Melkie_final_revised_Respiratory_for_comprehensive_nursing_2016.pptx

Disorder of Respiratory System Unit II by MA

Learning objectives Review of respiratory system Assessment of patient with respiratory disorder upper respiratory tract disorders Lower respiratory tract disorders Nursing management of patient with respiratory disorders by MA

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Anatomy and Physiologic Overview The respiratory system is divided into the upper respiratory tract and lower respiratory tract The upper tract consists of nose, sinuses and nasal passages, pharynx, tonsils and adenoids, larynx, and trachea. Its function is warms and filters inspired air. by MA

Nose Is composed of an external and internal portion. External portion protrudes from the face and is supported by the nasal bones and cartilage. anterior nares ( nostrils) are the external openings Internal portion is a hollow cavity separated by a narrow vertical divider called the septum. by MA

Cont.. The nose serves as a passageway for air to pass to and from the lungs. It filters impurities and humidifie s and warms the air as it is inhaled. It is responsible for olfaction (smell) because the olfactory receptors are located in the nasal mucosa. This function diminishes with age. by MA

Paranasal Sinuses Four pairs of bony cavities that are lined with nasal mucosa and ciliated. The sinuses are named by their location: frontal, ethmoidal, sphenoidal, and maxillary. These air spaces are connected by a series of ducts that drain into the nasal cavity . A prominent function of the sinuses is to serve as a resonating chamber in speech. The sinuses are a common site of infection. by MA

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Pharynx The pharynx is a passageway from the back of the mouth and nose to the upper part of the esophagus and into the voice box, or larynx. It acts like a station where the food tube and the air tube meet. It is divided into three sections: The nasopharynx The oropharynx The laryngopharynx . The function of the pharynx is to provide a passage way for both the respiratory and digestive tracts. by MA

Tonsils, and Adenoids The adenoids, or pharyngeal tonsils, are located in the roof of the nasopharynx. The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes. The tonsils act as a filter to protect the body from bacterial invasion via the oral cavity and also to produce white blood cells by MA

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Types of tonsil by MA

Larynx Larynx (Voice organ) is a cartilaginous epithelium-lined structure that connects the pharynx and the trachea. Epiglottis-a valve flap of cartilag e that covers the opening to the larynx during swallowing Glottis-the opening between the vocal cords in the larynx Thyroid cartilage-the largest of the cartilage structures; part of it forms th e Adam’s apple by MA

Cont.. Cricoid cartilag e -the only complete cartilaginous ring in the larynx (located below the thyroid cartilage ) Arytenoid cartilages -used in vocal cord movement with the thyroid cartilage Vocal cords -ligaments controlled by muscular movements that produce sounds; located in the lumen of the larynx The major function of the larynx is vocalization. It also protects the lower airway from foreign substances and facilitates coughing. by MA

Trachea Windpipe, is composed of smooth muscle with C-shaped rings of cartilage. Cartilaginous rings are incomplete on the posterior surface and give firmness to the wall of the trachea, preventing it from collapsing. serves as the passage between the larynx and the bronchi.

LOWER RESPIRATORY TRACT The lower respiratory tract consists of the bronchi, bronchioles, lungs, and alveoli. Accessory structures include the diaphragm, rib cage, sternum, spine, muscles, and blood vessels. Structures needed for gas exchange. by MA

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Lungs The lungs are paired elastic structures enclosed in the thoracic cage. The inspiratory phase of respiration normally requires energy; the expiratory phase is normally passive. In respiratory diseases, such as chronic obstructive pulmonary disease (COPD), expiration requires energy. anteriorly the apex of each lung raises about 2-4 cm the base crosses the sixth rib at mid-clavicle line and eighth rib at the mid axillary line posteriorly by MA

Cont.. PLEURA the serous membrane investing the lungs (visceral p.) and lining the walls of the thoracic cavity (parietal) The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate. The mediastinum is in the middle of the thorax, between the pleural sacs that contain the two lungs. by MA

LOBES The left lung consists of an upper and lower lobe, whereas the right lung has an upper, middle, and lower lobe. BRONCHI AND BRONCHIOLES First are the lobar bronchi (three in the right lung and two in the left lung). Lobar bronchi divide into segmental bronchi (10 on the right and 8 on the left). Segmental bronchi then divide into subsegmental bronchi. The subsegmental bronchi then branch into bronchioles, which have no cartilage in their walls. by MA

The bronchioles then branch into terminal bronchioles, which do not have mucous glands or cilia. Terminal bronchioles then become respiratory bronchioles, which are considered to be the transitional passageways between the conducting airways and the gas exchange airways. Up to this point, the conducting airways contain about 150 mL of air in the tracheobronchial tree that does not participate in gas exchange. ALVEOLI The lung is made up of about 300 million alveoli. Oxygen and carbon dioxide exchange takes place in the alveoli. by MA

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Function of Respiratory system Oxygen transport (o 2 is supplied to, and carbon dioxide is removed from. Respiratio n is whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body Ventilation (Movement of air in and out of the airways) Perfusion is the filling of the pulmonary capillaries with blood. by MA

Cont.. Ventilation is the flow of gas in and out of the lungs, and perfusion is the filling of the pulmonary capillaries with blood . Adequate gas exchange depends on an adequate ventilation–perfusion by MA

Gas Exchange Oxygen is supplied to the circulating blood Carbon dioxide is removed from circulating blood O 2 & Co 2 exchange takes place in the alveoli Alveoli are in close contact with capillaries The walls of alveoli permit easy exchange of O 2 & Co 2 The movement of O 2 & Co 2 occurs by diffusion

Gases diffuse from areas of higher pressure to areas of lower pressure Oxygen concentration is higher in the alveoli Carbon dioxide concentration is higher in the blood Oxygen diffuses from the alveoli to the blood Carbon dioxide diffuses from the blood into the alveoli

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Neurologic Control of Ventilation Several mechanisms control ventilation. The respiratory centers in the medulla oblongata and pons control rate and depth. Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid . They convey a message to the lungs to change the depth and rate of ventilation . Peripheral chemoreceptors in the aortic arch and carotid arteries respond to changes in the pH and levels of oxygen and CO2 in the blood . by MA

Other neurologic controls of ventilation by MA

Nursing assessment of a client with respiratory problems Nursing health history -is the systematic collection of subjective data or the physical and functional problems experienced by the patient. Identifying the chief complaint why the patient is seeking health care. Often is related to one or more of the following: by MA

Cont.. Dyspnea (shortness of breath) Chest pain Sputum production Wheezing Hemoptysis (blood spit up from the respiratory tract) Clubbing of the fingers Cough General fatigue and weakness edema of the ankles and feet by MA

Dyspnea Is difficult or labored breathing, breathlessness, shortness of breath a symptom common to many pulmonary and cardiac disorders Sever in case of acute disease than chronic disease Sudden dyspnea in a healthy person may indicate pneumothorax , acute respiratory obstruction, or ARDS In immobilized patients, sudden dyspnea may denote pulmonary embolism . by MA

Clubbing Of Fingers by MA

Cont.. It is also important to determine: When the health problems or symptoms started How long it lasted Medication, specific adaptations of patients to the problems In this history information about precipitating factors, durations, severities that may contribute to the patient’s lung condition should be assessed by MA

Cont.. Smoking ( the single most important contributor to lung disease) Exposure to allergens and environmental pollutants Occupational history Previous personal or family history of lung disease Recreational history by MA

Asst…. b. Physical examination Follows health history Assessment of the thorax and lungs uses the skills of inspection, palpation, percussion and auscultation I) Inspection Inspection of the thorax provides information about musculoskeletal structure, nutritional and the status of the respiratory system. by MA

Cont.. Assessment of chest configuration In the normal chest configuration the transverse diameter is twice of anteroposterior diameter. There are four main deformities associated with respiratory disease. Barrel chest- occurs as a result of the over inflation of the lungs. There is an increase in the antrioposterior diameter of the thorax, can be observed in a patient with advanced emphysema. by MA

Causes Asthma Chronic bronchitis Emphysema Chronic obstructive pulmonary disease Obesity by MA

Cont.. Funnel chest ( pectus excavatum ) - occurs when there is depression in the lower portion of the sternum . This condition may occur with rickets, mar fan’s syndrome. Pigeon chest (pectus carinatum) - occurs as a result of displacement of sternum. There is increase in the AP diameter. Kyphoscoliosis - appears with an elevation of the scapula with corresponding S- shaped spine. It may occur with osteoporosis and other skeletal disorders that affect the thorax. by MA

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Barrel chest by MA

Funnel chest by MA

Pigeon chest by MA

kyphoscliosis by MA

Cont.. Breathing patterns Observing the rate and depth of respiration is also important. Tachypnea, bradypnea Hyperpnoea Hyper ventilation, hypoventilation Using of accessory muscle, abnormal retraction of the lower interspaces during inspiration by MA

Cont.. R/R and breathing pattern : normal adult who is resting comfortably takes 12 to 18 breaths per minute. Eupnea : normal pattern. Bradypnea : slow breathing Tachypnea : rapid breathing Hyperpnea: increase in depth and rate of respirations Kussmaul’s respiration : increase in rate and depth Apnea : varying periods of cessation of breathing Cheyne-Stokes : respiration alternating episodes of apnea and periods of deep breathing. by MA

II. Palpation The thorax is palpated for tenderness, masses, lesions, respiratory excursion and vocal fremitus. Respiratory excursion- is an estimation of the thoracic expansion and may disclose significant information about thoracic movement during breathing. This movement is normally symmetric. Asymmetrical movement (Respiratory impairment) is often the result of pleurisy, fractured ribs or trauma by MA

Method to asses respiratory excursion by MA

Cont.. Tactile fremitus- is the capacity to feel sound (vibration) on the chest wall, which is transmitted from larynx via the airways. Have client say “ninety-nine” or “44” and compare the transmission of sound on both sides of the chest for symmetry by using palmar surface of the fingers and hands. by MA

Cont.. Findings: Strong (increased) vibration indicates consolidation of the underlying lung (as with pneumonia) Decrease or no tactile fremitus indicates air in the pleural space such as pleural effusion and pneumothorax by MA

III. percussion- is an assessment technique of producing sounds by tapping on the chest wall with hand/fingers. The examiners use percussion to determine whether or not underlying tissue is filled with air, fluid or solid materials. Percussion can also be used to estimate the size and location of certain structure with in the thorax . (E.g. heart, liver). by MA

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Cont.. Auscultation Auscultation is useful in assessing the flow of air through the bronchial tree and in evaluating the presence of fluid or solid obstruction in the lung. The nurse auscultates for normal breath sounds, adventitious sounds, and voice sounds Breath sounds include :- Bronchial breath sound Broncho-vesicular sound Vesicular sound by MA

A. Normal breath sounds Are classified in to three I. VESICULAR , Soft and low pitched. Heard through out inspiration. Inspiratory sounds last longer than expiratory sounds. Heard Over most of both lung area Sound quality appears as rustling of leaves on a tree by MA

II. Bronchovesicula r Intermediate in pitch Inspiratory and expiratory sounds are about equal in length. Are often heard in the 1 st & 2 nd interspaces anteriorly and between the scapulae posteriorly . Originate from larger airways . The sound resembles that obtained by listening over the trachea. Has hollow/tubular quality. by MA

III. Bronchial Are louder and higher in pitch. Expiratory sound lasts longer than the inspiratory. Heard over the manubrium . If broncho-vesicular or bronchial breath sounds are heard in locations distant from those listed, suspect that air-filled lung has been replaced by fluid-filled or solid lung tissue. by MA

Adventitious sound Crackles -discrete, non continuous sounds, often present in such conditions as pneumonia, bronchitis, heart failure, bronchiectasis, and pulmonary fibrosis Wheezing - continuous musical sound best heard during expiration commonly heard in patients with asthma, chronic bronchitis, or bronchiectasis. by MA

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Abnormal sounds Description Etiology Crackles Soft, high-pitched, discontinuous popping sounds that occur during inspiration Fluid in the airways Wheezes High-pitched musical sound Usually heard on expiration Bronchial wall oscillation Friction Rubs Harsh, crackling sound heard during inspiration Loss of lubricating pleural flluids

Site of Auscultation and percussion by MA

Generally Manifestations of Pulmonary Disease Coughing Reflex response to irritation of upper/lower respiratory tract Sputum production If yellowish- green ------ infection If rusty ------- blood + pus = pneumococcal pneumonia If bloody -- TB & cancer Large amounts & foul = bronchiectasis and lung abscess Thick & sticky = asthma

Cyanosis Bluish coloring of the skin Indicator of hypoxia Clubbing of the Fingers: Indicator chronic hypoxic conditions, chronic lung infections, or malignancies of the lung

Diagnostic Evaluation A wide range of diagnostic studies may be performed in patients with respiratory conditions. Pulmonary Function Tests Arterial Blood Gas Studies Sputum Studies Imaging Studies Endoscopic Procedures by MA

Diagnostic Evaluation Pulmonary function tests Spirometer is used to measure certain lung volumes, called dynamic lung volumes The two most important dynamic lung volumes measured are the Forced vital capacity (FVC) and forced expiratory volume in the 1st second (FEV1) Measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. They are routinely used in patients with chronic respiratory disorders. by MA

Pulmonary function test by MA

…… diagnostic studies Pulse Oximetry Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2 ). When oxygen saturation is measured with pulse oximetry, it is referred to as SpO2 (Clark, Giuliano & Chen, 2006). Normal range SPO2 95 % - 100% except COPD and congested heart failure patient by MA

… diagnostic studies Arterial blood gas (ABG) studies Determines patient’s Ventilation status Tissue oxygenation Acid-base status 3-5 mL of blood is sampled from an artery by MA

The normal results are: pH 7.35–7.45 PaO 2 80–100 mmHg PaCO 2 35–45 mmHg HCO 3 22–26 mEq /L Key: PaO2 = partial pressure of oxygen PaCO2 = partial pressure of carbon dioxide

… diagnostic studies Laboratory studies Culture : Throat cultures may be performed to identify organisms responsible for pharyngitis, infection of the LRT - Nasal swabs also may be performed for the same purpose. Sputum studies: Sputum is obtained for analysis to identify pathogenic organisms. Sputum cultures are used in diagnosis, for drug sensitivity testing, and to guide treatment.

…diagnostic studies Thoracentesis A thin layer of pleural fluid normally remains in the pleural space. An accumulation of pleural fluid may occur with some disorders. A sample of this fluid can be obtained by thoracentesis ( aspiration of pleural fluid for diagnostic or therapeutic purposes ).

…diagnostic studies Studies of pleural fluid include Gram’s stain culture and sensitivity, acid-fast staining and culture, differential cell count, cytology, pH, specific gravity, total protein, and lactic dehydrogenase. Biopsy: the excision of a small amount of tissue, may be performed to permit examination of cells from the pharynx, larynx, nasal passages, lymph nodes and pleura or lungs. Local, topical, or general anesthesia may be administered, depending on the site and the procedure.

…diagnostic studies Imaging studies Chest X-Ray: Normal pulmonary tissue is radiolucent; therefore, densities produced by fluid, tumors, foreign bodies, and other pathologic conditions can be detected by x-ray examination. A chest x-ray may reveal an extensive pathologic process in the lungs in the absence of symptoms .

…diagnostic studies Imaging studies Computed Tomography: an imaging method in which the lungs are scanned in successive layers by a narrow-beam x-ray. The images produced provide a cross-sectional view of the chest. CT may be used to define pulmonary nodules and small tumors adjacent to pleural surfaces that are not visible on routine chest x-ray & to demonstrate mediastinal abnormalities & hilar adenopathy, which are difficult to visualize with other techniques .

…diagnostic studies Imaging studies Magnetic Resonance Imaging(MRI):- Are similar to CT scans except that magnetic fields and radiofrequency signals are used instead of a narrow-beam x-ray. It yields a much more detailed diagnostic image than CT scans. Magnetic resonance imaging is used to characterize: - Pulmonary nodules - Acute pulmonary embolism

…diagnostic studies MRI..… Stage bronchogenic carcinoma (assessment of chest wall invasion). Evaluate inflammatory activity in interstitial lung disease. Chronic thrombolytic pulmonary hypertension.

…diagnostic studies Endoscopic procedures Bronchoscopy: is the direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiber-optic bronchoscope or a rigid bronchoscope. The fiber-optic scope is used more frequently in current practice. Bronchoscopy permits the clinician not only to diagnose but also to treat various lung problems.

…diagnostic studies Endoscopic procedures

…diagnostic studies Endoscopic procedures Thoracoscopy : is a diagnostic procedure in which the pleural cavity is examined with an endoscope. Small incisions are made into the pleural cavity in an intercostal space; the location of the incision depends on the clinical and diagnostic findings. It is primarily indicated in the diagnostic evaluation of pleural effusions, pleural disease, and tumor staging . A combined diagnostic–treatment procedure, thoracoscopy includes excising tissue for biopsy.

…diagnostic studies Biopsies of the lesions can be performed under visualization for diagnosis.

Respiratory disorders by MA

Upper Respiratory Disorders Disorders of the upper airway range from common colds to cancer. The severity depends on the Nature of the disorder and The client’s physiologic response. The most common upper airway illnesses are infectious and inflammatory disorders. The average, person experiences three to five upper respiratory infections (URIs) each year. by MA

RHINITIS Inflammation and irritation of the nasal mucous membranes . inflammation and swelling of the mucous membrane of the nose, characterized by a runny nose and stuffiness and usually caused by the common cold or a seasonal allergy. It also is referred to as the common cold, or coryza. Mucous membranes lining the nasal passages become inflamed, congested, and edema tous. cause , it may be acute, chronic, or allergic. The most common cause is the rhinovirus by MA

RHINITIS-------- Characterized by presence of two or more of the following symptoms: Nasal blockage, Sneezing, Rhinorrhoea (a persistent watery mucous discharge from the nose) and Nasal itching which last for an hour or more on most days by MA

Allergic rhinitis(hay fever) is caused by a reaction of the body’s immune system to an environmental trigger. The most common environmental triggers include dust, molds, pollens, grasses, trees, and animals. Both seasonal allergies and year-round allergies can cause allergic rhinitis . by MA

Presentation itching, sneezing, runny nose, stuffiness, and itchy, watery eyes. headaches and swollen eyelids and also may cough and wheeze. treatments can help avoid or treat symptoms of allergic rhinitis: Avoiding the substance that triggers the allergy prevents symptoms but is often not possible. Nasal corticosteroid sprays decrease nasal inflammation caused by many sources and are relatively safe for long-term use. by MA

Continue Antihistamines help prevent the allergic reaction and thus symptoms. Antihistamines dry the mucous membrane of the nose but many of them also cause sleepiness and other problems, especially in older people. Newer ones require a prescription but do not have as many of these side effects . A saltwater solution flushed through the nose via a squeeze bottle or a bulb syringe (nasal irrigation) or using a saltwater spray as needed also can help symptoms. by MA

Continue Desensitization injections that contain small amounts of the substance that triggers the allergy (called desensitization immunotherapy, or sometimes allergy shots), help to build long-term tolerance to specific environmental triggers, but they may take months or years to become fully effective. Antibiotics do not relieve the symptoms of allergic rhinitis. by MA

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Cont.. For allergic rhinitis, antihistamines are often used. An example of a first-generation antihistamine is diphenhydramine (Benadryl ). Newer antihistamines include loratadine (Claritin), fexofenadine (Allegra), and cetirizine ( Zyrtec ). by MA

Cont.. The nurse teaches the client simple measures to treat rhinitis Teaching clients about URIs helps prevent them and minimizes potential complications vitamin C modestly shortens the duration of a cold. by MA

… cont For patient taking Cetirizine Instruct the patient: To avoid drinking alcohol To chew the tablet before swallow Cetirizine may induce sleep Careful for patient who drive by MA

For all types of rhinitis: Rest as much as possible. Increase fluid intake to assist in liquefying secretions. Use a vaporizer to help liquefy secretions.. Wash hands frequently to avoid spreading infection. Use medications as directed; be aware of possible side effects, especially interactions with food and alcohol. Maintaining a healthy lifestyle of adequate rest and sleep, proper diet, and moderate exercise is the best prevention. by MA

Cont.. For allergic rhinitis: Be tested for allergen sensitivity. Avoid specific allergens. Use antihistamines and decongestants as ordered by MA

SINUSITIS Refers to an inflammatory condition involving the four paired structures surrounding the nasal cavities.. The maxillary sinus is affected most often. If not treated Sinusitis can lead to serious complications, such as infection of the middle ear or brain. Also severe and occasionally life-threatening complications such as meningitis, brain abscess, ischemic infarction, and osteomyelitis. The principal causes are the spread of an infection from the nasal passages to the sinuses and the blockage of normal sinus drainage. by MA

Cont.. It is typically classified by duration of illness (acute vs. chronic); by etiology (infectious vs. noninfectious); and, when infectious, by the offending pathogen type (viral, bacterial, or fungal). by MA

Clinical Manifestations Facial pain or pressure over the affected sinus area, Nasal obstruction, localized headache or toothache Fatigue, purulent nasal discharge, Fever, ear pain, Cough, a decreased sense of smell, sore throat, or Tenderness to palpation over the infected sinus area Decrease in the transmission of light. by MA

Management Goal is to treat the infection, shrink the nasal mucosa, and relieve pain Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in adult patients with mild to moderate symptoms of<7 days’ duration are therapies aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. by MA

Cont.. Adult patients who do not improve after 7 days and those with more severe symptoms (regardless of duration) should be treated with antibiotics Antibiotics like Amoxicillin, trimethoprim/ sulfamethoxazole (Bactrim, Cotrimoxazole ), erythromycin, amoxicillin clavulanate (Augmentin). Decongestant drugs like naphazoline , pseudoephedrine, oxymetazoline , phenylephrine. by MA

Cont.. Antihistamines diphenhydramine, cetirizine. Inhaling steam (steam bath, hot shower, and facial sauna), increasing fluid intake, and applying local heat Be alert for rebound congestion and avoide long use of decongestant (fear of dependency). by MA

PHARYNGITIS Pharyngitis is an inflammation or infection in the throat, usually causing symptoms of a sore throat. It can be acute or chronic Most cases of acute pharyngitis are caused by viral infection. the most common bacterial organism, causes acute pharyngitis, is group A beta-hemolytic streptococcus by MA

Cont.. Chronic pharyngitis is a persistent inflammation of the pharynx. It is common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, and habitually use alcohol and tobacco. by MA

Clinical Manifestations Fiery-red pharyngeal membrane and tonsils, Lymphoid follicles that are swollen and flecked with white-purple exudate, Enlarged and tender cervical lymph nodes and no cough. Fever, malaise, and sore throat also may be present by MA

pharyngitis by MA

Cont.. by MA

Generally ,if the cause is Group A beta-hemolytic streptococcus the following CMs are observed Anorexia Rash with urticaria Painful sore throat Headache Myalgia Painful cervical adenopathy Nausea Bad breath odor

Diagnostic Findings Swab specimens CBC

Management Medical Management Viral pharyngitis is treated with supportive measures since antibiotics will have no effect on the organism. Bacterial pharyngitis is treated with a variety of antimicrobial agents by MA

Cont.. If a bacterial cause is suggested or demonstrated, penicillin is usually the treatment of choice. For patients who are allergic to penicillin or have organisms that are resistant to erythromycin, cephalosporin and macrolides (clarithromycin and azithromycin) may be used. Antibiotics are administered for at least 10 days to eradicate the infection from the oropharynx. by MA

NUTRITIONAL THERAPY A liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree of discomfort that occurs with swallowing. Occasionally, the throat is so sore that liquids cannot be taken in adequate amounts by mouth. In severe situations, fluids are administered intravenously. by MA

Nursing Management TEACHING PATIENTS SELF-CARE To prevent the infection from spreading, the nurse instructs the patient to avoid contact with others until the fever subsides. The nurse encourages the patient to drink plenty of fluids. Gargling with warm saline solutions may relieve throat discomfort To take medications as perscribed by MA

Cont.. Complications include sinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, or nephritis. by MA

TONSILLITIS I s an infection and swelling of the tonsils, which are oval-shaped masses of lymph gland tissue located on both sides of the back of the throat. . Frequently serve as the site of acute infection. Incidence Extremely common in children and young people but it can occur at any age by MA

Causes Bacterial tonsillitis- Group A β-hemolytic streptococcus Viral tonsillitis- Epstein-Barr virus, Adenovirus, CMV, rhinovirus, etc by MA

Diagnoses History Physical examination Tonsillar site culture A blood test may also be done to rule out a more serious infection or condition, and to check the white blood cell count by MA

culture positive case of Streptococcal pharyngitis with typical tonsillar exudate by MA

Clinical Manifestations sore throat red, swollen tonsils pain when swallowing high temperature (fever) coughing headache tiredness chills a general sense of feeling unwell (malaise) white pus-filled spots on the tonsils swollen lymph nodes (glands) in the neck pain in the ears or neck by MA

Management/Treatment Treatments to reduce the discomfort from tonsillitis symptoms include; pain relief, anti-inflammatory, fever reducing medications ( paracetamol /acetaminophen and/or ibuprofen) sore throat relief (warm salt water gargle, If the tonsillitis is caused by group A streptococus , then antibiotics are useful with penicillin or amoxicillin being primary choices. by MA

Mgt… If recurrent tonsillitis, tonsillectomy is usually performed when medical treatment is unsuccessful and there is severe hypertrophy, asymmetry, or peritonsillar abscess that occludes the pharynx, making swallowing difficult and endangering the airway. by MA

PERITONSILLAR ABSCESS is an abscess that develops in the connective tissue between the capsule of the tonsil and the constrictor muscle of the pharynx. It may follow a severe streptococcal or staphylococcal tonsillar infection. And as complication of an untreated or partially treated episode of acute tonsillitis. Both aerobic and anaerobic bacteria can be causative. Commonly involved species include streptococci, staphylococci and hemophilus . by MA

Clinical manifestation Severe unilateral pain in the throat; Pyrexia above 103 degree F (39°C); Unilateral Earache; Odynophagia ( severe sensation of burning, squeezing pain while swallowing) dysphagia (difficulty swallowing saliva) Intense salivation and dribbling, Halitosis Pain in the neck; by MA

Right sided peritonsillar abscess by MA

Management Treatment is surgical incision and drainage of the pus, thereby relieving the pain of the pressed tissues. However, it has been shown to be safe to "wait and observe" as a mode of treatment. Antibiotics are also given to treat the infection. Internationally, the infection is frequently penicillin resistant, so it is now common to treat with clindamycin Intravenous fluid administration until the inflammation resolves and they are able to resume an adequate oral fluid intake. by MA

Nursing management the client undergoing drainage of an abscess includes placing the client in a semi-Fowler’s position to prevent aspiration. An ice collar may be ordered to reduce swelling and pain. The nurse encourages the client to drink fluids. He or she observes the client for signs of respiratory obstruction (e.g., dyspnea, restlessness, cyanosis) or excessive bleeding. by MA

Laryngitis Is an inflammation of the larynx. It causes hoarse voice or temporary complete loss of the voice because of irritation to the vocal folds (vocal cords) Categorized as acute if it lasts less than three weeks. Otherwise it is categorized as chronic, and may last over three weeks. It is mainly caused by excessive smoking . by MA

Laryngitis can be infectious as well as noninfectious in origin. Noninfectious causes Acid reflux disease Excessive coughing, smoking, or alcohol consumption Inflammation due to overuse of the vocal cords Prolonged use of inhaled corticosteroids for asthma treatment Thermal or chemical burns by MA

Cont.. Infectious causes Viral infections can be caused by rhinovirus, influenza virus etc. Bacterial infections can be caused by group A streptococcus, streptococcus pneumoniae etc. Bacterial infections usually follow preexisting viral infection. Fungal infections can be caused by Histoplasma , Blastomyces , Candida by MA

Clinical manifestation Signs of acute laryngitis include hoarseness or aphonia (complete loss of voice) and severe cough. Chronic laryngitis is marked by persistent hoarseness. Laryngitis may be a complication of upper respiratory infections by MA

Treatment General measures: Voice rest Steam inhalations, help loosen secretions. Cough sedatives are given to reduce cough. If laryngitis is due to gastro-esophageal reflux, ranitidine or omeprazole is used to reduce gastric acid secretions. In viral laryngitis, drinking sufficient fluids is helpful. If laryngitis is due to a bacterial or fungal infection, appropriate antibiotic or antifungal therapy is given by MA

Cont.. Antibiotics- usually penicillin is administered. Erythromycin or another antibiotics ( ceftriaxon 1gm, IV or IM every 12 hrs for 7 days) by MA

Steam inhalations by MA

Lower respiratory systems disorders Conditions affecting the lower respiratory tract range from acute problems to long-term chronic disorders. Many of these disorders are serious and often life-threatening. by MA

BRONCHITIS Inflammation of the mucous membranes that line the major bronchi and their branches. If the inflammatory process involves the trachea, it is referred to as tracheobronchitis . It can be acute or chronic Typically, acute bronchitis begins as an upper respiratory infection (URI) inflammatory process extends to the tracheobronchial tree. by MA

Causes Viral infections most commonly give rise to acute bronchitis. Bacterial infection Streptococcus pneumonia, Haemophilus influenza Mycoplasma pneumonia Fungal infections such as Aspergillus Chemical irritation from noxious fumes, gases, and air contaminants by MA

Cont.. Chronic bronchitis may be caused by one or several factors, but the primary cause is heavy, long-term cigarette smoking. Approximately 90% of cases of acute bronchitis are viral infections, while 10% are bacterial. by MA

Signs and symptoms Initially include Fever, chills, malaise, headache, A dry, irritating, and nonproductive cough. Shortness of breath The patient may report sternal soreness from coughing Later, the cough produces mucopurulent sputum, which may be blood-streaked Wheezing may be heard on chest auscultation. by MA

Acute bronchitis usually comes on quickly and gets better after several weeks. by MA

Chronic bronchitis is defined clinically as a daily cough with production of mucus for at least a 3 month period, two years in a row. by MA

Diagnoses A sputum sample is collected for culture and sensitivity testing to rule out bacterial infection. A chest film also may be done to detect additional pathology, such as pneumonia. History by MA

Medical Management Acute bronchitis usually is self-limiting, lasting for several days. Antibiotics usually aren't helpful. That's because acute bronchitis is almost always caused by a virus, which will not respond to antibiotics. The suggested treatment is bed rest, antipyretics, expectorants, antitussives (drugs used to prevent coughing), and increased fluids. by MA

Cont.. In severe cases of chronic bronchitis, inhaled or oral steroids may be recommended to reduce inflammation. Smoking cessation is important for chronic bronchitis be treated. When a secondary infection is evident, broad-spectrum antibiotic is prescribed when sputum culture results are available For acute exacerbations of chronic bronchitis, if antibiotics are used, amoxicillin or doxycycline is recommended. by MA

Cont.. Ipratropium is a bronchodilator that may be useful for people with chronic obstructive pulmonary disease, such as chronic bronchitis. Albuterol is also a common drug for this disease. by MA

PNEUMONIA is an inflammatory illness of the lung and lung parenchyma/alveolar and characterized by an i nflammatory infiltrate in alveoli ( consolidation) . It is the sixth leading cause of death in the United States for all ages and both genders. Leading cause of morbidity & mortality in infants and older people & people who are chronically & terminal ill. by MA

Cont.. Normally, lungs are well protected For pneumonia to occur, at least one of the following three conditions must occur: Failure or Defect in Host Defenses Exposure to very virulent pathogens Exposure to an overwhelming load of pathogens by MA

Cont.. Failure of Host Defenses Absence of cough or epiglottis (gag) reflex Dysfunctional muco-ciliary blanket Prior Viral Infection (Common Cold) Compromised overall immunity due to systemic sepsis, immunosuppressive drugs Cigarette/second-hand exposure or other toxic fume also weaken lung system Change in mental sta tus (coma, seizure, drug intoxication) by MA

Incidence Common illness which occurs in all age group Leading cause of morbidity & mortality in infants and older people & people who are chronically & terminal ill. It is the most common fatal infection acquired by already hospitalized patients . Nevertheless, in developing countries, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death by MA

Causes Pneumonia -caused by bacteria or viruses and less commonly by fungi and parasites . Bacteria Streptococcus pneumonia Haemophilus influenza Moraxella catarhalis "Atypical" bacteria Chlamydophila pneumonia Mycoplasma pneumonia Legionella pneumophila by MA

Cont.. Viral pneumonia Influenza virus Respiratory syncytial virus (RSV) Adenovirus Herpes simplex virus CMV- in immune system problems by MA

Cont.. Fungi Histoplasma capsulatum Blastomyces Cryptococcus neoformans Pneumocystis jiroveci Parasites Toxoplasma gondii Strongyloides stercoralis Ascariasis by MA

CLASSIFICATION of pneumonia Several systems are used to classify pneumonias. Classically, pneumonia has been categorized into one of four categories: Bacterial or typica l, Atypical, A naerobic/ cavitary , And opportunistic. by MA

Cont.. Typical pneumonia usually is caused by bacteria such as Streptococcus pneumonia . Atypical pneumonia usually is caused by the influenza virus, mycoplasma , chlamydia, legionella, adenovirus, or other unidentified microorganism . by MA

Classification of pneumonia ( cont …) A more widely used classification scheme categorizes the major pneumonias as Community-acquired pneumonia (CAP), Hospital-acquired (nosocomial) pneumonia (HAP), Pneumonia in the immuno-compromised host, And aspiration pneumonia by MA

Classification of pneumonia ( cont …) by MA According to the X-ray appearance Lobar pneumonia- it is a radiological and pathological term referring to homogeneous consolidation of one or more lung lobes Broncho-pneumonia - refers to multiple patchy shadows in a localized or segmental area, alveolar consolidation associated with bronchial and bronchiolar inflammation.

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Community-acquired pneumonia (CAP) CAP is infectious pneumonia in a person who has not recently been hospitalized & within the first 48 hrs after hospitalization. CAP is the most common type of pneumonia . The need for hospitalization for CAP depends on the severity of the pneumonia The absence of a responsible caregiver in the home may be another indication for hospitalization . Risk factors include cigarette smoking, alc ohol, pre-existing lung disease, old age by MA

Microbial Causes of Community-Acquired Pneumonia, by Site of Care Outpatients Streptococcus pneumoniae ( the most common ) Mycoplasma pneumoniae Haemophilus influenzae C. pneumoniae Respiratory viruses by MA

Microbial Causes of Community-Acquired Pneumonia, by Site of Care Non-ICU S. pneumoniae M. pneumoniae Chlamydia pneumoniae H. influenzae Legionella spp Respiratory viruses a ICU S. pneumoniae Staphylococcus aureus Legionella spp. Gram-negative bacilli H. influenzae by MA

Identified Pathogens in CAP Streptococcus pneumoniae 20-60% Haemophilus influenzae 3-10% Staphylococcus aureus ………….3-5% Gram-negative bacilli……………3-10% Legionella species ………….......2-8% Mycoplasma pneumoniae ………1-6% Chlamydia pneumoniae ……… 4-6% Viruses………………………….2-15% Aspiration……………………….6-10% Others …………………………..3-5% by MA

Cont.. Viruses are the most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults. The chief causes of viral pneumonia in the immunocompetent adult are influenza viruses types A and B, adenovirus, parainfluenza virus, coronavirus, and varicella-zoster virus . by MA

Hospital-acquired pneumonia (HAP) Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia acquired during or after hospitalization for another illness or procedure with onset at least 48-72 hours after admission. . To develop HAP there should be either/together Low immunity, High virulent pathogens and Transmission and inoculums (entrance) of pathogen . by MA

Causes of HAP Commonly caused by gram negative bacteria Escherichia coli, Klebsiella species, Proteus, P. aeruginosa, methicillin-sensitive or methicillin-resistant Staphylococcus aureus by MA

Cont.. HAP accounts for approximately 15% of hospital-acquired infections. It is estimated to occur in 0.5% to 1% of all hospitalized patients and in 15% to 20% of intensive care patients. Nosocomial pneumonia is the 2nd most common hospital-acquired infections after UTI and is the leading cause of death from hospital-acquired infections . by MA

Risk factors of HAP Mechanical ventilation Prolonged malnutrition Underlying heart and lung diseases, Immune disturbances. Endo tracheal intubation Previous antibiotic treatment High gastric pH Postoperative pneumonia Cardiac, pulmonary, hepatic and renal insufficiency by MA

Aspiration pneumonia This occurs when large amount of oropharyngeal or gastric contents are aspirated into the lower respiratory tract . Aspiration occurs more frequently in patients with: Decreased level of consciousness (alcoholism, seizure, strokes or general anesthesia) Neurologic dysfunction of oropharynx and swallowing disorders. People with periodontal disease are affected more. . by MA

Cont.. Aspiration pneumonia may occur in the community or hospital setting; common pathogens are An a erobic organisms in the oral cavity o Enterobateriacae o S. pneumoniae o S.aureus by MA

Pneumonia In The Immunocompromised Is type of pneumonia occurring in patients with low immunity (Immunocompromised). Immunocompromised hosts such as transplant recipients, HIV infected patients, and patients on Chemotherapy etc. are prone to develop pneumonia. The etiologic agents are St. Pnumoniae , H.influenzae , Mycoplasma Gram negative organisms : Enterobacteriaceae Funguses such as Pneumocystis carinii ( jerovecii ), Histoplasmosis , Aspergillus Mycobacterium tuberculosis Viruses : HSV , CMV by MA

Pathophysiology by MA Pathophysiology…… Once inside, bacteria may invade the spaces b/n cells and b/n alveoli through connecting pores. Invasion triggers the immune system to send neutrophils Neutrophils & macrophages engulf and kill the offending organisms The alveolar macrophages also initiate the inflammatory response

Pneumonia cont’d… by MA Pathophysiology…… It releases cytokines , causing a general activation of the immune system. Neutrophils, bacteria and fluid from surrounding blood vessels fill the alveoli Interrupt normal oxygen transportation and venous blood entering the lungs passes through the under ventilated area .

Pneumonia cont’d… by MA Pathophysiology…… Bacteria often travel from an infected lung into the bloodstream, causing serious or even fatal illness such as septic shock Bacteria can also travel to the area between the lungs and the chest wall (the pleural cavity) causing a complication called an empyema .

Pneumonia cont’d… by MA Generally Four stage of pathophysiological change occur due to pneumonia 1. Congestion- occurs during the first 24 hrs Out pouring of fluid from tissue to alveoli- b/se of inflammatory process. Only a few neutrophils are seen at this stage.

Pneumonia cont’d… by MA 2. Red hepatization - Lungs look like the liver There is massive capillary dilation Characterized microscopically by the presence of many RBC, neutrophils , micro-organisms , fibrins in the alveolar spaces

Pneumonia cont’d… by MA 3. Gray hepatization The lung is dry, friable and gray-brown to yellow as a consequence of a persistent fibrinopurulent exudates WBC and fibrin consolidate the alveoli and lung Second and third stages last for 2 to 3 days each

Pneumonia cont’d… by MA 4. Resolution Characterized by enzymatic digestion of the alveolar exudate; Resorption, phagocytosis or coughing up of the residual debris an d Restoration of the pulmonary architecture.

Clinical Manifestations rapid and bounding pulse, ( increases about 10 beats/min for every degree of temperature (Celsius) elevation. Cough producing greenish or yellow sputum , or which may be blood tingled. Pleuritic chest pain , either experienced with/ worsened by deep breaths or coughs use of accessory muscles in respiration central cyanosis , poor a ppetite by MA

Cont.. High fever (38.5° to 40.5°C) that may be accompanied by shaking, chills Tachypnea (25 to 45 breaths/min) Headaches , Sweaty and clammy (moist) skin, Nausea , vomiting , Mood swings, and Joint pains or muscle aches by MA

Generally Clinical Manifestations of Typical pneumonia Sudden onset High grade fever Productive cough Greenish or yellow sputum production Chest pain that is aggravated by coughing Headaches Loss of appetite

Generally Clinical Manifestations of T ypical pneumonia Consolidation of lung tissue Increased tactile fremitus Percussion dullness Tachypnea (25 to 45 breaths/min) Pulse is rapid and bounding

Generally Clinical Manifestations of A t ypical pneumonia Gradual onset Low grade fever Cough Chest pain Sputum production Accompanied by nasal congestion and discharges

differential diagnosis includes both infectious and noninfectious entities such as Acute bronchitis, Acute exacerbations of chronic bronchitis, Heart failure, Pulmonary embolism, and radiation Pneumonitis. by MA

Pneumonia cont’d… by MA Diagnosis History Physical examination Inspection Increase respiratory rate cyanosis Palpation Increase vibration of the chest when speaking The way of chest expands

Pneumonia cont’d… by MA Percussion Dullness Auscultation A lack normal breath sounds Crackle sounds Increase loudness of whispered speech

Pneumonia cont’d… by MA Chest x-ray Chest x-rays can reveal areas of opacity (seen as white) which represent consolidation. Blood tests- a CBC may show a high WBC count. Sputum cultures Chest CT scan or other tests may be needed to distinguish pneumonia from other illness.

Pneumonia cont’d… by MA Pneumonia as seen on chest x-ray A : Normal chest x-ray. B : Abnormal chest x-ray

Prognosis The overall mortality rate is low, if treated early. Factors that herald a poor prognosis include the following:- Extremes of age, especially < 1 yr or >60yrs, Positive blood culture Involvement of more than one lobe Peripheral WBC < 5000/ml Presence of associated diseases (e.g. cirrhosis, CHF, immunosuppression) Development of extrapulmonary complications like meningitis and endocarditis. by MA

Medical Management When managing a patient with pneumonia one should Assess the severity of the pneumonia Decide whether it is community or home acquired Determine if the patient is over 65 or has a comorbid illness Decide whether to treat orally or with IV meds N ote: Used the CURB-65 ( confusion,urea,respiratory rate,blood pressure,and age >65 year)severity score to predict mortality secondary to community acquired pneumonia and widely used to identify patients who can managed as out patients by MA

CURB-65 scoring for CAP by MA

Medical Management Most cases of pneumonia can be treated without hospitalization. Typically, oral antibiotics, rest, fluids and home care are sufficient for complete resolution. People with pneumonia who are having trouble breathing, other medical problems & the elderly may need more advanced treatment. by MA

Cont.. Initially be treated with a broad-spectrum antibiotic regimen aimed at covering all likely bacterial pathogen This regimen should subsequently be narrowed, according to the result of culture by MA

Cont.. According to DACA: For community acquired ambulatory pts (mild pneumonia ):- Amoxicillin 500 mg po TID for 5-7 days OR Erythromycin 500 mg po QID for 5-7 days OR Doxycyciline 100 mg po BID for 7-10 days OR by MA

Severe community acquired pneumonia If patients are seriously ill they should be admitted and treated as inpatient. Criteria for Hospitalization of patients with Pneumonia are: Respiratory rate of >28/min ( Tachypnea ) tachycardia >140/min Systolic blood pressure <90mm Hg (hypotension Hypoxemia (arterial PO2< 60mm Hg) while breathing room air or O2saturation < 90 % by MA

Cont.. New onset of confusion or impaired level of consciousness . Unstable /Significant co-morbidity (e.g. Heart faiure , uncontrolled diabetes, Chronic Renal insufficiency ,alcoholism , immunosuppresion ) Multilobar pneumonia, hypoxemia is present Pleural effusion and with analysis showing characteristics of complication by MA

Cont.. Other conditions in which inpatient management may be advisable Elderly patient >65 yrs of age Leukopenia <5000 WBC/ml Pneumonia caused by St. aureus or Gram negative bacilli Suppurative complications e.g. empyema, arthritis, meningitis, endocarditis Failure of Outpatient treatment Inability to take oral medication or persistent vomiting by MA

Cont.. For community acquired hospitalized patients (severe pneumonia):- Non-Drug treatment: Frequent monitoring of temperature, blood pressure and pulse rate in order to detect complications early and to monitor response to therapy. Give attention to fluid and nutritional replacements. Administer Oxygen via nasal prongs or face mask Analgesia for chest pain, Bed rest by MA

Cont.. Drug treatment: Crystalline penicillin, 3-4 million IU, IV QID for 7-10 days PLUS Gentamicin 3-5 mg/kg IV QD in divided dose for 7days or Ceftriaxon 1 gm IV or IM every 12-24 hrs for 7 days. Pseudomonas aeruginosa : Ceftazidime, 1-2 gm IV TID for 7-10 days OR Ceftriaxone, 1-2 g IV or IM BID for 7-10 days. PLUS Gentamicin, 3-5 mg/kg/day IV in 3 divided dose for 7-10 days by MA

Cont.. HAP (nosocomial pneumonias) - antimicrobials effective against gram-negative and gram-positive should be given in combination. Suitable combination is: Cloxacillin plus Gentamicin OR Ceftriaxone plus Gentamicin (see dose above For aspirational pneumonia It is treated with crystalline penicillin and metronidazole IV for several weeks if lung abscess develops by MA

Pneumonia in the Compromised Host In patients with HIV infection and “atypical” pneumonia, PCP should be considered and treated with high dose of co- trimoxazole ( 3 tablets every 6 hours for 3 weeks ) if clinically considered. by MA

Complication of pneumonia Congestive heart failure (CHF), Empyema (collection of pus in the pleural cavity), Pleurisy (inflammation of the pleura), Septicemia (infective microorganisms in the blood), Atelectasis , hypotension, and shock . by MA

Cont.. In addition, septicemia may lead to a secondary focus of infection, such as Endocarditis (inflammation of the endocardium), Pericarditis (inflammation of the pericardium), and Purulent arthritis. by MA

Prevention of Pneumonia Cessation of smoking and alcoholism Vaccines : Influenza an Pneumococcal vaccines PCV 10 HiB Strict hand washing protocols by health care providers Extubate an entubated patient as soon as the patient is stable Remove NG tubes when the patient is stable Proper aseptic handling of IV lines by MA

Cont.. Promote coughing and expectoration of secretions. Encourage smoking cessation. Reposition frequently and promote lung expansion exercises and coughing. Initiate suctioning and chest physical therapy if indicated. Promote frequent oral hygiene. Minimize risk for aspiration by checking placement of tube and proper positioning of patient. by MA

Chronic obstructive pulmonary disease (COPD) by MA

Chronic obstructive pulmonary disease (COPD) by MA COPD) is a preventable and treatable disease with some significant extra-pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by chronic airflow limitation that is not fully reversible . The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

Cont.. COPD by MA COPD may include Emphysema Chronic bronchitis The chronic airflow limitation characteristic of COPD is caused by a mixture of small airway disease (obstructive bronchiolitis) and parenchymal destruction ( emphysema), the relative contributions of which vary from person to person.

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Chronic obstructive… by MA Incidence Currently, COPD is the fourth leading cause of mortality and the 12th leading cause of disability in the United States; However, by the year 2020 COPD is six leading cause of d eath. M ore common in men than women

Chronic bronchitis by MA Presence of recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years . Etiology/ risk factors Bronchial irritants (e.g. cigarette smoke, exposure to pollution) Genetic predisposition (alpha-1 antitrypsin deficiency) Secondary bacterial or viral infections

Chronic Bronchitis: Pathophysiology by MA Chronic inflammation Hypertrophy & hyperplasia of bronchial glands that secrete mucus Increase number of goblet cells Cilia are destroyed

Chronic Bronchitis: Pathophysiology by MA Narrowing of airway airflow resistance work of breathing Hypoventilation & CO 2 retention  hypoxemia & hypercapnea

Chronic Bronchitis: Pathophysiology by MA Bronchial walls thickened, bronchial lumen narrowed, and mucus may plug in the airway Alveoli become damaged and fibrosed, Altered function of the alveolar macrophages. T he patient becomes more susceptible to respiratory infection .

Chronic Bronchitis: Pathophysiology by MA

Chronic Bronchitis: Pathophysiology by MA M ucus plug Normal lumen

Chronic Bronchitis: Pathophysiology by MA It is characterized by:- An increase in the size and number of sub mucous glands in the large bronchi An increased number of goblet cell Impaired cilliar function Bronchial mucosa inflammation Bronchial smooth muscle hyper reactivity

Chronic Bronchitis cont’d… by MA Clinical manifestations In early stages Clients may not recognize early symptoms Symptoms progress slowly May not be diagnosed until severe episode with a cold or flu Productive cough (copious) Cyanosis Dyspnea Tachypnea Wheezing

Chronic Bronchitis cont’d… by MA Diagnoses Hx (e.g., smoking, occupation, environmental exposure) Physical exam Radiology Sputum culture ABG analysis (  PaCo 2 , decrease PaO 2 )

Chronic Bronchitis: Management by MA The treatment is complex and depends on the stage of b ronchitis and whether other health problems are present. Lifestyle changes, such as quitting smoking or polluted air, c ontrolled regular exercise. S upplemental oxygen Treat other respiratory infections Nutritional support, Fluid intake ~3 lit/day

Chronic Bronchitis cont’d… by MA Medical management Medications Inhaled bronchodilators Short acting B 2 -agonists salbutamol, levosalbutamol , terbutaline pirbuterol, etc. Long-acting B 2 -agonists Anti-inflammatory Corticosteroids

Chronic Bronchitis cont’d… by MA Expectorants for cough Codeine phosphate Dextromethorphan hydro bromide Antipyretics for fever Mucolytic, e.g. Acetylcysteine

Chronic Bronchitis cont’d… by MA Nursing management Rest Encourage Increased fluid intake Smoking cessation Maxim ize self-management and improved coping ability, Adherence to the therapeutic program and home care Promoting absence of complications.

Chronic Bronchitis cont’d… by MA Prognosis The progression of chronic bronchitis may be slowed , and an initial improvement in symptoms may be achieved. H owever, there is no cure for chronic bronchitis, and the disease can often lead to or coexist with emphysema.

Emphysema by MA An abnormal distention of the air spaces beyond the terminal bronchioles, with destruction of the alveoli result impaired gas exchange. impaired gas exchange results from destruction of the walls of over distended alveoli.

Emphysema cont’d… by MA Types of emphysema Two main types, both may occur in the same patient. Pan lobular- there is destruction of the respiratory bronchioles, alveolar duct and alveoli. Corticobulbar- pathologic changes take place mainly in the center of the secondary lobule, preserving the peripheral portions or alveoli unchanged.

Emphysema cont’d… by MA

Emphysema cont’d… by MA Etiology /risk factors Actual cause is unknown Tobacco smoking ( 80%) Other percentages is caused by inhaling too many air pollutants (especially in occupational setting) Underlying respiratory disease Congenital-alpha 1-antitrypsin deficiency

Emphysema cont’d… by MA Pathophysiology Smoking damages cleansing mechanism of lung Airflow is obstructed and Air becomes trapped behind the obstruction. Affects alveolar membrane Destruction of alveolar wall Loss of elastic recoil Over distended alveoli Smoking also irritates the goblet cells and mucus glands- infection and damage to the lung.

Emphysema cont’d… by MA

Emphysema cont’d… by MA Walls of the alveoli are destroyed that causing An increase in dead space & Impaired oxygen diffusion. In later stages of disease, carbon dioxide elimination is impaired Resulting in increase carbon dioxide tension in arterial blood and causing respiratory acidosis.

Fig. Scanning electron microscopy (SEM) of lung tissue indicating emphysema. by MA

Emphysema cont’d… by MA Clinical manifestation Early stages Barell chest Central cyanosis Finger clubbing Dyspnea Wheezing Chronic fatigue Difficult in sleeping Hypoxia Polycythemia Cough & sputum production

Emphysema cont’d… by MA Later stages Hypercapnea Purse-lip breathing Use of accessory muscles to breathe Underweight No appetite & increase breathing workload

by MA Barrel-shaped chest of emphysema Normal chest wall

Emphysema cont’d… by MA

Emphysema cont’d… by MA Diagnoses Hx (smoking, occupational exposure), Physical exam Chest-X-ray ABG analysis Normal in moderate disease Later: hypercapnia and respiratory acidosis CBC Increase RBC Leukocytes

by MA Fig. X ray showing emphysema in the lungs

Emphysema cont’d… by MA Management Medications Anti-inflammatory- Corticosteroids Bronchodilators Beta-adrenergic agonist Anticholinergics Mucolytics Expectorants

Emphysema cont’d… by MA Anti-infective drugs Steroid medications- Prednisolone. Antitrypsin replacement therapy -prolastin Oxygen Surgery : in advanced emphysema. Lung-reduction surgery , Transplantation of either one or both lungs

Emphysema cont’d… by MA Client teaching Support to stop smoking Conservation of energy Breathing exercises Pursed lip breathing Chest physiotherapy Percussion, vibration Postural drainage

Emphysema cont’d… by MA Nursing diagnosis Ineffective Air way clearance related to broncho -spasm evidenced by statement of difficulty breathing Imbalanced nutrition, less than body requirements related to dyspnea evidenced by weight loss.

Emphysema cont’d… by MA Nursing interventions Maintain patient air way Assist patient to assume position of comfort Keep environmental pollution to a minimum Encourage/assist with abdominal or pursed-lip breathing exercises Increase fluid intake to 300 ml/day within cardiac tolerance.

Emphysema cont’d… by MA Maintain adequate diet intake Assess dietary habits, recent food intake. Give frequent oral care, remove expectorated secretions promptly Encourage a rest period of 1 hr before and after meals. Provide frequently small feedings Avoids gas-producing foods and carbonated beverages. Avoid very hot or very cold foods.

Emphysema cont’d… by MA Prognosis It is a serious and chronic disease that cannot be reversed. Overall, the prognosis for patients with emphysema is poor If detected early, the effects and progression can be slowed . Complications of emphysema include : higher risks for pneumonia and acute bronchitis . However, individual cases vary and many patients can live much longer with supplemental oxygen and other treatment

Bronchiectasis It is a pathologic, chronic irreversible destruction and dilatation of the wall of bronchi and bronchioles , usually resulting from supportive infection in an obstructed bronchus. Bronchiectasis is usually localized, affecting a segment or lobe of a lung, most frequently the lower lobes. by MA

Etiology May be caused by Airway obstruction Pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections Genetic disorders such as cystic fibrosis Abnormal host defense ( eg , ciliary dyskinesia or humoral immunodeficiency) Idiopathic causes by MA

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Pathophysiology Inflammatory process associated with pulmonary infections damages the bronchial wall, Causing a loss of its supporting structure and resulting in thick sputum that ultimately obstructs the bronchi. Walls become permanently distended and distorted Then impair mucociliary clearance by MA

Pathophysiology cont.. Inflammatory scarring or fibrosis replaces functioning lung tissue . The retention of secretions and subsequent obstruction ultimately cause the distal alveoli obstruction to collapse (atelectasis). In time patient develops respiratory insufficiency with reduced vital capacity, decreased ventilation, results in hypoxia. by MA

Clinical Manifestations Chronic cough, productive of copious and offensive purulent sputum is the cardinal feature of bronchiectasis. Hemoptysis , Clubbing of the fingers Cyanosis Recurrent pulmonary infection. by MA

Clubbing of fingers by MA

Assessment and Diagnostic Findings Not readily diagnosed because the symptoms can be mistaken with bronchitis. Prolonged history of productive cough, Sputum consistently negative for tubercle bacilli . CT scan , which demonstrates either the presence or absence of bronchial dilation. Cultured sputum. Bronchography The sputum typically forms three layers when collected in a glass container: the upper layer is foam (mucus), the middle one is liquid and the lower one is sediment . by MA

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Management Treatment objectives are To promote bronchial drainage to clear excessive secretions from the affected portion of the lungs and To prevent or control infection. Control of respiratory infections : Broad spectrum antibiotics that should be given whenever signs of pulmonary infection appear and symptoms are exacerbated (Ampicillin, tetracycline or erythromycin), Immunization for influenza and S. pneumoniae if available by MA

Cont.. Improve drainage of secretion : using Chest physiotherapy, including percussion and postural drainage, liquefaction and bronchodilators. O2therapy :may be given in patients with hypoxemia. Surgical resection of the affected part is indicated when bronchiectasis is localized, and in those with recurrent massive hemoptysis that fails to respond to conservative treatment. This is effective if done early in life. by MA

Complications In advanced cases include Recurrent hemoptysis Cor-pulmonale Respiratory failure And recurrent pneumonia. by MA

Asthma Learning objective Define Asthma Compare and contrast Asthma with COPD Identify risk factors for asthma Type Describe pathophysiology of Asthma Explain pathologic features of asthma Identify CM of Asthma List Typical features of Asthma Apply diagnostic steps of Asthma Discuss management of asthma by MA

Asthma by MA A chronic inflammatory disease of the airways that characterized by reversible airflow obstruction which causes : Airway hyper responsiveness Mucosal edema Mucus production Patients with asthma may experience symptom-free periods alternating with acute exacerbations, which last from minutes to hours or days.

Cont.. Asthma differs from other obstructive lung diseases in that it is largely reversible , either spontaneously or with treatment. Is the most common chronic disease of childhood and can occur at any age. About 50% of patients develop asthma before the age of 10 and another 35% before the age of 40. . Asthma attacks(or exacerbations) are episodic, but airway inflammation is chronically present. by MA

Asthma cont’d… by MA Asthma is characterized as: Reversible inflammation and obstruction Intermittent attacks Sudden onset Varies from person to person Severity varies from shortness of breath to death

Cont.. The inflammation leads to obstruction due to the following factors: Mucosal edema ) swelling of the membranes that line the airways Bronchospasm contraction of the bronchial smooth muscle that encircles the airways Increased mucus production , which diminishes airway size and may entirely plug the bronchi. by MA

Risk factors Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or allergens also increases the risk of asthma. Common allergens can be Seasonal ( grass, tree, and weed pollens ) or Perennial (e.g. mold, dust, roaches, animal dander). Airway irritants (e.g. air pollutants, cold, heat, weather changes, strong odors or perfumes, smoke), by MA

Cont.. Common triggers and exacerbations include Airway irritants ( eg , air pollutants, cold, heat, weather changes, strong odors or perfumes, smoke), Exercise, stress or emotional upset, Sinusitis with postnasal drip , Medications,(aspirin and beta blockers) Viral respiratory infections(most common cause) a nd Gastroesophageal reflux. Most people who have asthma are sensitive to a variety of triggers by MA

Cont.. Asthma can be classified in to 3 types Allergic (atopic) /IgE-mediated/extrinsic/, Nonallergic ( idiosyncratic ) and Mixed In general asthma which has its onset early in life tends to have strong allergic component, where as asthma that develops late in life tends to be nonallergic or to have mixed etiology. by MA

Comparison of the two major types of Asthma by MA

Pathophysiology of asthma by MA

. ; Mucus plag Broncho spasm Mucus formation Inflamed bronchial tisue

Asthma: Pathophysiology

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Pathologic features of asthma Inflammatory cell infiltration of the airways Increased thickness of the bronchial smooth muscle Partial or full loss of the respiratory epithelium Subepithelial fibrosis Hypertrophy and hyperplasia of the submucosal glands and goblet cells Partial or full occlusion of the airway lumen by mucous plugs Enlarged mucous glands and blood vessels

Asthma cont’d… by MA Clinical manifestation The most common three symptoms are:- Cough Dyspnea Wheezing (Prolonged expiratory phase) may have Chest tightness and Nocturnal Cough/Breathlessness Activity Induced Cough/Wheeze If exacerbation progresses:- Diaphoresis Tachycardia Central cyanosis (hypoxemia)

Asthma cont’d… by MA C/M… Hypoxia Confusion Increased heart rate & blood pressure Respiratory rate up to 40/minute Use of accessory muscles Flaring nostrils

Symptomatology Cough – 90% Wheezing – 74% Exercise induced wheeze or cough – 55% Ind J Ped 2002;69:309-12

Typical features of Asthma Afebrile episodes Personal atopy Family history of atopy or asthma Exercise /Activity induced symptoms History of triggers Seasonal exacerbations Relief with bronchodilators Asthma by Consensus, IAP 2003

Asthma cont’d… by MA Diagnosis Hx Physical examination Chest X-ray Sputum increase CBC- eosinophills Lung Function Tests Arterial blood gas analysis and pulse oximetry

History taking (Ask) Has the child had an attack or recurrent episode of wheezing (high-pitched whistling sounds when breathing out)? Does the child have a trouble some cough which is particularly worse at night or on waking ? Is the child awakened by coughing or difficult breathing ? Does the child cough or wheeze after physical activity (like games and exercise) or excessive crying? Does the child experience breathing problems during a particular season?

History taking (Ask) Does the child cough, wheeze, or develop chest tightness after exposure to airborne allergens or irritants e.g. smoke, perfumes, animal fur? Does the child’s cold frequently ‘go to the chest’ or take more than 10 days to resolve? Does the child use any medication when symptoms occur? How often? Are symptoms relieved when medication is used? If the answer is ‘yes’ to any of the questions, a diagnosis of asthma should be considered

Physical Examination/Look/ What all features one should look for specifically? Dyspnea Expiratory wheeze- an unreliable sign to gauge severity of attack Accessory muscle movement/signs of RD&RF Difficulty in feeding, talking, getting to sleep Irritability “ Silent chest” is ominous sign of impending respiratory failure CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look for specifically? Cough Persistent/ recurrent / nocturnal/ exercise-induced Associated conditions Eczema Allergic Rhinitis Weight/Height Pulsus paradoxus (drop in systolic BP during inspiratory cycle >10)

What all investigations can be performed in asthmatic children? (PERFORM) Peak expiratory flow rate: It is highly suggestive of asthma when: Bedside spirometry provides a rapid, objective assessment of patients. The (FEV 1 ) and the (PEF) rate Pulse oximetry. Arterial blood gas to assess for hypoventilation A normal or slightly elevated PaCO 2 (e.g., >42 mm Hg) indicates extreme airway obstruction OR >20% In children on bronchodilator 1. Asthma by Consensus, IAP 2003 2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

Diagnosing Asthma: Spirometry Testing of lung function is one means of diagnosing asthma .

Classifying Severity of Asthma Exacerbations Symptoms and Signs Initial PEF (or FEV 1 s) Response to Treatment before ED. Mild Dyspnea only with activity PEF 70% predicted Prompt relief with inhaled SABA. Moderate Dyspnea interferes with or limits usual activity PEF 40%–69% predicted Relief from frequent inhaled SABA. Symptoms for 1–2 d after oral corticosteroids begun. Severe Dyspnea at rest; interferes with conversation PEF <40% predicted Partial relief from frequent inhaled SABA. Symptoms for 3 d after oral corticosteroids begun. life-threatening Too dyspneic to speak; perspiring PEF <25% predicted Minimal or no relief from frequent inhaled SABA.

Severity of asthma severe imminent failure Breathlessness- On lying down Speaking-Words cannot speak Level of consciousness- confused Always agitated Breathing rate->30/min Muscle retraction- Usually paradoxical movements Wheezing- Very strong absent Pulse/minute->120 bradycardia

Management Of Acute Asthma Aims Of Management To prevent death To relieve respiratory distress To restore the patient’s lung function to the best possible level as soon as possible. To prevent early relapse

Management cont… The management depends on the severity of asthma Mild Moderate Severe Normal mental status Agitated Agitated and confused Little or no accessory muscle use Mild to moderate accessory muscle use Significant accessory muscle use So2 >95 % SO2 = 90-95 % So2 <90 Talks in sentences Talks in phrases Talks in single words or unable to talk Wheeze and normal breath sound Wheeze and decrease breath sound Wheeze and significant decreased breath sound or absent breath sounds

Asthma Treatments Classified into Controllers and Relievers Controllers – medications to be taken on daily long term basis. - Achieve and maintain control of persistent asthma Relievers – medications to be used on as-needed basis to relieve symptoms quickly/Rescuers/ - Treat symptoms of exacerbations

Asthma Management Algorithm

…In patient asthma management criteria Patients who are diagnosed to have severe and life threatening asthma need in patient management. Some may even need admission to ICU. Signs of Severity of acute asthmatic attack 1) Tachycardia HR > 120/min , Tachypnea RR.30b/min 2) Presence of pulsus paradoxus 3) Use of accessory muscles of respiration 4) Cyanosis by MA

In patient asthma management criteria … 5) Altered state of consciousness ( confusion, drowsiness) 6) Silent chest 7) Presence of complications : Pneumothorax , atelectasis 8) Unable to finish a sentence with single breath ( frequent interruption of speech to take a breath ) 9 ) Laboratory parameters o PaO2 < 60mmHg o PaCO2 > 42 mmHg by MA

Asthma treatment can be administered in different ways/routes – inhaled, oral, injection. Advantage of inhaled therapy – -drugs are delivered directly into the airways, -producing higher local concentrations -less risk of systemic side effects. Inhaled medications for asthma are available as pressurized MDIs, DPIs, soft mist inhalers and nebulized or ‘wet’ aerosols.

The basic principles in the management of acute excacerbation of asthma Assess the severity of the attack Use inhaled short-acting beta agonists early and frequently . Start systemic glucocorticoids if there is no an immediate and marked response. Make frequent (every one to two hours) objective assessments of the response Admit patients who do not respond well after four to six hours.

Standard treatments/ Bronchdilators Inhaled beta agonist: / Albuterol,Salbutamol ( ventolin ) Give albuterol 2.5 to 5 mg every 20 minutes for three doses by nebulization , or 4 to 8 puffs every 20 minutes for up to four hours. Alternatively, for severe exacerbations , 10 to 15 mg can be administered by continuous nebulization over one hour Acts in minutes, lasts 4 to 8 hours Short-term relief of bronchoconstriction Treatment of choice in acute exacerbations

Standard treatments cont … Oxygen: give sufficient oxygen to maintain SaO 2 ≥92 percent (>95 percent in pregnancy ) IV: establish intravenous access; may give bolus of normal saline for prolonged episode to replace insensible losses Ipratropium bromide: give 500 mcg by nebulization every 20 minutes for 3 doses, or 8 puffs by MDI with spacer every 20 minutes as needed for up to 3 hours

Standard treatments cont …/ Antiiflammatory / Systemic glucocorticoids: For patients with impending respiratory failure, give methylprednisolone 60 to 125 mg IV. For the majority of less severe asthma exacerbations, give prednisone 40 to 60 mg orally; Alternatives include: dexamethasone 6 to 10 mg IV or hydrocortisone 150 to 200 mg IV; Glucocorticoids may be given IM or orally if IV access is unavailable.

Anti inflammatory drugs Corticosteroids (e.g., beclomethasone ) Suppress inflammatory response Inhaled form is used in long-term control Systemic form to control exacerbations and manage persistent asthma Do not block immediate response to allergens, irritants, or exercise Do block late-phase response to subsequent bronchial hyperresponsiveness Inhibit release of mediators from macrophages and eosinophils Mast cell stabilizers Inhibit release of histamine

Leukotriene modifiers Leukotriene – potent bronchco -constrictors and may cause airway edema and inflammation Have broncho -dilator and anti-inflammatory effects Take home Predinsone Predinsolon Methyl predinsolon Glucosteroide Corticosteroide

Additional treatments Magnesium sulfate( do smooth muscle relax): give 2 g (8 mmol ) IV over 20 minutes for life-threatening exacerbations and exacerbations that remain severe after one hour of intensive bronchodilator therapy Epinephrine/Adrenaline(1:1000 ) ( do Bronchodilator) up to a maximum of 0.2 ml in children for adult ( 0.3 to 0.5 ml IM/SC ): for patients suspected of having an anaphylactic reaction or unable to use inhaled bronchodilators. for severe asthma unresponsive to standard therapies

Additional treatments cont … Terbutaline : may be given 0.25 mg by SC injection every 20 minutes times 3 doses for severe asthma unresponsive to standard therapies; Give terbutaline OR epinephrine but not both Combination Medications Available for Asthma Ipratropium and albuterol ( Combivent ) Nebulizer 3 ml q 20 min X 3 doses MDI 4 to 8 puffs q 20 min X 3

Additional treatments Loading dose of : Theophyline 5-7mg/kg IV or PO , not to exceed 25mg/kg/min IV or Aminophyline : 6-7mg/kg IV/PO; IV infused over 20minutes Maintenance of; 0.4-0.6mg/kg/ hr IV or4.8-7.2mg/kg PO,theophyline or If administering Aminophyline increase dose by 25%.

Adverse effects of Aminophyline Peak serum concentration<20mcg/ml CNS :Headache ,insomnia ,irritability , restlessness, seizure GI: diarhea,nausea,vomiting , Renal : diuresis , Skin : exfoliative dermatitis Cardiac : Techycardia,flater Peak serum concentration>30mcg/ml Acute MI Seizures(resistant to anticonvulsants) Urinary retention

Noninvasive Positive Pressure Ventilation(NPPV) Shown significant reductions in hospitalization rate, and respiratory rate benefit. Still the role of NPPV in patients with severe acute asthma remains uncertain. NPPV should not be initiated in patients with suspected pneumothorax

Endotracheal intubation and ventilation The decision to intubate during the first few minutes of a severe asthma attack is clinical . Slowing of the respiratory rate, Depressed mental status, Inability to maintain respiratory effort, or Severe hypoxemia

Mechanical Ventilation(MV) The goal of mechanical ventilation is: To maintain adequate oxygenation and ventilation while minimizing elevated airway pressures. This is accomplished by: Using high inspiratory flow rates (80 to 100 L/min ), Low tidal volumes (6 to 8 ml/kg), and Low respiratory rates (10 to 14/minute ).

Complications of MV in asthmatic patients Increased airway resistance may lead to: Extremely high peak airway pressures, Barotrauma, and Hemodynamic impairment. Mucous plugging, often leading to: Increased airway resistance, Atelectasis, and Pulmonary infection .

MONTORING AND FOLLW UP Monitoring is essential to maintain control and establish the lowest step and dose of treatment to minimize cost and maximize safety. If asthma is not controlled , step up the treatment. Improvement is generally seen within 1 month. If asthma is partly controlled , consider stepping up treatment, depending more effective options available, safety and cost of possible treatment and patient’s satisfaction with the level of control achieved. If controlled asthma is maintained for at least 3 months , step down with a gradual, stepwise reduction in treatment. The goal is to decrease treatment to the least medication necessary to maintain control.

Stepwise Approach to Therapy for Adults and Children: Maintaining Control STEP 1 Quick-relief medication: PRN STEP 2 1 Long-term-control medication: anti-inflammatory (Preferred low-dose ICS) STEP 3 > 1 Long-term-control meds (Preferred low dose ICS+LABA) STEP 4 Multiple long-term-control medications, including prednisone STEP 1 Mild Intermittent STEP 2 Mild Persistent STEP 3 Moderate Persistent STEP 4 Severe Persistent Step Up Step Down

Assess severe attack Severe attack : a) Unable to complete sentences b) RR>25/min c) PR>110 bpm d) PEF< 50% of predicted or best Life-threatening attack: a) PEF<33% of predicted or best b) Silent chest , cyanosis, feeble respiratory effort c) Bradycardia / hypotension d) Exhaustion, confusion, or coma e) ABG : normal/high P a CO 2 >( 36mmHg) P a O 2 < ( 60mmHg) low pH, e.g. < 7.35

Status asthmatics by MA Severe & persistent asthma that does not respond to conventional therapy can be experienced as a complication. Pts aware of increasing chest tightness, wheezing, and dyspnea that are often not or poorly relieved The attacks can last longer than 24 hours.

Status asthmaticus … Severe, life-threatening attack refractory to usual treatment where patient poses risk for respiratory failure Increase frequency & dose of bronchodilators Continuous -adrenergic agonist nebulizer therapy may be given IV corticosteroids Continuous monitoring Supplemental O 2 to achieve values of 90% IV fluids are given due to insensible loss of fluids Mechanical ventilation is required if there is no response to treatment

Status Asthmaticus … by MA Nursing management Constantly monitors the patient for the first 12 to 24 hours. Assesses the patient’s skin turgor to identify signs of dehydration. Fluid intake is essential to combat dehydration, to loosen secretions & to facilitate expectoration. Room should be quiet and free of respiratory irritants

Start treatment immediately Sit patient up & give high dose O 2 in 100% via non-rebreathing bag Salbutamol 5mg (or terbutaline 10mg) + ipratropium bromide 0.5 mg nebulized with O 2 Hydrocortisone 100mg IV/prednisolone 30 mg PO (both if very ill) CXR to exclude pneumothorax If life threatening features (above) present: Inform ICU, and seniors Add MgSO 4 1.2-2g IV over 20 min Give Salbutamol nebulizers every 15 min, or 10mg continuously per hour

Post-attempt…. If patient still not improving Discuss with seniors. Repeat salbutamol nebulizers every 15 mins MgSO 4 1.2-2g IV over 20 min, unless already given. Consider aminophylline, if not already on a theophylline. Alternatively, give salbutamol IV. Monitoring the effects of treatment Repeat PEF 15-30min after initiating treatment Pulse oximeter monitoring: maintain SaO 2 >92 %. Check blood gases within 2h if:initial PaO 2 was normal/ raised or initial PaO2 <(60mmHg) or patient deteriorating Record PEF pre- and post- β -agonist in hospital at least 4 times.

Once patient improving… Once patient is improving Wean down and stop aminophylline over 12-24 h. Reduced nebulized salbutamol and switch to inhaled β -agonist. Initiate inhaled steroids and stop oral steroids if possible Continue to monitor PEF. Look for deterioration on reduced treatment and beware early morning dips in PEF Look for the cause of the acute exacerbation and admission

Further management If improving 40-60% O 2 Prednisolone 30-60mg/24h PO Nebulized salbutamol every 4 h Monitor peak flow and O 2 saturations If not improving after 15-30min Continue 100% O 2 and steroids Hydrocortisone 100mg IV or prednisolone 30mg PO if not already given Give Salbutamol nebulizers every 15 min, or 10 mg continuously per hour Continue ipratropium 0.5 mg every 4-6h

TO Summarize Wheezing in children A wheeze is a high-pitched whistling sound near the end of expiration It is caused by obstruction of intrathoracic airways The most common causes of infantile wheezing are viral respiratory infections and asthma

To summarize… Asthma is an inflammatory illness Diagnosis of asthma is clinical , and relies on history All asthma does not wheeze ALL THAT WHEEZES IS NOT ASTHMA In children < 3 yrs , ALRTI is an important differential diagnosis A family history of asthma / atopy increases risk of asthma Diagnosis

To summarize… Goals of Asthma Treatment Prevent and treat acute episodes of asthma Control chronic and nocturnal symptoms Maintain normal activity , including exercise Minimize ER visits and hospitalizations Minimize need for reliever medications Maintain near-normal pulmonary function Avoid adverse effects of asthma medications

To Summarize… To Manage asthma There are two general classes of asthma medications: Quick-relief medications for immediate treatment of asthma symptoms and exacerbations And long-acting medications to achieve and maintain control of persistent asthma by MA

To summarize… Patient education is a very important part of asthma management Drugs control , but do not cure asthma Clinical grading over time, decides long term management plan Mild intermittent asthma does not merit controllers Inhaled steroids are mainstay of long term asthma management Treatment should be stepped up or stepped down depending upon patient response Long term management

To summarize… by MA The nurse generally performs the following tasks: Obtains a history of allergic reactions to medications before administering medications. Identifies medications the patient is currently taking. Administers medications as prescribed and monitors the patient's responses to those medications.

Cont.. An antibiotic may be prescribed if the patient has an underlying respiratory infection. Administers fluids if the patient is dehydrated and one should be cautious in fluid administration. Oxygen is given at health centers or hospitals if the patient is hyopxemic (achieve O2 saturation of 95%) by MA

To summarize … Therapies not recommended f or treating asthma attacks include: Sedatives (strictly avoid) Mucolytic drugs (may worsen cough) Hydration with large volumes of fluid Antibiotics (do not treat attacks but are indicated for patients who also have pneumonia or bacterial infection such as sinusitis) by MA

To summarize… Complications of Asthma Status asthmatics Respiratory failure Pneumonia, Atelectasis Hypoxia and dehydration by MA

For general knowledge by MA

Normal Arterial and Venous Blood Gases analysis Normal Arterial and Venous Blood Gases Blood Gas Components Arterial and Venous blood respectively pH 7.35–7.45 and 7.31–7.41 PO2 80–100 mm Hg and 35–40 mm Hg PCO2 35–45 mm Hg and 41–51 mm Hg HCO3 22–26 mEq /L or mmol /L and 22–26 mEq /L or mmol /L Base Excess (BE) –2 to +2 mEq /L or mmol /L and –2 to +2 mEq /L or mmol /L O2 saturation 95%–100% and 68 %–77% by MA

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… cont Compensation: ■ Respiratory problem → the kidneys compensate by conserving or excreting HCO3 ■ Metabolic problem → the lungs compensate by retaining or blowing off CO2 by MA

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Thank you by MA

Reading assignment Atelectasis Lung abcess Lung cancer Pulmonary tuberculosis by MA

ATELECTASIS Closure or collapse of alveoli Described in relation to x-ray ﬁndings and S/S May be acute or chronic

Occurs most often in: Patients with a chronic airway obstruction Postoperative patient Immobilized patient with shallow, monotonous breathing Patient with lung cancer Patients with impaired cough mechanisms Patient with chronic chest pain

Pathophysiology Occur result of : Reduced ventilation Bronchial obstruction Excessive secretions Excessive pressure on the lung tissue Pleural effusion Pneumothorax Hemothorax Pericardial tumor growth

After the trapped alveolar air is absorbed into the bloodstream No additional air can enter into the alveoli because of the blockage The affected portion of the lung becomes airless and the alveoli collapse

Possible causes Altered breathing patterns Retained secretions Alterations in small airway function Prolonged supine positioning Restrictive defects Speciﬁc surgical procedures

Clinical Manifestations Dyspnea Cough Sputum production Tachycardia Tachypnea Pleural pain Central cyanosis Difﬁculty breathing in the supine position

Diagnostic Findings Chest auscultation Crackles are heard over the affected area Decreased breath sounds Chest x-ray may reveal Patchy inﬁltrates Consolidated areas Pulse oximetry may demonstrate L ow oxygen saturation ( less than 90%)

Management Goal To improve ventilation To remove secretions Improving ventilation Ambulation Deep-breathing exercises Incentive spirometry Coughing

Removing secretions Coughing Suctioning Chest physical therapy Chest percussion Postural drainage

Treatment for bronchial obstruction Bronchodilator Bronchoscopy Treatment of causative factors

Preventing Atelectasis in post-operative patient Change patient’s position frequently Encourage early mobilization from bed Encourage appropriate deep breathing and coughing Administer prescribed opioids and sedatives Perform postural drainage and chest percussion Institute suctioning to remove tracheobronchial secretions

LUNG ABSCESS Necrosis of the pulmonary parenchyma Caused by microbial infection The chest x-ray demonstrates a cavity of at least 2 cm

Risk factors Aspiration of foreign material Impaired cough reﬂexes Swallowing difﬁculties Alcoholism Esophageal disease Compromised immune function Altered state of consciousness

Causes The aspiration of infected mucus or tissue Inadequately treated bacterial pneumonia Presence of a foreign body within the lung Obstruction of an airway by tumor Septic emboli from other infected areas of the body Tuberculosis

Symptoms High swinging fever Breathlessness Cough Production of copious amounts of foul smelling sputum Haemoptysis Chest pains on breathing

Signs Fever Tachycardia Tachypnoea Chest wall tenderness Dull percussion note Poor air entry

Investigations C BC Chest X-ray Sputum culture Sputum AFB`s Blood culture

TREATMENT Objectives To clear abscess collection To treat underlying cause Non-pharmacological treatment Chest physiotherapy - postural drainage Improve nutritional status

Pharmacological treatment Antibiotics Cloxacillin , IV, 500 mg 6 hourly for 14 days Plus Gentamicin, IV, 40-80 mg 8 hourly for 14 days Plus Metronidazole, IV, 500 mg 8 hourly for 14 days

LUNG CANCER The leading cancer killer among men Risk Factors Tobacco Smoke Secondhand Smoke Environmental and Occupational Exposure Arsenic Asbestos Mustard gas Chromates Coke oven fumes Oil and radiation Genetics

Pathophysiology Arise from a single transformed epithelial cell Carcinogen binds to epithelial cell in the tracheobronchial airways Damages the cell’s DNA Results in cellular changes and abnormal cell growth DNA undergoes further changes and becomes unstable The pulmonary epithelium undergoes malignant transformation

Clinical Manifestations The signs and symptoms depend on The location and size of the tumor The degree of obstruction The existence of metastases

Dry, persistent chronic cough Dyspnea Hemoptysis or blood-tinged sputum Chest or shoulder pain Recurring fever On late stage patient produce bloody sputum

Diagnostic Findings Ches t x-ray reveal pulmonary nodule (coin lesion) CT scans identify small nodules Sputum cytology Fiberoptic bronchoscopy

Medical Management Treatment depends on The cell type The stage of the disease The patient’s physiologic status

Treatment involves Surgery Radiation therapy Chemotherapy Combination

Surgical resection Lobectomy : a single lobe of the lung is removed Bilobectomy : two lobes of the lung are removed Sleeve resection : cancerous lobe(s) is removed and a segment of the main bronchus is resected Pneumonectomy : removal of entire lung Segmentectomy : a segment of the lung is removed Wedge resection : removal of a small, pie-shaped area of the segment

Radiation Therapy Controlling neoplasms that cannot be surgically resected May be used To reduce the size of a tumor To make an inoperable tumor operable To relieve the pressure of the tumor on vital structures

Chemotherapy Used to Alter tumor growth patterns Treat distant metastases Adjunct to surgery or radiation therapy The choice of agent depends on the growth of the tumor cell Combinations of two or more medications may be used

Pulmonary Tuberculosis Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma but almost all organs can be affected, including “ the intestines, bones, joints, skin, the genitourinary, lymphatic, and nervous systems. TB is the most common infectious disease in the world today. To date, TB ranks seventh as a global cause of death. The primary infectious agent, Mycobacterium tuberculosis ( acid-fast, aerobic, rod and non motile) Mycobacterium bovis and Mycobacterium avium by MA

Cont.. TB has been recognized as major cause of morbidity and mortality in Ethiopia. TB is the second only HIV the major cause of death infectious diseases. 8.7 million incident cases and 1.4 million death 1 million deaths in HIV negative. 340000 deaths in HIV positive by MA

Cont.. Co infection with HIV significantly increases the risk of developing Active TB and HIV has become the most important risk factor to develop active TB. In HIV- infection increased risk by more than 10 times compared to those who are HIV negative. about 40% of adult TB cases in urban areas are HIV positive. by MA

Conti.. The incidence and prevalence of tuberculosis, in recent years has doubled or tripled because of the HIV pandemic, especially in developing countries. It is also shown that active tuberculosis can result in rapid progression of HIV infection in a patient. by MA

TB classification Based on site Pulmonary tuberculosis (PTB): lung parenchyma. Extra pulmonary tuberculosis (EPTB): other Military TB : Spread by MA

TB classification conti ---- Pulmonary TB (PTB): accounts for 85 % of all TB cases, and it is further classified in: Smear-positive PTB: comprises 75 – 80% of PTB cases, worldwide Smear-negative PTB: comprises 20 – 25% of PTB cases, worldwide by MA

2. Extra-pulmonary TB (EPTB): TB infecting other than lung EPTB can affect any organ in the body including: Cervical lymph glands (most common). Bone (particularly the spine). Pleural cavity (causing pleural effusion). Kidney and genitourinary tract. Intestines and peritoneum. Pericardium. Skin. Accounts for 15% of all TB cases. by MA

Cont.. EPTB Is treatable in most forms, The lasting damage may be permanently crippling (in the case of spinal TB) or even fatal (in TB meningitis). Bacillary load, extent of disease Anatomical site determine the severity of extra-pulmonary Tb. One of the most lethal forms of EPTB is tuberculosis meningitis. Extra-pulmonary TB is common in patients infected with HIV. by MA

Miliary tuberculosis is characterized by a chronic, contagious bacterial infection caused by Mycobacterium tuberculosis that has spread to other organs of the body by the blood or lymph system. by MA

TB Classification Bacteriology (result of sputum smear ) Pulmonary tuberculosis, sputum smear-positive (PTB+) At least one sputum smear examinations positive for AFB, or One sputum smear examination positive for AFB plus radiographic abnormalities consistent with active PTB, or One sputum smear positive for AFB plus sputum culture positive for M. tuberculosis. Pulmonary tuberculosis, sputum smear-negative (PTB- ) If a patient has symptoms suggestive of TB, at least two sputum examinations negative for AFB, and radiographic abnormalities consistent with active pulmonary TB, the patient should receive a full course of anti-TB therapy. by MA

Pulmonary Tb A person is a suspect of Pulmonary Tuberculosis when presenting with persistent cough for two weeks or more Cough is usually with expectoration , with or without blood stained sputum and can be accompanied by one or more of the following symptoms: Weight loss; Chest pain; Shortness of breath; Intermittent fever; Night sweats; Loss of appetite; Fatigue and malaise. by MA

Extra-pulmonary TB The signs and symptoms of Extrapulmonary Tuberculosis ( EPTB) depend mainly on the organ(s) involved Tuberculosis lymphadenitis Slowly developing and painless enlargement of lymph nodes, followed by matting and eventual drainage of pus. Tuberculosis pleurisy Pain while breathing in, dull lower chest pain, intermittent cough, breathlessness on exertion. by MA

Extra-pulmonary TB TB of bones and/or joints Localized pain and/or swelling, discharge of pus, muscle weakness, paralysis, stiffness of joints. Intestinal TB Loss of appetite and weight, abdominal pain, diarrhoea or constipation, mass in the abdomen, fluid in the abdominal cavity ( ascites ). Tuberculosis meningitis Headache, fever, vomiting, neck stiffness and mental confusion of insidious onset by MA

Pallor, clubbing and inspiratory crepitation General discomfort, uneasiness, or ill feeling ( malaise ) by MA

Some of the main risk factors for TB include: History of TB, personally, or amongst friends or family Compromised immunity due to illness, e.g., HIV infection. Migration from a country with a high incidence of TB. History of travel to an area with a high incidence of TB. Alcohol and/or drug abuse. Malnutrition. Homelessness. by MA

TB Transmission TB is spread when an infectious person coughs, sneezes, talks or sings, releasing droplets containing the bacilli into the air. However, TB can also be spread when TB bacilli are aerosolized by treatments, such as irrigating a wound that is infected with TB. In either case, a susceptible person inhales the airborne droplets, which then traverse the upper respiratory tract and bronchi to reach the alveoli of the lungs. by MA

Factors that facilitate transmission of pulmonary tuberculosis are Infectivity of the contact ( patients with heavy bacterial load) Environment: overcrowding Duration of contact ( prolonged exposure ) Intimacy (how close the source and the subject are) Host factor (HIV, DM, Immunocompromised , malnutrition, leukimia , renal failure, extreme ages ……..) by MA

Natural history of TB Latent TB infection (90-95%) Active TB disease (5-10%) Post-primary pulmonary TB (>85%) 20-25% would have natural healing 25-30% would remain chronically ill 50% deaths within 5 years-if untreated by MA

Risk factors for developing active TB The risk depends on a number of factors : Host immune defences : – HIV infection (risk multiplied by 20-40); – Diabetes mellitus (risk multiplied by 3-5); – Malnutrition; – Prolonged therapy with corticosteroids (such as prednisolone ) and other immuno - suppressive therapies; – Certain types of cancer (e.g., leukaemia , Hodgkin's lymphoma, or cancer of the head and neck); by MA

Risk conti …… – Severe kidney disease; – Alcoholism; – Substance abuse; – Age: • Young children (children under 5 have twice the risk and higher risks are observed for those under 6 months); • Persons over sixty years have 5 times the risk; – Pregnancy by MA

Risk conti …… 2. Conditions that damage the lung : – Tobacco smoking; – Silicosis . 3. Intensity of exposure (number of inhaled bacilli): – Contagiousness of the source; – Environment and proximity in which the exposure took place; – Duration of exposure; – Residents and employees of high-risk congregate setting by MA

Pathophysiology M. tuberculosis enters the body mostly via respiratory tract. Bacteria interacts with host immune system immediately after entry. Activated alveolar macrophages ingest the bacilli Small areas in the lung infected with the bacilli gradually merge to form a bigger lesion filled with infected material. This material can become liquid, which is then coughed out, leaving a cavity in the lung. by MA

Pathophysiology Entrance of mycobacterium Granulomatous inflammatory process occurs within the lung called __ primary ( ghon ) focus Bacilli drain via lymphatics to the regional lymph nodes.-- Primary ( ghon ) complex Nodes bacilli enter the systemic circulation directly or via the lymphatic duct--- target organ effect by MA

Assessment and Diagnostic Findings A complete history, physical examination, tuberculin skin test, chest x-ray, acid-fast bacillus smear, and sputum culture are used to diagnose TB. If the patient is infected with TB, the chest x-ray usually reveals lesions in the upper lobes, and the acid-fast bacillus smear contains mycobacteria . by MA

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Diagnostic methods All suspects of any form of TB must be examined according to the standardized diagnostic procedures microscopic examination of sputum is the most important and reliable. By rank of importance the diagnostic methods to confirm/exclude TB are: • Microscopic examination of sputum smears • Radiological investigation • AFB culture • Histo -pathology by MA

Microscopic examination of sputum smears Most efficient way of identifying sources of tuberculosis infection, and the primary tool for diagnosing TB Reliability depends on the quality of sputum. Every patient suspected TB should summit at least two sputum If done correctly 80 % of TB found in first sample. 15% in the second sample Two samples collected one hour apart. by MA

Conti----------- If one of the sputum plus suggestive symptoms Report positive If negative treat with broad spectrum ABC and appoint after 10 days. If improve continue ABCS If no treat as smear TB by MA

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TB treatment Once diagnosed, patients should be classified by whether they have had previous treatment for TB, and its outcome. This helps to identify patients at increased risk of drug resistance and to prescribe appropriate treatment . by MA

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Management The main objectives of anti-TB treatment are to: Cure the patient of TB (by rapidly eliminating most of the bacilli); Prevent death from active TB or its late effects Prevent relapse of TB (by eliminating the dormant bacilli); Prevent the development of drug resistance (by using a combination of drugs); Decrease TB transmission to others. by MA

Management conti ….. Chemotherapy is considered to be adequate when it: Rapidly and substantially reduces the number of actively multiplying bacteria. Cures patients. Prevents relapse of the disease Prevents the development of resistance to the drugs. by MA

Management General measures Promoting airway clearance, Increasing fluid intake promotes systemic hydration and serves as an effective expectorant and postural drainage Emphasis on drug adherence unless resistance will develop and burden on community, nation Promoting activity and adequate nutrition by MA

Management High-calorie nutritional supplements may be suggested Instruct the patient to take the medication either on an empty stomach or at least 1 hour before meals. Be alert for side effects of medications and take proper measure. by MA

Group of Anti TB drugs Group 1 : First-line oral agents : Isoniazid (H);Rifampicin (R); Ethambutol (E); Pyrazinamide (Z); Rifabutin ( Rfb ) Group 2: Injectable agents : Kanamycin (Km); Amikacin(Am); Capreomycin (Cm); Streptomycin (S) Group 3: Fluoroquinolones : Moxifloxacin ( Mfx ); Levofloxacin ( Lfx ) Group 4: Oral bacteriostatic second-line agents : Ethionamide ( Eto ); Cycloserine (Cs); para-aminosalicylic acid (PAS) by MA

Conti….. 5. Group 5 : Agents with unclear role in DR-TB treatment : Clofazimine ( Cfz ); Linezolid ( Lzd ); Amoxicillin/ clavulanate ( Amx / Clv ); Thioacetazone ( Thz ); Imipenem / cilastatin ( Ipm / Cln ); High-dose isoniazid (High-dose H). by MA

TB treatment Category TB treatment Category Patient Drugs Category 1 New smear positive patients; new smear negative patients with extensive parenchymal involvement; concomitant HIV disease or severe forms of extrapulmonary TB DOTs short course HRZE/S for 2 months + HR 4 MO Category 2 Relapse Treatment Failure Return after Default Retreatment 2HRZES+1RHZE 5ERH Category 3 Smear negative PTB with limited EPTB HRZE/S for 2 months + HR 4 MO Category 4 Chronic Case 2nd Line Anti TB drugs by MA

Points on TB Rx For category I and III patients, treatment with the drugs recommended by WHO is divided into two phases: Initial intensive phase – four drugs given daily (isoniazid, rifampicin, pyrazinamide, and ethambutol ) in fixed dose combination, and directly observed for at least 2 months. This rapidly improves clinical symptoms and reduces the bacterial population without allowing drug resistance. by MA

Cont.. 2. Continuation phase – a combination of two drugs (isoniazid and rifampicin) in fixed dose combination, three times per week, for 4 more months to eliminate remaining bacilli and prevent relapse. For category II , the initial phase is 2 months of daily drug treatment with isoniazid, rifampicin, pyrazinamide, ethambutol and streptomycin . The continuation phase For one month 1(ERHZ) and 5 months with isoniazid, rifampician and ethambutol . 5REH by MA

Points on TB Rx Primary drug resistance : resistance to one of the first-line antituberculosis agents in a person who has not had previous treatment. Secondary or acquired drug resistance : resistance to one or more antituberculosis agents in a patient undergoing therapy. Multidrug resistance : resistance to two agents, isoniazid (INH) and rifampin . XDR-TB Extensively Drug Resistant Tuberculosis r esistance to at least rifampicin and isoniazid , in addition to any fluoroquinolone , and to at least one of capreomycin , kanamycin and amikacin. by MA

Side Effects of common Anti TB drugs and Treatment of side effects by MA

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Important points to consider in the treatment of tuberculosis: Streptomycin should not be given to pregnant woman, and patients with renal failure and ear problems. It should be replaced by Ethambutol . Streptomycin dose should not be more than 750mg if the patient's age is > 50 years. Children who are 6 years or below should not be given Ethambutol because of damage to the eyes and children may not complain of it. Patients should be strictly followed after initiation of the drugs. by MA

Elements of the DOTS Strategy The DOTS Strategy remains at the heart of the Stop TB Strategy. It combines five elements or essential principles that must be fully implemented to achieve effective TB control: Political commitment to effective TB control. Case detection by sputum smear microscopy among symptomatic people. by MA

Cont.. Standardized treatment regimen of 6-8 months with first-line anti-TB drugs, administered under proper case management conditions, including direct observation for the first two months. Uninterrupted supply of all essential anti-TB drugs. Standardized recording and reporting system, allowing monitoring and evaluation of treatment results. by MA

Prevention Prevention of Tuberculosis :Vaccination BCG Vaccination: infants children and youngster of tuberculin negative (vaccination is of course of no use in tuberculin-positive persons) Finding patients earlier Early Treatment and management of patients Prevention with medicines by MA

Complications Pneumothorax Bronchiectasis Empyema Extrapulmonary expansion Hemoptysis Chronic pulmonary heart disease by MA

Drug-resistant TB Drug-resistant TB (DR-TB) is a growing worldwide problem, with no country or region spared. Multidrug-resistant TB (MDR-TB) is defined as TB that is resistant to at least isoniazid and rifampicin. Extensively drug-resistant TB (XDR-TB) is defined as TB that is resistant to isoniazid and rifampin , any fluoroquinolone and at least one of three injectable second-line drugs (amikacin , kanamycin or capreomycin ) drug resistance in an individual could be microbial, clinical and/or programmatic by MA

MDR TB conti …… However, common causes are essentially man-made errors following an inadequate or poorly administered treatment regimen that allows a drug-resistant strain to become the dominant strain in a patient infected with TB. by MA

Conti…. Potential causes of inadequate treatment can be broadly categorized in to:- Health care factors: provider, program related factors Drug related factors Patient related factor by MA

Conti….. by MA

Epidemiology of Drug Resistant Tuberculosis Globally in 2012, there were an estimated 450 000 new cases of MDR-TB 3.6% of newly diagnosed TB cases 20 % of those previously treated cases are estimated to have MDR-TB. 94 000 TB patients eligible for MDR-TB treatment were detected in 2012. At least one case of extensively drug-resistant TB (XDR-TB) had been reported by 92 countries by the end of 2012. by MA

MDR TB epidemiology conti … Globally 9.6% of MDR-TB cases are estimated to be XDR-TB Global Plan to Stop TB 2011–2015 sets targets To screen 20% of all new bacteriologic ally positive TB cases All previously treated cases with DST for at least rifampicin and isoniazid , Planned to perform SLDs DST for all patients with MDR-TB. by MA

MDG TB epidemiology conti …. However, in 2012, only 5% of new and 9% of previously treated cases was tested for MDR-TB In Ethiopia, FLD DST was performed for 469(<1%) new and 180(4%) re-treatment TB cases, respectively, in 2012 to confrm 284 MDRTB; 30 among new and 102 among previously treated cases. by MA

National DR-TB Control Framework It addresses TB/HIV and MDRTB, health system strengthening, engagement community and all care providers and operational researches in addition to DOTS addressing multidrug-resistant TB will strengthen the existing TB control program . It requires by MA

National DR-TB Control Framework Sustained political commitment Addressing the factors leading to the emergence of MDR-TB Long-term investment of staff and resources Coordination of efforts between communities, local governments and international agencies A well-functioning DOTS program by MA

National DR-TB Control Framework Appropriate case-finding strategy including quality-assured culture and drug susceptibility testing (DST) • Rational triage of patients into DST and the DR-TB control programmed • Relationship with supranational TB reference laboratory Appropriate treatment strategies that use second-line drugs under proper case management conditions Rational treatment design DOT Monitoring and management of adverse effects Properly trained human resources Active pharmacovigilance in the introduction of new drugs or novel regimens by MA

National DR-TB Control Framework Uninterrupted supply of quality-assured second-line anti-tuberculosis drugs Recording and reporting system designed for drug resistance-TB control programs by MA

MDR-TB Model of care National Tuberculosis Control program has shifted from the hospitalized model of care for DR-TB case management, to Clinic–based Ambulatory model of care More suitable for rapid decentralization of PMDT services in the local context and Creates better convenience for patient follow-up. by MA

Clinic-based Ambulatory Model of care designed to deliver the treatment course on outpatient basis so long as the clinical panel team decides that the patient is fit to ambulate. The place of temporary inpatient care is reserved mainly for patients who develop severe adverse events during the course of treatment . However , patients either with serious medical or social reason may be admitted, at referral centers, with the decision of the panel team. by MA

MDR-TB treatment centers In Ethiopia , health facilities could serve as either Treatment initiating centers (TIC) Treatment follow up centers (TFC) or Both. Treatment initiating centers (TIC): selected by the TB program to provide patient care and treatment services right from time of DRTB diagnosis and throughout the course of treatment with SLDs by MA

Conti… Authorized to Initiate treatment Perform all scheduled clinical evaluation and lab monitoring tests, Manage difficult cases and those with serious complications and/or ADR decide on the need of regimen modification when indicated. by MA

Responsibilities of Treatment Initiation center (TIC) Designate space for inpatient and outpatient MDRTB treatment service Involve in case finding process of DR-T handle all Patient preparation and initiation of treatment with SLDs Admit difficult cases and those with serious complications by MA

MDR TB treatment center Conti… Treatment follow up centers (TFC ): are health facilities with TB DOTS clinic where clinically stable patients continue to receive DOT for SLDs Perform routine screening of adverse events an Management with the aim to decentralize the delivery of treatment services closer to the patient residence. by MA

Responsibilities of Treatment follow up center (TFC) Manage all patients referred/transferred from treatment initiation center Involve in case finding process of DR-TB Routine screening of adverse events, supervise DOT and administer injection by MA

Phases of treatment in treatment delivery The national TB program designed the DR TB treatment to be delivered in three phases whereby the respective treatment centers have specific tasks and responsibilities at each phase in order to implement the standard patient care packages defined by the national guidelines. They are Phase I: Intensive phase: stabilization Phase II: Intensive phase: out patient Phase III: Continuation Phase by MA

Phases of treatment in treatment delivery Phase I: Intensive phase: stabilization Directed to ensure that patients are both clinically stable and adherent to SLDS The role of clinical team at TICs is more intensive to provide the necessary clinical, adherence and social support arrangements to enables the patient to be fit enough to be followed at TFC level Team responsible for patient preparation, regimen selection and treatment initiation & monitoring. by MA

conti ,…… Patient can start treatment at TFC level if the panel team decides to link the patient to TFC right from the start for daily DOT and administration of injection . TIC must handle patient preparation and treatment initiation and arrange weekly evaluation of the patient till stabilization and move to next phase. Or Patient can stay at TIC level till the panel team decides to transfer to next phase and link the patient to TFC to continue with phase II. by MA

Conti….. Criteria for transferring patients to next phase include : Clinical condition and satisfactory treatment adherence of the patient , Having satisfactory follow-up plan with the patient Arrangement with TFC and the TB program officer. by MA

Indication for in-patient care of MDRTB patients Patients who are not able to ambulate for medical or social reason Poorly controlled or complicated co-morbidities (diabetes, Liver failure, renal insufficiency, psychiatric illness, cardiac problems and substance dependency Patients from congregate settings (prisoners, refuges and homeless shelters ) Patient who developed serious ADR or other concomitant illness by MA

Conti….. XDR suspect/case or contact of presumed or known XDRTB case Adherence problems or with failing MDR regimens All confirmed or presumptive XDR-TB cases by MA

Phase II - Intensive phase out-patient In phase II, the clinical management of the patient is similar to stabilization phase, but now the patient has Stable clinical condition, Satisfactory adherence to treatment and Can be followed at TFC level, while tics continue to perform the scheduled monthly clinical and lab assessment of treatment. by MA

Conti…. TFC are responsible for daily dot supervision and routine screening of adverse events. Patient must be referred back to tic if they develop severe adverse events or serious medical condition requiring admission or expert evaluation by MA

Phase III – Continuation Phase The continuation phase of treatment is provided under directed supervision of either HCWs at TFC, HEWs at Health post or by family DOT provider, under close supportive supervision by the treatment follow up center. Supervision of treatment at home level must consider: Linkage with the responsible HEWs at HP to support treatment Patients clinical condition Availability and Capacity family DOT provider Demonstrated successful adherence to oral and injectable TB medicines by MA

Case-finding Strategies for DR-TB The national TB program recommends DST for selected group of patients based on treatment and contact history and information from recent national drug resistance survey. On the second round DRS performed in Ethiopia (2011-13), MDRTB prevalence is as shown in the table below by MA

Contin -------- by MA

Risk stratification for MDR TB by MA

Conti…. by MA

MDR-TB diagnostic Algorithm in Ethiopia by MA

Principles of Designing MDRTB Treatment Start with first line drugs if sensitivity confirmed Each MDR TB regimen will consist of at least four new drugs As standard all patients will receive Pyrazinamide , Kanamycin /Amikacin, Levofloxacin , Ethionamide , and Cycloserine Ethambutol is continued if DST suggests susceptibility to the drug. However, as most patients have already used Ethambutol for prolonged periods and DST for Ethambutol is not fully reliable, this drug will not count as one of the 4 effective drugs 'with certain effectiveness', even if the DST shows susceptibility by MA

Continued Pyrazinamide will be used throughout in all patients as resistance uncommon and no reliable DST available, but it will also not be counted as an effective drug . Kanamycin DST is used as a surrogate marker also for Amikacin. In case of resistance to Kanamycin /Amikacin, Capreomycin can be used as injectable and can be counted as effective drug. Ofloxacin DST is used as a surrogate marker for quinolone resistance. However, in case of resistance to Ofloxacin , Levofloxacin , a higher generation of quinolone , will be kept in the regime, unless Moxifloxacin is available which should then be used. In case of quinolone resistance neither Levofloxacin nor Moxifloxacin will count as one of the drugs 'with certain effectiveness'. Thus PAS is added when resistance to quinolones is confirmed. The drugs dosages are determined by body weight. by MA

MDR-TB Treatment Regimens in Ethiopia The standardized treatment regimen addresses 5 patient categories: Patients with MDR-TB confirmation, but no full DST results available yet: Regimen: E-Z-Km(Am )- Lfx - Eto -Cs MDR-TB Patients susceptible to both Kanamycin and Quinolone : Regimen is the same as above MDR-TB Patients susceptible to Kanamycin , but resistant to Quinolone : Regimen: E-Z-Km(Am)- Mfx - Eto -Cs-PAS MDR-TB Patients susceptible to Quinolone , but resistant to Kanamycin : Regimen: E-Z-Cm- Lfx - Eto -Cs XDR-TB Cases (i.e.: MDR-TB and resistance to Quinolone and Kanamycin ) Regimen : E-Z-Cm- Mfx - Eto -Cs-PAS Clinical team at M(X)DR-TB treatment referral hospital may modify the regimen after receiving the result of DST. by MA

Duration and Phases of Treatment Intensive phase : The injectable agent is used for minimum of 6 months and at least 4 months after culture conversion . Maximal bacillary load reduction is the aim noted by the presence of an injectable drug. Continuation phase : The total treatment is for minimum duration of 18 months beyond culture conversion ( eg . Pediatric patients receiving second line treatment with baseline culture negative result). injectable drug is discontinued and patient continues to take oral drugs if the culture is negative at completion of first month of MDR-treatment, intensive phase will be 6 months and continuation phase 13 months. by MA

Cont….. if culture conversion(- two consecutive negative cultures, from samples collected at least 30 days apart) is at completion of second months, intensive phase will be 6 months and continuation phase 14 months . If culture conversion is at completion of fourth months, intensive phase will be 8 months and continuation phase will be 14 months . Extension of therapy to 24 months may be indicated in chronic cases with extensive pulmonary damage. by MA

Standardized regimen in Ethiopia All newly diagnosed MDR-TB patients receive a standardized regimen. Intensive phase : 8 Z-Cm6-Lfx – Pto ( Eto ) – Cs Continuation phase : 12 Z- Lfx – Pto ( Eto ) -Cs by MA

Conti…. The following groups of DR-TB patients cannot receive the standardized regimen requiring either regimen modification or dose adjustment: History of previous exposure to second-line anti-TB drugs Patient who is household contact of a patient with RR-/MDR or XDR TB Children Pregnant Co-morbid diseases (Chronic renal dysfunction, HIV, Liver disease) by MA

DR TB AND NUTRITION Nutritional support is particularly important for MDR-TB patients. MDR-TB patients often are extremely wasted and have poor nutritional status. Second-line drugs can also decrease appetite, making adequate nutrition a greater challenge. Without nutritional support, patients, especially those already suffering from baseline malnutrition, can become enmeshed in a vicious cycle of malnutrition and disease. by MA

Nutrition Assessment Counseling and Support (NACS) Assess nutritional status of all DR TB Patients at every contact: Measure weight in kilograms to the nearest 100 grams and height in meters to the nearest centimeter at every visit and then calculate the BMI. If height or weight cannot be measured (e.g. Bed ridden or edematous or pregnant patient) measure the Mid Upper Arm Circumference (MUAC). Then compare the BMI or MUAC with the national nutrition guideline standards and classify the patient’s nutritional status. by MA

Thank u!! by MA

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