Nursing management of patient with Respiratory DO.pptx

12/10/2023 By Abdi Wakjira( Bsc, Msc) 1 NEKEMTE HEALTH SCIENCE COLLEGE Department of Nursing For Post Basic BSc Nursing Students Title: Nursing care of patient with Respiratory System Disorders

Objectives 12/10/2023 By Abdi Wakjira( Bsc, Msc) 2 At the end of this chapter students will able to:- Conduct the assessment of respiratory system Air way patency care in respiratory system disorder Describe upper respiratory system disorders and their managements Describe upper lower system disorders and their managements

Respiratory systems disorder 12/10/2023 By Abdi Wakjira( Bsc, Msc) 3 Anatomic and Physiologic Overview The respiratory system is composed of the upper and lower respiratory tracts. Upper Respiratory Tract consist of the nose , sinuses and nasal passages , pharynx , tonsils and adenoids , larynx , and trachea . warms and filters inspired air. Lower Respiratory Tract consists of the lungs , which contain the bronchial and alveolar structures needed for gas exchange . accomplish gas exchange. Together, the two tracts are responsible for ventilation (movement of air in and out of the airways).

Function of the Respiratory System 12/10/2023 By Abdi Wakjira( Bsc, Msc) 4 Provides oxygen to the blood stream and removes carbon dioxide Enables sound production or vocalization as expired air passes over the vocal chords Enables protective and reflexive non-breathing air movements such as coughing and sneezing, to keep the air passages clear Control of acid-base balance Control of blood ph

Diagnostic procedures Of Respiratory systems disorder 12/10/2023 By Abdi Wakjira( Bsc, Msc) 5 Pulmonary Function Tests: used in patients with chronic respiratory disorders. Complete blood count. Measurement of red blood cells and hemoglobin can give information about the oxygen-carrying capacity of the blood . Arterial Blood Gas Studies :- Measurements of blood pH and of arterial oxygen and carbon dioxide tensions The arterial oxygen tension ( PaO2) indicates the degree of oxygenation of the blood. The arterial carbon dioxide tension (PaCO2) indicates the adequacy of alveolar ventilation.

Diagnostic …. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 6 Sputum Studies used to: Identify pathogenic organisms Determine whether malignant cells are present. Assess for hypersensitivity states (in which there is an increase in eosinophils). Pulse Oximetry :- is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). C hest x-ray :_ ordered to help diagnose a variety of pulmonary disorders. Usually, posterior-anterior and side views (lateral) are taken.

Diagnostic…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 7 Computed Tomography is an imaging method in which the lungs are scanned in successive layers by a narrow-beam x-ray. Bronchoscopy :- is the direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. Thoracoscopy :- is a diagnostic procedure in which the pleural cavity is examined with an endoscope. Thoracentesis (aspiration of fluid or air from the pleural space) is performed for diagnostic or therapeutic reasons.

Chest Examination 12/10/2023 By Abdi Wakjira( Bsc, Msc) 8 Physical Examination. Vital signs, including temperature, pulse , respirations, blood pressure, and SpO2 (oxygen saturation obtained by pulse oximetry ), are important data to collect before examination of the respiratory system.

FOUR COMPONENTS OF A RESPIRATORY ASSESSMENT INSPECTION PALPATION PERCUSSION AUSCULTATION

INSPECTION 12/10/2023 By Abdi Wakjira( Bsc, Msc) 10 Nose. Inspect the nose for patency, inflammation, deformities, symmetry, and discharge. Check each naris for air patency with respiration while the other naris is briefly occluded. Tilt the patient’s head backward and push the tip of the nose upward gently . With a nasal speculum and a good light, inspect the interior of the nose.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 11 Mouth and Pharynx. Using a good light source, inspect the interior of the mouth for color, lesions, masses, gum retraction, bleeding , and poor dentition. Inspect the tongue for symmetry and lesions. Observe the pharynx by pressing a tongue blade against the middle of the back of the tongue. A normal response (gagging) indicates that cranial nerves IX (glossopharyngeal) and X ( vagus ) are intact and that the airway is protected

Cont ..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 12 Neck. Inspect the neck for symmetry and tender or swollen areas . Palpate the lymph nodes while the patient is sitting erect with the neck slightly flexed . Progression of palpation is from the nodes around the ears, to the nodes at the base of the skull, and then to those located under the angles of the mandible to the midline . The patient may have small, mobile, nontender nodes ( shotty nodes), which are not a sign of a pathologic condition. Tender , hard, or fixed nodes indicate disease.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 13 Thorax and Lungs. Picture imaginary lines on the chest to help identify abnormalities. Describe abnormalities in terms of their location relative to these lines (e.g., 2 cm from the right mid clavicular line ). Chest examination is best performed in a well-lighted, warm room with measures taken to ensure the patient’s privacy. Perform all physical assessment maneuvers (inspection, palpation, percussion, auscultation) on either the anterior or the posterior chest rather than moving from anterior to posterior or vice versa with each maneuver.

Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 14 Inspection- When inspecting the anterior chest , have the patient sit upright or with the head of the bed upright. The patient may need to lean forward for support on the bedside table to facilitate breathing. First , observe the patient’s appearance and note any evidence of respiratory distress, such as tachypnea or use of accessory muscles. Next , determine the shape and symmetry of the chest.

Inspection Cont ..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 15 Chest movement should be equal on both sides, and the AP diameter should be less than the side-to-side or transverse diameter by a ratio of 1:2. An increase in AP diameter (e.g., barrel chest) may be a normal aging change or result from lung hyperinflation. Observe for abnormalities in the sternum (e.g., pectus carinatum [a prominent protrusion of the sternum] and pectus excavatum [ an indentation of the lower sternum above the xiphoid process]).

Inspection Cont ..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 16 Next observe the respiratory rate, depth, and rhythm. The normal rate is 12 to 20 breaths/minute; in the older adult, it is 16 to 25 breaths/minute. Inspiration (I) should take half as long as expiration (E) (I:E ratio = 1:2).

Inspection Cont ..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 17 Observe for abnormal breathing patterns, such as Kussmaul (rapid, deep breathing), CheyneStokes (abnormal respirations characterized by alternating periods of apnea and deep, rapid breathing), or Biot’s (irregular breathing with apnea every four to five cycles) respirations. Skin color provides clues to respiratory status. Cyanosis, a late sign of hypoxemia, is best observed in a dark-skinned patient in the conjunctivae, lips, and palms and under the tongue .

Inspection Cont ..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 18 Inspect the fingers for evidence of long-standing hypoxemia known as clubbing (an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger)

Palpation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 19 Palpation. Determine tracheal position by gently placing the index fingers on either side of the trachea just above the suprasternal notch and gently pressing backward. Normal tracheal position is midline; deviation to the left or right is abnormal. Tracheal deviation occurs away from the side of a tension pneumothorax or a neck mass, but toward the side of a pneumonectomy or lobar atelectasis.

Palpation cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 20 Symmetry of chest expansion and extent of movement are determined at the level of the diaphragm. Place your hands over the lower anterior chest wall along the costal margin and move them inward until the thumbs meet at midline. Ask the patient to breathe deeply. Observe the movement of the thumbs away from each other. Normal expansion is 1 in (2.5 cm). Hand placement on the posterior side of the chest is at the level of the tenth rib. Move the thumbs until they meet over the spine. Check expansion anteriorly or posteriorly, but it is not necessary to check both.

Palpation cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 21 Normal chest movement is equal. Unequal expansion occurs when air entry is limited by conditions involving the lung (e.g ., atelectasis , pneumothorax) or the chest wall (e.g., incisional pain). Equal but diminished expansion occurs in conditions that produce a hyperinflated or barrel chest or in neuromuscular diseases (e.g., amyotrophic lateral sclerosis, spinal cord lesions ) . Movement may be absent or unequal over a pleural effusion , an atelectasis, or a pneumothorax.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 22 Fremitus is the vibration of the chest wall produced by vocalization . Tactile fremitus can be felt by placing the palmar surface of the hands with hyperextended fingers against the patient’s chest. Ask the patient to repeat a phrase such as “ninety-nine ” in a deeper, louder than normal voice. Move your hands from side to side at the same time from top to bottom on the patient’s chest. Fremitus is less intense farther away from these areas

Fremitus Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 23 When performing percussion, palpate all areas of the chest and compare vibrations from similar areas. Tactile fremitus is most intense adjacent to the sternum and between the scapulae because these areas are closest to the major bronchi. Fremitus is less intense farther away from these areas

Fremitus Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 24 Increased fremitus occurs when the lung becomes filled with fluid or is denser . As the patient’s voice moves through a dense tissue or fluid , you can feel that the vibration is increased. This is found in pneumonia, in lung tumors, with thick bronchial secretions, and above a pleural effusion (the lung is compressed upward ). Fremitus is decreased if the hand is farther from the lung (e.g ., pleural effusion) or the lung is hyperinflated (e.g., barrel chest ).Absent fremitus may be noted with pneumothorax or atelectasis.

Percussion 12/10/2023 By Abdi Wakjira( Bsc, Msc) 25 Percussion. Percussion is performed to assess the density or aeration of the lungs. The anterior chest is usually percussed with the patient in a semi-sitting or supine position. Starting above the clavicles, percuss downward, interspace by interspace The area over lung tissue should be resonant, with the exception of the area of cardiac dullness. For percussion of the posterior chest, have the patient sit leaning forward with arms folded. The posterior chest should be resonant over lung tissue to the level of the diaphragm

Percussion Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 26 Sound Description Resonance Low-pitched sound heard over normal lungs Hyperresonance Loud, lower-pitched sound than normal resonance heard over hyperinflated lungs, such as in chronic obstructive pulmonary disease and acute asthma Tympany Sound with drumlike , loud, empty quality heard over gas-filled stomach or intestine, or pneumothorax Dull Sound with medium-intensity pitch and duration heard over areas of “mixed” solid and lung tissue, such as over top area of liver , partially consolidated lung tissue (pneumonia ), or fluid-filled pleural space Flat Soft, high-pitched sound of short duration heard over very dense tissue where air is not present, such as posterior chest below level of diaphragm

Auscultation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 27 Auscultation. During chest auscultation, instruct the patient to breathe slowly and a little more deeply than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily; if so, start at the bases Place the stethoscope over lung tissue, not over bony prominences. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. Note the pitch (e.g., high, low), duration of sound, and presence of adventitious or abnormal sounds.

Auscultation Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 28 At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. Note the pitch (e.g., high, low), duration of sound, and presence of adventitious or abnormal sounds. The lung sounds are heard anteriorly from a line drawn perpendicular to the xiphoid process lateral to the midclavicular line. Palpate inferiorly (down) two ribs in the midaxillary line and around to the posterior chest. .

Auscultation Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 29 This gives you a fairly accurate and easy way to determine the lung fields to be auscultated When documenting the location of the lung sounds, divide the anterior and posterior lung into thirds (upper, middle, and lower) and note, for example, “crackles posterior right lower lung field.” You are not expected to define which lobe of the lung has particular lung sounds

Auscultation Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 30 The three normal breath sounds are vesicular, bronchovesicular , and bronchial. Vesicular sounds are relatively soft, lowpitched , gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Vesicular sounds have a 3:1 ratio , with inspiration three times longer than expiration. Bronchovesicular sounds have a medium pitch and intensity and are heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae. Bronchovesicular sounds have a 1:1 ratio, with inspiration equal to expiration.

Auscultation Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 31 Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchial sounds have a 2:3 ratio with a gap between inspiration and expiration. This reflects the short pause between the respiratory cycles. To hear the likeness of bronchial breath sounds, place the stethoscope alongside the trachea in the neck. The term abnormal breath sounds describes bronchial or bronchovesicular sounds heard in the peripheral lung fields.

Auscultation Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 32 Adventitious sounds are extra breath sounds that are abnormal. Adventitious breath sounds include crackles, rhonchi, wheezes , and pleural friction rub (described in Table 26-7 ). A variety of terms are used to describe breath sounds. The spoken voice can be auscultated over the thorax just as it can be palpated for fremitus. Egophony is positive (abnormal) when the person says “E” but it is heard as “A .”

12/10/2023 By Abdi Wakjira( Bsc, Msc) 33 Palpation Description Possible Etiology and Significance Tracheal deviation Leftward or rightward movement of trachea from normal midline position. Nonspecific indicator of change in position of mediastinal structures . Medical emergency if caused by tension pneumothorax. Trachea deviates to the side opposite the collapsed lung. Altered tactile fremitus Increase or decrease in vibrations. ↑ In pneumonia, pulmonary edema. ↓ In pleural effusion, lung hyperinflation. Absent in pneumothorax, atelectasis. Altered chest movement Unequal or equal but diminished movement of two sides of chest with inspiration. Unequal movement caused by atelectasis, pneumothorax, pleural effusion, splinting. Equal but diminished movement caused by barrel chest, restrictive disease, neuromuscular disease.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 34 Palpation Description Possible Etiology and Significance Percussion Hyperresonance Loud, lower-pitched sound over areas that normally produce a resonant sound. Lung hyperinflation (COPD), lung collapse (pneumothorax), air trapping (asthma). Dullness Medium-pitched sound over areas that normally produce a resonant sound. ↑ Density (pneumonia, large atelectasis), ↑ fluid in pleural space (pleural effusion).

12/10/2023 By Abdi Wakjira( Bsc, Msc) 35 Auscultation Description Possible Etiology and Significance Fine crackles Series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration. Result of rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open. Similar sound to that made by rolling hair between fingers just behind ear. Idiopathic pulmonary fibrosis, interstitial edema ( early pulmonary edema), alveolar filling (pneumonia), loss of lung volume (atelectasis), early phase of heart failure. Coarse crackles Series of long-duration, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa . Evident on inspiration and, at times, expiration. Similar sound to blowing through straw under water. Increase in bubbling quality with more fluid. Heart failure, pulmonary edema, pneumonia with severe congestion , COPD. Rhonchi Continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions. Most prominent on expiration. Change often evident after coughing or suctioning. COPD, cystic fibrosis, pneumonia, bronchiectasis.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 36 Auscultation Description Possible Etiology and Significance Wheezes Continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls. First evident on expiration but possibly evident on inspiration as obstruction of airway increases. Possibly audible without stethoscope. Bronchospasm (caused by asthma), airway obstruction (caused by foreign body, tumor), COPD. Stridor Continuous musical or crowing sound of constant pitch. Result of partial obstruction of larynx or trachea. Croup, epiglottitis, vocal cord edema after extubation , foreign body. Absent breath sounds No sound evident over entire lung or area of lung. Pleural effusion, mainstem bronchi obstruction, large atelectasis, pneumonectomy , lobectomy.

Sequence for examination of chest 12/10/2023 By Abdi Wakjira( Bsc, Msc) 37 Sequence for examination of the chest. A, Anterior sequence. B, Lateral sequence. C, Posterior sequence . For palpation, place the palms of the hands in the position designated as “1 ” on the right and left sides of the chest. Compare the intensity of vibrations. Continue for all positions in each sequence. For percussion, tap the chest at each designated position, moving downward from side to side. Compare percussion sounds at all positions . For auscultation, place the stethoscope at each position and listen to at least one complete inspiratory and expiratory cycle. Keep in mind that, with a female patient, the breast tissue will modify the completeness of the anterior examination.

Auscultation Cont..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 38 Bronchophony is positive (abnormal) when a person repeats “ninety-nine” and the words are easily understood and are clear and loud. Whispered pectoriloquy is positive (abnormal) when the patient whispers “one-two-three” and the almost inaudible voice is transmitted clearly and distinctly. Conditions that increase lung density or a consolidated lung (e.g., pneumonia) have positive (abnormal ) voice sounds.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 39 UPPER RESPIRATORY DISORDERS

Types of Rhinitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 40 1. Allergic Rhinitis - is the reaction of the nasal mucosa to a specific allergen . Allergic rhinitis can be classified according to the causative allergen (seasonal or perennial) or, the frequency of symptoms (episodic, intermittent, or persistent ). Episodic refers to symptoms related to sporadic exposure to allergens that are not typically encountered in the patient’s normal environment, such as exposure to animal dander when visiting another person’s home .

Allergic Rhinitis … 12/10/2023 By Abdi Wakjira( Bsc, Msc) 41 Intermittent means that the symptoms are present less than 4 days a week or less than 4 weeks per year. Persistent means that the symptoms are present more than 4 days a week and for more than 4 weeks per year

Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 42 Sensitization to an allergen occurs with initial allergen exposure, which results in the production of antigen-specific immu noglobulin E ( IgE ). After exposure, mast cells and basophils release histamine, cytokines, prostaglandins, and leukotrienes . These cause the early symptoms of sneezing, itching , rhinorrhea, and congestion. Four to 8 hours after exposure, inflammatory cells infiltrate the nasal tissues, causing and maintaining the inflammatory response. Because symptoms of rhinitis resemble those of the common cold, the patient may believe the condition is a continuous or repeated cold.

Clinical Manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 43 Manifestations of allergic rhinitis are initially sneezing; watery, itchy eyes and nose; altered sense of smell; and thin, watery nasal discharge that can lead to a more sustained mucus production and nasal congestion. The nasal turbinates appear pale,boggy , and swollen. C/M is characterized by 4 cardinal symptoms of watery Rhinorrhoea , nasal obstruction, nasal itching and sneezing.

Clinical Manifestations Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 44 The posterior ends of the turbinates can become so enlarged that they obstruct sinus aeration or drainage and result in sinusitis. With chronic exposure to allergens , the patient’s responses include headache, congestion, pressure , nasal polyps, and postnasal drip as the most common cause of cough. The patient may complain of cough, hoarseness, and the recurrent need to clear the throat. Congestion may cause snoring

DIAGNOSIS OF Allergic Rhinitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 45 The diagnosis of AR is based on a typical history of allergic symptoms and diagnostic tests. When 2 or more symptoms out of watery Rhinorrhoea, sneezing, nasal obstruction and nasal pruritus persist for ≥1 hour on most days, Allergic Rhinitis is strongly suspected Skin testing Skin testing is the most important to find offending allergens. There are various testing methods including the scratch, prick/ puncture, intradermal and patch tests. The radioallergosorbent test (RAST);Serum specific IgE level Multiple allergen simultaneous test (MAST ); uses a photo reagent instead of a radioactive isotope,

TREATMENT OF ALLERGIC RHINITIS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 46 Requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of Allergen avoidance, Pharmacotherapy, Immunotherapy and Surgery. The four major categories of medications used to manage cold symptoms are antihistamines , decongestants, antitussives, and expectorants.

Pharmacotherapy 12/10/2023 By Abdi Wakjira( Bsc, Msc) 47 An over-the-counter (OTC), non-sedating antihistamine Competitively inhibit the interaction of histamine with H1 receptors. They prevent and relieve nasal itching, sneezing, and Rhinorrhoea, and ocular symptoms, e.g. Loratadine 10 mg once daily Desloratadine 5 mg once daily Cetirizine 10 mg once daily or divided BID Levocetirizine 5 mg once daily in the evening

Intranasal corticosteroids 12/10/2023 By Abdi Wakjira( Bsc, Msc) 48 Are potent inhibitors of the late-phase allergic reaction in Allergic Rhinitis. They inhibit recruitment of Langerhans cells, macrophages, mast cells, T cells, and eosinophils into the nasal mucosa They control itching, sneezing, Rhinorrhoea, and stuffiness E.g . Beclomethasone dipropionate 2 sprays EN/day Fluticasone (Flonase), 1–2 sprays EN /day

Decongestants 12/10/2023 By Abdi Wakjira( Bsc, Msc) 49 Decrease swelling of the nasal mucosa which, in turn, alleviates nasal congestion e.g. Oxymetazoline nasal spray 60 mg every 4-6 h 120mg ER every 12h 240mg ER once daily Pseudoephedrine pills

NURSING AND COLLABORATIVE MANAGEMENT 12/10/2023 By Abdi Wakjira( Bsc, Msc) 50 The most important step in managing allergic rhinitis is identifying and avoiding triggers of allergic reactions The goal of medications is to reduce inflammation associated with allergic rhinitis, reduce nasal symptoms, minimize associated complications, and maximize quality of life. Appropriate oral medication options include: H1-antihistamines , corticosteroids, decongestants, and leukotriene receptor antagonists (LTRAs ).

NURSING AND COLLABORATIVE MANAGEMENT Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 51 Second-generation antihistamines are preferred over first generation antihistamines because of their nonsedating effects. Remind patients who are taking antihistamines to have adequate fluid intake to reduce adverse symptoms. Nasal corticosteroid sprays are used to decrease inflammation locally with little absorption in the systemic circulation. Therefore systemic side effects are rare.

2. Non-Allergic Rhinitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 52 This form of rhinitis does not depend on the presence of IgE and is not due to an allergic reaction. The symptoms can be triggered by cigarette smoke and other pollutants as well as strong odors, alcoholic beverages, and cold. Other causes may include blockages in the nose, a deviated septum, infections, and over-use of medications such as decongestants.

3. Acute viral Rhinitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 53 Acute viral rhinitis (common cold or acute coryza ) is an infection of the upper respiratory tract that can be caused by more than 200 different viruses. The majority of colds, which are caused by rhinoviruses, are mild and self-limiting. Cold symptoms may last 2 to 14 days, with typical recovery in 7 to 10 days. Caution patients to use the intranasal decongestant sprays for no more than 3 days to prevent rebound congestion from occurring. Cough suppressants may be used.

3. Acute viral Rhinitis Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 54 Complications of acute viral rhinitis include pharyngitis, sinusitis, otitis media, tonsillitis, and lung infections. Unless symptoms of complications are present, antibiotic therapy is not indicated . If symptoms remain for 10 to 14 days with no improvement, acute bacterial sinusitis may be present, and antibiotics will be prescribed. Teach the patient to recognize the symptoms of secondary bacterial infection, such as a temperature higher than 100.4° F (38 ° C); tender, swollen glands; severe sinus or ear pain; or significantly worsening symptoms.

Nasal polyp 12/10/2023 By Abdi Wakjira( Bsc, Msc) 55 Def : is a non cancerous growth(benign) develop on the lining of the passage at sinuses. Small growth may cause no problem, Big growth may cause complications. It may come in many sizes & shapes. Causes - exact cause is unknown Risk factors – person with chronic viral or bacterial infections have a higher incidence of nasal polyps. Allergies, asthma, chronic rhinitis, and chronic sinusitis

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 56 Incidence Common in adult Rare in children 4 times are common in men than in women.

Clinical Manifestation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 57 Bluish, glossy projections in the nares – can exceed the size of grape Nasal congestion, nasal discharges (usually clear mucus), speech distortion Reduced ability to smell ( hyposmia ) Loss of smell (anosmia)

Types 12/10/2023 By Abdi Wakjira( Bsc, Msc) 58 Antrochoanal polyps – single, unilateral and usually found in children, originate from maxillary sinus Ethmoidal polyps – multiple, bilateral and usually found in adults, originating form ethmoidal air cells

Medical management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 59 Corticosteroid sprays or local injection of a steroid into the polyp Steroid used to reduce the size, prevention of recurrence and reduction of inflammation thus reducing swelling Antibiotics (amoxicillin or erythromycin) if infection present.

Surgical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 60 Polypectomy – removal of polyps after nose is anesthetized, NASAL SNARE is slipped around polyp, which is transected and removed with forceps . Removal of polyp via CALDWELL- LUC OPERATION, Procedure named after George Caldwell & Guy Luc,who desgined an operation to remove infected polypoid tissue

Epistaxis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 62 Def : Epistaxis (nosebleed) occurs in a bimodal distribution, with children 2 to 10 years of age and adults over age 50 most affected. Epistaxis can be caused by: low humidity, allergies, upper respiratory tract infections, sinusitis , trauma, foreign bodies , hypertension , chemical irritants such as street drugs, overuse of decongestant nasal sprays, facial or nasal surgery,

Epistaxis Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 63 Epistaxis can be caused by …. Anatomic malformation, and tumors. Any condition that prolongs bleeding time or alters platelet counts will predispose the patient to epistaxis. Bleeding time may also be prolonged if the patient takes aspirin, NSAIDs , warfarin, or other anticoagulant drugs .

N ursing and collaborative management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 64 Use simple first aid measures to control epistaxis: ( 1) keep the patient quiet; ( 2) place the patient in a sitting position, leaning slightly forward with head tilted forward; and (3) apply direct pressure by pinching the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes. If bleeding does not stop within 15 to 20 minutes, seek medical assistance.

N ursing and collaborative … 12/10/2023 By Abdi Wakjira( Bsc, Msc) 65 Medical management involves identifying the bleeding site and applying a vasoconstrictive agent, C auterization , or anterior packing. Pledgets (nasal tampon) impregnated with anesthetic solution ( lidocaine ) and/or V asoconstrictive agents such as cocaine or epinephrine are placed into the nasal cavity and left in place for 10 to 15 minutes. Silver nitrate may be used to chemically cauterize an identified bleeding point after epistaxis is controlled. Thermal cauterization is reserved for more severe bleeding and requires the use of local or general anesthesia.

N ursing and collaborative … 12/10/2023 By Abdi Wakjira( Bsc, Msc) 66 If bleeding does not stop, packing may be used. Packing with compressed sponges (e.g., Merocel ) or epistaxis balloons (e.g ., Rapid Rhino) is preferred over the use of traditional Vaseline ribbon gauze The balloon is inflated with air to achieve the same pressure effect. Closely monitor respiratory rate, heart rate and rhythm, O xygen saturation using pulse oximetry (SpO2), and L evel of consciousness, and observe for signs of aspiration. Because of the risk of complications, all patients with posterior packing should be admitted to a monitored unit to permit closer observation .

N ursing and collaborative … 12/10/2023 By Abdi Wakjira( Bsc, Msc) 67 Nasal packing may be left in place for a few days. Before removal , medicate the patient for pain because this procedure is very uncomfortable. After removal, cleanse the nares gently and lubricate them with water-soluble jelly. Instruct the patient to avoid vigorous nose blowing, engaging in strenuous activity, lifting, and straining for 4 to 6 weeks. Teach the patient to use saline nasal spray and/or a humidifier, to sneeze with the mouth open, and to avoid the use of aspirin-containing products or NSAIDs .

Sinusitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 68 Four pairs of paranasal sinuses Frontal-above eyes in forehead bone Maxillary-in cheekbones, under eyes Ethmoid-between eyes and nose Sphenoid-in center of skull, behind nose and eyes

Sinusitis--- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 69 An acute inflammatory process involving one or more of the paranasal sinuses. A complication of 5%-10% of URIs in children. Persistence of URI symptoms >10 days without improvement. Maxillary and ethmoid sinuses are most frequently involved.

Types of Sinusitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 70 It is typically classified by:_ Duration of illness (acute vs. Chronic) Etiology (infectious vs. Noninfectious) Pathogen type (viral, bacterial, or fungal) Acute Sinusitis – respiratory symptoms last longer than 10 days but less than 30 days. Sub acute sinusitis – respiratory symptoms persist longer than 30 days without improvement. Chronic sinusitis – respiratory symptoms last longer than 120 days.

Pathophysiology of sinusitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 71

Predisposing Factors 12/10/2023 By Abdi Wakjira( Bsc, Msc) 72 Allergies, Cold weather High pollen counts Day care attendance Smoking in the home Reinfection from siblings Anatomical: septal deviation, nasal deformities, nasal polyps Muco c iliary functions: cystic fibrosis, immotile cilia syndrome. S y stemic disease: immune deficiency.: DM, AIDS, Neoplasia

Etiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 73 Acute sinusitis Str. pneumoniae %41 H. influenzae %35 M. catarrhalis %8 Others %16 Strep. pyogenes S. aureus Rhinovirus Parainfluenzae Veilonella, pepto co ccus Chronic sinusitis Anaerob ba c teria: Bactroides, fusobacterium S. Aureus Strep. Pyogenes Str. Pneumoniae Gram (-) ba c teria fungi

Signs and Symptoms 12/10/2023 By Abdi Wakjira( Bsc, Msc) 74 Headache, congestion, facial pain, fatigue, and cough, Purulent nasal discharge. Pain over the region of the affected sinuses If a maxillary sinus is affected, the patient experiences pain over the cheek and upper teeth. In ethmoid sinusitis , pain occurs between and behind the eyes. Pain in the forehead typically indicates frontal sinusitis . Fever may be present in acute infection, with or without generalized fatigue and foul breath.

Diagnosis of sinusitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 75 History ;persistent symptom of URI and physical findings Radiographic studies Opacification and mucosal thickening air filled level Others : Translumination of sinus cavity Sinus aspirate culture Nasal endoscopy If repeated episodes occur:- x-ray examination computed tomography (CT) scan magnetic resonance imaging (MRI)

Treatment of Sinusitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 76 Nondrug measures : Maintain adequate hydration(drink 6-10glasses of liquid ) Personal Steam vaporizer Apply warm facial packs (warm wash cloth, hot water bottle) Saline irrigation lavage or sniff (1/4 teaspoon salt dissolved in 1cup of water ) Sleep ahead of bed elevated Adequate rest Avoid cigarette smoke and extremely dry or cool air

Drug Treatment 12/10/2023 By Abdi Wakjira( Bsc, Msc) 77 Antibiotics First-line: Amoxicillin, 1.5 to 3.5 g/d divided 2 or 3 times daily) Trimethoprim– sulfamethoxazole 800/160 mg twice daily Second-line: Amoxicillin– Clavulanate (500/125 mg 3 times daily) Second- or third-generation cephalosporin Cefuroxime, 250 or 500 mg twice daily, Doxycycline 200 mg on first day then 100 mg twice daily for 2 to 10 days

Antibiotics---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 78 Macrolides : Clarithromycin, 500 mg twice daily or Azithromycin, 500 mg daily for 5 days Fluoroquinolones : Ciprofloxacin, 500 twice a day or Levofloxacin, 500 mg once daily Oral antihistamines :Loratadine, 10 mg daily Nasal decongestant : Xylometazoline intranasally, 2 to 3 sprays every 8 to 10 hr. Nasal steriods :Fluticasone, 2 puffs) intranasally [200 µg] daily Acetaminophen or ibuprofen is given for pain and fever.

Nursing management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 79 Patient teaching self care Instruct patient to blow the nose gently and to use tissue to remove the nasal drainage. Increasing fluid intake, Applying local heat (hot wet packs), and Elevating the head of the bed promote drainage of the sinuses. Instructs the patient about the importance of medication regimen.

Tonsillitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 80 Tonsils are protective (lymph) glands that are situated on both sides in the throat. The tonsils constitute an important part of the body's immune system and are vital defense organs. They protect the body from bacteria and viruses by fighting these as soon as they enter the body (via the oral / nasal cavity). Inflammatory process of the mucosa and structures of the pharyngo-tonsillar area, usually of infectious origin Tonsillitis is contagious. It affects all ages, but is most common in children between ages 5 and 10

Tonsillitis --- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 81

Clinical Manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 82 Throat pain, either mild or severe. Swallowing with difficulty. Odynophagia, pharyngeal exudate, anterior cervicolateral lymphadenopathy, scarlet rash and headache Chills and fever as high as 104° F (40° C) or more. Swollen lymph glands on either side of the jaw. Ear pain. Cough (sometimes). Vomiting (sometimes). Refusal to eat in a very young child. Erythema, Edema, Ulcer or vesicles

Causes of Tonsillitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 83 Viruses: Rhinovirus, adenovirus, influenza virus, Para influenza virus,Coxsackie virus and Epstein-Barr virus Aerobic Bacteria: GABHS and other streptococcal species, Neisseria gonorrhoeae, Corynebacterium diphtheriae. Yeast : Candida species. Spirochetes: Treponema pallidum (syphilis)

Causes ---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 84

Assessment and Diagnostic Findings 12/10/2023 By Abdi Wakjira( Bsc, Msc) 85 History : look at throat to see red and swollen tonsils with spots or sores. Throat culture : rapid strep test Blood test ;done to confirm presence of infection

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 86 Bed rest , except to use the bathroom, is necessary until fever subsides. DIET Supportive measures include Increase all fluid intake. While the throat is very sore, use liquid nourishment, such as milk shakes, soups, and high-protein fluids (diet or instant-breakfast milk drinks). Viral tonsillitis is not effectively treated with antibiotic therapy. Tonsillectomy if complicated

Antibiotic treatment of choice 12/10/2023 By Abdi Wakjira( Bsc, Msc) 87 Penicillin V: <12 years or <27 kg: 250mg / 12h 10 days >12 years or >27 kg: 500mg / 12h 10 days Penicillin G Benzathine : <12 years or <27 kg: 600.000 UI, single dose >12 years or >27 kg: 1.200.000 UI, single dose Amoxicillin: 50mg /kg/day, every 12-24 hours, 10 days, with a maximum dose of 500mg /12h or 1g/24h. Mediated by IgE: - Azithromycin : 20mg/kg /day, once a day, 3 days (maximum 500mg/day) - Clindamycin: 20-30mg/kg /day, every 8-12h, 10 days (maximum 900mg/day).

Indications for tonsillectomy 12/10/2023 By Abdi Wakjira( Bsc, Msc) 88 Recurrent tonsillitis (more than seven per year Persistent, chronic tonsillitis Recurrent peritonsillar abscess with previous history of recurrent or persistent tonsillitis. Unilateral tonsillar hypertrophy. Hemorrhagic tonsillitis. Chronic tonsillolithiasis. Nasal obstruction with speech abnormalities, orodental abnormalities.

Complications of tonsillitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 89 Classified into suppurative and nonsuppurative complications. The nonsuppurative complications include Scarlet fever, Acute rheumatic fever, and Post-streptococcal glomerulonephritis. Suppurative complications include Peritonsillar, parapharyngeal and retropharyngeal abscess formation.

Pharyngitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 90 ACUTE PHARYNGITIS :is a sudden painful inflammation of the pharynx, the back portion of the throat that includes the posterior third of the tongue, soft palate, and tonsils. It is commonly referred to as a sore throat Causes Viral infection- most common( adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus) Bacterial infection- Group A beta-hemolytic streptococcal bacterial infection called strep throat.

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 91 Pathophysiology Viral/ strep throat infection The body responds by triggering an inflammatory response in the pharynx. This results in pain, fever, vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar pillars, uvula, and soft palate. A creamy exudate may be present in the tonsillar pillars If caused by GA hemolytic streptococcus- it may be severe If caused by uncomplicated virus- may be subside promptly( 3 to 10 days after the onset).

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 92 Complications Sinusitis Otitis media Peritonsillar abscess Mastoiditis Cervical adenitis In rare cases, the infection may lead to bacteremia , pneumonia, meningitis, rheumatic fever, and nephritis .

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 93 Clinical features Fiery-red pharyngeal membrane and tonsils Lymphoid follicles that are swollen and flecked with white-purple exudate, and enlarged Tender cervical lymph nodes No cough Fever Malaise Sore throat

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 94

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 95 Assessment and dxs Accurate diagnosis of pharyngitis is essential to determine the cause (viral or bacterial) Newer and more rapid diagnostic tests ( eg , the rapid streptococcal antigen test ( RSAT). Medical mgt For virus- supportive care For bacterial- penicillin is a drug of choice if allergic and resistance ( clarithromycin and azithromycin ) may be used. Analgesic medications, as prescribed( i.e. Aspirin or acetaminophen)can be taken

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 96 Nursing management Instructs the patient to:_ Stay in bed during the febrile stage of illness and Full course of antibiotic therapy Preventive measures Not sharing eating utensils, glasses, napkins, food, or towels; cleaning telephones after use Using a tissue to cough or sneeze Disposing of used tissues appropriately Avoiding exposure to tobacco and secondhand smoke.

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 97 Chronic pharyngitis :- is a persistent inflammation of the pharynx. Types Hypertrophic : characterized by general thickening and congestion of the pharyngeal mucous membrane Atrophic: probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled) Chronic granular (“clergyman’s sore throat”) , characterized by numerous swollen lymph follicles on the pharyngeal wall

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 98 Common in person :_ work in dusty surroundings Use their voice to excess Suffer from chronic cough Habitually use alcohol and tobacco. Clinical manifestation Sense of irritation or fullness in the throat, Mucus that collects in the throat and can be expelled by coughing Difficulty swallowing.

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 99 Medical management Nasal congestion medications (ephedrine sulfate ( Kondon’s Nasal) or phenylephrine hydrochloride) Antihistamine decongestant medications , such as Pseudoephedrine. For adults with chronic pharyngitis , tonsillectomy is an effective option. Nursing management Avoid alcohol, tobacco, secondhand smoke, and exposure to cold or to environmental or occupational pollutants.

LARYNGITIS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 100

DEFINITION It is the inflammation of larynx leading to oedema of laryngeal mucosa and underlying structures.

ETIOLOGY 102 INFECTIOUS: Viral laryngitis can be caused by rhinovirus, influenza virus, parainfluenza virus, adenovirus, coronavirus, and RSV. Bacterial laryngitis can be caused by group A streptococcus, streptococcus pneumoniae , C. diphtheriae , M. catarrhalis , haemophilus influenzae , bordetella pertussis , and M. tuberculosis . Fungal laryngitis can be caused by Histoplasma , Candida (especially in immunocompromised persons)

NON INFECTIOUS Inhaled fumes Acid reflux disease Allergies 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 Laryngeal trauma, including iatrogenic one caused by endotracheal intubation

Predisposing factors Smoking Psychological strain Physical stress Voice abuse misuse Acid reflux (GERD) Frequent sinus infectionsr Types – acute (less then 3 weeks)and chronic (more than 3 weeks )

Pathophysiology Due to etiological factors The mucosa of the larynx becomes congested and may become oedematous . A fibrinous exudate may occur on the surface. Signs and symptoms Sometimes infection involves the perichondrium of laryngeal cartilages producing perichondritis .

Types of Laryngitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 106 1. Acute Laryngitis 2. Chronic laryngitis Acute laryngitis: Def : It is the inflammation of larynx which lasts less than a few days & leads to edema of laryngeal mucosa & underlying structures. Most cases of AL are temporary & improve after the underlying causes get better.

Acute Laryn …. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 107 Frequently caused by ‘Rhinovirus” Other causative Organisms: Para influenza virus Respiratory syncytial virus Adeno virus Measles & Mumps Bacterial infection- such as Diphteria , these are rae .

12/10/2023 By Abdi Wakjira( Bsc, Msc) 108 Vocal misuse, vocal strain or yelling or over use of the voice. Exposure to noxious Viral infections such as that cause a cold. Frank aphonia

Chronic Laryngitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 109 Laryngitis that lasts more than 3 weeks is known as chronic laryngitis. More persistent disorder that produces lingering hoarseness & other voice changes It is usually painless & has no significant sign of infection.

Etiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 110 Vocal misuse Exposure to noxious agent. Infectious agents leading to upper respiratory tract infections. Most often viral but some times bacterial Inhaled irritants such as chemical fumes, allergens or smoking. Acid reflex, also gastro esophageal reflux disease (GERD)

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 111 Chronic sinusitis, bronchitis Excessive alcohol use Habitual over use of the voice such as with singers or cheerleaders. Smoking Less common cause of chronic laryngitis include: Infections such as TB, syphilis or a fungal infections. Infections with certain parasites. Cancer Vocal cord paralysis, which can result from injury, stroke or a lung tumor or other conditions.

C linical features Husky, high pitched voice, Body aches, Fever, Malaise. Dysphonia (hoarseness) or aphonia (inability to speak) Dysphagia (difficulty in swallowing) Dyspnea (difficulty in breathing), predominantly in children Dry, burning throat, Dry irritating paroxysmal cough. Cold or flu-like symptoms , Swollen lymph nodes in the throat, chest, or face Hemoptysis (coughing out blood), Increased production of saliva.

Clinical features Cont…d Signs of acute URTI. Dry thick sticky secretions. Dusky red and swollen vocal cords. congestion of laryngeal mucosa.

Treatment SUPPORTIVE Voice rest. Steam inhalation. Cough suppressants. Avoid smoking and cold climate. Fluid intake.

Diagnosis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 115 Based upon a combination of a complete history & physical exam. If symptoms are severe, particularly in children, the doctor may order an x-ray of the neck & chest. CBC Some times in children rarely in adults.

Laryngoscopy 12/10/2023 By Abdi Wakjira( Bsc, Msc) 116 Visual examination of vocal cords in a procedure called laryngoscopy, by using a light & a tiny mirror to look in to the back of the throat. Fiber optic -laryngoscopy Biopsy

Treatment DEFINITIVE If laryngitis due to gastroesophageal reflux, an H2-inhibitor (ranitidine) or proton-pump inhibitor (omeprazole) is used to reduce gastric acid secretions. If laryngitis is caused by thermal or chemical burns, steroids are used. In viral laryngitis, drinking sufficient fluids will be helpful. If laryngitis is due to a bacterial or fungal infection, appropriate antibiotic or antifungal therapy is given.

Supportive Therapy Drinking lot of fluids - Drink 7-9 glasses of water per day; herbal tea and chicken soup also provides soothing effect. maintaining good general health - Exercise regularly. Avoiding smoking - They are bad for the heart, lungs and vocal tract. Eating a balanced diet - Include vegetables, fruits and whole grain foods. Avoid dry, artificial interior climates. Do not eat late at night - may have problems when stomach acid backs up on the vocal cords. Use a humidifier to assist with hydration.

Laryngotracheal bronchitis (Viral croup) 12/10/2023 By Abdi Wakjira( Bsc, Msc) 119 Known as laryngotracheitis or laryngotracheobronchitis Most common etiology is viral Parainfluenza virus, adenovirus, RSV Leads to infection and inflammation of the larynx and subglottic area Decreased mobility of the vocal cords Frequently affects children

Etiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 120 Most common etiology is viral Parainfluenza virus, adenovirus, RSV Leads to infection and inflammation of the larynx and subglottic area Decreased mobility of the vocal cords Frequently affects children

Clinical manifestation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 121 Begins with respiratory symptoms Within 2 days progresses to: Hoarseness Barking seal like cough Stridor- Symptoms worse at night Fever

Viral Croup 12/10/2023 By Abdi Wakjira( Bsc, Msc) 122 Mild disease: occasional barking cough, no strider at rest, mild to no suprasternal retractions Moderate : frequent cough, audible strider at rest, retractions, Severe : frequent cough, Barking type inspiratory/expiratory strider , retractions, decreased air entry, distress, and agitation.

Viral Croup Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 123 A/P neck x-ray: Shows subglottic narrowing CBC might show lymphocytosis- DDx : Diphtheria Epiglottitis Peritonsillar abscess Inhalation injuries

Viral Croup Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 124 Moist steam Exposure to out door cool air Adequate hydration Glucocorticoid Racemic epinephrine Dexamethasone for severe cases

Hospitalization Indication 12/10/2023 By Abdi Wakjira( Bsc, Msc) 125 Dehydration- Significant respiratory compromise Signs of respiratory failure Spasmodic Croup No prodrome of upper respiratory syndrome. Subglottic edema Affects individual at night. Affects children between 1-3 years Managed at home

Epiglottitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 126 Def : The epiglottis is a cartilaginous structure covered with mucous membrane. Epiglottitis is an acute inflammation of the epiglottis and pharyngeal structures Can be severe life threatening disease Primarily affects children 2-7 years. Presents more acutely in young children Etiology : H. influenzae type B, also group A S pneumoniee , H pereintluensee , S sureus , and beta hemolytic streptococci

C/M 12/10/2023 By Abdi Wakjira( Bsc, Msc) 127 Triad of drooling, dysphagia, and distress . High fever Positioning- tripod position Dyspnea/inspiratory stridor/ accessory muscle use/muffled voice Brassy cough

Diagnosis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 128 Lateral neck –enlarged, edematous epiglottis. Laryngoscopy : Direct inspection of epiglottis under controlled conditions Leukocytosis Blood cultures positive

Differential Dx 12/10/2023 By Abdi Wakjira( Bsc, Msc) 129 Anaphylaxis Croup Retropharyngeal Abscess Foreign body obstruction

Epiglottitis Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 130 Secure airway with endotracheaI intubation . Might need cricothyroidotomy . Child should sit upright Humidified oxygen Hospitalization No tongue blades IV antibiotics : Ceftriaxone ( Rocephin ) cefotaxime ( Ceftin ), Ampicillin with chloramphenicol

Epiglottitis Management …. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 131 Evaluate for extubation 24-48 hours post intubation. Rifampin prophylaxis for 4days for household contacts if: children in household have not been vaccinated with the entire series

12/10/2023 By Abdi Wakjira( Bsc, Msc) 132 AIR WAY PATENCY CARE IN respiratory disorder

Management of pt with respiratory disorder 12/10/2023 By Abdi Wakjira( Bsc, Msc) 133 Oxygen Therapy Is the administration of oxygen at a concentration greater than that found in the environmental atmosphere The goal of oxygen therapy is to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium Indications Change in the patient’s respiratory rate or pattern( hypoxemia or hypoxia) Need for oxygen is assessed by arterial blood gas analysis, pulse oximetry , and clinical evaluation.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 134 Oxygen therapy is the administration of oxygen at a concentration greater than that found in the environmental atmosphere. At sea level, the concentration of oxygen in room air is 21%. The goal of oxygen therapy is to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Oxygen transport to the tissues depends on factors such as cardiac output, arterial oxygen content, concentration of hemoglobin, and metabolic requirements. These factors must be kept in mind when oxygen therapy is considered.

Indications 12/10/2023 By Abdi Wakjira( Bsc, Msc) 135 A change in the patient’s respiratory rate or pattern may be one of the earliest indicators of the need for oxygen therapy. The change in respiratory rate or pattern may result from hypoxemia or hypoxia. Hypoxemia - a decrease in the arterial oxygen tension in the blood is manifested by changes in mental status. Such as: progressing through impaired judgment, agitation , disorientation,

Indications Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 136 Sign & symptoms of hypoxemia include: confusion, lethargy , and coma, dyspnea , increase in blood pressure, changes in heart rate, dysrhythmias , central cyanosis ( late sign ), diaphoresis , and cool extremities. Hypoxemia usually leads to hypoxia , which is a decrease in oxygen supply to the tissues. Hypoxia, if severe enough, can be life-threatening.

Indications Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 137 The signs and symptoms signaling the need for oxygen may depend on how suddenly this need develops. With rapidly developing hypoxia, changes occur in the central nervous system because the higher neurologic centers are very sensitive to oxygen deprivation. The clinical picture may resemble that of alcohol intoxication, with the patient exhibiting lack of coordination and impaired judgment.

Indications Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 138 Longstanding hypoxia (as seen in chronic obstructive pulmonary disease [COPD] and chronic heart failure) may produce fatigue, drowsiness, apathy, inattentiveness, and delayed reaction time. The need for oxygen is assessed by arterial blood gas analysis and pulse oximetry as well as by clinical evaluation . Cautions in Oxygen Therapy As with other medications, the nurse administers oxygen with caution and carefully assesses its effects on each patient. Oxygen is a medication and except in emergency situations is administered only when prescribed by a physician.

Indications Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 139 In general, patients with respiratory conditions are given oxygen therapy only to raise the arterial oxygen pressure (PaO2) back to the patient’s normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve the blood at these levels is 80% to 98% saturated with oxygen; higher inspired oxygen flow (FiO2) values add no further significant amounts of oxygen to the red blood cells or plasma.

Indications Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 140 Types of Hypoxia: Hypoxia can occur from either severe pulmonary disease (inadequate oxygen supply) or from extrapulmonary disease ( inadequate oxygen delivery) affecting gas exchange at the cellular level. The four general types of hypoxia are hypoxemic hypoxia, circulatory hypoxia, anemic hypoxia, and histotoxic hypoxia.

Types of Hypoxia Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 141 1. Hypoxemic Hypoxia Hypoxemic hypoxia is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. It may be caused by hypoventilation, high altitudes, ventilation–perfusion mismatch (as in pulmonary embolism), shunts in which the alveoli are collapsed and cannot provide oxygen to the blood ( commonly caused by atelectasis), and pulmonary diffusion defects. It is corrected by increasing alveolar ventilation or providing supplemental oxygen

Types of Hypoxia Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 142 2. Circulatory Hypoxia Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation . It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 143 3. Anemic Hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia because hemoglobin levels may be normal Types of Hypoxia Cont …d

Types of Hypoxia Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 144 4. Histotoxic Hypoxia Histotoxic hypoxia occurs when a toxic substance, such as cyanide, interferes with the ability of tissues to use available oxygen

OXYGEN TOXICITY 12/10/2023 By Abdi Wakjira( Bsc, Msc) 145 Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours). It is caused by overproduction of oxygen free radicals, which are byproducts of cell metabolism. If oxygen toxicity is untreated, these radicals can severely damage or kill cells. Antioxidants such as vitamin E, vitamin C, and beta-carotene may help defend against oxygen free radicals. ( Scanlan , Wilkins & Stoller , 1999).

OXYGEN TOXICITY Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 146 Signs and symptoms of oxygen toxicity include: substernal discomfort, paresthesias , dyspnea , restlessness , fatigue , malaise , progressive respiratory difficulty, and alveolar infiltrates evident on chest x-rays.

SUPPRESSION OF VENTILATION 12/11/2023 By Abdi Wakjira( Bsc, Msc) 147 In patients with COPD, the stimulus for respiration is a decrease in blood oxygen rather than an elevation in carbon dioxide levels. Thus , administration of a high concentration of oxygen removes the respiratory drive. The resulting decrease in alveolar ventilation can cause a progressive increase in arterial carbon dioxide pressure (PaCO2), ultimately leading to the patient’s death from carbon dioxide narcosis and acidosis. Oxygen-induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 L/min).

OTHER COMPLICATIONS 12/11/2023 By Abdi Wakjira( Bsc, Msc) 148 Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post “no smoking” signs when oxygen is in use. Oxygen therapy equipment is also a potential source of bacterial cross-infection; thus, the nurse changes the tubing according to infection control policy and the type of oxygen delivery equipment.

Methods of Oxygen Administration 12/11/2023 By Abdi Wakjira( Bsc, Msc) 149 Oxygen is dispensed from a cylinder or a piped-in system. A reduction gauge is necessary to reduce the pressure to a working level, and a flow meter regulates the flow of oxygen in liters per minute. When oxygen is used at high flow rates, it should be moistened by passing it through a humidification system to prevent it from drying the mucous membranes of the respiratory tract.

Methods of Oxygen Administration … 12/11/2023 By Abdi Wakjira( Bsc, Msc) 150 Oxygen delivery systems are classified as low-flow or high-flow delivery systems. Low-flow systems contribute partially to the inspired gas the patient breathes. The amount of inspired oxygen changes as the patient’s breathing changes . Examples of low-flow systems include: nasal cannula, oropharyngeal catheter, simple mask, partial- rebreather and non- rebreather masks.

Methods of Oxygen Administration … 12/11/2023 By Abdi Wakjira( Bsc, Msc) 151 2. High-flow systems provide the total amount of inspired air. A specific percentage of oxygen is delivered independent of the patient’s breathing. High-flow systems are indicated for patients who require a constant and precise amount of oxygen. Examples of such systems include: transtracheal catheters, Venturi masks, aerosol masks, tracheostomy collars, T-piece , and face tents

Chest physiotherapy 12/10/2023 By Abdi Wakjira( Bsc, Msc) 152 Includes postural drainage , chest percussion , and vibration, and breathing retraining . The goals of CPT are to remove bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles.

Postural drainage 12/10/2023 By Abdi Wakjira( Bsc, Msc) 153 Allows the force of gravity to assist in the removal of bronchial secretions. The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning. Used to prevent or relieve bronchial obstruction caused by accumulation of secretions. Patient usually sits in an upright position, secretions are likely to accumulate in the lower parts of the lungs.

Positions used for postural drainage 12/10/2023 By Abdi Wakjira( Bsc, Msc) 154

Positions used for postural drainage 12/10/2023 By Abdi Wakjira( Bsc, Msc) 155

Positions used for postural drainage 12/10/2023 By Abdi Wakjira( Bsc, Msc) 156

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 157 The nurse should be aware of:- Patient’s diagnosis as well as the lung lobes or segments involved Cardiac status Any structural deformities of the chest wall and spine Auscultating the chest before and after the procedure is used to identify the areas that need drainage and assess the effectiveness of treatment The nurse explores strategies that will enable the patient to assume the indicated positions at home(use of objects readily available at home, such as pillows, cushions, or cardboard boxes

Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 158 PD is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime The nurse makes the patient as comfortable as possible in each position and provides an emesis basin, sputum cup, and paper tissues. If the patient cannot cough , the nurse may need to suction the secretions mechanically.

Chest Percussion and Vibration 12/10/2023 By Abdi Wakjira( Bsc, Msc) 159 Thick secretions that are difficult to cough up may be loosened. Help dislodge mucus adhering to the bronchioles and bronchi. Percussion is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained. The patient uses diaphragmatic breathing during this procedure to promote relaxation percussion over chest drainage tubes, the sternum, spine, liver, kidneys, spleen, or breasts (in women) is avoided. Percussion is performed cautiously in the elderly (b/c of increase incidence of osteoporosis and risk of rib fracture)

Vibration 12/10/2023 By Abdi Wakjira( Bsc, Msc) 160 Is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration Helps increase the velocity of the air expired from the small airways, thus freeing the mucus. After three or four vibrations, the patient is encouraged to cough, contracting the abdominal muscles to increase the effectiveness of the cough

12/10/2023 By Abdi Wakjira( Bsc, Msc) 161 Fig. showing Percussion and vibration. A. Proper hand position for vibration. B. Proper technique for vibration. The wrists and elbows remain stiff; the vibrating motion is produced by the shoulder muscles . C. Proper hand position for percussion.

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 162 The nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten. Gives medication for pain, as prescribed, before percussion and vibration and splints any incision and Provides pillows for support as needed.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 163 Deep Breathing and Coughing Effective coughing can keep the airways clear of secretions. An ineffective cough is exhausting and fails to bring up secretions. Instruct the patient to take two or three deep breaths, using the diaphragm. This helps get the air behind the secretions. After the third deep inhalation, tell the patient to hold the breath and cough forcefully. This is repeated as necessary. Good hydration can facilitate this process.

Incentive Spirometry 12/10/2023 By Abdi Wakjira( Bsc, Msc) 164 Def : Incentive spirometry , also referred to as sustained maximal inspiration (SMI). Incentive Spirometry is designed to mimic natural sighing or vomiting by encouraging the patient to take long, slow, deep breaths. This is accomplished by using a device that provides patients with visual or other positive feed back when they inhale at a predetermined flow rate or volume & sustain the inflation for at least 5 seconds.

Purpose 12/10/2023 By Abdi Wakjira( Bsc, Msc) 165 To increase tran -pulmonary pressure & inspiratory volumes, improve inspiratory muscle performance, & re- establish or simulate the normal pattern of pulmonary hyperinflation. When the procedure is repeated on a regular basis, airway patency may be maintained & lung atelectasis prevented & reversed.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 166 Indication: Upper abdominal or thoracic- surgery Lower abdominal surgery Prolonged bed rest Surgery in patients with COPD Lack of pain control Presence of thoracic or abdominal binders.

Using an Incentive Spirometer 12/10/2023 By Abdi Wakjira( Bsc, Msc) 167 The inhalation of air, in a slow and controlled manner, helps inflate the lungs. The marker within the spirometer will measure the depth of each breath. Assume an upright position if possible (sitting or semi-Fowler’s). Breathe using your diaphragm. Place mouthpiece firmly in the mouth, to breathe in deeply and slowly, holding each breath in for 3–4 seconds and exhaling slowly. Repeat 6–10 times per session. Use spirometer every hour while awake (keep it within reach). Try coughing, with splinting of incision, after each use.

Incentive spirometer 12/10/2023 By Abdi Wakjira( Bsc, Msc) 168 How to use an incentive spirometer

ARTIFICIAL AIRWAYS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 169 The patient with an airway disorder such as a laryngeal obstruction or cancer may require the use of a temporary or, in some cases, a permanent artificial airway. Two types of artificial airways that may be used include an endotracheal tube (ETT) or a tracheostomy tube. General recommendations are to favor a tracheostomy tube rather than ETT if the patient will be intubated for 21 days or greater, and to favor the ETT over a tracheostomy if support will be required for 10 days or less (Morris et al., 2013).

ARTIFICIAL AIRWAYS Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 170 ETT and tracheostomy tubes have several disadvantages . The tubes cause discomfort, the cough reflex is depressed because closure of the glottis is hindered, and S ecretions tend to become thicker because the warming and humidifying effect of the upper respiratory tract has been bypassed.

ARTIFICIAL AIRWAYS Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 171 The swallowing reflexes are depressed because of prolonged disuse and the mechanical trauma produced by the endotracheal or tracheostomy tube, thus increasing the risk of aspiration. In addition, ulceration and stricture of the larynx or trachea may develop. Of great concern to the patient is the inability to talk and to communicate needs.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 172 Endotracheal intubation involves passing an endotracheal tube through the mouth or nose into the trachea.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 173 It is a means of providing an airway for patients who cannot maintain an adequate airway on their own Comatose patients, Patients with upper airway obstruction), For patients needing mechanical ventilation, For suctioning secretions from the pulmonary tree

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 174 Tracheotomy is a surgical procedure in which an opening is made into the trachea. The indwelling tube inserted into the trachea is called a tracheostomy tube It may be either temporary or permanent. Equipment Sterile gloves Hydrogen peroxide Normal saline solution or sterile water Cotton-tipped applicators Dressing Twill tape Type of tube prescribed, if the tube is to be changed

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 175 A tracheotomy is used To bypass an upper airway obstruction, To allow removal of tracheobronchial secretions, To permit the long-term use of mechanical ventilation, To prevent aspiration of oral or gastric secretions in the unconscious or paralyzed patient (by closing off the trachea from the esophagus) To replace an endotracheal tube

Tracheostomy tube in place 12/10/2023 By Abdi Wakjira( Bsc, Msc) 176

Tracheostomy tubes. A. Cuffed tracheostomy tube; used for patients on mechanical ventilation . B. Cuffed fenestrated tube; allows the patient to talk. C. Uncuffed tracheostomy tube; not used for adult patients on mechanical ventilation; often used for permanent tracheostomy patients who are not ventilator dependent. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 177

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 178 Continuous monitoring and assessment. Newly made opening must be kept patent by proper suctioning of secretions. The patient is placed in a semi-fowler’s position to facilitate ventilation, promote drainage, minimize edema, and prevent strain on the suture lines After the vital signs are stable Analgesia and sedative agents must be administered with caution because of the risk of suppressing the cough reflex.

Preventing Complications Associated With Endotracheal and Tracheostomy Tubes 12/10/2023 By Abdi Wakjira( Bsc, Msc) 179 Administer adequate warmed humidity. Maintain cuff pressure at appropriate level. Suction as needed per assessment findings. Maintain skin integrity. Change tape and dressing as needed or per protocol. Auscultate lung sounds. Monitor for signs and symptoms of infection, including temperature and white blood cell count.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 180 Administer prescribed oxygen and monitor oxygen saturation. Monitor for cyanosis. Maintain adequate hydration of the patient. Use sterile technique when suctioning and performing tracheostomy care.

12/10/2023 By Abdi Wakjira( Bsc, Msc) 181 Lower Respiratory Tract Disorders

Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 182 Pneumonia (from the Greek pneuma, “breath”) is a potentially fatal infection and inflammation of the lower respiratory tract (i.e., bronchioles and alveoli) usually caused by inhaled bacteria and viruses Is an inflammation of the lung parenchyma. Is a lung infection involving the lung alveoli (air sacs) and can be caused by microbes, including bacteria, viruses, or fungi. Pneumonitis -- immune-mediated inflammation of alveoli Clinical Definition Symptoms of acute LRT infection a) Cough, sputum, chest pain b) Fever,sweating,shiver, aches and pains • New focal chest signs on examination OR • New radiographic pulmonary infiltrates

Classification of pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 183 Based on causative agent Bacterial or typical pneumonia, Atypical pneumonia Viral pneumonia Fungal pneumonia etc

Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 184 Anatomic(morphological) classification Lobar pneumonia- homogeneous consolidation of one or more lung lobes Broncho - pneumonia- multiple patchy shadows in a localized or segmental area.

Bronchopneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 185 Infants + young children and the elderly. Usually secondary to other conditions associated with local and general defense mechanisms: Viral infections (influenza, measles) Aspiration of food or vomitus Obstruction of a bronchus (foreign body or neoplasm) Inhalation of irritant gases Major surgery Chronic debilitating diseases, malnutrition

Lobar pneumonia: 12/10/2023 By Abdi Wakjira( Bsc, Msc) 186 S. pneumoniae. Previously healthy individuals. Abrupt onset. Unilateral stabbing chest pain on inspiration (due to fibrinous pleurisy).

Types of Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 187 Community-acquired pneumonia(CAP) Infection of the pulmonary parenchyma acquired from exposure in the community Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. Infection usually spread by droplet inhalation. Highest incidence in winter Smoking important risk factor

“Typical” CAP: 12/10/2023 By Abdi Wakjira( Bsc, Msc) 188 History Previously healthy with sudden onset of fever and shortness of breath Presents with “typical” severe, acute infection Infectious agent (usually S. Pneumonia or H. Flu ) is culturable/ identifiable Responsive to cell-wall active antibiotics Physical signs and symptoms Tachycardia Tachypnea Productive cough with purulent sputum and possible hemoptysis Pallor and cyanosis

Typical CAP---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 189 localized: dullness to percussion decreased breath sounds crackles , ronchi , egophony Investigations CXR showing lobar consolidation CBC showing leukocytosis w/ left shift Sputum sample contains neutrophil, RBCs; Gram stain may be positive depending on organism

“Atypical” CAP 12/10/2023 By Abdi Wakjira( Bsc, Msc) 190 History : Previously healthy present with is usually sub-acute, low grade fever, sore throat, and intractable cough Minimal sputum production Able to continue to work No sick contacts, recent travel, or evidence of altered immune system PE reveals a mildly ill-appearing patient with diffuse wheezes on lung exam “Walking pneumonia” syndrome Causative pathogens are difficult to culture/identify by standard methods Not responsive to penicillins

Types Of Atypical Pneumonia. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 191 Mycoplasma pneumonia Caused by tiny bacteria mycoplasma pneumoniae. It is generally milder than other types Children and adults who are infected often show symptoms resembling those of a cold or flu , such as coughing, sneezing, and a mild fever. Generally, not have to be hospitalized. Chlamydophila pneumonia . Caused by chlamydophila pneumoniae bacteria. School-age children at greatest risk for this type. Legionella pneumonia (legionnaires’ disease) Caused by legionella pneumophila bacteria. Not spread through person-to-person contact. Legionnaires’ disease tends to be more serious than other types of atypical pneumonia. It can lead to respiratory failure and death in some cases.

Common causes Of CAP 12/10/2023 By Abdi Wakjira( Bsc, Msc) 192 The causative agents for CAP that requires hospitalization are: Previously healthy individual: → S. pneumoniae Pre-existing viral infection → Staph. aureus or S. pneumoniae Chronic bronchitis → Haemophilus influenzae or S. pneumoniae AIDS → Pneumocystis carinii, cytomegalovirus, TB Elderly people and those with co morbid illnesses → H. Influenzae Legionella, pseudomonas Aeruginosa, and other gram-negative rods. Viruses ( infants and children) Atypical bacteria

The most common causes for viral pneumonia are: 12/10/2023 By Abdi Wakjira( Bsc, Msc) 193 Influenza Parainfluenza Adenovirus Respiratory syncytial virus (RSV) appears mostly in children Cytomegalovirus In immunocompromised hosts

Features of Severe Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 194 ‘Core’ clinical adverse prognostic features (CURB) Confusion Urea > 7 mM (>19.1 mg/ dL ) Respiration rate >30 /min Blood Pressure: Systolic BP < 90 mm Hg and/or diastolic BP ≤ 60 mmHg NOTE: Patients with 2 or more CURB are at high risk of death

Hospital-Acquired Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 195 Also known as nosocomial pneumonia Is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission. Is an acute lower respiratory tract infection acquired after at least 48 hours of admission to hospital and is not incubating at the time of admission. Ventilator-associated pneumonia (VAP), is pneumonia occurring more than 48 hours after endotracheal intubation .

Predisposing factors 12/10/2023 By Abdi Wakjira( Bsc, Msc) 196 Defense mechanisms are incompetent or overwhelmed Decreased cough and epiglottal reflexes (may allow aspiration) Mucociliary mechanism impaired Pollution Cigarette smoking Upper respiratory infections Tracheal intubation Aging Metabolic disorder Mechanical ventilation ( VAP) Supine positioning and aspiration

Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 197 The common organisms responsible for HAP Enterobacter species, Escherichia coli, H. influenzae, Klebsiella species, Proteus, Serratia marcescens , P. aeruginosa, methicillin -sensitive or methicillin -resistant Staphylococcus aureus (MRSA), and S. pneumoniae

Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 198 Pneumonia in the Immunocompromised Host Includes Pneumocystis pneumonia (PCP), fungal pneumonias, and Mycobacterium tuberculosis. Aspiration Pneumonia Is the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway.

Pathophysiology of Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 199 Pneumonia results from the proliferation of microbial pathogens at the alveolar level and the host's response to those pathogens Their are three mechanisms by which pathogens reach to the lungs Inhalation, Aspiration and Hematogenous e.g. Tricuspid endocarditis

Pathophysiology pneumonia---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 200 Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment Aspiration : occurs when the Pt aspirates colonized upper respiratory tract secretions Stomach: reservoir of GN that can ascend, colonizing the respiratory tract. Hematogenous : originate from a distant source and reach the lungs via the blood stream.

Pathology of lobar pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 201 Four stage of pathiophysiological change occur due to pneumonia 1. Congestion Lasts < 24 hours: Out pouring of fluid from tissue to alveoli- b/se of inflammatory process. Alveoli filled with oedema fluid and bacteria. Only a few neutrophil are seen at this stage.

Stage of pathiophysiological- --- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 202 2 . Red hepatization Lungs look like the liver Firm, 'meaty' and airless appearance of lung. Alveolar capillary dilatation. Strands of fibrin extending from one alveolus to another via inter-alveolar pores of Kohn. Also neutrophil in alveoli. Pleura: Fibrinous exudate. Characterized microscopically by the presence of many RBC, neutrophil, micro-organisms , fibrins in the alveolar spaces

Stage of pathiophysiological---- … 12/10/2023 By Abdi Wakjira( Bsc, Msc) 203 3 . Gray hepatization Less hyperaemia. Macrophages, neutrophil + fibrin The lung is dry, friable and gray-brown to yellow as a consequence of a persistent fibrino-purulent exudates WBC and fibrin consolidate the alveoli and lung Second and third stages last for 2 to 3 days each

Stage Of Pathiophysiological---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 204 4. Resolution Lyses and removal of fibrin via sputum + lymphatics . Begins after 8-9 days (without antibiotics). Sudden improvement of patient's condition. Characterized by enzymatic digestion of the alveolar exudate; Resorption, phagocytosis or coughing up of the residual debris and Restoration of the pulmonary architecture.

Clinical manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 205 Cough producing greenish or yellow sputum High fever that may be accompanied by shaking chills Shortness of breath Tachypnea Pleuritic chest pain Headache

Clinical manifestations… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 206 Sweaty and clammy (moist) skin, Loss of appetite Fatigue Blueness of the skin Nausea, vomiting Mood swings Joint pains or muscle aches

Investigations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 207 History Physical exam Chest x-ray Gram stain of sputum Sputum culture and sensitivity Pulse oximeter or ABGs CBC, differential, chemistry Blood cultures Invasive diagnostic techniques Transtracheal aspiration Bronchoscopy with a protected brush catheter Direct needle aspiration of the lung

What are the differential diagnoses? 12/10/2023 By Abdi Wakjira( Bsc, Msc) 208 Alternative diagnosis Supporting clinical feature(s) Exacerbation of COPD Known COPD, history of smoking, or industrial exposure to inorganic dust,Bilateral polyphonic wheeze Lack of focal chest signs Exacerbation of asthma History of asthma or atopy , Bilateral polyphonic wheeze Lack of fever and focal chest signs Pulmonary oedema Features of left ventricular or biventricular failure (elevated jugular venous pressure, peripheral oedema, fine bibasal crackles in the lung) Bronchiectasis longer history,Finger clubbing Chronic cough productive of purulent sputum Bilateral crackles at the lung bases Lung cancer Haemoptysis, weight and appetite loss, smoking history Finger clubbing Lymphadenopathy Cachexia

Medical management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 209 EMPIRIC ANTIBIOTIC THERAPY First line ( Mild ):Amoxicillin 1g PO TID #5-7days and if penicillin allergy Clarithromycin 250gm PO BID #5-7days ( Moderate ): Benztylpencillin 1.2g IM QID #7days plus Doxycycline100mg PO BID #7days or Clarithromycin 500gm PO BID #7days If penicillin allergy Cefriaxone 1gm Iv daily #7days plus Doxycycline100mg PO BID #7days or Clarithromycin 500gm PO BID #7days ( Severe ): Benztylpencillin 1.2g IM every 4hours plus Gentamycin IV daily plus Azithromycin 500mg IV/PO daily If penicillin allergy :Cefriaxone 1gm Iv daily #7days plus Azithromycin 500mg IV/PO daily

Pneumonia cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 210 Medical management… E.g. according to DACA For community acquired ambulatory pts (mild pneumonia):- Amoxicillin OR Erythromycin OR Doxycyciline

Pneumonia cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 211 For community acquired hospitalized pts (severe pneumonia):- Non-Drug treatment: Bed rest Frequent monitoring of temperature, blood pressure and pulse rate. Give attention to fluid and nutritional replacements Administer Oxygen Analgesia for chest pain

Pneumonia cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 212 Drug treatment: Benzyl penicillin PLUS Gentamicin OR Ceftriaxon . Pneumonia due to staphylococcus aureus: Cloxacillin 1-2 gm, IV or IM QID for 10-14 days.

Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 213 HAP (nosocomial pneumonias) Antimicrobials effective against gram-negative & gram-positive should be given in combination. Suitable combination is: Cloxacillin plus Gentamicin OR Ceftriaxone plus Gentamicin Ciprofloxacin Pneumocytis pneumonia responds to Trimethoprin + Sulfamethoxazole

Complications of Pneumonia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 214 Abscess formation Empyema Failure of resolution ⇒ intra-alveolar scarring (' carnification ') ⇒ permanent loss of Ventilatory function of affected parts of lung. Bacteraemia: Infective endocarditis Cerebral abscess / meningitis Septic arthritis Shock and Respiratory Failure Pleural Effusion Atelectasis

Sample case scenarios 12/10/2023 By Abdi Wakjira( Bsc, Msc) 215 A 35-year-old male patient presented to Nekemte Specialized hospital with fever and cough. He was well 3 days back, when he suffered the onset of nasal stuffiness, mild sore throat, and a cough productive of small amounts of clear sputum. On Physical examination his temperature was 38.9°C , pulse 110 beats/min and regular, and his respiratory rate is 18 breaths/min. The case most likely? A 65-year-old man presented to the emergency department a few hours after the gradual onset of left-sided weakness and expressive aphasia. On admission all Vital signs were normal. However, On the fourth hospital day, Unfortunately, his temperature increases to 39.3C with concomitant coughing that sounds productive. Basilar rales are audible at the right lung base. A chest radiograph reveals the presence of a new right lower lobe infiltrate without an associated pleural effusion. The case most likely?

Chronic Obstructive Pulmonary Disease 12/10/2023 By Abdi Wakjira( Bsc, Msc) 216 COPD is also known as: Chronic obstructive lung disease (COLD), Chronic obstructive airway disease (COAD), Chronic airflow limitation (CAL) and Chronic obstructive respiratory disease (CORD) It is pulmonary disease characterized by airflow limitation that is not fully reversible. Refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath

12/10/2023 By Abdi Wakjira( Bsc, Msc) 217 In COPD, less air flows in and out of the airways because of one or more of the following: The airways and air sacs lose their elastic quality. The walls between many of the air sacs are destroyed. The walls of the airways become thick and inflamed. The airways make more mucus than usual, which tends to clog them.

Causes 12/10/2023 By Abdi Wakjira( Bsc, Msc) 218 Smoking Occupational exposures Air pollution sudden airway constriction in response to inhaled irritants, Bronchial hyperresponsiveness, is a characteristic of asthma. Genetics-Alpha 1-antitrypsin deficiency

Pathophysiology of COPD 12/10/2023 By Abdi Wakjira( Bsc, Msc) 219

Clinical features 12/10/2023 By Abdi Wakjira( Bsc, Msc) 220 Chronic cough Sputum production Wheezing Chest tightness Dyspnea on exertion Wt.loss Respiratory insufficiency Respiratory infections Barrel chest- chronic hyperinflation leads to loss of lung elasticity

DIFFERENTIAL DIAGNOSIS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 221 Diagnosis Suggestive feature COPD Onset mid-life Symptom slowly progressive History of tobacco smoking Asthma Onset early in life Symptom varies widely from day to day Symptom worse at night/morning Family history Congestive heart failure Chest X-ray shows dilated heart, pulmonary edema Pulmonary function test shows volume restriction not airway limitation Bronchiectasis Large volume of purulent sputum Commonly associated with bacterial infection Chest x-ray shows bronchial dilation Tuberculosis Onset all ages Chest x-ray shows infiltrate Microbiological confirmation Oblitrative bronchiolitis Has history of rheumatoid arthritis

Assessment 12/10/2023 By Abdi Wakjira( Bsc, Msc) 222 DX: Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation. According to Modified British Medical Research Council (mMRC) : mMRC Grade 0 :Only get breathlessness with extraneous exercise mMRC Grade 1: I get short of breath when hurrying the level mMRC Grade 2: I walk slower than people of the same age the level b/se of breathlessness mMRC Grade 3: I stop for breath after walking 100m mMRC Grade 4:I am too breathlessness to leave the house

COPD includes 12/10/2023 By Abdi Wakjira( Bsc, Msc) 223 Bronchitis Emphysema

Bronchitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 224 Bronchitis is a condition in which the bronchial tubes become inflamed. Acute (short term) and chronic (ongoing). Infections or lung irritants cause acute bronchitis. Chronic bronchitis is an ongoing, serious condition. It occurs if the lining of the bronchial tubes is constantly irritated and inflamed, causing a long-term cough with mucus.

Chronic bronchitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 225 Presence of recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years. It is defined as the presence of cough and sputum production for at least 3 months. Risk factors Bronchial irritants (e.g. cigarette smoke, exposure to pollution) Genetic predisposition (alpha-1 antitrypsin deficiency) Respiratory infections

Chronic Bronchitis: Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 226 Chronic inflammation Hypertrophy & hyperplasia of bronchial glands that secrete mucus Increase number of goblet cells Cilia are destroyed Bronchial smooth muscle hyper reactivity

Chronic Bronchitis: Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 227 Narrowing of airway airflow resistance work of breathing Hypoventilation & CO 2 retention  hypoxemia & hypercapnea

Chronic Bronchitis: Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 228 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 12/10/2023 By Abdi Wakjira( Bsc, Msc) 229

Chronic Bronchitis: Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 230 M ucus plug Normal lumen

Signs and symptom 12/10/2023 By Abdi Wakjira( Bsc, Msc) 231 Acute sore throat, fatigue (tiredness), fever, body aches, stuffy or runny nose, vomiting, and Diarrhea persistent cough cough may produce clear mucus shortness of breath Chronic coughing, wheezing, and chest discomfort. The coughing may produce large amounts of mucus. This type of cough often is called a smoker's cough.

Diagnosis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 232 History - medical history Whether you've recently had a cold or the flu Whether you smoke or spend time around others who smoke Whether you've been exposed to dust, fumes, vapors, or air pollution – Mucus -to see whether you have a bacterial infection chest x ray lung function tests, CBC ABG analysis

MEDICAL MANAGEMENT 12/10/2023 By Abdi Wakjira( Bsc, Msc) 233 Improve ventilation Broncho dilators like beta2agonists ( albuterol ) ,anticholinergics( ipratropium bromide- atrovent ). Methylxanthines( theophylline,aminophylline ) Corticosteroids Oxygen administration Remove bronchial secretion Promote exercises Control complications Improve general health

Surgical management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 234 BULLECTOMY Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the Lung volume reduction surgery : It involves the removal of a portion of the diseased lung parenchyma. Lung transplantation

Sample case scenarios 12/10/2023 By Abdi Wakjira( Bsc, Msc) 235 A 62-year-old auto mechanic who presents with progressive shortness of breath for the past several days. His problem began four days ago when I got a cold. Initially, the cough was dry but within 24 hours of onset, it produced abundant yellow-green sputum that he stated , "I cough up a cup of this stuff every day." His wife states that he "hack and spits up" every morning when he gets up from bed. The case most likely? 2. A 38 year old female presented to wollega university referral hospital with chief complain of mild, occasionally productive cough for the past 3-4 months . she has been smoking about one pack per day for the past 20 years. She has had no fever or chills. She does admit to more shortness of breath when she exercises over the past six months. Her case most likely?

Emphysema 12/10/2023 By Abdi Wakjira( Bsc, Msc) 236 Is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli. Is defined as enlargement of the air spaces distal to the terminal bronchioles , with destruction of their walls of the alveoli due to the action of the proteinases. . As the alveoli are destroyed the alveolar surface area in contact with the capillaries decreases causing formation of dead spaces

Types 12/10/2023 By Abdi Wakjira( Bsc, Msc) 237 The part of the acinus affected determines the subtype. It can be subdivided pathologically into: Centrilobular (Proximal Acinar)- The respiratory bronchiole (proximal and central part of the acinus) is expanded. The distal acinus or alveoli are unchanged. Occurs more commonly in the upper lobes is the most common type and is commonly associated with smoking. It can also be seen in coal workers pneumoconiosis.

Classification 12/10/2023 By Abdi Wakjira( Bsc, Msc) 238 Panacinar- Is most commonly seen with alpha one antitrypsin deficiency. The entire respiratory acinus from respiratory bronchiole to alveoli, is expanded. Occurs more commonly in the lower lobes, especially basal segments, and anterior margins of the lungs. Paraseptal (Distal acinar ) - may occur alone or in association with above and the usual association is spontaneous pneumothorax in a young adult.

Emphysema…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 239

Emphysema…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 240 Clinical manifestation Early stages Barell chest Central cyanosis Finger clubbing Dyspnea Wheezing Chronic fatigue Difficult in sleeping Hypoxia Polycythemia Cough & sputum production

Clubbing of the Fingers as a Result of Chronic Hypoxia 12/10/2023 By Abdi Wakjira( Bsc, Msc) 241

Emphysema…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 242 Later stages Hypercapnea Purse-lip breathing Use of accessory muscles to breathe Underweight No appetite & increase breathing workload

Emphysema….. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 243

Emphysema Use accessory muscle Pursed lips breathing 12/10/2023 By Abdi Wakjira( Bsc, Msc) 244

Assessment and Diagnostic Findings 12/10/2023 By Abdi Wakjira( Bsc, Msc) 245 History (smoking, occupational exposure) Physical exam PFT Spirometry -to find out airflow obstruction. ABG analysis CT scan of the lung. Screening of alpha antitrypsin deficiency X-ray radiography may aid in the diagnosis. CBC Sputum analysis

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 246 Risk Reduction (smoking cessation) Pharmacologic Therapy Bronchodilators Beta2-Adrenergic Agonist Agents :- salbutamol , albuterol Anticholinergic Agents:- Ipratropium bromide Methylxanthines:- aminophylline , theophylline Corticosteroids Other Medications(alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.

Medical Management ……. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 247 O xygen Therapy Surgical Management Lung Volume Reduction Surgery Pulmonary Rehabilitation Patient Education Breathing Exercises Activity Pacing Self-Care Activities Nutritional therapy Coping Measures

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 248 Assessing the Patient Achieving Airway Clearance Improving Breathing Patterns Improving Activity Tolerance Monitoring and Managing Potential Complications (respiratory insufficiency and failure)

Comparison of emphysema and chronic bronchitis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 249 Emphysema Chronic bronchitis Pink Puffers Blue Bloaters Thin Appearance Airway Flow Problem Increased CO2 retention Color is Dusky to Cyanotic Minimal Cyanosis Recurrent Productive Cough Purse Lip Breathing Hypoxia Dyspnea Hypercapnia Hyper-resonance on Chest Percussion Respiratory Acidosis Orthopneic High Hemoglobin Barrel Chest Increased Respiratory Rate Exertional Dyspnea( Early ) Dyspnea on Exertion ( late ) Prolonged Expiratory Time Digital clubbing Speaks in short jerky sentences Cardiac enlargement Anxious Bilateral lower extremity edema

12/10/2023 By Abdi Wakjira( Bsc, Msc) 250 E B

Sample case scenarios 12/10/2023 By Abdi Wakjira( Bsc, Msc) 251 A 66-year-old man with a smoking history of 1 pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. Lung examination reveals a barrel chest and poor air entry bilaterally. Based on the above scenarios the diagnosis is most likely?

Asthma 12/10/2023 By Abdi Wakjira( Bsc, Msc) 252 Asthma is a chronic inflammatory disorder of the airways that is characterized: Clinically by recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night/early morning. Physiologically by widespread, reversible narrowing of the bronchial airways and a marked increase in bronchial responsiveness to direct or indirect stimuli and with chronic airway inflammation Is a heterogeneous disease, usually characterized by chronic airway inflammation

12/10/2023 By Abdi Wakjira( Bsc, Msc) 253 The chronic inflammation is associated with airway hyper‐responsiveness that leads to recurrent episodes of wheezing , breathlessness, chest tightness and coughing particularly at night or early morning. These episodes are usually associated with widespread, but variable airflow obstruction within the lung that is often reversible either spontaneously or with treatment Is a chronic inflammatory disease of the airways that causes:- Airway hyperresponsiveness Mucosal edema Mucus production

Asthma classification 12/10/2023 By Abdi Wakjira( Bsc, Msc) 254 Asthma is divided into two main categories, intrinsic and extrinsic. Intrinsic asthma is due to hypersensitivity of the airways independent of antibodies. These sensitivities can include chemicals, exercise, complement activation, cold air, infection, and emotional stress. Extrinsic asthma is due to increased levels of IgE in the plasma.

Classification---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 255 Atopic /extrinsic /allergic ( 70%) Due to increased levels of IgE in the plasma in responses to environmental antigens. Genetically transmitted Childhood onset 2. Non-atopic/ intrinsic /non-allergic( 30%) Intrinsic asthma is due to hypersensitivity of the airways independent of antibodies Triggered by non immune stimuli. Patients have negative skin test to common inhalant allergens and normal serum concentrations of ige . Asthma may be triggered by aspirin, pulmonary infections, cold, exercise, psychological stress or inhaled irritants..

12/10/2023 By Abdi Wakjira( Bsc, Msc) 256

Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 257 Chronic inflammation Airway Hyperresponsiveness

Pathophysiology of Asthma 12/10/2023 By Abdi Wakjira( Bsc, Msc) 258

ETIOLOGY 12/10/2023 By Abdi Wakjira( Bsc, Msc) 259 Allergy is the strongest predisposing factor for asthma. Common allergens can be Seasonal (grass, tree, and weed pollens) or Perennial (e.g., mold, dust, roaches, animal dander). Common triggers for asthma symptoms and exacerbations Airway irritants (e.g., air pollutants, cold, heat, weather changes, strong odors or perfumes, smoke) Exercise, stress or emotional upset Rhino sinusitis with postnasal drip Medications Viral respiratory tract infections Gastroesophageal reflux.

Clinical Manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 260 The three most common symptoms of asthma are Cough Dyspnea Wheezing As the exacerbation progresses Diaphoresis Tachycardia Hypoxemia and central cyanosis (a late sign of poor oxygenation)

Status Asthmaticus 12/10/2023 By Abdi Wakjira( Bsc, Msc) 261 The severe and prolonged asthma exacerbation with intensive progressive respiratory failure, hypoxemia, hypercapnia, respiratory acidosis, increased blood viscosity and the most important sign is blockade of bronchial b2-receptors. Stages: 1 st - refractory response to b2-agonists ( relaxation of the smooth muscles ) 2 nd - “silent” lung because of severe bronchial obstruction and collapse of small and intermediate bronchi; 3 rd stage – the hypercapnic coma.

Asthma…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 262 Assessment and Diagnostic Findings Hx Physical examination Chest X-ray Sputum increase viscosity CBC- eosinophills Lung Function Tests Arterial blood gas analysis and pulse oximetry

Pharmacological Treatment 12/10/2023 By Abdi Wakjira( Bsc, Msc) 263 A stepwise approach is recommended as follows Inhaled salbutamol prn (when necessary) Inhaled salbutamol prn plus low-dose inhaled beclometasone , starting with 100ug twice daily for adults Add low-dose oral theophylline to Step 3 treatment (assuming long-acting beta agonists and leukotriene antagonists are not available) Add oral prednisolone , but in the lowest dose possible to control symptoms (nearly always less than 10mg daily)

12/10/2023 By Abdi Wakjira( Bsc, Msc) 264 REFER The patient should be referred in the following conditions: • When asthma is poorly controlled When the diagnosis of asthma is uncertain When regular oral prednisolone is required to maintain control 5. FOLLOW UP Patient and family education should be provided • Advise the patient to carry the device always • Emphasize the need for adherence to drugs. • Advice regarding dealing with triggers

Asthma cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 265 Medical management There are two general classes of asthma medications: Quick-relief medications for immediate treatment of asthma symptoms and exacerbations. Long acting medications to achieve and maintain control of persistent asthma.

Asthma cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 266 According to DACA: Initial treatment Salbutamol (metered dose inhaler MDI). Alternatives Aminophylline , 5mg/kg by slow I.V. push over 5 minutes. OR Adrenaline, 0.5ml sc.

Asthma cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 267 Maintenance therapy for chronic asthma in adults: Requires prolonged use of anti-inflammatory drugs mainly in the form of steroid inhalers Intermittent asthma: Salbutamol, inhaler 200 microgram/puff,1-2 puffs to be taken as needed but not more than 3-4 times a day Alternative Ephedrine + Theophylline

Asthma cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 268 Persistent mild asthma Salbutamol, inhaler, 200 micro gram/puff 1-2 puffs to be taken, as needed but not more than 3-4 times/day PLUS Beclomethasone, oral inhalation 1000mcg QD for two weeks Alternative Ephedrine + Theophylline (11mg + 120mg), P.O. two to three times a day PLUS Beclomethasone oral inhalation 1000mcg QD for two weeks.

Asthma cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 269 Persistent moderate asthma Salbutamol, inhalation 200microgram/puff 1-2 puffs as needed PRN not more than 3-4 times a day. PLUS Beclomethasone, 2000mcg, oral inhalation QD for two weeks and reduce to 1000 mcg if symptoms improve.

ACUTE EXACERBATION OF ASTHMA 12/10/2023 By Abdi Wakjira( Bsc, Msc) 270 The following patients have a high risk of future exacerbations and may have a poor asthma outcome. Risks for exacerbation • Uncontrolled asthma symptoms • One or more severe exacerbation in previous year • Start of the patient’s usual ‘flare-up’ season • Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens • Major psychological or socio-economic problems for child or family • Poor adherence with controller medication, or incorrect inhaler technique

Management of Asthma exacerbation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 271 Prednisolone 30–40mg for five days for adults and 1mg per kg for three days for children, or longer, if necessary, until they have recovered; Salbutamol in high doses by metered dose inhaler and spacer (e.g. four puffs every 20 minutes for one hour) or by nebulizer; Oxygen , if available, if O2 saturation levels are below 90%)

Asthma cont’d… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 272 Severe persistent asthma Salbutamol, inhalation , 200 micro gram/puff 1-2 puffs not more than 3-4 times a day PLUS Beclomethasone, 2000 mcg, oral inhalation daily

Asthma…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 273 Nursing management Assessing patients respiratory status The purpose and action of each medication Triggers to avoid, and how to do so Proper inhalation technique

Asthma…. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 274 Complications Status asthmaticus Respiratory failure Pneumonia Atelectasis

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) 12/10/2023 By Abdi Wakjira( Bsc, Msc) 275 Def : Condition characterized by acute inflammatory lung injury resulting in widespread pulmonary edema as a result of increased alveolar capillary permeability and epithelial destruction . “The acute onset of severe respiratory distress and cyanosis that was refractory to oxygen therapy and associated with diffuse CXR abnormality and decreased lung compliance ” Lancet 1967

Causes 12/10/2023 By Abdi Wakjira( Bsc, Msc) 276 Shock Aspiration Trauma Infections Inhaled fumes Drugs and poisons Miscellaneous

Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 277 Neutrophils release inflammatory mediators -->degrading integrity of capillary endothelial cells--->capillary permeability, interstitial edema. Influx of proteinaceous plasma fluid, erythrocytes, and inflammatory cells into the interstitium destroyed surfactant and type 1 and 2 pneumocyte Increases alveolar surface tension, thus producing alveolar collapse

Stages of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 278 1. Exudative (acute): 0-4 d 2. Proliferative:4-8 d 3. Fibrotic:>8 d 4. Recovery

PATHOGENESIS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 279 Exudative Phase: Injury begins with activation of alveolar macrophages by microbial or cell injury products, locally derived in primary lung injury (pulmonary ARDS) or systemically derived ( extrapulmonary ARDS). Cytokine/chemokine release by macrophages recruits and activates circulating neutrophils, which release myriad inflammatory molecules . t hey also injure the normally tight alveolar endothelial–epithelial barrier consisting of adherent cell-cell contacts and glycocalyx linings.

PATHOGENESIS Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 280 Alveolar type II pneumocytes secrete surfactant and along with type I pneumocytes reabsorb alveolar fluid by active ion transport back into the interstitium for lymphatic clearance. As a result of loss of the normal low permeability characteristics, the alveolar space fills with an inflammatory cell-rich proteinaceous edema fluid (exudative phase of ARDS), a prime determinant of lung injury severity, alveolar collapse, and derecruitment

PATHOGENESIS Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 281 The proliferative phase of ARDS: C learance of pathogens and damaged host cells from the alveolar space, the immune response is recalibrated to prioritize repair and restoration of normal function. Clearance involves neutrophil apoptosis and removal, expansion of resident fibroblasts and interstitial matrix reformation, and R egrowth of alveolar epithelium by differentiation of type II alveolar cells into type I cells . If the proliferative phase is impaired or prolonged, ongoing inflammation and fibroblast proliferation impair alveolar clearance and functional recovery

PATHOGENESIS Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 282 Fibrotic phase: It is likely that uncleared , insoluble proteins in the alveolar space (forming hyaline membranes observed histologically) seed the formation of fibrotic tissue by mesenchymal cells, U ltimately leading to the long-term consequence of fibrosing alveolitis (fibrotic phase of ARDS) in some but not all patients.

Gas Exchange impairment in ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 283 A bnormalities from areas with reduced ventilation-to-perfusion (V A /Q) ratios and intrapulmonary shunting to high V A /Q ratios and dead space. Low V A /Q and shunt are responsible for increased venous admixture and arterial hypoxemia. Given little or no ventilation to these areas, arterial hypoxemia is insensitive to global increases in ventilation.

Clinical Manifestation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 284 Signs and symptoms In the first 24 to 48 hours, signs and symptoms include dyspnea, tachypnea, dry cough, fatigue, and tachycardia. Even with supplemental oxygen, a patient’s skin may look cyanotic and mottled. Auscultation reveals adventitious breath sounds (crackles, rhonchi, and wheezes) or increasingly diminished breath sounds.

Clinical Manifestation 12/10/2023 By Abdi Wakjira( Bsc, Msc) 285 Signs and symptoms As oxygenation and perfusion diminish, the patient may become agitated, anxious, confused, and restless. A chest X-ray shows diffuse infiltrates, and ABG results indicate respiratory alkalosis with very low PaO2 levels. In the later stages, hypercapnia may develop. Further metabolic imbalances can lead to mixed acidosis, signaling a low ventilation-to-perfusion (V./Q.) ratio and a deteriorating P/F ratio.

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 286 The primary focus in the management of ARDS includes identification and treatment of the underlying condition. Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important.

Medical Management Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 287 Positive end-expiratory pressure (PEEP) is a critical part of the treatment of ARDS. PEEP usually improves oxygenation, but it does not influence the natural history of the syndrome. Use of PEEP helps to increase functional residual capacity and reverse alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation and a reduction in the severity of the ventilation–perfusion imbalance. By using PEEP, a lower FiO2 may be required. The goal is a PaO2 greater than 60 mm Hg or an oxygen saturation level of greater than 90% at the lowest possible FiO2.

Medical Management Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 288 PHARMACOLOGIC THERAPY Numerous pharmacologic treatments are under investigation to stop the cascade of events leading to ARDS. These include: Human recombinant interleukin-1 receptor antagonist, N eutrophil inhibitors, pulmonary-specific vasodilators, S urfactant replacement therapy, antisepsis agents, A ntioxidant therapy, and corticosteroids late in the course of ARDS

Cont….d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 289 NUTRITIONAL THERAPY Adequate nutritional support is vital in the treatment of ARDS. Patients with ARDS require 35 to 45 kcal/kg per day to meet caloric requirements. Enteral feeding is the first consideration; however , parenteral nutrition also may be required.

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 290 GENERAL MEASURES The patient with ARDS is critically ill and requires close monitoring because the condition could quickly change to a life threatening situation. Most of the respiratory modalities used in this situation: O xygen administration, N ebulizer therapy, c hest physiotherapy, E ndotracheal intubation or tracheostomy, M echanical ventilation, S uctioning , B ronchoscopy ).

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 291 5 P’s of ARDS therapy Managing patients with ARDS requires maintaining the airway, providing adequate oxygenation, and supporting hemodynamic function. The five P’s of supportive therapy include perfusion, positioning, protective lung ventilation, protocol weaning, and preventing complications .

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 292 Perfusion The goal of care for ARDS patients is to maximize perfusion in the pulmonary capillary system by increasing oxygen transport between the alveoli and pulmonary capillaries. To achieve the goal, you need to increase fluid volume without overloading the patient. Give either crystalloids or colloids to replace the fluids that have leaked from the capillaries into the alveolar spaces.

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 293 Positioning Patient positioning also affects perfusion. If a patient is standing, blood flow moves to the base of the lung and away from the apex. If a patient is supine, the posterior area of the lung will be more perfused than the anterior area. Because the better aerated surfaces of the lungs are the nondependent areas, the result is a ventilation/perfusion mismatch.

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 294 Positioning Three positioning therapies can decrease these complications and improve perfusion in ARDS patients: 1. Kinetic Therapy (bilateral turning of a patient 40 degrees or more per side) 2. Continuous lateral rotational therapy (bilateral turning of a patient no more than 40 degrees per side) 3. prone positioning . These therapies improve oxygenation by mobilizing secretions, resolving atelectasis, improving V./Q. ratio

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 295 Protective Lung Ventilation During the early stages of ARDS, use mechanical ventilation to open collapsed alveoli. The primary goal of ventilation is to support organ function by providing adequate ventilation and oxygenation while decreasing the patient’s work of breathing. But mechanical ventilation itself can damage the alveoli, making protective lung ventilation necessary .

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 296 Indication for mechanical ventilation PaO2 < 50 mm Hg with FiO2 > 0.60 PaO2 > 50 mm Hg with pH < 7.25 Vital capacity < 2 times tidal volume Negative inspiratory force < 25 cm H2O Respiratory rate > 35/min

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 297 Protective Lung Ventilation Current recommendations for protective lung ventilation include: limiting plateau pressures to less than 30 cm H2O, maintaining positive end-expiratory pressure (PEEP) of at least 5 cmH2O is required reducing FiO2 to 50% to 60%, Intermittent positive pressure breathing (IPPB) is a technique used to provide short term or intermittent mechanical ventilation via mouthpiece or mask.

Nursing Management of ARDS 634 12/10/2023 By Abdi Wakjira( Bsc, Msc) 298 There are three types of positive-pressure ventilators, which are classified by the method of ending the inspiratory phase of respiration: pressure-cycled, time-cycled, and volume-cycled. Another type of positive-pressure ventilator used for selected patients is noninvasive positive-pressure ventilation.

Nursing Management of ARDS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 299 Preventing complications The most common complications are VILI, deep vein thrombosis (DVT), pressure ulcers, decreased nutritional status, and ventilator-associated pneumonia (VAP).

Respiratory Failure 12/10/2023 By Abdi Wakjira( Bsc, Msc) 300 Def : Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in the body. Respiratory failure is a condition where there is no enough oxygen in the tissues (hypoxia) or when you have too much carbon dioxide in your blood ( hypercapnia ). It can happen all at once (acute) or come on over time (chronic). Many underlying conditions can cause it. Acute respiratory failure is life-threatening .

Types of Respiratory Failure 12/10/2023 By Abdi Wakjira( Bsc, Msc) 301 It is important to distinguish between acute respiratory failure (ARF) and chronic respiratory failure . 1. Chronic Respiratory Failure Chronic respiratory failure is defined as a deterioration in the gas exchange function of the lung that has developed insidiously or has persisted for a long period after an episode of ARF. The absence of acute symptoms and the presence of a chronic respiratory acidosis suggest the chronicity of the respiratory failure.

1. Chronic Respiratory Failure … 12/10/2023 By Abdi Wakjira( Bsc, Msc) 302 Two causes of chronic respiratory failure are: COPD and neuromuscular diseases. Patients with these disorders develop a tolerance to the gradually worsening hypoxemia and hypercapnia . However, a patient with chronic respiratory failure may develop ARF . This is seen in the COPD patient who develops an exacerbation or infection that causes additional deterioration of the gas exchange mechanism.

Acute Respiratory Failure 12/10/2023 By Abdi Wakjira( Bsc, Msc) 303 Def : Respiratory failure is a sudden and life-threatening deterioration of the gas exchange function of the lung . It exists when the exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of oxygen consumption and carbon dioxide production by the cells of the body. Acute respiratory failure (ARF) is defined as a fall in arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and a rise in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg ( hypercapnia ), with an arterial pH of less than 7.35.

ARF Cont ..d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 304 Respiratory system mechanisms leading to ARF include: • Alveolar hypoventilation • Diffusion abnormalities • Ventilation–perfusion mismatching • Shunting

Etiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 305 Common causes of ARF can be classified into four categories: Decreased respiratory drive 2. Dysfunction of the chest wall 3. D ysfunction of the lung parenchyma 4. O ther causes.

Pathogenesis related to the cause 12/10/2023 By Abdi Wakjira( Bsc, Msc) 306 1. Decreased respiratory drive: Decreased respiratory drive may occur with severe brain injury, large lesions of the brain stem (multiple sclerosis), use of sedative medications , and metabolic disorders such as hypothyroidism. These disorders impair the normal response of chemoreceptors in the brain to normal respiratory stimulation.

Pathogenesis related to the cause 12/10/2023 By Abdi Wakjira( Bsc, Msc) 307 2. Dysfunction of the chest wall: The impulses arising in the respiratory center travel through nerves that extend from the brain stem down the spinal cord to receptors in the muscles of respiration. Thus , any disease or disorder of the nerves, spinal cord, muscles, or neuromuscular junc tion involved in respiration seriously affects ventilation and may ultimately lead to ARF.

Pathogenesis related to the cause 12/10/2023 By Abdi Wakjira( Bsc, Msc) 308 2. Dysfunction of the chest wall: These include: musculoskeletal disorders (muscular dystrophy, polymyositis ), neuromuscular junction disorders (myasthenia gravis, poliomyelitis), some peripheral nerve disorders , and spinal cord disorders (amyotrophic lateral sclerosis, Guillain-Barré syndrome, and cervical spinal cord injuries). dysfunction of the lung parenchyma, and other causes.

Pathogenesis related to the cause 12/10/2023 By Abdi Wakjira( Bsc, Msc) 309 3 . Dysfunction of the lung parenchyma These are conditions that interfere with ventilation by preventing expansion of the lung. They include: Pleural effusion, hemothorax , pneumothorax , and upper airway obstruction. These conditions, which may cause respiratory failure, usually are produced by an underlying lung disease, pleural disease, or trauma and injury.

3. Dysfunction of the lung parenchyma …. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 310 Other diseases and conditions of the lung that lead to ARF include: pneumonia, status asthmaticus , lobar atelectasis, pulmonary embolism, and pulmonary edema.

3. O ther causes . 561 12/10/2023 By Abdi Wakjira( Bsc, Msc) 311 In the postoperative period, especially after major thoracic or abdominal surgery, inadequate ventilation and respiratory failure may occur because of several factors. F or example , ARF may be caused by the effects of: anesthetic agents, analgesics , and sedatives, These may depress respiration as described earlier or enhance the effects of opioids and lead to hypoventilation . Pain may interfere with deep breathing and coughing . A mismatch of ventilation to perfusion is the usual cause of respiratory failure after major abdominal, cardiac, or thoracic surgery.

Clinical Manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 312 Early signs are those associated with impaired oxygenation; and may include: restlessness , fatigue , headache , dyspnea , air hunger, tachycardia , and increased blood pressure.

Clinical Manifestations Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 313 As the hypoxemia progresses, more obvious signs may be present; may including: confusion, lethargy , tachycardia , tachypnea , central cyanosis, diaphoresis, and finally respiratory arrest.

Clinical Manifestations Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 314 Physical findings are those of acute respiratory distress, including : use of accessory muscles, decreased breath sounds if the patient cannot adequately ventilate, and other findings related specifically to the underlying disease process and cause of ARF.

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 315 The objectives of treatment are to correct the underlying cause, and T o restore adequate gas exchange in the lung. Intubation and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the underlying cause is corrected .

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 316 Nursing management of the patient with ARF includes: Assisting with intubation and, maintaining mechanical ventilation. The nurse assesses the patient’s respiratory status by: monitoring the patient’s level of response, arterial blood gases , pulse oximetry , and vital signs and, assessing the respiratory system .

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 317 The nurse implements strategies such as: turning schedule, mouth care, skin care, range of motion of extremities to prevent complications .

Nursing Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 318 The nurse also assesses the patient’s understanding of: the management strategies that are used and, initiates some form of communication to enable the patient to express his or her needs to the health care team. Nursing care also addresses the problems that led to ARF. As the patient’s status improves, the nurse assesses the patient’s knowledge of the underlying disorder, provides teaching as appropriate to address the underlying disorder.

Bronchiectasis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 319 Is a chronic, irreversible dilation of the bronchi and bronchioles. Bronchiectasis is a chronic respiratory disease characterized by a syndrome of productive cough and recurrent respiratory infections due to permanent dilatation of the bronchi. Bronchiectasis represents the final common pathway of different disorders, some of which may require specific treatment.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 320 Bronchiectasis may be caused :- Airway obstruction Diffuse airway injury 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

12/10/2023 By Abdi Wakjira( Bsc, Msc) 321

Etiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 322 Congenital causes (e.g. Mounier -Kuhn syndrome) COPD, and smoking Cystic fibrosis Mucociliary dysfunction (e.g. primary ciliary dyskinesia) Primary or secondary immune deficiency Pulmonary fibrosis and pneumoconiosis Post obstruction (e.g. with a foreign body) Post infection (e.g. TB, recurrent pneumonia) Recurrent small volume aspiration Allergic bronchopulmonary aspergillosis Systemic inflammatory diseases ( eg . rheumatoid arthritis, sarcoidosis )

Features suggest Bronchiectasis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 323 Diagnosis of asthma that is unresponsive to usual management Digital clubbing (this is rare in COPD and asthma) Lack of a significant smoking history (less than an average of 20 cigarettes per day for 10 years) in a person with suspected COPD History of recurrent and/or severe pneumonia including tuberculosis Presence of ‘unusual organisms’ in sputum (e.g. Aspergillus, atypical/ nontuberculous mycobacterium, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae ) Childhood associated with significant environmental and social disadvantage

Clinical Manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 324 Chief complaints are : Chronic cough, Purulent sputum (Copious and purulent and pools in the dilated airways). Dyspnea and Sometimes haemoptysis Clubbing of the fingers also is common because of respiratory insufficiency. Wheezes and crackles Repeated episodes of pulmonary infection

Diagnostic tests 12/10/2023 By Abdi Wakjira( Bsc, Msc) 325 History Sputum culture The chest CT is the golden standard diagnostic tool for Bronchiectasis with the typical presentation of bronchial diameter larger than nearby pulmonary artery without normal bronchial tapering.

Medical management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 326 Antibiotics may be used intermittently or for prolonged periods. Bronchodilators improve airway obstruction. Mucolytic agents help thin secretions Chest physiotherapy helps mobilize secretions Oxygen is used if hypoxemia is present

Nursing management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 327 Encourage to stop smoking & other factors that increase the production of mucus Teaching the patient and family How to perform postural drainage Assess patients’ nutritional status/appetite T each t he patient about early signs of respiratory infection and the progression of the disorder .

Chest trauma 12/10/2023 By Abdi Wakjira( Bsc, Msc) 328 Chest trauma is classified as either blunt or penetrating . Blunt chest trauma results from sudden compression or positive pressure inflicted to the chest wall. Common Causes of Bunt Chest Trauma are: Motor vehicle crashes (trauma due to steering wheel, seat belt), falls , and, bicycle crashes (trauma due to handlebars ).

Chest trauma Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 329 Penetrating trauma occurs when a foreign object penetrates the chest wall. The most common causes of penetrating chest trauma include: G unshot wounds and stabbings. 1. BLUNT TRAUMA is more common, it is often difficult to identify the extent of the damage because the symptoms may be generalized and vague. In addition, patients may not seek immediate medical attention,

Pathophysiology 12/10/2023 By Abdi Wakjira( Bsc, Msc) 330 Injuries to the chest are often life-threatening and result in one or more of the following pathologic mechanisms: Hypoxemia from disruption of the airway; injury to the lung parenchyma, rib cage, and respiratory musculature; massive hemorrhage; collapsed lung; and pneumothorax Hypovolemia from massive fluid loss from the great vessels, cardiac rupture, or hemothorax Cardiac failure from cardiac tamponade , cardiac contusion, or increased intrathoracic pressure

Assessment and Diagnostic Findings 12/10/2023 By Abdi Wakjira( Bsc, Msc) 331 Time is critical in treating chest trauma. Therefore , it is essential to assess the patient immediately to determine the following: • When the injury occurred • Mechanism of injury • Level of responsiveness • Specific injuries • Estimated blood loss • Recent drug or alcohol use • Pre hospital treatment

Assessment and Diagnostic Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 332 The initial assessment of thoracic injuries includes: Assessment of the patient for airway obstruction, T ension pneumothorax, O pen pneumothorax, M assive hemothorax , F lail chest, and cardiac tamponade . These injuries are life-threatening and need immediate treatment.

Assessment and Diagnostic Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 333 Secondary assessment would include: Simple pneumothorax , H emothorax , P ulmonary contusion, Traumatic aortic rupture, T racheobronchial disruption, E sophageal perforation , T raumatic diaphragmatic injury, and P enetrating wounds to the mediastinum (Owens, Chaudry , Eggerstedt & Smith, 2000). Although listed as secondary, these injuries may be life-threatening as well depending upon the circumstances.

Assessment and Diagnostic Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 334 The vital signs and skin color are assessed for signs of shock. The thorax is palpated for tenderness and crepitus; the position of the trachea is also assessed . The initial diagnostic workup includes: a chest x-ray, CT scan, complete blood count, clotting studies, type and cross-match, electrolytes , oxygen saturation, arterial blood gas analysis, and ECG . The patient is completely undressed to avoid missing additional injuries that can complicate care.

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 335 The goals of treatment are to evaluate the patient’s condition and to initiate aggressive resuscitation . An airway is immediately established with oxygen support in some cases, intubation and ventilatory support. Re-establishing fluid volume and negative intrapleural pressure and draining intrapleural fluid and blood are essential .

Flail Chest 12/10/2023 By Abdi Wakjira( Bsc, Msc) 336 Flail chest is frequently a complication of blunt chest trauma from a steering wheel injury. It usually occurs when three or more adjacent ribs (multiple contiguous ribs) are fractured at two or more sites, resulting in free-floating rib segments. PATHOPHYSIOLOGY During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner ( pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs.

Flail Chest 12/10/2023 By Abdi Wakjira( Bsc, Msc) 337 Flail chest is caused by a free floating segment of rib cage resulting from multiple rib fractures. ( A ) Paradoxical movement on inspiration occurs when the flail rib segment is sucked inward and the mediastinal structures shift to the unaffected side. The amount of air drawn into the affected lung is reduced . ( B ) On expiration, the flail segment bulges outward and the mediastinal structures shift back to the affected side.

MEDICAL MANAGEMENT 12/10/2023 By Abdi Wakjira( Bsc, Msc) 338 As with rib fracture, treatment of flail chest is usually supportive. Management includes providing ventilatory support, clearing secretions from the lungs, and controlling pain. The specific management depends on the degree of respiratory dysfunction. When a severe flail chest injury is encountered, endotracheal intubation and mechanical ventilation are required to provide internal pneumatic stabilization of the flail chest and to correct abnormalities in gas exchange. This helps to treat the underlying pulmonary contusion, serves to stabilize the thoracic cage to allow the fractures to heal.

2. PENETRATING TRAUMA 12/10/2023 By Abdi Wakjira( Bsc, Msc) 339 GUNSHOT AND STAB WOUNDS Gunshot and stab wounds are the most common types of penetrating chest trauma. They are classified according to their velocity : Stab wounds are generally considered of low velocity because the weapon destroys a small area around the wound. Knives and switchblades cause most stab wounds. The appearance of the external wound may be very deceptive; B ecause pneumothorax, hemothorax , lung contusion, and cardiac tamponade , along with severe and continuing hemorrhage, can occur from any small wound , even one caused by a small-diameter instrument such as an ice pick.

Gunshot & Stab wound Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 340 Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the hole in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds. In such patients, not only does the lung collapse , but the structures of the mediastinum (heart and great vessels ) also shift toward the uninjured side with each inspiration and in the opposite direction with expiration. This is termed mediastinal flutter or swing, and it produces serious circulatory problems .

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 341 Nursing Allert ! Traumatic open pneumothorax calls for emergency interventions. Stopping the flow of air through the opening in the chest wall is a life threatening measure. Medical management of pneumothorax depends on its cause and severity . The goal of treatment is to evacuate the air or blood from the pleural space. A small chest tube (28 French) is inserted near the second intercostal space; this space is used because it is the thinnest part of the chest wall, minimizes the danger of contacting the thoracic nerve, and leaves a less visible scar .

Medical Management Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 342 If the patient also has a hemothorax , a large-diameter chest tube (32 French or greater ) is inserted, usually in the fourth or fifth intercostal space at the midaxillary line. The tube is directed posteriorly to drain the fluid and air. Once the chest tube or tubes are inserted and suction is applied (usually to 20 mm Hg suction), effective decompression of the pleural cavity (drainage of blood or air) occurs. If an excessive amount of blood enters the chest tube in a relatively short period, an autotransfusion may be needed. This technique involves taking the patient’s own blood that has been drained from the chest, filtering it, and then transfusing it back into the patient’s vascular system.

Medical Management Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 343 In such an emergency, anything may be used that is large enough to fill the chest wound; a towel, a handkerchief, or the heel of the hand. If conscious, the patient is instructed to inhale and strain against a closed glottis. This action assists in reexpanding the lung and ejecting the air from the thorax.

Medical Management Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 344 In the hospital , the opening is plugged by sealing it with gauze impregnated with petrolatum. A pressure dressing is applied. Usually , a chest tube connected to water-seal drainage is inserted to permit air and fluid to drain. Antibiotics usually are prescribed to combat infection from contamination.

Medical Management Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 345 The pleural cavity can be decompressed by needle aspiration ( thoracentesis ) or chest tube drainage of the blood or air. The lung is then able to re-expand and resume the function of gas exchange. As a rule of thumb, the chest wall is opened surgically (thoracotomy) when more than 1,500 mL of blood is aspirated initially by thoracentesis (or is the initial chest tube output) or when chest tube output continues at greater than 200 mL/hour. The urgency with which the blood must be removed is determined by the respiratory compromise. An emergency thoracotomy may also be performed in the emergency department if there is suggested cardiovascular injury secondary to chest or penetrating trauma.

CARDIAC TAMPONADE 12/10/2023 By Abdi Wakjira( Bsc, Msc) 346 Cardiac tamponade is the compression of the heart as a result of fluid within the pericardial sac. It usually is caused by blunt or penetrating trauma to the chest. A penetrating wound of the heart is associated with a high mortality rate. Cardiac tamponade also may follow diagnostic cardiac catheterization, angiographic procedures , and pacemaker insertion, which can produce perforations of the heart and great vessels.

CARDIAC TAMPONADE Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 347 Pericardial effusion with fluid compressing the heart also may develop from metastases to the pericardium from malignant tumors; such as: B reast , lung , and mediastinum and may occur with lymphomas and leukemias , R enal failure, TB , and high-dose radiation to the chest.

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Pneumothorax 579 12/10/2023 By Abdi Wakjira( Bsc, Msc) 349 Literally means “ air in the chest ” Is used to describe conditions in which air has entered the pleural space outside the lungs. TYPES 1.Simple Pneumothorax or spontaneous pneumothorax occurs when air enters the pleural space through a breach of either the parietal or visceral pleura. It may be associated with diffuse interstitial lung disease and severe emphysema.

Pneumothorax …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 350 2. Traumatic pneumothorax Occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. It may result from blunt trauma ( eg , rib fractures), penetrating chest or abdominal trauma ( eg , stab wounds or gunshot wounds), or diaphragmatic tears. Occur during invasive thoracic procedures ( ie , thoracentesis , transbronchial lung biopsy, insertion of a subclavian line) Chest surgery

Pneumothorax …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 351 3. Tension pneumothorax If a pneumothorax is closed , air, and therefore tension, builds up in the pleural space. In tension pneumothorax, air enters but cannot leave the chest. As the pressure increases, the heart and great vessels are compressed and the mediastinal structures are shifted toward the opposite side of the chest. The trachea is pushed from its normal midline position toward the opposite side of the chest, and the unaffected lung is compressed.

Open Pneumothorax Vs Tension Pneumothorax 12/10/2023 By Abdi Wakjira( Bsc, Msc) 352 In open pneumothorax, air enters the chest during inspiration and exits during expiration. A slight shift of the affected lung may occur because of a decrease in pressure as air moves out of the chest. In tension pneumothorax, air enters but cannot leave the chest. As the pressure increases, the heart and great vessels are compressed and the mediastinal structures are shifted toward the opposite side of the chest.

Pneumothorax …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 353 Clinical Manifestations Signs and symptoms associated with pneumothorax depend on its size and cause Pain(sudden & plueritic ) Dyspnea Respiratory distress Increased use of accessory muscles Centeral cynosis Expansion of chest decreased Breath sound may diminished Normal sounds or hyperresonance on percussion.

Pneumothorax …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 354 In a tension pneumothorax , The trachea is shifted away from the affected side Chest expansion may be decreased or fixed in a hyperexpansion state. Breath sounds are diminished or absent Percussion to the affected side is hyperresonant .

HEMOTHORAX. 12/10/2023 By Abdi Wakjira( Bsc, Msc) 355 It is the presence of blood in the pleural space. Can occur with or without accompanying pneumothorax . Cause:- Traumatic injury (often). Lung cancer, Pulmonary embolism Anticoagulant use.

HEMOTHORAX. …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 356 Diagnostic Tests History Physical examination Chest x-ray examination Arterial blood gases and oxygen saturation

HEMOTHORAX. …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 357 Medical Management Depends on its cause and severity . The goal of treatment is to evacuate the air or blood from the pleural space. A small pneumothorax :_ - May absorb with no treatment other than rest -Trapped air may be removed with a small bore needle inserted into the pleural space Chest tubes connected to a water seal drainage system are used to remove larger amounts of air or blood from the pleural space.

HEMOTHORAX. …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 358 If the pneumothorax is recurrent Other treatments can be used to prevent additional episodes. Sterile talc or certain antibiotics (such as tetracycline) can be injected into the pleural space via thoracentesis , irritating the pleural membranes and making them stick together, -this is called pleurodesis or sclerosis .

CHEST TUBES AND PLEURAL DRAINAGE 12/10/2023 By Abdi Wakjira( Bsc, Msc) 359 Whenever fluid or air accumulates in the pleural space, the pressure becomes positive instead of negative and the lungs collapse . Chest tubes are inserted to drain the pleural space and reestablish negative pressure, allowing for proper lung expansion. Tubes may also be inserted in the mediastinal space to drain air and fluid postoperatively. Chest tubes are approximately 20 inches (51 cm) long and vary in size from 12F to 40F. The size inserted is determined by the patient’s condition. Large (36F to 40F) tubes are used to drain blood, medium (24F to 36F) tubes are used to drain fluid, and small (12F to 24F) tubes are used to drain air.

Chest Tube Insertion 12/10/2023 By Abdi Wakjira( Bsc, Msc) 360 Insertion of a chest tube can take place in the emergency department, at the patient’s bedside, or in the operating room. The patient is positioned with the arm raised above the head on the affected side to expose the midaxillary area, the standard site for insertion. Elevate the patient’s head 30 to 60 degrees, when possible, to lower the diaphragm and reduce the risk of injury. A chest x-ray is used to confirm the affected side. The area is cleansed with an antiseptic solution.

Chest Tube Insertion 12/10/2023 By Abdi Wakjira( Bsc, Msc) 361 The chest wall is prepared with a local anesthetic, and a small incision is made over a rib. The chest tube is advanced up and over the top of the rib to avoid the intercostal nerves and blood vessels that are behind the rib inferiorly. Once inserted, the tube is connected to a pleural drainage system Two tubes may be connected to the same drainage unit with a Y-connector. The incision is closed with sutures, and the chest tube is secured . The wound is covered with an occlusive dressing. Some clinicians prefer to seal the wound around the chest tube with petroleum gauze. Proper tube placement is confirmed by chest x-ray .

Chest Tube Insertion Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 362 Pleural Drainage The second type of chest drainage is larger and less portable, and it contains three basic compartments, each with a separate function (see Fig. 28-8). The first compartment , or collection chamber , receives fluid and air from the pleural or mediastinal space . The drained fluid stays in this chamber while the air vents to the second compartment. The second compartment, called the water-seal chamber, contains 2 cm of water, which acts as a one-way valve. The incoming air enters from the collection chamber and bubbles up through the water.

Pleural Drainage Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 363 The water prevents backflow of air into the patient from the system. Initially , brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. Intermittent bubbling during exhalation, coughing, or sneezing ( when the patient’s intrathoracic pressure is increased) will continue as long as there is air in the pleural space. As the source of the air in the pleural space gets smaller, it will take more and more positive intrapleural pressure to force air out. Eventually , the air leak seals and the lung is fully expanded

Pleural Drainage Cont…d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 364 The incoming air enters from the collection chamber and bubbles up through the water. The water prevents backflow of air into the patient from the system. Initially , brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. Intermittent bubbling during exhalation, coughing, or sneezing ( when the patient’s intrathoracic pressure is increased) will continue as long as there is air in the pleural space. As the source of the air in the pleural space gets smaller, it will take more and more positive intrapleural pressure to force air out. Eventually , the air leak seals and the lung is fully expanded

Pleural Drainage Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 365 Normal fluctuation of the water within the water-seal chamber is called tidaling . This up and down movement of water in concert with respiration reflects the intrapleural pressure changes during inspiration and expiration. Investigate any sudden cessation of tidaling , since this may signify an occluded chest tube. Gradual reduction and eventual cessation of tidaling are expected as the lung reexpands . The parietal and visceral pleura will form a tight seal around the chest tube openings, obliterating the response to changes in intrapleural pressures with respiration.

Pleural Drainage Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 366 The third compartment, the suction control chamber, applies suction to the chest drainage system. There are two types of suction control: water and dry. The water suction control chamber uses a column of water with the top end vented to the atmosphere to control the amount of suction from the wall regulator . The chamber is typically filled with 20 cm of water. When the negative pressure generated by the suction source exceeds the set 20 cm, air from the atmosphere enters the chamber through the vent on top and the air bubbles up through the water, causing a suction-breaker effect. As a result, excess pressure is relieved.

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HEMOTHORAX. …… 12/10/2023 By Abdi Wakjira( Bsc, Msc) 368 Nursing management Close monitoring & frequent assessment of:- Level of consciousness, Skin and mucous membrane color, Vital signs, Respiratory rate & depth Presence of dyspnea, Chest pain, Restlessness, or anxiety Lung sounds

EMPYEMA 12/10/2023 By Abdi Wakjira( Bsc, Msc) 369 An accumulation of thick , purulent fluid within the pleural space, often with fibrin development and a loculated (walled-off) area where infection is located. Pathophysiology Most empyemas occur as complications of bacterial pneumonia or lung abscess. Penetrating chest trauma, hematogenous infection of the pleural space, nonbacterial infections, and iatrogenic causes (after thoracic surgery or thoracentesis ). At first the pleural fluid is thin, with a low leukocyte count, but it frequently progresses to a fibropurulent stage Finally, to a stage where it encloses the lung within a thick exudative membrane ( loculated empyema ).

Cont… d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 370 Clinical Manifestations Fever Night sweats Pleural pain Cough Dyspnea Anorexia Weight loss

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 371 Assessment and Diagnostic Findings Chest auscultation (decreased or absent breath sounds over the affected area. Chest percussion there is dullness on as well as decreased fremitus . The diagnosis is established by chest CT. Usually a diagnostic thoracentesis is performed, often under ultra sound guidance

Medical Management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 372 The objectives of treatment are To drain the pleural cavity To achieve complete expansion of the lung. Fluid is drained, and appropriate antibiotics (Sterilization of the empyema cavity requires 4 to 6 weeks of antibiotics) are used.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 373 Drainage of the pleural fluid depends on the stage of the disease and is accomplished by one of the following methods: Needle aspiration ( thoracentesis ) with a thin percutaneous catheter, if the volume is small and the fluid is not too purulent or too thick. Tube thoracostomy ( chest drainage using a large diameter intercostal tube attached to water-seal drainage. Open chest drainage via thoracotomy , including potential rib resection, to remove the thickened pleura, pus, and debris and to remove the underlying diseased pulmonary tissue.

Nursing management 12/10/2023 By Abdi Wakjira( Bsc, Msc) 374 Instructs the patient in lung-expanding breathing exercises to restore normal respiratory function. Provides care specific to the method of drainage of the pleural fluid ( eg , needle aspiration, closed chest drainage, rib resection and drainage

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SUBCUTANEOUS EMPHYSEMA 12/10/2023 By Abdi Wakjira( Bsc, Msc) 376 W hen the lung or the air passages are injured, air may enter the tissue planes and pass for some distance under the skin ( eg , neck, chest). The tissues give a crackling sensation when palpated, Fortunately , subcutaneous emphysema is of itself usually not a serious complication. The subcutaneous air is spontaneously absorbed if the underlying air leak is treated or stops spontaneously. In severe cases in which there is widespread subcutaneous emphysema , a tracheostomy is indicated if airway patency is threatened .

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PULMONARY TUBERCULOSIS 12/10/2023 By Abdi Wakjira( Bsc, Msc) 380 In 46o B.C. The Greek physician Hippocrates described tuberculosis as an "almost always fatal disease of the lungs. Called phthisis from Greek term phthinein which means wasting or decay. In English, pulmonary TB was long known by the term “consumption.” disease would have felt hopeless, much like how people feel about many cancers today. TB was treated with gold, arsenic, cod liver oil, herbs, bed rest, sunshine and fresh air, etc. ( Birnbaum et al. 1891 ), but none of these therapies were really effective. German physician Robert Koch discovered and isolated m tuberculosis in 1882.

Tuberculosis ( TB)-Definition 12/10/2023 By Abdi Wakjira( Bsc, Msc) 381 Neo-Latin word : Tubercle”- Round nodule/Swelling “Osis” – Condition Tuberculosis (TB) : Is an infectious disease that primarily affects the lung parenchyma. Is a potentially fatal contagious disease that can affect almost any part of the body but is mainly an infection of the lungs. Is a chronic bacterial infectious disease that primarily affects the lungs, but can also infect other organs in the body. It also may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes.

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 382 The primary infectious agent, M. tuberculosis , is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection Common causative bacilli: Mycobacterium tuberculosis (most cases) M. bovis – bovine tubercle bacillus M. Africana – West Africa M. Microti M. Canetti

MODE OF TRANSMISSION 12/10/2023 By Abdi Wakjira( Bsc, Msc) 383 Airway droplets : the main mode of transmission from person infected with pulmonary TB to others by respiratory droplets. Ingestion: Less frequently transmitted by ingestion of mycobacterium bovis found in unpasteurized milk products Direct inoculation TB spreads from person to person by airborne transmission. An infected person releases droplet nuclei (usually particles 1 to 5 u m in diameter) through talking, coughing, sneezing, laughing, or singing. Larger droplets settle; smaller droplets remain suspended in the air and are inhaled by a susceptible person.

Factors influence transmission 12/10/2023 By Abdi Wakjira( Bsc, Msc) 384 The number of bacilli in the droplets, The virulence of the bacilli, Exposure of the bacilli to UV light, Degree of ventilation, and Occasions for aerosolization all influence transmission

HIGH RISK FOR PROGRESSION 12/10/2023 By Abdi Wakjira( Bsc, Msc) 385 Persons more likely to progress from LTBI to TB disease includes: HIV infected persons Persons with a history of prior, untreated TB or fibrotic lesions on CXR Recent TB infection (within the past 2 years) Injection drug users Age ( very young or very old) Patients with certain medical conditions ( DM, chronic renal failure, hemodialysis, solid organ transplantation, cancer, malnourished patient, silicosis)

SPREAD OF TB TO OTHER PARTS OF THE BODY 12/10/2023 By Abdi Wakjira( Bsc, Msc) 386 Spread if infection will take place by: A. Local spread : to the surrounding lung tissue and pleura B. Lymphatic spread : along bronchi, leading to tuberculous bronchopneumonia C. Hematogenous spread : leading to: Lungs (85% of all cases) Pleura CNS Lymph nodes Genitourinary system Bones and joints Disseminated ( eg miliary )

Classification 12/10/2023 By Abdi Wakjira( Bsc, Msc) 387 Tuberculosis Pulmonary TB Primary Disease Secondary Disease Extra pulmonary i . Lymph node TB ii. Pleural TB iii. TB of upper airways iv. Skeletal TB v. Genitourinary TB vi. Miliary TB vii. Pericardial TB viii. Gastrointestinal TB ix. Tuberculous Meningitis

Pathogenesis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 388

Primary pulmonary TB 12/10/2023 By Abdi Wakjira( Bsc, Msc) 389 Also called ghon’s complex or childhood tuberculosis . Is an infection of persons who have not had prior contact with the tubercle bacillus The infection of an individual who has not been previously infected or immunized Lesions forming after infection is peripheral and accompanied by hilar which may not be detectable on chest radiography. Inhaled bacilli are commonly deposited in alveoli immediately beneath the pleura, usually in the lower part of the upper lobes or the upper part of the lower lobes Macrophages ingest the bacilli and transport them to regional lymph nodes

Primary infection---- 12/10/2023 By Abdi Wakjira( Bsc, Msc) 390 The primary infection characteristically produces a " Ghon complex" formed of: Ghon focus : small area of pneumonic consolidation about 1-3 cm in diameter, sub pleural in location present in the base of the upper lobe or apex of the lower lobe Tuberculous lymphangitis : of the draining lymphatic channels Tuberculous lymphadenitis : of the tracheobronchial nodes which are enlarged, matted together and their cut surface show areas of caseous necrosis

MICROSCOPIC PICTURE 12/10/2023 By Abdi Wakjira( Bsc, Msc) 391 The Ghon focus consists of a central area of pink caseous necrosis surrounded by inflammatory infiltrate and walled of by an area of granulation tissue containing multinucleated Langhans giant cells FATE OF PRIMARY TB This depends on: Virulence of the organism Dose of infection Degree of resistance of the host A. If the patient resistance is good and the organism is of low virulence, Ghon complex undergo healing and over time usually evolve to fibrocalcific nodules B.If the patient resistance is poor and/or the organism of high virulence, progressive pulmonary tuberculosis will develop, the primary Ghon focus in the lung enlarges rapidly, erodes the bronchial tree, and spread

Secondary Tuberculosis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 392 The infection that individual who has been previously infected or sensitized is called secondary or post primary or reinfection or chronic tuberculosis.

Clinical Manifestations 12/10/2023 By Abdi Wakjira( Bsc, Msc) 393 As the cellular processes tuberculosis develop differently, according to the status of the patient’s immune system. Stages include latency, primary disease, primary progressive disease, and extra pulmonary disease Early infection Immune system fights infection Infection generally proceeds without signs or symptoms Patients may have fever, paratracheal lymphadenopathy, or dyspnea Infection may be only subclinical and may not advance to active disease

Early primary progressive (active) 12/10/2023 By Abdi Wakjira( Bsc, Msc) 394 Immune system does not control initial infection Inflammation of tissues ensues Patients often have nonspecific signs or symptoms ( eg , fatigue, weight loss, fever) Nonproductive cough develops Diagnosis can be difficult: findings on chest radiographs may be normal and sputum smears may be negative for mycobacteria Late primary progressive (active) Cough becomes productive More signs and symptoms as disease progresses Patients experience progressive weight loss, rales, anemia Findings on chest radio - graph are normal Diagnosis is via cultures of sputum

Latent 12/10/2023 By Abdi Wakjira( Bsc, Msc) 395 Mycobacteria persist in the body No signs or symptoms occur Patients do not feel sick Patients are susceptible to reactivation of disease Granulomatous lesions calcify and become fibrotic, become apparent on chest radiographs Infection can reappear when immunosuppression occurs

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Symptom of pulmonary TB 12/10/2023 By Abdi Wakjira( Bsc, Msc) 397 Productive cough lasting for more than 2 weeks(the most common) . Shortness of breath, Chest pains and hemoptysis (coughing up blood) Lose appetite, Lose weight, fever or night sweats, or feel tired. Symptoms may vary depending on a person’s age, hiv status and the site of the infection (pulmonary or extra pulmonary).

Diagnostic Tests For Tuberculosis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 398 Sputum smear : Detect acid fast bacilli within 24hours Sputum culture : Identify Mycobacterium tuberculosis for 3-6 weeks with solid media, 4-14 days with high-pressure liquid chromatography Polymerase chain reaction : Identify M tuberculosis within hours Tuberculin skin test : Detect exposure to mycobacteria within 48-72 hours Quanti FERON TB test : Measure immune reactivity to M tuberculosis within 12 -24 hours Chest radiography : Visualize lobar infiltrates with cavitations within minutes

Approaches for TB diagnosis 12/10/2023 By Abdi Wakjira( Bsc, Msc) 399 Medical history 2. Physical examination 3. Bacteriologic ◦ AFB Smear FM/ ZN microscopy ◦ Culture & Drug Susceptibility testing\ ◦ Molecular tests 4. Antibody detection ◦Tuberculin Skin Test ◦IGRA 5. Radiology ◦ Chest radiography ◦ CT scan ◦ Ultrasound 6. Histo -pathologic exam ◦ FNAC, Biopsy 7. Other Nonspecific Tests like o ESR,CRP

Currently recommended diagnostic methods 12/10/2023 By Abdi Wakjira( Bsc, Msc) 400 Conventional Phenotypic Methods • AFB Microscopy /ZN and FM Methods • Culture Identification • Culture-based drug susceptibility testing (DST) 2. Molecular Genotypic Methods • Line Probe Assay • GeneXpert MTB/RIF

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 401 Assessment and Diagnostic Findings History Physical examination Tuberculin skin test Chest x-ray(reveals lesions in the upper lobes ) Acid-fast bacillus smear Sputum culture

MEDICAL MANAGEMENT 12/10/2023 By Abdi Wakjira( Bsc, Msc) 402 The two aims of TB treatment are :- To interrupt transmission by rendering patients noninfectious and To prevent morbidity and death by curing patients with TB while preventing the emergence of drug resistance. Four major drugs are considered the first-line agents for the treatment of TB: isoniazid , rifampin , pyrazinamide , and ethambutol .

Cont …d 12/10/2023 By Abdi Wakjira( Bsc, Msc) 403 Standard short-course regimens are divided into an initial, or bactericidal, phase and a continuation, or sterilizing, phase. During the initial phase, the majority of the tubercle bacilli are killed, symptoms resolve, and usually the patient becomes noninfectious. The continuation phase is required to eliminate persisting mycobacteria and prevent relapse. The treatment regimen of choice for virtually all forms of TB in adults consists of a 2-month initial phase of isoniazid , rifampin , pyrazinamide , and ethambutol followed by a 4-month continuation phase of isoniazid and rifampin Streptomycin is the only anti-TB drug documented to have harmful effects on the human fetus (congenital deafness) and should not be used.

Recommended Antituberculosis Treatment Regimens 12/10/2023 By Abdi Wakjira( Bsc, Msc) 404 Initial Phase Continuation Phase Indication Duration, months drugs Duration, months drugs New smear- or culture-positive cases 2 HRZE 4 HR New culture-negative cases 2 HRZE 4 HR Pregnancy 2 HRE 7 HR Relapses and treatment default (pending susceptibility testing) 3 HRZES 5 HRE Abbreviation:- E, ethambutol ; H, isoniazid ; R, rifampin ; S, streptomycin Z, pyrazinamide .

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