials1gm
NB:streptomycinisadministeredbyinjectionandthe
otherantiTBdrugsaretobetakenorally
Alldrugsshouldbetakentogetherasasingle,daily
dose,preferablyonanemptystomach.
77BY: A.O7/27/2022

78. Phases of medical therapy
.
78
1.Intensivephase:
Fornewcases;aphaseconsistsofcombinationof
fourdrugsforthefirst8weeksfollowedbytwo
drugs,tobetakenfor4months
Forre-treatmentcases:withcombinationoffivedrugs
forthefirst8weeksfollowedbyfourdrugsforthe
nextfourweeks.
BY: A.O7/27/2022

79. Phases of medical therapy …
79
2.Continuationphase
Thisphaseimmediatelyfollowstheintensivephaseand
isimportanttoensurecureorcompletionoftreatment.
Necessarytoavoidrelapseaftercompletionoftreatment.
Fornewcases:treatmentwithacombinationoftwo
drugs,tobetakenfor4monthsand
Forre-treatmentcases:treatmentwithacombination
offourdrugsfor4monthsorthreedrugsfor5months.
BY: A.O7/27/2022

80. TB patient categories and how to select the
correct treatment regimen
80
BeforeputtingpatientsonantiTBdrugs:
DeterminethetypeofTB:PTB+,PTB-andEPTB
Selectbasedonthethreestandardtreatment
regimen:
i.Newpatientregimen
ii.Previouslytreatedpatientregimen
iii.MDR-TBregimen
BY: A.O7/27/2022

81. Conti…
.
81
TB patient type Recommendedregimen
New Treatmentas new
2RHZE/4RH
Previously
treated
Treatmentafter failure Treatas retreatment
2RHZES/RHZE/5RHE
Treatment after defaulter or relapse
after one course of Rx
Treatas retreatment
2RHZES/RHZE/5RHE
Transfer in Continue same Rxregimen
Others
Previously successfullyRx pt coming
with PTB-ve or EPTB
Treatmentas new
2RHZE/4RH
Defaulted pt coming with smear –ve
TB ,EPTB,or previously Rxedpt with
unknown RX outcome
Treatas retreatment
2RHZES/RHZE/5RHE
7/27/2022

82. Recommended Dose of First-Line Anti-TB
Drugs for Adults
Drugs Recommended dose
Dose and range
(mg/kg Bwt)
Maximum
(mg)
Isoniazid 5(4-6) 300
Rifampicin 10(8-12) 600
Pyrazinamide 25(20-30) 2,000
Ethambutol 15(15-20) 1600
Streptomycin 15(12-18) 1000
82BY: A.O7/27/2022

83. Anti TB Drugs Dosage of New TB cases
83
Patient’s Weight in
Kgs
Treatment regimen and dose
Intensive phase
2RHZE
Continuation phase
4RH
20-29 1½ 1½
30-39 2 2
40-54 3 3
≥55 4 4
BY: A.O7/27/2022

84. Anti TB Drugs dosage for previously treated cases
84
Patients'
weights in
kgs
Treatment regimen and dose
Intensive phase
2SRHZE/1RHZE
Continuation phase
5(RH)E
s* RHZE RH E
20-29 ½(0.5g)1½ 1½ 1½
30-39 ½(0.5g)2 2 1½
40-54 ¾(0.75g)3 3 2
≥55 1g 4 4 3
BY: A.O7/27/2022

85. Standard code for TB treatment regimen
ThereisastandardcodeforwritingoutTBtreatment
regimens.
Eachantituberculosisdrughasanabbreviation.
aM(X)DR-TBregimenconsistsoftwophases:
1)Thefirstphaseistheperiodinwhichtheinjectable
agentisusedandthesecondisafterithasbeenstopped.
ForinstanceinEthiopiastandardtreatmentfor
MDR-TB is 6E-Z-KM(AM)-LFX-Eto-Cs/12/E-Z-Lfx-Eto-Cs
85BY: A.O7/27/2022

86. 86
Grouping Drugs
Group 1:-first line oral agents Isoniazid (H) ; Rifampicin (R); Ethambutol
(E); pyrazinamide(Z); Rifabutin (Rfb)
n
Group 2:-Inject able agents Kanamycin (Km); Amikacin (Am);
Capreomycine (Cm); Streptomycin (S)
Group 3:-Fluoroquinolones Moxifloxacilin (Mfx); Levofloxacilin (Lfx)
Group 4:-Oral bacteriostatic second line
agents
Ethionamide (Eto); Cycloserine (Cs); para-
aminosalicylic acid (PAS)
Group 5:-Agents with unclear role in DR-
TB treatment (not recommended by the
WHO for routine use in DR-TB patients)
Clofazimine (Cfz); Linezolid (Lzd);
Amoxicillin /clavulanate (Amx/Clv);
Thioacetazone (Thz); Imipenem/ciliastain
(Imp/Cln); High-doseisoniazid(High-dose
H)
b
;clarithromycin (Clr)
BY: A.O7/27/2022

87. Standard MDR-TB Regimen
87
MDR-TBpatientssusceptibletobothKanamycinand
Quinolone
Regimen:E-Z-KM(AM)-Lfx-Eto-Cs
MDR-TBpatientssusceptibletobothKanamycin,but
resistanttoQuinolone
Regimen:E-Z-KM(AM)-Mfx-Eto-Cs-PAS
MDR-TBpatientssusceptibletoQuinolone,but
resistanttoKanamycin
Regimen:E-Z-Cm-Lfx-Eto-Cs
XDR-TB cases (I.e. MDR-TB and resistance to
Quinolone
Regimen: E-Z-Cm -Mfx-Eto-Cs-PAS
BY: A.O7/27/2022

88. Nursing intervention
88
Promote air way clearance
Increasefluidintakepromotesystemicrehydration.
PtunderstandthatTBiscommunicablediseasesand
takingthedragregularforprescribedandduration.
Instruct about important hygiene
Mouth care
Covering mouth and nose when cough and sneezing
Proper disposal of tissue property
Hand wash
Promote adduct nutrition
BY: A.O7/27/2022

89. Prevention
89
Generalpreventivemeasures(e.g.stayingathome,
avoidingvisitors,coveringmouthduringcoughswith
hand,openingwindow.
Vaccination:
TheBCGvaccine,madefromanattenuatedstrainofM.
bovisisgivento>80%oftheworld'schildren,primarily
inhigh-burdencountries.
BY: A.O7/27/2022

90. PELURALDISORDERS
by Amanuel.O 907/27/2022

91. Introduction to Pleural disorder
Pleuraldisorderisadisorderthatinvolves:
Themembranescoveringthelungs(visceralpleura)
Thesurfaceofthechestwall(parietalpleura)or
Thedisordersaffectingthepleuralspace.
7/27/2022 by Amanuel.O 91

92. 7/27/2022 by Amanuel.O 92

93. 1. Pleurisy
Pleurisy(pleuritis)referstoinflammationofbothparietal
andviscerallayersofthepleurae.
Pathophysiology-Pleurisymaydevelop:
•Inpneumonia,TB,orcollagendisease
•Aftertraumatothechest,
•Pulmonaryinfarction,orpulmonaryembolism;
•Primaryandmetastaticcancer;and
•Afterthoracotomy.
by Amanuel.O 937/27/2022

94. Pathophysiology…
Theparietalpleurahasnerveendings;thevisceralpleura
doesnot.
Whentheinflamedpleuralmembranesrubtogether
duringinspiration,theresultissevere,sharp,knifelike
pain.
by Amanuel.O 947/27/2022

95. Clinical Manifestations
Takingadeepbreath,coughing,orsneezingworsensthe
pain,i.eakeycharacteristicofpleuriticpain.
Pleuriticpainisrestrictedindistribution;usuallyoccurs
onlyononeside.
Painmaybelocalizedorradiatetotheshoulderor
abdomen.
Latter,aspleuralfluiddevelops,thepaindecreases.
by Amanuel.O 957/27/2022

96. Assessment and Diagnostic Findings
Pleuralfrictionrubsoundintheearlyperiod,butit
disappearslateraslittlefluidaccumulates.
Chestx-rays
Sputumexaminations,
Pleuralfluidforexaminationviathoracentesis
Pleuralbiopsy-lesscommonlydone.
by Amanuel.O 967/27/2022

97. Management
Theobjectivesare:
Totreattheunderlyingconditioncausingthepleurisy
(pneumonia,infection)
Torelievethepainand
Tomonitorsignsandsymptomsofpleuraleffusionsuch
as:-Shortnessofbreath.
Assumptionofapositionthatdecreasespain,and
decreasedchestwallexcursion.
by Amanuel.O 977/27/2022

98. Medical Management
NSAIDs:Indomethacinmayprovidepainreliefduring
deepbreathingandcoughing.
Topicalheatorcoldapplicationsmayprovide
symptomaticrelief.
Intercostals'nerveblockmayberequiredIfthepainis
severe.
by Amanuel.O 987/27/2022

99. Nursing Management
Turningthepatientfrequentlyontotheaffectedsideto
splintthechestwallandreducethestretchingofpleurae.
Toenhancecomfortand
Toreducepainduringinspiration.
Teachabouttheusethehandsorapillowtosplinttherib
cagewhilecoughing.
by Amanuel.O 997/27/2022

100. 2. Pleural effusion
Pleuraleffusionisacollectionoffluidinthepleuralspace,
inresponsetoinjury,inflammationorboth.
Itmayrepresentsalocalresponsetodiseaseor
manifestationofasystemicillness.
Normally,pleuralspacecontains(5to15ml)ofpleural
fluid,whichactsasalubricantthatallowsthepleural
surfacestomovewithoutfriction.
by Amanuel.O 1007/27/2022

101. Causes of plural effusion
Pleural effusion may be a complicationof:
Heart failure,
TB,
Pneumonia,
Viral pulmonary infection
Nephrotic syndrome,
Connective tissue disease,
Pulmonary embolism, and
Bronchogenic carcinoma
by Amanuel.O 1017/27/2022

102. Pathophysiology
Incertaindisorders,fluidmayaccumulateinthepleural
spacetoapointwhereitbecomesclinicallyevident.
Thisalwayshaspathologicsignificance.
Theeffusioncanbe:-
Clearfluid
Bloody
Transudates
Exudates(maybepurulent)
by Amanuel.O 1027/27/2022

103. Pathophysiology…
Atransudateoccurswhentheformationandreabsorption
ofpleuralfluidarealtered.
Transudativeeffusionimpliesthatthepleuralmembranes
arenotdiseased.
Themostcommoncauseofatransudativeeffusionis
heartfailure.
Anexudateusuallyresultsfrominflammationby
bacterialproducts/tumorsinvolvingthepleuralsurfaces.
by Amanuel.O 1037/27/2022

104. Clinical Manifestations
IfeffusionisfromPneumonia:
fever,chills,andpleuriticchestpain,
Malignanteffusion:
dyspneaandcoughing
Alargepleuraleffusion
shortnessofbreath
Whenasmalltomoderatepleuraleffusionispresent,
minimalorabsenceofdyspnea.
by Amanuel.O 1047/27/2022

105. Assessment and Diagnostic Findings
Physicalexamination
Decreasedorabsentbreathsoundsinauscultation
Decreasedfremitus,and
Dull,flatsoundwhenpercussed
Acuterespiratorydistress-ifextremepleuraleffusion.
Trachealdeviationawayfromtheaffectedside
Chestx-ray
ChestCTscan
by Amanuel.O 1057/27/2022

106. Assessment and Diagnostic Findings…
Thoracentesisconfirmthepresenceoffluid
Pleuralfluidanalysis:-bacterialculture,Gramstain,
AFBstain,RBCandWBCcounts,
Chemistrystudies(glucose,protein),
Cytologicalanalysisformalignantcells,and
PH
Pleuralbiopsy
by Amanuel.O 1067/27/2022

107. Management
Theobjectivesare:
Totreattheunderlyingcause(e.g,heartfailure,
pneumonia,lungcancer,cirrhosis)
Topreventre-accumulationoffluid,and
Torelievediscomfort,dyspnea,andrespiratory
compromise.
Ifthepleuralfluidisanexudate,moreextensive
diagnosticproceduresareperformedtodeterminethe
cause.
by Amanuel.O 1077/27/2022

108. Management…
Thoracentesisisperformed:
Toremovefluid,andtorelievedyspneaandrespiratory
compromise.
Toobtainaspecimenforanalysis,
Dependingonthesizeofthepleuraleffusion,thepatient
maybetreatedby:
Removingthefluidbythoracentesis
Insertingachesttubeconnectedtoawater-sealdrainagesystemor
Suctioningtoremovefluidandre-expandthelung.
by Amanuel.O 1087/27/2022

109. Management
Repeatedthoracentesisresultin:
pain,
depletionofproteinandelectrolytes,and
pneumothorax.
Iftheunderlyingcauseisamalignancy,however,the
effusiontendstorecurwithinafewdaysorweeks.
Thereforesurgical:-
pleurectomy
Pleurodesismaybeperformed.
by Amanuel.O 1097/27/2022

110. Management…
Pleurodesisisamedicalprocedureinwhichthepleural
spaceisartificiallyobliterated.
Itinvolvestheadhesionofthetwopleuraeusing
chemicallyirritatingagents(e.g.,bleomycinortalc)are
instilledinthepleuralspace.
by Amanuel.O 1107/27/2022

111. Nursing Management
Preparingandpositioningforthoracentesisandoffers
supportthroughouttheprocedure.
Painmanagementisapriority,andinassumingpositions
thataretheleastpainful.
Frequentturningandambulationfacilitatedrainage.
Analgesicsasprescribedandasneeded.
Careofchesttube.
by Amanuel.O 1117/27/2022

112. 3. Empyema
Anempyemareferstocollectionofpusinsidethe
pleuralspace(deadcellsandinfectedfluid).
Causes;-
Penetratingchesttrauma,
Hematogenousinfectionofthepleuralspace,
Non-bacterialinfections,or
Iatrogeniccauses(afterthoracicsurgeryorthoracentesis)
by Amanuel.O 1127/27/2022

113. Causes….
Complicationsofbacterialpneumoniaorlungabscessare
thetwocommonestwaysthatbacteriagetintopleural
space.
Inorderforempyematooccur:
Bacteria,
Fungi,or
Chemicalsmustgetintothepleuralspaceandcause
inflammation,leadingtotheproductionofpus.
Bacteria can also get into the pleural space from medical
instruments that are used to do tests or operate the chest.
by Amanuel.O 1137/27/2022

114. Risk for Empyema
Thegreatestriskfactorsforempyemaare:
Pneumonia,
Medicalproceduresdoneinthelungandsurroundingstructures,
Chesttraumaand
Pre-existinglungdiseases(COPDandlungcancer).
Peoplewhohavepre-existinglungdiseaseswhodevelop
empyemaaremorelikelytodiethanthosewhodon’t.
by Amanuel.O 1147/27/2022

115. Clinical Manifestations
Fever,nightsweats,pleuralpain,cough,dyspnea.
SOB-E.g.Pneumonia
Fatigue,lossofappetite,andweightloss
Empyemaassociatedwithsepsisisthemostsevere.
Highfever,chills,tachypnea,tachycardia,andlowB/P.
Sepsisislife-threateningandrequiresemergencytreatment.
by Amanuel.O 1157/27/2022

116. Diagnostic Findings
Blood cultures
WBCs count
X-ray (pneumonia, lung abscess)
CT scan of the chest
Thoracentesis for microscopic examination
Thoracic ultrasound
Chest auscultation: Decreased or absent breath sounds &
Dullness on chest percussion & decreased fremitus.
by Amanuel.O 1167/27/2022

117. Management
Theobjectivesoftreatmentaretodrainthepleuralcavity
andtoachievefullexpansionofthelung.
Drainingthefluid
largedosesofappropriateantibioticsbasedonthecausative
organism.
Cephalosporins,Metronidazole,and
Penicillins with Beta lactamase (Ampicillin/
sulbactam).
Sterilizationofempyemarequires4to6wksofantibiotics.
by Amanuel.O 1177/27/2022

118. Management…
Drainageofthepleuralfluidisaccomplishedbytheff:
Needleaspiration(Thoracentesis)or
Tubethoracostomy(Chestdrainageusingalarge-
diameterintercostaltubeattachedtowater-seal
drainage.
by Amanuel.O 1187/27/2022

119. Nursing Management
Deepbreathingexercisestorestorenormalrespiratorion
Providecare(e.g,needleaspiration,closedchestdrainage).
Whenapatientisdischargedtohomewithadrainagetube
orsysteminplace:
instructsthepatientandfamilyoncareofthedrainage
systemanddrainsite,measurementand
observationofdrainage,signsandsymptomsofinfection
by Amanuel.O 1197/27/2022

120. CHRONIC OBSTRUCTIVE PULMONARY
DISEASE(COPD)
COPDisadiseasestatecharacterizedbyairflowlimitation
thatisnotfullyreversible.
COPDisthediseasesthatcauseairflowobstruction(e.g,
emphysema,chronicbronchitis).
COPDcancoexistwithasthma&bothdiseaseshavethe
samemajorsymptoms.
Otherdiseases(bronchiectasis,andasthma)arenow
classifiedaschronicpulmonarydisorders.
by Amanuel.O 1207/27/2022

121. Pathophysiology
InCOPD,theairflowlimitationisassociatedwithan
abnormalinflammatoryresponseofthelungstonoxious
particlesorgases.
Theinflammatoryresponseoccursthroughouttheairways,
parenchyma,andpulmonaryvasculature.
Becauseofthechronicinflammationandthebody’s
attemptstorepairit,narrowingoccursinthesmall
peripheralairways.
by Amanuel.O 1217/27/2022

122. Pathophysiology…
Overtime,thisinjuryandrepairprocesscausesscartissue
formationandnarrowingoftheairwaylumen.
Airflowobstructionmayalsobeduetoparenchymal
destructionasseenwithemphysema,adiseaseofthe
alveoliorgasexchangeunits.
by Amanuel.O 1227/27/2022

123. Pathophysiology…
EarlyinthecourseofCOPD,theinflammatoryresponse
causespulmonaryvasculature(thickeningofvesselwall).
Thesechangesmayresultfrom:
Exposuretocigarettesmoke,
Useoftobaccoproducts,or
Releaseofinflammatorymediators
by Amanuel.O 1237/27/2022

124. Chronic Bronchitis
Chronicbronchitis,adiseaseoftheairways,isdefinedas
thepresenceofcoughandsputumproductionforatleast3
monthsineachoftwoconsecutiveyears.
Thecausesare:
Cigarettesmokingor
Otherenvironmentalpollutantsirritatetheairways.
Thisresultsininflammation&hypersecretionofmucus.
by Amanuel.O 1247/27/2022

125. Pathophysiology
Thisconstantirritationcausesthemucus-secretingglands
andgobletcellstoincreaseinnumber.
Ciliaryfunctionisreduced,andmoremucusisproduced.
Thebronchialwallsbecomethickened,thelumennarrows,
andmucusmayplugtheairway.
Alveoliadjacenttothebronchiolesmaybecomedamaged
andfibrosed,
Resultinginalteredfunctionofthealveolarmacrophages
thatplayroleindestroyingforeignparticles(bacteria).
by Amanuel.O 1257/27/2022

126. Pathophysiology…
Asaresult,thepatientbecomesmoresusceptibleto
respiratoryinfection.
Awiderangeofviral,andbacterialinfectionscanproduce
acuteepisodesofbronchitis.
Exacerbationsofchronicbronchitisaremostlikelyto
occurduringthewinter.
by Amanuel.O 1267/27/2022

127. Risk Factors for COPD
Exposure to tobacco smoke accounts 80% to 90% of
COPD cases
Passive smoking
Occupational exposure
Deficiency of alpha1-antitrypsin.
by Amanuel.O 1277/27/2022

128. Clinical Manifestations
COPDischaracterizedbythreeprimarysymptoms:
Cough,
Sputumproduction,and
Dyspneaonexertionissevereandofteninterfereswiththe
patient'sactivities.
Chroniccoughandsputumproductionoftenprecedethe
developmentofairflowlimitationbymanyyears.
Weightlossiscommon,becausedyspneainterfereswith
eatingandtheworkofbreathingisenergy-depleting.
by Amanuel.O 1287/27/2022

129. Clinical Manifestations
Oftenpatientscannotparticipateinevenmildexercisebecauseof
dyspnea
AsCOPDprogresses,dyspneaoccursevenatrest.
Astheworkofbreathingincreasesovertime,theaccessorymuscles
arerecruitedinanefforttobreathe.
PatientswithCOPDareatriskfor:
respiratoryinsufficiency,
respiratoryinfections,and
increasetheriskofrespiratoryfailure.
by Amanuel.O 1297/27/2022

130. Diagnostic Findings
Exposuretoriskfactors
Pastmedicalhistory:asthma,allergy,sinusitis,nasalpolyps,
historyofRTIs.
FamilyhistoryofCOPD
Patternofsymptomdevelopment
Historyofexacerbationsor
HistoryofprevioushospitalizationsforRTIs.
PresenceofCo-morbidities
Barrelchest
by Amanuel.O 1307/27/2022

131. Medical Management
Smokingcessation:isthesinglemosteffective
interventiontopreventCOPDorslowitsprogression.
Bronchodilators:Relievebronchospasmandincrease
oxygendistributionthroughoutthelungsandimproving
alveolarventilation.
Corticosteroids:Inhaledandsystemicmaybeused
Oxygentherapy:preventacutedyspnea.
by Amanuel.O 1317/27/2022

132. Bronchodilators
Beta-Adrenergic Agonist Agents
Salbutamol
Salmeterol
Terbutaline
Anticholinergic Agents
Ipratropium bromide
Oxitropium bromide
Methylxanthines
Aminophylline
Theophylline
by Amanuel.O 1327/27/2022

133. Emphysema
Emphysemaisadestructivediseaseofthelunginwhich
thealveoli(smallsacs)aredestroyed.
Emphysemaisapathologictermthatdescribesan
abnormaldistentionoftheairspaceswithdestructionof
thewallsofthealveoli.
Inemphysema,impairedgasexchangeresultsfrom
destructionofthewallsofoverdistendedalveoli.
by Amanuel.O 1337/27/2022

134. Chronic Pulmonary Disorders
Bronchiectasisisachronic,irreversibledilationofthe
bronchiandbronchioles.
Itmaybecausedbyavarietyofconditions:
Airwayobstruction
Diffuseairwayinjury
Pulmonaryinfectionsandobstructionofthebronchus
Geneticdisorderssuchascysticfibrosis
Abnormalhostdefense(e.g,ciliarydyskinesiaor
humoralimmunodeficiency)
Idiopathiccauses
by Amanuel.O 1347/27/2022

135. Bronchiectasis….
Apersonmaybepredisposedtobronchiectasisasaresultof
recurrentrespiratoryinfectionsinearlychildhood:
Measles,
influenza,
tuberculosis,and
immunodeficiencydisorders.
Bronchiectasisisusuallylocalized,affectingasegmentor
lobeofalung,mostfrequentlythelowerlobes.
by Amanuel.O 1357/27/2022

136. Bronchiectasis….
Cigarettesmokingimpairsbronchialdrainageby:
Paralyzingciliaryaction,
Hyperplasiaofthemucousglands,
Increasingbronchialsecretions,and
Causinginflammationofthemucousmembranes
by Amanuel.O 1367/27/2022

137. by Amanuel.O 1377/27/2022

138. Pathophysiology
Theinflammatoryprocessassociatedwithpulmonary
infectionsdamagesthebronchialwallanditssupporting
structure
Thisresultsinthicksputumthatultimatelyobstructsthe
bronchi.
Thewallsbecomepermanentlydistendedanddistorted,
impairingmucociliaryclearance.
Theinflammationandinfectionextendtothe
peribronchialtissues.
by Amanuel.O 1387/27/2022

139. Pathophysiology
Theretentionofsecretionsandsubsequentobstruction
ultimatelycausethealveolidistaltotheobstructionto
collapse(atelectasis).
Inflammatoryscarringorfibrosisreplacesfunctioning
lungtissue.
Thereisventilation–perfusionimbalanceandhypoxemia.
by Amanuel.O 1397/27/2022

140. Clinical Manifestations
Chroniccough&purulentsputum
Hemoptysis
Clubbingofthefingers=>b/cofrespiratoryinsufficiency.
Repeatedepisodesofpulmonaryinfection
Evenwithmoderntreatmentapproaches,themeanageat
deathis~55years.
by Amanuel.O 1407/27/2022

141. Assessment and Diagnostic Findings
Bronchiectasisisnotreadilydiagnosedbecausethe
symptomscanmimicwithchronicbronchitis.
AdefinitesignisprolongedHxofproductivecough,
withsputumconsistentlynegativeforAFB.
CTscan:Demonstratesbronchialdilation.
by Amanuel.O 1417/27/2022

142. Medical Management
Treatmentobjectivesare:
Topromotebronchialdrainage
Toclearexcessivesecretionsfromtheaffectedportion
ofthelungsand
Topreventorcontrolinfection.
by Amanuel.O 1427/27/2022

143. Medical Management
Chestphysiotherapy-percussionandposturaldrainage,is
importantinsecretionmanagement.
Smokingcessation
Antimicrobialtherapy:basedontheresultsofsputum
culture&sensitivity.
Surgicalintervention:Diseasedtissueisremoved.
asegmentofalobe(segmentalresection),
alobe(lobectomy),or
rarelyanentirelung(pneumonectomy).
by Amanuel.O 1437/27/2022

144. Asthma
Asthmaisachronicinflammatorydiseaseoftheairways
thatcausesairwayhyperresponsiveness,mucosaledema,
andmucusproduction.
Thisinflammationultimatelyleadstorecurrentepisodes
ofasthmasymptoms:
Cough
Chesttightness
Wheezingand
Dyspnea
by Amanuel.O 1447/27/2022

145. Asthma…
Statusasthmaticusissevereandpersistentasthmathat
doesnotrespondtoconventionaltherapyandis
consideredlife-threatening.
Theattackscanlastlongerthan24hours.
by Amanuel.O 1457/27/2022

146. Asthma
Asthmadiffersfromtheotherobstructivelungdiseasesin
thatitislargelyreversible,eitherspontaneouslyorwith
treatment.
Patientswithasthmamayexperiencesymptom-free
periodsalternatingwithacuteexacerbations.
Asthmacanoccuratanyage.
by Amanuel.O 1467/27/2022

147. Asthma…
Chronicexposuretoairwayirritants,orallergensalso
increasestheriskfordevelopingasthma.
Allergyisthestrongestpredisposingfactorforasthma.
Commonallergenscanbeseasonal(e.g,grass,tree,and
weedpollens)orperennial,mold,dust,oranimaldander.
by Amanuel.O 1477/27/2022

148. Common triggers
Commontriggersofsymptomsandexacerbationsof
Asthma:
Airpollutants,cold,heat,weatherchanges,strong
odorsorperfumes,smoke
Exercise
Stressoremotionalupsets,
Medications,and
Gastroesophagealreflux
RTIs:viralRTI,sinusitisetc.
by Amanuel.O 1487/27/2022

149. Pathophysiology
Asthmaisareversibleanddiffuseairwayinflammation.
Inflammationcauses:
Mucosaledema,
Increasedmucusproductionwhichmayentirely
plugtothebronchi&
Furtherlydiminishesairwaysizeordiameter.
Thisleadstoalveolihyperinflation
by Amanuel.O 1497/27/2022

150. Pathophysiology…
Thecellsthatplayakeyroleintheinflammationof
asthmaare:
Mastcells,
Neutrophil,
Eosinophils,andlymphocytes
Mastcellsisactivated,releasedseveralchemicals
mediators(Histamine,Bradykinin,Prostaglandins,and
Leukotrienes).
by Amanuel.O 1507/27/2022

151. Pathophysiology…
Thesechemicalsperpetuatetheinflammatoryresponse,
Vasodilatation–occursaftertransientvasoconstriction
(lastingonlyforseconds),
Results in locally increased blood flow
Fluidleakfromthevasculature,
AttractionofWBCstothearea,and
Bronchoconstriction.
by Amanuel.O 1517/27/2022

152. Pathophysiology…
Furtherstimulationofalphaandbeta
2-adrenergic
receptorsofthesympatheticNSarelocatedinthebronchi.
Whenthealphaadrenergicreceptorsarestimulated,
bronchoconstrictionoccurs.
whenthebeta
2-adrenergicreceptorsarestimulated,
bronchodilationoccurs.
by Amanuel.O 1527/27/2022

153. Pathophysiology…
Thebalancebetweenalphaandbeta
2receptorsiscontrolled
primarilybycyclicadenosinemonophosphate(cAMP).
Alpha-adrenergicreceptorstimulationresultsinadecreasein
cAMP,whichleadstoanincreaseofchemicalmediatorsreleased
bythemastcellsandbronchoconstriction.
Beta2-receptorstimulationresultsinincreasedlevelsofcAMP,
whichinhibitsthereleaseofchemicalmediatorsandcauses
bronchodilation.
by Amanuel.O 1537/27/2022

154. by Amanuel.O 1547/27/2022

155. Clinical manifestations
Anasthmaexacerbationmaybeginabruptly
Thethreemostcommonsymptomsofasthmaare
Cough,
Dyspnea,and
Wheezing
Asthmaattacksoftenoccuratnightorearlyinthe
morning.
by Amanuel.O 1557/27/2022

156. Clinical manifestations…
Generalizedchesttightness
Expirationrequireseffortandbecomesprolonged
Astheexacerbationprogresses,diaphoresis,tachycardia,
andawidenedpulsepressurealongwithhypoxemiaand
centralcyanosis(alatesign).
Thehypoxemiais2
0
toaventilation–perfusionmismatch
andreadilyrespondstosupplementaloxygenation.
by Amanuel.O 1567/27/2022

157. Clinical manifestations….
Symptomsofexercise-inducedasthmainclude:
Maximalsymptomsduringexercise,
Absenceofnocturnalsymptoms,and
Sometimesonlyasignofa“choking”sensationduring
exercise.
by Amanuel.O 1577/27/2022

158. Diagnostic findings
ApositivefamilyHx,
Occupationalhistory
Environmental factors:
seasonal changes,
high pollen counts, mold,
Climate changes (particularly cold air), and
Air pollution are primarily associated with asthma.
by Amanuel.O 1587/27/2022

159. Diagnostic findings…
Occupation-relatedchemicalsandcompounds:
metalsalts,woodandvegetabledust,medications(e.g,
ASA,Antibiotics,Piperazine,Cimetidine),
Industrialchemicalsandplastics,(e.g,laundry
detergents),
Animalandinsectdusts,secretions.
by Amanuel.O 1597/27/2022

160. Diagnostic findings…
Sputum and blood tests may disclose elevated levels of
eosinophils.
Serum levels of IgEmay be elevated if allergy is present.
Arterial blood gas analysis and Pulse oximetry reveal
hypoxemia during acute attacks
by Amanuel.O 1607/27/2022

161. MEDICAL MANAGEMENT
GoalsofAsthmaTreatment
Preventchronicandtroublesomesymptoms
Maintainnear-normalpulmonaryfunction
Maintainnormalactivitylevels(exerciseandother
physicalactivity)
Preventrecurrentexacerbationsofasthmaandminimize
theneedforemergencyOPDvisitsorhospitalizations
by Amanuel.O 1617/27/2022

162. MEDICAL MANAGEMENT
Long-Acting Medications:Corticosteroids:
Beclomethasone
Prednisone
Mast cell stabilizers:
cromolyn sodium (Intal),
Nedocromil sodium (Tilade)
Long-acting beta2-adrenergic agents
Salmeterol , formoterol fumarate
Xanthine derivatives: aminophylline, theophylline
Quick-Relief Medications: Short-acting
beta2-adrenergic agents:
Albuterol (Proventil), levalbuterol, pirbuterol , bitolterol.
by Amanuel.O 1627/27/2022

163. Complication
Status asthmatics
Respiratory failure
Pneumonia
Atelectasis.
Hypoxemia
by Amanuel.O 1637/27/2022

164. Nursing management
Monitoring the severity of symptoms, breath sounds, peak
flow , pulse oximetry, and vital signs.
Obtain a history of allergic reactions to medications before
administering medications.
Administer medications as prescribed and monitor the
patient’s responses to those medications
Administer fluids if the patient is dehydrated.
by Amanuel.O 1647/27/2022