RESPIRATORY SYSTEM

The respiratory system is situated in the thorax, and is responsible for gaseous
exchange. The system provides the route by which the supply of oxygen present
in the atmospheric air enters the body and water vapor, carbon dioxide, and
other waste gases move from inside the body into the outside air. The cells of
the body needs energy for all their activities, most of this energy is derived from
chemical reactions, which can only take place in the presence of oxygen (O 2).
The atmospheric air entering the body varies according to the external
environment [Link] may be dry, cold, moist or hot, and may contain dust particle
or fumes. As the air moves through the air passages to the lungs, it is warmed or
cooled to the body temperature, moistened to become saturated with water
vapour and cleaned as the dust particles stick to the mucus which coats the
linings. There are two types of respiration; external and internal respiration.
Eternal respiration is the exchange of gases between the blood and the lungs,
while the internal respiration is the exchange of gases between the blood and the
cells (cellular respiration). Cellular respiration is the metabolic process in
which cells obtain energy, usually by “burning” glucose in the presence of
oxygen. When cellular respiration is aerobic, it uses oxygen and releases carbon
dioxide as a waste product. Respiration by the respiratory system supplies the
oxygen needed by cells for aerobic cellular respiration and removes the carbon
dioxide produced by cells during cellular respiration

Organs of the Respiratory System

The organs of the respiratory system form a continuous system of passages

called the respiratory tract, through which air flows into and out of the body.
The respiratory tract has two major divisions: the upper respiratory tract and the
lower respiratory tract. The organs of the respiratory system include the nose,
pharynx, larynx, trachea, bronchi, and their smaller branches, respiratory
muscles (intercostals muscles and diaphragm) and the lungs, which contain the
alveoli. The upper respiratory tract, consist of the nose, nasal cavity the
pharynx larynx and trachea; and the lower respiratory tract, consist of the
bronchi and the lungs.

The trachea, which begins at the edge of the larynx, divides into two bronchi
and continues into the lungs. The trachea allows air to pass from the larynx to
the bronchi and then to the lungs. The bronchi divide into smaller bronchioles

1
which branch in the lungs forming passageways for air. The terminal parts of
the bronchi are the alveoli. The alveoli are the functional units of the lungs and
they form the site of gaseous exchange.

Upper Respiratory Tract

All of the organs and other structures of the upper respiratory tract are involved
in the conduction or the movement of air into and out of the body. Upper
respiratory tract organs provide a route for air to move between the outside
atmosphere and the lungs. They also clean, humidify, and warm the incoming
air. However, no gas exchange occurs in these organs.

Nasal Cavity

The nasal cavity is a large, air-filled space in the skull above and behind the
nose in the middle of the face. It is a continuation of the two nostrils. As inhaled
air flows through the nasal cavity, it is warmed and humidified. Hairs in the
2
nose help trap larger foreign particles in the air before they go deeper into the
respiratory tract. In addition to its respiratory functions, the nasal cavity also
contains chemoreceptors that are needed for the sense of smell and that
contribute importantly to the sense of taste.

Pharynx

The pharynx is a tube-like structure that connects the nasal cavity and the back
of the mouth to other structures lower in the throat, including the larynx. The
pharynx has dual functions: both air and food (or other swallowed substances)
pass through it, so it is part of both the respiratory and digestive systems. Air
passes from the nasal cavity through the pharynx to the larynx (as well as in the
opposite direction). Food passes from the mouth through the pharynx to the
esophagus. The pharynx is divided into three major regions: the nasopharynx,
the oropharynx, and the laryngopharynx.

The nasopharynx is flanked by the conchae of the nasal cavity, and it serves
only as an airway. At the top of the nasopharynx are the pharyngeal tonsils. A
pharyngeal tonsil, also called an adenoid, is an aggregate of lymphoid tissue
similar to a lymph node. The function of the pharyngeal tonsil is not well
understood, but it contains a rich supply of lymphocytes and is covered with

3
ciliated epithelium that traps and destroys invading pathogens that enter during
inhalation. The pharyngeal tonsils are large in children, but interestingly, tend to
regress with age and may even disappear. The uvula is a small bulbous,
teardrop-shaped structure located at the apex of the soft palate. Both the uvula
and soft palate move like a pendulum during swallowing, swinging upward to
close off the nasopharynx to prevent ingested materials from entering the nasal
cavity. In addition, auditory (Eustachian) tubes that connect to each middle ear
cavity open into the nasopharynx. This connection is why colds often lead to
ear infections.

The oropharynx is a passageway for both air and food. The oropharynx is
bordered superiorly by the nasopharynx and anteriorly by the oral cavity. The
fauces is the opening at the connection between the oral cavity and the
oropharynx. The oropharynx contains two distinct sets of tonsils, the palatine
and lingual tonsils. A palatine tonsil is one of a pair of structures located
laterally in the oropharynx in the area of the fauces. The lingual tonsil is located
at the base of the tongue. Similar to the pharyngeal tonsil, the palatine and
lingual tonsils are composed of lymphoid tissue, and trap and destroy pathogens
entering the body through the oral or nasal cavities.

The laryngopharynx is inferior to the oropharynx and posterior to the larynx. It

continues the route for ingested material and air until its inferior end, where the
digestive and respiratory systems diverge. Anteriorly, the laryngopharynx opens
into the larynx, whereas posteriorly, it enters the esophagus.

Larynx

The larynx connects the pharynx and trachea and helps to conduct air through
the respiratory tract. The larynx is also called the voice box because it contains
the vocal cords, which vibrate when air flows over them, thereby producing
sound. Certain muscles in the larynx move the vocal cords apart to allow
breathing. Other muscles in the larynx move the vocal cords together to allow
4
the production of vocal sounds. The latter muscles also control the pitch of
sounds and help control their volume.

The opening to the trachea is closed by epiglottis during swallowing. A very

important function of the larynx is protecting the trachea from aspirated food.
When swallowing occurs, the backward motion of the tongue forces a flap
called the epiglottis to close over the entrance to the larynx. This prevents
swallowed material from entering the larynx and moving deeper into the
respiratory tract. If swallowed material does start to enter the larynx, it irritates
the larynx and stimulates a strong cough reflex. This generally expels the
material out of the larynx and into the throat

Trachea

The trachea and other passages of the lower respiratory tract conduct air
between the upper respiratory tract and the lungs. It is only in the lungs,
however, that gas exchange occurs between the air and the bloodstream.

The trachea, or windpipe, is the widest passageway in the respiratory tract. It is

about 2.5 cm (1 in.) wide and 10-15 cm (4-6 in.) long. It is formed by rings of
cartilage, which make it relatively strong and resilient. The trachea connects the
larynx to the lungs for the passage of air through the respiratory tract. The
trachea branches at the bottom to form two bronchial tubes.

Lower Respiratory Tract

Bronchi and Bronchioles

There are two main bronchial tubes, or bronchi (singular, bronchus), called
the right and left bronchi. The bronchi carry air between the trachea and lungs.
Each bronchus branches into smaller, secondary bronchi; and secondary bronchi
branch into still smaller tertiary bronchi. The smallest bronchi branch into very
small tubules called bronchioles. The tiniest bronchioles end in alveolar ducts,
which terminate in clusters of minuscule air sacs, called alveoli (singular,
alveolus), in the lungs.

The Lung
The lungs are the largest organs of the respiratory tract. They are suspended
within the pleural cavity of the thorax. Each of the two lungs is divided into

5
sections. These are called lobes, and they are separated from each other by
connective tissues. The right lung is larger and contains three lobes. The left
lung is smaller and contains only two lobes. The smaller left lung allows room
for the heart, which is just left of the center of the chest.
Lung tissue consists mainly of alveoli (air sacs). These tiny air sacs are the
functional units of the lungs where gas exchange takes place. The two lungs
may contain as many as 700 million alveoli, providing a huge total surface area
for gas exchange to take place. Each time you breathe in, the alveoli fill with
air, making the lungs expand. Oxygen in the air inside the alveoli is absorbed by
the blood in the mesh-like network of tiny capillaries that surrounds each
alveolus. The blood in these capillaries also releases carbon dioxide into the air
inside the alveoli. Each time you breathe out, air leaves the alveoli and rushes
into the outside atmosphere, carrying waste gases with it.

The lungs receive blood from two major sources. They receive deoxygenated
blood from the heart. This blood absorbs oxygen in the lungs and carries it back
to the heart to be pumped to cells throughout the body. The lungs also receive
oxygenated blood from the heart that provides oxygen to the cells of the lungs
for cellular respiration.

The functions of the respiratory system are:

1. Oxygen supplier: The job of the respiratory system is to keep the body
constantly supplied with oxygen.
2. Elimination: Elimination of carbon dioxide.
3. Gas exchange: The respiratory system organs oversee the gas exchanges
that occur between the blood and the external environment.
4. Passageway: Passageways that allow air to reach the lungs.
5. Humidifier: Purify, humidify, and warm incoming air.

Respiratory Tract Infection

A respiratory tract infection affects the respiratory system, the part of the body
responsible for breathing. There are two types of respiratory infections:

 Upper respiratory infections.

 Lower respiratory infections.

6
 UPPER RESPIRATORY INFECTION

The upper respiratory tract includes the sinuses, nasal passages, pharynx, and
larynx. These structures direct the air we breathe from the outside to the trachea
and eventually to the lungs for respiration to take place. An upper respiratory
tract infection, or upper respiratory infection, is an infectious process of any of
the components of the upper airway. Infection of the specific areas of the upper
respiratory tract can be named specifically. Examples;

 Rhinitis: Inflammation of the nasal cavity,

 Sinusitis or rhinosinusitis: Inflammation of the sinuses located around
the nose,
 Nasopharyngitis: Inflammation of the nares, pharynx, hypopharynx,
uvula, and tonsils,
 Pharyngitis (sore throat): Inflammation of the pharynx, uvula, and
tonsils),
 Epiglottitis: Inflammation of the upper portion of the larynx or the
epiglottis,
 Laryngitis: Inflammation of the larynx
 Laryngotracheitis: Inflammation of the larynx and the trachea
 Tracheitis: Inflammation of the trachea

A majority of upper respiratory infections are due to self-limited viral

infections. Occasionally, bacterial infections may cause upper respiratory
infections. Most often, upper respiratory infection is contagious and can spread
from person to person by inhaling respiratory droplets from coughing or
sneezing. The transmission of respiratory infections can also occur by touching
the nose or mouth by hand or other objects exposed to the virus.

The URTI is generally caused by the direct invasion of the inner lining (mucosa
or mucus membrane) of the upper airway by the virus or bacteria. In order for
the pathogens (viruses and bacteria) to invade the mucus membrane of the upper
airways, they have to fight through several physical and immunologic barriers.

The hair in the lining of the nose acts as a physical barrier and can potentially
trap the invading organisms. Additionally, the wet mucus inside the nasal cavity
can engulf the viruses and bacteria that enter the upper airways. There are also
small hair-like structures (cilia) that line the trachea which constantly moves

7
any foreign invaders up towards the pharynx to be eventually swallowed into
the digestive tract and into the stomach.

In addition to these intense physical barriers in the upper respiratory tract, the
immune system also does its part to fight the invasion of the pathogens or
microbes entering the upper airway. Despite these defense processes, invading
viruses and bacteria adopt various mechanisms to resist destruction. They can
sometimes produce toxins to impair the body's defense system or change their
shape or outer structural proteins to disguise from being recognized by the
immune systems (change of antigenicity). Some bacteria may produce adhesion
factors that allow them to stick to the mucus membrane and hinder their
destruction.

It is also important to note that different pathogens have varying abilities to

overcome the body's defense system and cause infections. Also, different
organisms require a varying time of onset from when they enter the body to
when symptoms occur (incubation period). Some of the common pathogens for
upper respiratory infection and their respective incubation times are the
following:

Signs and symptoms of upper respiratory infections

 Cough
 Fever
 Hoarse voice
 Fatigue and lack of energy
 nasal congestion
 Red eyes
 Sneezng
 Runny nose
 Swollen lymph nodes (swelling on the sides of your neck)
 Sore or scratchy throat, foul breath,
 reduced ability to smell
 Headache,
 Body aches

8
 COMMON COLD

Common cold is a viral infection of the nose and throat (upper respiratory tract).
It's usually harmless. May types of viruses can cause a common cold. Healthy
adults can expect to have two or three colds each year. Infants and young
children may have even more frequent colds. Symptoms of a common cold
usually appear one to three days after exposure to a cold-causing virus. Most
people recover from a common cold in a week or 10 days. Symptoms might last
longer in people who smoke.

Signs and Symptoms

Signs and symptoms, which can vary from person to person, might include:

 Runny or stuffy nose

 Sore throat
 Cough
 Congestion
 Slight body aches or a mild headache
 Sneezing
 Low-grade fever
 Generally feeling unwell

Causes

Although many types of viruses can cause a common cold, rhinoviruses are the
most common cause. A cold virus enters your body through your mouth, eyes or
nose. The virus can spread through droplets in the air when someone who is
sick coughs, sneezes or talks.

It also spreads by hand-to-hand contact with someone who has a cold or by

sharing contaminated objects, such as eating utensils, towels, toys or telephones.
If you touch your eyes, nose or mouth after such contact, you're likely to catch a
cold.

Risk factors

These factors can increase your chances of getting a cold:

9
  Age: Infants and young children are at greatest risk of colds, especially if
they spend time in child care settings.
 Weakened immune system: Having a chronic illness or otherwise
weakened immune system increases your risk.
 Time of year: Both children and adults are more likely to get colds
during cold season, but you can get a cold anytime.
 Smoking: You're more likely to catch a cold and to have more-severe
colds if you smoke or are around secondhand smoke.
 Exposure: Being around crowds, such as school is likely to expose one
to viruses that cause colds.

Complications

These conditions can occur along with your cold:

 Acute ear infection (otitis media): This occurs when bacteria or viruses
enter the space behind the eardrum. Typical signs and symptoms include
earaches or the return of a fever following a common cold.
 Asthma: A cold can trigger wheezing, even if one doesn’t have asthma.
For those that have asthma, a cold can make it worse.
 Acute sinusitis: In adults or children, a common cold that doesn't resolve
can lead to swelling and pain (inflammation) and infection of the sinuses.
 Other infections. A common cold can lead to other infections, including
pneumonia or bronchiolitis in children. These infections need to be
treated by a doctor.

Prevention

There's no vaccine for the common cold, but certain precautious measures can
slow the spread of cold viruses:

 Proper and regular washing of hands.

 Disinfecting infected surfaces or materials
 Cover the nose and mouth while coughing or sneezing
 Don't share drinking glasses or eating utensils with other family members
that have cold.
 Avoid close contact with anyone who has a cold, stay out of crowds,
when possible.
 Avoid touching your eyes, nose and mouth

10
  Look for a child care setting with good hygiene practices and clear
policies about keeping sick children at home.
 Eating well and getting exercise and enough sleep is good for your
overall health.

PHARYNGITIS

Pharyngitis is inflammation of the pharynx, which is in the back of the throat. It

is most often referred to simply as “sore throat.” Pharyngitis can also cause
difficulty swallowing. In order to properly treat a sore throat, it’s important to
identify its cause. Pharyngitis may be caused by bacterial or viral infections.

Causes of pharyngitis

Viruses are the most common cause of sore throats. Pharyngitis is most
commonly caused by viral infections such as the common cold, influenza etc.
Viral infections don’t respond to antibiotics, and treatment is only necessary to
help relieve symptoms.

Less commonly, pharyngitis is caused by a bacterial infection. Bacterial

infections require antibiotics. The most common bacterial infection of the throat
is strep throat, which is caused by group A streptococcus. Rare causes of
bacterial pharyngitis include gonorrhea, chlamydia, and corynebacterium.

Frequent exposure to colds can increase the risk for pharyngitis. This is
especially true for people with allergies, and frequent sinus infections. Exposure
to secondhand smoke may also raise the risk. The incubation period is typically
two to five days. Symptoms that accompany pharyngitis vary depending on the
underlying condition.

The length of the contagious period will also depend on your underlying
condition. If it is viral infection, it will be contagious until the fever runs its
course. If it is strep throat, it may be contagious from the onset until one has
spent 24 hours on antibiotics.

Signs and Symptoms of Pharyngitis

 Sneezing

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  Runny nose
 Sore, Dry, Or Itchy Throat
 Headache
 Cough
 Fatigue
 Chills
 Fever (a low-grade fever)

Diagnoses

 Physical exam: The doctor checks the throat for any white or gray
patches, swelling, and redness. The doctor may also look into the ears and
nose. To check for swollen lymph nodes, they will feel the sides of your
neck.
 Throat swab culture to identify the causative organism

Prevention of Pharyngitis

 Maintaining proper hygiene can prevent many cases of pharyngitis.

 Wash your hands often, especially before eating and after coughing or
sneezing
 Use alcohol-based hand sanitizers when soap and water aren’t available
 Avoid smoking and inhaling secondhand smoke

Management of Pharyngitis

If a virus is causing the pharyngitis, care should be given to relieve symptoms.

 Ensure intake of fluid

 Give semi solid food rich in protein
 Ensure regular oral hygiene
 Maintain adequate rest
 For pain and fever relief, take analgesics
 Throat lozenges may also be helpful in soothing a painful, scratchy
throat.
 For pharyngitis caused by a bacterial infection take prescribed antibiotics.
Amoxicillin and penicillin are the most commonly prescribed treatments
for strep throat. It’s important to take the entire course of antibiotics to

12
 prevent the infection from returning or worsening. An entire course of
these antibiotics usually lasts 7 to 10 days.

LARYNGITIS

Laryngitis is the inflammation of the voice box (larynx) from overuse, irritation
or infection. Most cases of laryngitis are triggered by a temporary viral infection
and aren't serious. Laryngitis can be acute (short-term), lasting for a short
period. Or it can be chronic (long-term), lasting for a long period. Other
conditions that can cause laryngitis includes; environmental factors, and
bacterial infections.

Acute laryngitis is a temporary condition caused by overusing the vocal cords.

It can also be caused by an infection. Treating the underlying condition causes
the laryngitis to go away. Acute laryngitis can be caused by:

 viral infections
 straining your vocal cords by talking or yelling
 bacterial infections
 drinking too much alcohol

Chronic laryngitis results from long-term exposure to irritants. It’s usually

more severe and has longer-lasting effects than acute laryngitis. Chronic
laryngitis can be caused by:

 frequent exposure to harmful chemicals or allergens

 acid reflux
 frequent sinus infections
 smoking or being around smokers
 overusing your voice
 low-grade yeast infections caused by frequent use of an asthma inhaler

Signs and Symptoms of Laryngitis

 Hoarseness
 Weak voice or voice loss
 Sore throat
 Dry throat
13
  Dry cough

Risk factors

Risk factors for laryngitis include:

 Having a respiratory infection, such as a cold, bronchitis or sinusitis

 Exposure to irritating substances, such as cigarette smoke, excessive
alcohol intake, or workplace chemicals
 Overusing the voice, by speaking too much, speaking too loudly,
shouting or singing

Complications

In some cases of laryngitis caused by infection, the infection may spread to

other parts of the respiratory tract.

Prevention

To prevent dryness or irritation to your vocal cords:

 Avoid smoking and stay away from secondhand smoke: Smoke dries
your throat. It can also cause your vocal cords to become irritated.
 Limit alcohol and caffeine: These cause one to lose total body water.
 Drink enough water: Fluids help keep the mucus in the throat thin and
easy to clear.
 Avoid upper respiratory infections: Wash the hands often, and avoid
contact with people who have upper respiratory infections such as colds.

Diagnosis

If you have chronic hoarseness, your doctor may

 Review of medical history and symptoms: The most common sign of

laryngitis is hoarseness. Changes in the person’s voice can vary with the
degree of infection or irritation, ranging from mild hoarseness to almost
total loss of the voice.
 Laryngoscopy: In this procedure the doctor can visually examine the
vocal cords by using a light and a tiny mirror to look into the back of your
throat. \

14
Treatment

Acute laryngitis often gets better on its own within a week or so. Self-care
measures, such as voice rest, drinking fluids also can help improve symptoms.

For chronic laryngitis treatments are aimed at treating the underlying causes,
such as heartburn, smoking or excessive use of alcohol.

Medications used in some cases include:

 Antibiotics for bacterial infection

 Corticosteroids sometimes can help reduce vocal cord inflammation.
Acute laryngitis

TONSILLITIS

Tonsillitis is inflammation of the tonsils, two oval-shaped pads of tissue at the

back of the throat — one tonsil on each side. Signs and symptoms of tonsillitis
include swollen tonsils, sore throat, difficulty swallowing and tender lymph
nodes on the sides of the neck. Tonsillitis most commonly affects children
between preschool ages and the mid teenage years.

Most cases of tonsillitis are caused by infection with a common virus, but
bacterial infections also may cause tonsillitis. The tonsils are the immune
system's first line of defense against bacteria and viruses that enter your mouth.
This function may make the tonsils particularly vulnerable to infection and
inflammation. However, the tonsil's immune system function declines after
puberty — a factor that may account for the rare cases of tonsillitis in adults.

Because appropriate treatment for tonsillitis depends on the cause, it's important
to get a prompt and accurate diagnosis. Surgery to remove is usually performed
only when tonsillitis occurs frequently, and doesn't respond to other treatments
or causes serious complications.

Types of Tonsilities

 Superficial Tonsilities: There is general inflammation of the tonsil

15
  Follicular Tonsilities: The tonsil is filled with pus with small yellowish
spots scattered over the surface of the red and swollen tonsil.
 Suppurative Tonsilities: the infection spreads to the surrounding tissues
producing a peritonsilar abscess

Signs and Symptoms

Common signs and symptoms of tonsillitis include:

 Red, swollen tonsils

 White or yellow coating or patches on the tonsils
 Sore throat
 Difficult or painful swallowing (dysphagia)
 Fever
 Enlarged, tender glands (lymph nodes) in the neck
 Bad breath
 Neck pain or stiff neck
 Headache

In young children who are unable to describe how they feel, signs of tonsillitis
may include:

 Drooling due to difficult or painful swallowing

 Refusal to eat

Causes

Tonsillitis is most often caused by common viruses, but bacterial infections also
can be the cause.

The most common bacterium causing tonsillitis is Streptococcus pyogenes,

other strains of strep and other bacteria also may cause tonsillitis.

Risk factors

Risk factors for tonsillitis include:

 Young age. Tonsillitis most often affects children, and tonsillitis caused
by bacteria is most common in children ages 5 to 15.

16
  Frequent exposure to germs. School-age children are in close contact
with their peers and frequently exposed to viruses or bacteria that can
cause tonsillitis.

Complications

Inflammation or swelling of the tonsils from frequent or ongoing (chronic)

tonsillitis can cause complications such as:

 Obstructive sleep apnea due to hypertrophy of the tonsils

 Infection that spreads deep into surrounding tissue (tonsillar cellulitis)
 Infection that results in a collection of pus behind a tonsil (peritonsillar
abscess)
 Septicaemia

Diagnosis

 Oral examination will reveal red swollen tonsil

 Throat swab for culture to identify the causative organism

Prevention

The germs that cause viral and bacterial tonsillitis are contagious. Therefore, the
best prevention is to practice good hygiene. Teach the child to:

 Wash their hands thoroughly and frequently, especially after using the
toilet and before eating
 Replace their toothbrush after being diagnosed with tonsillitis

To help a child prevent the spread of a bacterial or viral infection to others:

 Keep the child at home when he or she is ill

 Ask the doctor when it's alright for the child to return to school
 Teach the child to cough or sneeze into a tissue or, when necessary, into
his or her elbow
 Teach children to wash their hands after sneezing or coughing

Management

 Use of medications

17
  Antibiotic can be used depending on the isolated organism
 Analgesics to relief pain
 Vitamins especially vitamin C to aid healing

 Surgical management: This involves the surgical removal of the tonsil,

which is known as tosilectomy.

Nursing management
 Ensure that patient is comfortable and have adequate rest to conserve
energy.
 Oral care should be carried out regularly because the patient is prone to
mouth infection and halithosis.
 Nutrition and fluid:
- Give light and semi solid diet.
- Give adequate diet rich in protein, vitamins, and carbohydrate.
- Encourage copious fluid intake
 Observations
- Observe and record the vital signs.
- Measures should be taken to reduce body temperature if there is fever
 Drugs to be taken as prescribed.
 Prevention of infection.

Tonsillectomy

Tonsillectomy is the surgical removal of the tonsils.

Indications

 Recurrent attack of tonsillitis

 Failure of the tonsillitis to respond to medical management

Complications of Tonsillectomy

18
  Haemorrhage
 Shock following haemorrhage
 Secondary infection
 Respiratory obstruction
 Lung infection

Lower respiratory tract infections

Lower respiratory tract infections are any infections in the lungs or below the
larynx. These include pneumonia, bronchitis, and tuberculosis. A lower
respiratory tract infection can affect the airways, such as with bronchitis, or the
air sacs at the end of the airways, as in the case of pneumonia.

Lower respiratory tract infections Upper respiratory tract infections

Lower respiratory tract infections Upper respiratory tract infections
involve the airways below the trachea occur in the structures in the trachea or
above
People who have lower respiratory People with upper respiratory tract
tract infections will experience infections will feel the symptoms
coughing as the primary symptom. mainly above the neck, such as
sneezing, headaches, and sore throats.
Lower respiratory tract infections Upper respiratory tract infections
include: bronchitis, pneumonia, include: common colds, sinusitis,
bronchiolitis, tuberculosis tonsillitis, pharyngitis, laryngitis

Pneumonia
Pneumonia is an infection of the air sacs of the lungs. It affects people of any
age but can be more serious in older people, babies, and those with weakened
immune systems. The infection can occur in one or both lungs and is caused by
bacteria, viruses, or fungi. The infection leads to inflammation in the air sacs of
the lungs, which are called alveoli. The alveoli fill with fluid or pus, making it
difficult to breathe. Both viral and bacterial pneumonia are contagious. This
19
means they can spread from person to person through inhalation of airborne
droplets from a sneeze or cough. It can also be acquired by coming into contact
with surfaces or objects that are contaminated with pneumonia-causing bacteria
or viruses. Fungal pneumonia can be contracted from the environment. It does
not spread from person to person.

Classification of Pneumonia Based on where or how it was acquired:

 Hospital-acquired pneumonia (HAP). This is also known as

nosocomial pneumonia. This type of bacterial pneumonia is acquired
during a hospital stay. The pneumonia symptoms normally start more
than 48hours in a patient with no evidence of pneumonia during at the
time of admission. It can be more serious than other types, as the bacteria
involved may be more resistant to antibiotics.
 Community-acquired pneumonia (CAP). This refers to pneumonia that
is acquired in the community setting or within 48hours after
hospitalization.
 Ventilator-associated pneumonia (VAP). This is a nosocomial
pneumonia that is associated with endotracheal intubation and mechanical
ventilation. When people who are using a ventilator get pneumonia, it’s
called VAP.
 Aspiration pneumonia. This occurs as a result of inhaling bacteria into
your lungs from food, drink, or saliva. It’s more likely to occur if the
person has a swallowing problem, or if the person is too sedated from the
use of medications, alcohol, or other drugs.
 Pneumonia in the immunocompromised host: This occurs with the use
of corticosteroids or other immunosuppressive agents, chemotherapy,
nutritional depletion, use of broad spectrum antibiotics, acquired
immunodeficiency virus (AIDS), and long term advanced life-support
technology (mechanical ventilators).

Classification Based on Location

Pneumonia may be classified based on the area of the lungs it’s affecting:

20
Bronchopneumonia: It involves the alveoli concentrated around the bronchus.
It’s often localized close to or around the bronchi, and can equally affect areas
throughout both of lungs. However it only affects parts of the lobes.

Lobar pneumonia: Lobar pneumonia affects only the lobes of the lungs. It can
involve one or more of the lobes. This normally affects adult.

Symptoms of Pneumonia

Pneumonia symptoms can be mild or life threatening. They can include:

 coughing that may produce mucus

 fever
 sweating or chills
 shortness of breath that happens while doing normal activities, or even
while resting
 chest pain that’s worse when breathing or coughing
 feelings of tiredness or fatigue
 loss of appetite
 nausea or vomiting
 headaches

Causes of Pnuemonia

Bacterial pneumonia: The most common cause of bacterial pneumonia is

Streptococcus pneumoniae. Other causes include:

 Mycoplasma pneumoniae
 Haemophilus influenzae
 Legionella pneumophila
 Staphylococci pneumonia

Viral pneumonia: Respiratory viruses are often the cause of pneumonia.

Examples of viral infections that can cause pneumonia include:

 influenza (flu)
 respiratory syncytial virus (RSV)
 rhinoviruses (common cold)
 human parainfluenza virus (HPIV) infection
 human metapneumovirus (HMPV) infection
21
  adenovirus infection

Although the symptoms of viral and bacterial pneumonia are very similar, viral
pneumonia is usually milder. It can improve in 1 to 3 weeks without treatment.

Fungal pneumonia: Fungi from soil or bird droppings can cause pneumonia.
They most often cause pneumonia in people with weakened immune systems.
Examples of fungi that can cause pneumonia include:

 Pneumocystis jirovecii
 Cryptococcus species
 Histoplasmosis species

Risk factors

Anyone can get pneumonia, but certain groups do have a higher risk. These
groups include:

 infants from birth to 2 years old

 people ages 65 and older
 people with weakened immune systems due to:
o pregnancy
o HIV
o the use of certain medications, such as steroids or certain cancer
drugs
 people with certain chronic medical conditions, such as:
o asthma
o sickle cell disease
o liver disease
o kidney disease
 people who’ve been recently or are currently hospitalized, particularly if
they were or are on a ventilator
 people who have had a brain disorder, which can affect the ability to
swallow or cough, such as:
o stroke
o head injury
o dementia
 people who’ve been regularly exposed to lung irritants, such as air
pollution and toxic fumes, especially on the job

22
  people who live in a crowded living environment, such as a prison or
nursing home
 people who smoke, which makes it more difficult for the body to get rid
of mucus in the airways
 people who use drugs or drink heavy amounts of alcohol, which weakens
the immune system and increases the odds of inhaling saliva or vomit
into the lungs due to sedation

Complications

 Emphyema (collection of pus in a cavity i.e. pleural cavity )

 Pleurisy (inflammation of the pleura)
 Atelectasis (failure of lung to expand)
 Septicaemia
 Otitis media
 Impaired breathing
 Lung abscesses

Pathophysiology of Pneumonia
During inhalation, the hairs in the nose filter particles from inspired air. The mucus
membrane that lines the respiratory passages traps debris and micro organism that
enters with air preventing them from reaching the sterile lower respiratory tract. The
defense mechanisms of the respiratory tract against infection are so sufficient that not
until the body is weakened do the lungs become infected.
Pneumonia is the inflammation of the lung tissue in which the alveoli are usually
filled with inflammatory exudates. Whenever the pneumococci or any of the
organisms causing pneumonia enter the lungs, they will inflame the lungs tissue
(including the bronchioles and alveoli) causing the formation of inflammatory
exudates. These exudates containing plasma, cellular debris, causative organisms and
their toxins and the blood cells start filling up the alveoli.
The inflammatory exudates later make the alveoli and even the whole lung tissue to
become consolidated i.e. becoming solid with exudates. This consolidation impairs
the gaseous exchange between the alveoli and the surrounding blood capillaries,
leading to dyspnoea, since enough oxygen cannot diffuse into the blood system as a
result of alveolar consolidation, this then leads to cyanosis. As a result of low oxygen
content in the blood circulation, the heart beats faster to pump sufficient blood to the

23
diseased lungs for oxygenation to meet the oxygen needs of the body tissues. This
leads to increased pulse rates (tarchycardia) which will be full and bounding.
The consolidation of the lung tissue interferes with the expiration of the carbon-
dioxide leading to its accumulation in the blood stream. Carbon-dioxide excess in the
blood stream brings about fast respiration with flarring nose.
When this infection spreads to the pleurae covering the lungs, the pleurae become
inflamed leading to pleurisy which brings about the characteristic chest pain. The
chest pain is felt more during coughing or inspiration, when the lungs will expand and
rub against the stretched and inflamed pleurae. It is the chest pain felt especially in
deep inspiration that causes the shallow respiration. The presence of the exudates and
bacteria toxins within the bronchioles serve as foreign matters irritating the bronchial
lining to produce mucus and to set up cough reflex, in order to get rid of these
foreign matters. At first the cough will be dry, painful and unproductive but later
becomes less painful but productive of sputum.
In bronchopneumonia, the sputum is tenacious, blood streaked and
mucopurulent. The microorganisms and their toxins which causes any disease
including pneumonia serve as pyrogens capable of producing fever, when these
pyrogens enters blood stream they first react with the leucocytes forming what is
known as endogenous pyrogens. The endogenous pyrogens on circulating to the brain
then stimulate the heat regulating centre in the hypothalamus, causing more heat
production in the body and consequently a higher body temperature. The body
temperature will continue to increase as long as the pyrogens are present resulting
into shivering, headache, malaise and anorexia. In infants and young children there
can be convulsion due to the immaturity and instability of the heat regulating centre
and the nervous system generally to cope with the continuous fever, with the
administration of appropriate antibiotics the pyrogen will be destroyed and their
concentration greatly reduced. There will be stimulation of the body to loss heat
through peripheral vasodilatation, sweating and evaporation of the sweat. This leads
to cooling of the body and a return to normal of the body temperature.
In severe cases of pneumonia where the body temperature has risen above
o
40.5 C, there is danger of damage to brain cells characterized by disorientation and
delirium. As at this time, the heat regulating centre in the hypothalamus is losing its
capacity to regulate the temperature, resulting into continuous fever until death
occurs. Death most often occurs when the temperature has risen between 43.4 oC to
44.4oC.

24
Diagnosis

 Physical examination of the chest: This will include listening to your

lungs with a stethoscope for any abnormal sounds, such as crackling.
 Sputum and blood culture to identify the causative organism
 Chest X-ray: An X-ray helps your doctor look for signs of inflammation
in the chest, its location and the extent.
 CT scan: CT scans provide a clearer and more detailed picture of your
lungs.

Prevention

In many cases, pneumonia can be prevented.

 Vaccination (Pneumococcal conjugate vaccine): Pneumonia vaccines

won’t prevent all cases of the condition, but vaccinated people, have a
milder and shorter illness as well as a lower risk of complications.
 Hib vaccine: This vaccine protects against Haemophilus influenzae type
b (Hib), a type of bacterium that can cause pneumonia and meningitis.
 Quit smoking because it makes one more susceptible to respiratory
infections, especially pneumonia.
 Regularly wash your hands with soap and water for at least 20 seconds.
 Cover your coughs and sneezes. Promptly dispose used tissues.
 Maintain a healthy lifestyle to strengthen the immune system. Get enough
rest, eat a balanced diet, and get regular exercise.

Treatment

This will depend on the type of pneumonia, the severity, and the person’s
general health.

Medications

 Antibiotic therapy: The choice depends on the sensitivity test and it is

always good to take the complete dose of the antibiotics, even if the
personyou begin to feel better. Not doing so can prevent the infection
from clearing, and it may be harder to treat in the future. Antibiotic
medications don’t work on viruses. In some cases, your doctor may

25
 prescribe an antiviral. However, many cases of viral pneumonia clear on
their own with at-home care.
 Antifungal medications are used to treat fungal pneumonia. This
medication may be taken for several weeks to clear the infection.
 Analgesics can be given to relieve pain and fever. These may include:
ibuprofen, acetaminophen (Tylenol)
 Oxygen Therapy to maintain oxygen levels in the bloodstream
(humidified oxygen should be give to help liquefy secretions).

Nursing Management

 Admission
- Admit patient in quiet and well ventilated corner of the ward.
- Ensure that patient is comfortable.
 Position
- Nurse patient in a fowler’s position with the head of the bed raised
- This position promotes adequate lung expansion and facilitates easy
breathing
 Observation
- Observe the vital signs
- Assess for signs and symptoms of fever, chills, increase or decreased
pulse, labored breathing (dyspnoea or orthopnoea)
- Patient should be observed closely for restlessness which may indicate
hypoxia
 Physical care
- Give bed bath when the patient condition is severe.
- Give oral care.
- Change bed linen if dirty or wet.
 Nutrition and diet
- Give adequate diet rich in protein, vitamins, carbohydrate and roughage.
- Encourage copious fluid intake to prevent dehydration
- Record of fluid intake and output must be kept
 Rest/Activity
- Breathing exercise should be done to avoid problems such as atelectasis
- Avoid strenuous physical activity.
- Organize all activities to provide maximum time for rest.
 Psychological care
- Give psychological support to patient and relatives.

26
 - Allow close relation to visit the patient.
- Avoid situation that promote anxiety.
- Answer patient’s questions properly.
 Medication/supportive treatment.
- Administer drugs as prescribed.
- Monitor patient for any change in the condition.
 Advice on discharge
- Emphasis the importance of rest.
- Drugs to be taken as prescribed.
- Prevention of infection.
- Keeping to hospital appointments.
- Avoidance of precipitating factors.

Bronchitis
Bronchitis is an inflammation of the lining of the bronchial tubes, which carry
air to and from the lungs. People who have bronchitis often cough up thickened
mucus, which can be discolored. Bronchitis may be either acute or chronic.

Acute bronchitis, also called a chest cold often develops from a cold or other
respiratory infection, and is very common. It is associated with symptoms, such
as a mild headache or body aches. While these symptoms usually improve in
about a week, there may be a nagging cough that lingers for several weeks.

Chronic bronchitis, a more serious condition, is a constant irritation or

inflammation of the lining of the bronchial tubes, often due to smoking. It is
characterized by a productive cough that lasts at least three months, with
recurring bouts occurring for at least two consecutive years. Chronic bronchitis
is one of the conditions included in chronic obstructive pulmonary disease
(COPD).

Symptoms

For either acute bronchitis or chronic bronchitis, signs and symptoms may
include:

27
  Cough
 Production of mucus (sputum), which can be clear, white, yellowish-gray
or green in color — rarely, it may be streaked with blood
 Fatigue
 Shortness of breath
 Wheezing respiration
 Slight fever and chills
 Chest discomfort (soreness in the chest)
 Headaches
 Blocked nose and sinuses

Causes

Acute bronchitis

Acute bronchitis can result from:

 a virus, for example, a cold virus

 a bacterial infection
 exposure to substances that irritate the lungs, such as tobacco smoke,
dust, fumes, vapors, and air pollution

People have a higher risk of developing acute bronchitis if they:

 smoke or inhale secondhand smoke

 have asthma or an allergy

Chronic bronchitis

Chronic bronchitis results from: repeated irritation and damage to the lung and
airway tissues. The most common cause is smoking, but not everyone with
bronchitis is a smoker.

Other possible causes include:

 long term exposure to air pollution, dust, and fumes from the
environment
 genetic factors
 repeated episodes of acute bronchitis

28
  a history of respiratory disease or gastroesophageal reflux disease
(GERD)

Risk factors

Factors that increase your risk of bronchitis include:

 Cigarette smoke. People who smoke or who live with a smoker is at

higher risk of both acute bronchitis and chronic bronchitis.
 Low resistance. This may result from another acute illness, such as a
cold, or from a chronic condition that compromises the immune system.
Older adults, infants and young children have greater vulnerability to
infection.
 Exposure to irritants on the job: The risk of developing bronchitis is
greater if one work around certain lung irritants, such as grains, or are
exposed to chemical fumes.
 Gastric reflux: Repeated bouts of severe heartburn can irritate your
throat and make one more prone to developing bronchitis.

Complications

 It can lead to pneumonia in some people.

 Repeated bouts of bronchitis, can lead to chronic obstructive pulmonary
disease (COPD).

Diagnosis

 Physical examination by using a stethoscope to listen for unusual sounds

in the lungs.
 History taking
 Using sputum swab to test for bacteria or viruses in the lab
 Chest X-ray
 Blood tests

Prevention

To reduce your risk of bronchitis, follow these tips:

 Avoid cigarette smoke: Cigarette smoke increases your risk of chronic

bronchitis.
29
  Get vaccinated: Many cases of acute bronchitis result from influenza, a
virus. Getting vaccinated can help protect one.
 Practice regular hand washing: To reduce the risk of catching a viral
infection, wash your hands frequently and get in the habit of using
alcohol-based hand sanitizers.
 Avoid inhalation of lung irritants, such as smoke, dust, fumes, vapors,
and air pollution
 Wear a mask when you’re around things that bother your lungs, such as
paint fumes.

Treatment

Strategies for treating bronchitis include the following:

 Removing a lung irritant, for example, by not smoking

 Exercising to strengthen the chest muscles to help breathing
 Using a humidifier can loosen mucus, improve airflow, and relieve
wheezing.
 Taking 2 spoonfuls of honey may bring relief of cough symptoms.

 Antibiotics: If acute bronchitis results from a bacterial infection, a doctor

may prescribe antibiotics. Taking antibiotics may also help prevent a
secondary infection, in some cases. These drugs are not suitable for a
person with a virus, however.
 Oxygen therapy: In severe cases, a person may need supplemental
oxygen to ease their breathing
 Anti-inflammatory and steroid drugs: These can help reduce
inflammation that can cause tissue damage.
 Bronchodilators: These open the bronchial tubes and may help clear out
mucus.
 Mucolytics: These loosen or thin mucus in the airways, making it easier
to cough up sputum.
 Cough medicine: Coughing is useful for removing mucus from the
bronchial tubes.

30
 Bronchiectasis
Bronchiectasis is a long-term condition where the airways of the lungs become
widened, leading to a build-up of excess mucus that can make the lungs more
vulnerable to infection. In bronchiectasis, the inside surfaces of the bronchi get
thicker over time from inflammation that leaves scars. Thicker walls cause
mucus to collect in these passages because the walls are not strong enough to
make the mucus move out of the lungs. In addition, the cilia (thin strands that
look like hair and that help move mucus) are destroyed. When that happens,
infections can happen more easily and breathing becomes difficult.

The most common symptoms of bronchiectasis include a persistent cough that

usually brings up sputum and breath. The severity of symptoms can vary
widely. Some people have only a few symptoms that do not appear often, while
others have wide-ranging daily symptoms. The risk of getting this condition
increases with age. However, younger people can and do get bronchiectasis. In
adults, it is much more common in women than in men. In children, it is more
common in boys than girls. It is possible, but rare, for children to be born with
bronchiectasis.

Some Causes of Bronchiectasis

 Respiratory infections
o Bacterial infections, such as those caused by Staphylococcus or
Pseudomonas
o Mycobacterial infections, such as tuberculosis
o Viral infections caused by influenza, respiratory syncytial virus , or
adenoviruses
 Bronchial blockage
o Inhaled object
o Enlarged lymph nodes
o Lung tumor
o Lung surgery
o Mucus plugs (for example, due to allergic bronchopulmonary
aspergillosis)
 Inhalation injuries
o Injury from noxious fumes, gases, or particles
o Inhalation of stomach acid and food particles (for example, as a

31
 result of severe gastroesophageal reflux disease or a swallowing
disorder)
 Hereditary disorders
o Cystic fibrosis
o Alpha-1 antitrypsin deficiency
o Marfan syndrome
 Immunologic abnormalities
o Immunoglobulin deficiency syndromes
o White blood cell dysfunction
o Certain autoimmune disorders, such as rheumatoid arthritis, and
ulcerative colitis
 Other conditions
o Human immunodeficiency virus (HIV) infection
o Diffuse panbronchiolitis (characterized by inflammation of the
bronchioles throughout the lungs and chronic sinusitis)

Risk factors for bronchiectasis

 Chronic or severe lung infections, like tuberculosis or pneumonia

 Deficits in the immune system
 Repeated aspiration of things, such as food particles, that cause damage
to the lungs
 Atelectasis
 Foreign object occluding the bronchi

Symptoms

 coughing up blood
 wheezing sound in the chest with breathing
 shortness of breath
 chest pain
 coughing up large amounts of thick mucus every day
 weight loss
 fatigue
 Dyspnoea
 Pyrexia
 Anorexia
 Sweating mostly in the night
32
  change in the structure of the fingernails and toenails, known as clubbing
 frequent respiratory infections

Complications

 Pulmonary hypotension
 Respiratory acidosis
 Increased attack of pneumonia
 Lung abscess
 Pleurisy and pleural effusion
 Benign pericarditis

Prevention

There is no way to prevent congenital bronchiectasis (the kind you are born
with). However, there are ways to avoid developing the lung damage that leads
to bronchiectasis.

 Make sure to vaccinate children against diseases such as whooping

cough.
 If one develops any kind of lung infection, get medical treatment.
 Be aware of the risks of inhaling in any object. If a child or any adult
inhales an object, get immediate medical help.
 Stay away from airborne substances that can hurt your lungs like smoke,
fumes and gases.

Diagnosis and Tests

 Chest CT scan or X-ray, imaging tests to show the state of the lungs.
 Blood tests and sputum cultures to find out if there are infections.
 Lung function tests to determine how well the person is breathing/how
well the lungs are working.
 Bronchoscopy, which is a way to see inside the lungs. The method uses a
light and a camera on a tube inserted through the nose or mouth and then
down the trachea into the lungs. In the case of blockages, a bronchoscopy
can also find and remove the object blocking the airways. The procedure
can also be used to obtain lung secretions.

Management and Treatment

33
Bronchiectasis cannot be cured, but it can be managed. The doctor might
prescribe medication, the use of certain devices, or a combination of these
methods and possibly others.

If bronchiectasis is caused by an underlying condition, like aspergillosis or an

immune system disease, then that condition must be treated first.

 Lifestyle changes. Things like exercise, eating a healthy diet, and

drinking plenty of water may help improve the symptoms of
bronchiectasis.

Treatment choices might include medications, such as:

 Antibiotics, drugs used to treat bacterial infections. These include oral

(pill) forms and inhaled forms (breathed in using a nebulizer machine).
 Macrolides, drugs used to treat infections and inflammations at the same
time.
 Drugs that affect mucus and help to cough the mucus out.
 Treating underlying conditions. If conditions like immune disorders or
COPD are causing the bronchiectasis, the doctor will also treat those
conditions.

Bronchiolitis
Bronchiolitis occurs when a virus infects the bronchioles, which are the smallest
airways in the lungs. The infection makes the bronchioles swell and become
inflamed. Mucus collects in these airways, which makes it difficult for air to
flow freely in and out of the lungs. Bronchiolitis is a common lung infection in
young children and infants.

Most cases of bronchiolitis are caused by the respiratory syncytial virus (RSV).
RSV is a common virus that infects just about every child by 2 years of age. It
can also be caused by other viruses, including those that cause the flu or the
common cold.

The viruses that cause bronchiolitis are easily spread. It can be contracted
through droplets in the air when someone who is sick coughs, sneezes or talks.

34
You can also get them by touching shared objects — such as utensils, towels or
toys — and then touching your eyes, nose or mouth.

Symptoms

 Runny nose
 Stuffy nose
 Cough
 Slight fever (not always present)
 Less appetite
 Wheezing (a high-pitched, whistling sound when exhaling)
 Sluggish or tired appearance

Risk factors

 Premature birth
 Underlying heart or lung condition
 Depressed immune system
 Exposure to tobacco smoke
 Contact with multiple children, such as in a child care setting
 Spending time in crowded environments

Complications

Complications of severe bronchiolitis may include:

 Blue lips or skin (cyanosis), caused by lack of oxygen

 Dehydration
 Ear infection

Prevention

 If a child has bronchiolitis, keep him or her at home until the illness is
past to avoid spreading it to others.
 Limit contact with people who have a fever or cold
 Clean and disinfect surfaces and objects that people frequently touch,
such as doorknobs. This is especially important if a family member is
sick.

35
  Cover your mouth and nose with a tissue when coughing or sneezing.
Then throw away the tissue and wash your hands or use alcohol-based
hand sanitizer.
 Don't share glasses with others, especially if someone in your family is
ill.
 Frequently wash your own hands and those of your child. Keep an
alcohol-based hand sanitizer handy for yourself and the child when you're
away from home.

Diagnosis

 Physical Examination by using a stethoscope to listen to their breathing

and count the breaths per minute.
 Chest X-ray: This is done to look for possible signs of pneumonia.
 Blood tests: Blood is taken to check the white blood cell count (these are
cells that fight infection).
 Pulse oximetry: use to measure how much oxygen is in the blood.
 Nasopharyngeal swab to detect the organism responsible

Management and Treatment

In most cases, bronchiolitis is not treated. Antibiotics will not help because this
is a viral infection. You will be advised to keep your child hydrated as best you
can. Treat any presenting signs or symptoms

Pulmonary Tuberculosis
Pulmonary Tuberculosis (TB) is a contagious infection that usually attacks
the lungs. It can also spread to other parts of the body, like the brain and spine.
A TB infection doesn’t always mean that the person will get sick. There are two
forms of the disease: Latent TB and Active TB. Those people having latent TB
have the bacteria in their body, but their immune system keeps the organism
from spreading. They don’t have any symptoms, and are not contagious. But the
infection is still alive and can one day become active. If they are at high risk for
re-activation for instance, if they have HIV, and have had an infection in the
past 2 years, the person’s chest X-ray is unusual, and the immune system is
weakened. In most cases the doctor will give the person medications to prevent
36
active TB. But for those with active TB, the organisms multiply and make the
person sick. They can spread the disease to other people. Ninety percent of
active cases in adults come from a latent TB infection. A latent or active TB
infection can also be drug-resistant, meaning certain medications don’t work
against the bacteria.

Causative Agent

Tuberculosis is caused by bacteria that spread through the air; you can get TB
only if you come into contact with people who have it. It is caused by a type of
bacteria called Mycobacterium tuberculosis.

Mode of Transmission

Transmission is through the inhalation of infected droplets from the TB person,

which can happen as the person coughs, sneezes, talks, laugh, or sings. TB isn’t
easy to catch. People usually have to spend a long time around someone who
has a lot of the bacteria in their lungs. One is most likely to catch it from co-
workers, friends, and family members. Tuberculosis germs don’t thrive on
surfaces. It can’t be contracted from shaking hands with someone who has it or
by sharing their food or drink.

Pathophysiology of Pulmonary Tuberculosis

When the tubercle bacilli enter the lungs through the inhalation of the droplets
containing these micro-organisms, they will set up a chronic inflammation of
the lung tissue and the pleurae covering the lungs. Inflammation of the pleurae
leads to pleurisy which is characterized by chest pain. The inflammation of the
lung tissue (pneumonitis) leads to the formation of the tubercle (i.e. collection
of lung tissue, phagocytic cells and lymphocytes) around the tubercle bacilli.
If the body immunity is high, the tubercle bacilli will be destroyed by the
tubercle (walled TB) and the lung wound heals forming scar tissue. This is
known as primary focus or Ghon focus. If the body immunity is very low, the
tubercle breaks down to form caseation (i.e chessy mass). The caseation will
liquefy to form pus as part of the sputum. The presence of the tubercle bacilli
along the respiratory tract and lungs brings about the cough reflex to get the
bacilli out of the respiratory system. The coughing out of the sputum containing
pus and the bacilli leads to the creation of cavities in the lungs.

37
The distortion of the normal anatomical structures of the lungs tissue by the
bacilli based on the creation of the various cavities and the formation of some
scar tissue in the lungs invariably impairs the normal gaseous exchange within
the lungs causing dyspnoea. Dyspnoea leads to low intake of oxygen from the
lungs into the blood stream causing cyanosis.
The low oxygen content in the blood stream due to dyspnoea consequently
stimulates the heart to beat faster to circulate more blood to the lungs for
oxygenation. This leads to increase pulse rate. The dyspnoea similarly interferes
with the release of adequate volume of carbon-dioxide out of the lungs leading
to its increase in the blood stream. Increase carbon-dioxide in the systemic
circulation stimulates the respiratory centre causing increase respiration.
The destruction of the blood vessels in the lungs by the tubercle bacilli leads to
haemoptysis. Prolonged haemoptysis leads to anaemia, body weakness and
body wasting with loss of body weight. In women, prolonged anaemia may also
lead to amenorrhoea. The presence of the tubercle bacilli and their toxins in the
blood stream leads to profuse night sweating, due to increase basal metabolic
rate at this time. The increase basal metabolic rate also accounts for the evening
pyrexia which gets lowered in the morning.
At times, some patients may develop erythema nodosum (i.e. a bluish - red
raised lesions of about 2.5cm in diameter) on the anterior aspect of the leg, as a
result of allergic reactions to the tuberculosis in other parts of the body.

Signs and Symptoms of Tuberculosis

Latent TB doesn’t have symptoms. A skin or blood test can tell if you have it.
Signs of active TB disease include:

 A cough that lasts more than 3 weeks

 Chest pain
 Coughing up blood (haemoptysis)
 Feeling tired all the time
 Night sweats
 Chills
 Anaemia
 Rapid pulse rate
 Dyspnoea
 Fever of low grade

38
  Loss of appetite
 Weight loss

Risk factors

Anyone can get tuberculosis, but certain factors can increase your risk,
including:

Weakened immune system: A healthy immune system often successfully

fights TB bacteria. However, several conditions and medications can weaken
your immune system, including:

 HIV/AIDS
 Diabetes
 Severe kidney disease
 Cancer treatment, such as chemotherapy
 Drugs to prevent rejection of transplanted organs
 Some drugs used to treat rheumatoid arthritis, Crohn's disease and
psoriasis
 Malnutrition or low body weight
 Very young or advanced age

Other factors

 Using substances: IV drugs or excessive alcohol use weakens the

immune system and makes a person more vulnerable to tuberculosis.
 Using tobacco: Tobacco use greatly increases the risk of getting TB and
dying of it.
 Working in health care: Regular contact with people who are ill
increases ones chances of exposure to TB bacteria. Wearing a mask and
frequent hand-washing greatly reduce the risk.
 Living or working in a residential care facility: People who live or
work in prisons, psychiatric hospitals or nursing homes are all at a higher
risk of tuberculosis due to overcrowding and poor ventilation.
 Living with someone infected with TB: Close contact with someone
who has TB increases the risk.

Complications of Tuberculosis

39
  Pneumothorax
 Pleurisy
 Haemoptysis
 Anaemia
 Laryngitis
 Lung damage
 Infection or damage of your bones, spinal cord, brain, or lymph nodes

Diagnostic Measures

There are two common tests for tuberculosis:

 History and symptoms of the patient

 Skin test: This is also known as the Mantoux tuberculin skin test. To
carry out the test, small amount of fluid is injected into the skin of the
lower arm. After 2 or 3 days, the arm will be checked for sign of
swelling. If the is swelling, it means the result is positive, that the person
probably have TB bacteria. But one could also get a false positive result.
If you’ve gotten a tuberculosis vaccine called bacillus Calmette-Guerin
(BCG), the test could say that you have TB when you really don’t. The
results can also be false negative, saying that one doesn’t have TB when
the person really does, especially if the person has a very new infection.
 Blood test. These tests, also called interferon-gamma release assays
(IGRAs), measure the response when TB proteins are mixed with a small
amount of your blood.

Those tests don’t tell if the infection is latent or active. If one gets a positive
skin or blood test, the doctor will learn which type the person has through the
following test:

 A chest X-ray or CT scan to look for changes in your lungs

 Acid-fast bacillus (AFB) tests for TB bacteria in your sputum

Management

The management can be considered under the following headings:

 Prophylaxis
 Chemotherapy

40
  Surgical intervention

Prevention of Tuberculosis

To help stop the spread of TB:

 There is need to identify those with latent infection and treat the properly
so it doesn’t become active and contagious.
 For those that have active TB, there is need to limit their contact with
other people. Teach them to cover their mouth when laughing, sneezing,
or coughing. Wear a surgical mask when they are around other people
during the first weeks of treatment.
 Other measures include; avoid crowded area, practice good
environmental sanitation, proper nutrition, adequate housing etc. these
will help to reduce the development and spread of TB.
 Tuberculosis vaccine can be given to children

Chemotherapy: Multiple drug therapy (MDT) i.e. first line of action

 If you have latent TB the doctor will prescribe medications to kill the
bacteria so the infection doesn’t become active. The following
medications can be used; isoniazid, streptomycin sulphate, pyrazinamide,
para aminosalicylic acid (PAS), rifampicin. These can be given alone or
combined. The drugs will be taken for up to 9 months.
 For those with active TB, a combination of medicines is also used to treat
it. The person will take them for 6 to 12 months.

Chemotherapy: If a patient has drug-resistant TB, the second line of

treatment will be used, the doctor might give the person one or more
different medicines like ethionmide, kanamycin, viomycin, cycloserine,
thiacetazone, and pyrazinamide. The person may have to take them much
longer, up to 30 months, and they can cause more side effects.

Whatever kind of infection the patient has, it’s important to finish taking all of
the medications, even when the person feels better. Because, if the person stops
very early the bacteria can become resistant to the drugs

Surgical Procedures: In the situation where the lung tissues are severely
damaged, lobectomy can be performed

41
Nursing Management
Patients with TB are normally treated as out-patient except in situations where
admission is very necessary.
Admission:
 Admit patient in an open ward
 Ensure that the patients with active TB and has just resumed treatment is
isolated from other patients
Rest:
 Ensure that the patient obtain adequate rest so as to conserve energy
 Organize all activities to provide maximum time for rest.
 Avoid strenuous physical activity.
Nutrition and diet
 Give adequate diet rich in protein, vitamins, carbohydrate and roughage.
 Provide fruits to promote healing of the lungs
 Encourage copious fluid intake to prevent dehydration
 When patient cannot swallow solid foods, fluid diet may be necessary to
maintain nutritional status
Observation
 Observe the vital signs
 Assess for signs and symptoms of fever, chills, increase or decreased
pulse, labored breathing (dyspnoea)
 Patient should be observed closely for restlessness which may indicate
respiratory distress
 Daily record of patient’s weight is necessary
 Haemoglobin estimation should be done to monitor for anaemia
Physical care
 Give bed bath when the patient condition is severe.
 Give oral care.
 Change bed linen if dirty or wet.
Psychological care
 Give psychological support to patient and relatives.
 Allow close relation to visit the patient.
 Answer patient’s questions properly.
Medication/supportive treatment
 Administer drugs as prescribed.

42
  Watch out for side effects of the drugs and report when noticed
 Monitor patient for any change in the condition.
Advice on discharge
 Emphasis on the need to continue with the medications
 Keeping to hospital appointments.
 Provide the necessary health education

Asthma
Asthma, also called bronchial asthma, is a disease that affects the lungs and is
defined as an attack of breathlessness associated with bronchial obstruction or
spasm, characterized by expiratory wheeze. It’s a chronic (ongoing) condition
and needs ongoing medical management. Asthma can be life-threatening if
proper treatment is not given. Asthma causes bronchospasms, inflammation,
thick mucus and constriction in the airways, causing the air passages in the
lungs become narrow due to inflammation and tightening of the muscles around
the small airways. This causes asthma symptoms such as cough, wheeze,
shortness of breath and chest tightness. These symptoms are intermittent and are
often during exercise or when exposed to other triggers. Other common triggers
can make asthma symptoms worse. Triggers vary from person to person, but
can include viral infections (colds), dust, smoke, fumes, changes in the weather,
grass and tree pollen, animal fur and feathers, strong soaps and perfume.

Causes of Asthma

 Allergic bronchial asthma: Allergens include things like molds, pollens

dust etc.
 Non-allergic bronchial asthma: Outside factors can cause asthma to
flare up are exercise, stress, illness and weather.

Pathophysiology of Bronchial Asthma

In a normal situation, the bronchial trees are always patent for easy passage of
air to and from the alveoli of the lungs. The walls consist of certain amount of
smooth muscles and the inner lining is made up of mucus membrane which
produces mucus to keep the air passage moist. Whenever any of the offending
agents or stimuli gets to the bronchi either through inhalation or ingestion or
43
their mere physical presence before the victim, this causes the release of
chemical mediators like histamine, prostaglandins and other slow - reacting
substance of anaphylaxis in response to the antigen. These chemical mediators
act on receptor sites on the membrane of the bronchial smooth muscle. This
causes construction of the bronchial trees leading to their narrowing.
The presence of the antigen within the bronchi and bronchioles stimulates
the mucus – secreting glands to produce more mucus, in an attempt to dilute and
sweep away the antigen. The presence of more mucus further aggravates the
narrowing of these bronchial trees. The presence of the mucus and broncho-
constriction obstructs the easy expulsion of carbon dioxide through these air
passages causing the characteristic wheezy breathing with expiratory dyspnoea
(i.e. laboured breathing). The expiratory dyspnoea leads to accumulation of
carbon dioxide in the blood stream causing cyanosis.
The broncho-constriction causes the usual painful tightness (i.e. feeling of
suffocation) experienced in the chest, which makes the patient to be anxious.
The anxiety, expiratory dyspnoea and feeling of the suffocation lead to
insomnia. The presence of the offending agent along the respiratory tracts
initiates the cough reflex. The sputum produced during coughing is usually
scanty and thick. The excess carbon dioxide in the blood stream stimulates the
respiratory centre in the medulla oblongata leading to increase respiration. The
difficulty in breathing makes the heart to beat faster to pump more
deoxygenated blood to the lung for oxygenation. This causes an increase in
pulse rates. Since the victim will now be restless due to expiratory difficulty,
more muscle glycogen will be consumed leading to the release of heat causing a
slight increase in the body temperature. Excess of this heat leads to more
production of the characteristic sweat (perspiration) to expel heat from the body.
In adults, efforts will be made to sit up, bend forward and throw their heads
backward, in order to use all the accessory muscles of respiration in an attempt
to overcome the expiratory dyspnoea.

Precipitating factors (Asthma Triggers)

 Smoking and secondhand smoke

 Infections such as colds, flu, or pneumonia
 Allergens such as food, pollen, mold, dust mites, and pet dander
 Exercise
 Air pollution and toxins
44
  Weather, especially extreme changes in temperature
 Food additives
 Emotional stress and anxiety
 Singing, laughing, or crying
 Perfumes and fragrances
 Acid reflux

Signs and Symptoms of Asthma

 Chest tightness, pain or pressure.

 Coughing (especially at night).
 Shortness of breath.
 Wheezing
 Difficulty in breathing

Complications of Asthma

 Lung collapse
 Respiratory failure
 Heart failure

Diagnosis and Tests

 Medical history including information on parents, siblings, symptoms and

allergies.
 Physical examination e.g. auscultation of the heart
 chest X-ray

Management and Treatment

 The first step is to identify the cause of the asthma so that it can be
removed from the patient’s environment.
 Bronchodilators: These medicines relax the muscles around your
airways. The relaxed muscles let the airways move air. They also let
mucus move more easily through the airways. These medicines relieve
your symptoms when they happen and are used for intermittent and
chronic asthma. The medication can be in form of tablets, injections or
inhalers. Examples include; salbutamol, ventolin, aminophylline.

45
  Anti-inflammatory medicines: These medicines reduce swelling and
mucus production in your airways. They make it easier for air to enter
and exit your lungs.
 Oxygen therapy: In severe attack of asthma, oxygen therapy is indicated

Nursing Management
Patients with asthma can be hospitalized in severe cases
Admission:
 Admit patient in an open ward
 Allow proper ventilation
 Ensure that there is no substance that can trigger the attack in the
environment
Rest:
 Ensure that the patient obtain adequate rest so as to conserve energy
 Organize all activities to provide maximum time for rest.
 Avoid strenuous physical activity or exercise.
Nutrition and diet
 Give adequate diet rich in protein, vitamins, carbohydrate and roughage.
 Encourage copious fluid intake
Observation
 Observe the vital signs
 Assess for signs and symptoms of fever, increase or decreased pulse,
labored breathing (dyspnoea)
 Patient should be observed closely for restlessness which may indicate
respiratory distress
Physical care
 Give bed bath when the patient condition is severe.
 Give oral care.
 Change bed linen if dirty or wet.
Psychological care
 Give psychological support to patient and relatives.
 Allow close relation to visit the patient.
 Answer patient’s questions properly.
Medication/supportive treatment
 Administer drugs as prescribed.
 Monitor patient for any change in the condition.
Advice on discharge
 Emphasis on the need to continue with the medications
 Keeping to hospital appointments.
 Provide the necessary health education

46
Status Asthmaticus

Status asthmaticus also known as acute severe asthma is a severe asthma

attack that comes on abruptly or lasts a very long time. Status asthmaticus is a
severe and life-threatening asthma state. This condition is a medical emergency
that can cause death without treatment. In status asthmaticus, asthma
symptoms continued, and respiratory function declines, despite standard
treatments. Status asthmaticus can lead to respiratory failure, prolonged
hospitalization, and even death.
Unfortunately, some people with status asthmaticus may not recognize the
severity of their symptoms, and their breathing abilities may rapidly decline.
Without treatment, status asthmaticus can cause death. People should also seek
medical attention if they experience any of the symptoms associated with status
asthmaticus. This includes anxiety, confusion, and a blue tinge to the lips and
fingernails. A person can experience a bronchospasm, where the airways
become small. Mucus can plug the airways, making it impossible for air to
exchange. This can cause hypoxia, or low oxygen levels, which can lead to
cardiac arrest. A person should seek emergency medical attention if they are
having difficulty breathing, and their inhalers are not helping them breathe more
easily. The longer a person waits to seek medical attention, the more at risk they
are for respiratory failure.

Causes and triggers of status asthmaticus

The cause for Acute Severe Asthma attacks is still unknown and experts are
also unsure of why it’s developed and why it doesn't respond to typical asthma
treatments, although there are some speculations:
 An upper respiratory infection is one of the most common causes of a
status asthmaticus attack. The infection increases the amount of mucus in
a person’s lungs, making it harder for them to breathe.
 asthma that is not under good control
 Coming in contact with asthma triggers
 Allergies or severe allergic reactions
 Chlamydial pneumonia

47
  Cold viruses
 Herpes simplex virus infections
 severe stress
 cold weather
 air pollution
 exposure to chemicals and other irritants
 smoking

Types of Status Asthmaticus

 Slow-onset attack: This is the more common type that takes a long time
to unfold and usually occur because of inadequate treatment. The person
with this type of status asthmaticus will experience days or weeks of
worsening symptoms, punctuated by moments of relief and ending in
symptoms that cannot be reversed with medications in the home.
 Sudden-onset attack: The person experiencing this type of status
asthmaticus has not experienced any worsening symptoms in the
preceding weeks but is struck with sudden and severe bronchospasm,
breathlessness, wheezing, and cough. This type of asthma attack is often
brought on by a large exposure to trigger substances, such as pollen, dust,
or food allergens.

Symptoms

Symptoms of status asthmaticus are not unlike those of asthma, but they're
considerably more severe. The severe restriction of air coupled with the severity
of bronchial spasms will typically manifest with some or all of the following
symptoms:

 Difficulty in breathing
 Profuse sweating
 Trouble speaking
 Extreme fatigue and weakness
 Abdominal, back, or neck muscle pain
 Panic/ anxiety
 Confusion
 Blue-tinted lips or skin (cyanosis)
 Decreased alertness
 Loss of consciousness
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  Fatigue
 Wheezing

Seek emergency care if asthma symptoms cannot be resolved with a rescue

inhaler and other emergency medications. In emergency situations, these
symptoms are commonly referred to as "critical asthma syndrome" (CAS) and
suggest that the child or adult is at an increased risk of death.

Warning Signs of Status Asthmaticus

With slow onset status asthmaticus, there are several warning signs which
should alert the person to call a healthcare provider or seek emergency
treatment. These include:
 A decline in peak expiratory flow (PEF) of 20% or more using your peak
flow meter
 The increased need of a rescue inhaler
 Nighttime awakenings due to the asthma
 Increasing shortness of breath despite the consistent use of asthma
medications
 Using one or more canisters of a short-acting inhaler over the past month

Any person with asthma who has a decline of 30% or more in their PEF,
particularly if rescue inhalers are not effective, should seek emergency medical
care without exception.

Diagnosis

Status asthmaticus is typically diagnosed by symptoms and supported by

various tests that measure respiration rate and blood oxygen levels. The
common diagnostic signs of status asthmaticus include:

 Breathlessness at rest
 Inability to speak in sentences or not being able to speak at all
 Increased respiratory rate at rest (greater than 30 breaths per minute)
 Elevated pulse rate at rest (greater than 120 beats per minute)
 Agitation and irritability
 Low blood oxygen levels (hypoxemia followed by hypoxia)
 Reduced breathing capacity (as measured by peak flow meter)

49
Treatment

Status asthmaticus is always treated as a medical emergency. Standard

treatment protocols in the emergency room include:

 Emergency oxygen therapy delivered by mask

 Medications e.g. terbutaline (under the skin) and magnesium sulfate (IV)
to help the muscles around your airways relax.
 Short-acting beta-agonists (such as albuterol) via inhaler or nebulizer to
help improve the person’s breathing
 Corticosteroids (such as prednisone) given by mouth or intravenously:
Steroids are inflammation-reducing medications
 Inhaled anticholinergic medications (such as Atrovent): bronchodilators
enlarge the airways and make breathing easier.

.Longer-term treatment

 Measuring peak air flow may be part of a person’s long-term treatment.

 Educating a person about asthma and the warning signs and symptoms of
status asthmaticus.
 Teaching a person how to identify triggers and how to avoid them.
 Training a person how to measure their peak air flow using a flow-meter
and when to call a doctor.
 Prescribing medications such as maintenance inhalers, or immunotherapy
to reduce the body’s response to asthma triggers.

Prevention
You may not be able to prevent all severe asthma attacks. But you can take
steps to make them less likely:

 Take your asthma medication according to doctor’s prescrption.

 Use a peak flow meter several times a day. These devices help to check
on how well your lungs are working. Start treatment immediately,
according to your asthma action plan, if you notice a lower reading, even
if you feel fine.
 Keep up with the doctor’s appointments to find out how well your lungs
are doing and to make sure the medicines are working well.

Complications

50
There are a few, and they depend on the stage of treatment or other conditions:
 Respiratory failure or arrest: The airways dilate and fill with mucus so
the person can’t breathe.
 Cardiac arrest: This can occur due to lack of oxygen.
 Hypoxemia: Lack of enough oxygen in the blood for too long, can cause
brain damage or death.
 Respiratory alkalosis: Early hyperventilation may lead to low levels of
carbon dioxide in the blood.
 Pneumothorax: Accumulation of air or gases in the pleural cavity
resulting to lung collapse on the affected side
 Pneumomediastinum: Air leaks from the lungs and into the chest cavity.

Occupational Lung Diseases

Repeated and long-term exposure to certain irritants on the job can lead to
various kinds of lung diseases that may have lasting effects, even after exposure
ceases. Certain occupations, because of the nature of their location, work, and
environment, are more at risk for occupational lung diseases than others. For
instance, working in a construction site or textile factory can expose a person to
hazardous chemicals, dusts, and fibers that may lead to a lifetime of lung
problems if not properly diagnosed and treated. Most occupational lung diseases
are caused by repeated, long-term exposure, but even a severe, single exposure
to a hazardous agent can damage the lungs. Occupational lung diseases are
preventable.

Causes occupational respiratory disease

Many substances found in the workplace can cause disease. This occurs when
the toxins irritate the lining in your lungs. Common causes include:
 Dust from things such as wood, cotton, coal, asbestos, silica, talc,
pesticides, cereal grains, coffee particles, and food flavorings used to
make microwave popcorn can cause damage.
 Fumes from metals that are heated and cooled quickly. This process
results in fine, solid particles being carried in the air. Job examples
include welding, smelting, furnace work, pottery making, plastics
manufacturing, and rubber operations.

51
  Smoke from burning materials. Smoke can contain a variety of particles,
gases, and vapors. Firefighters are at an increased risk.
 Gases such as formaldehyde, ammonia, chlorine, sulfur dioxide, and
nitrogen oxides. These are found at jobs with high heat operations, such
as welding, smelting, oven drying, and furnace work. And also those that
work in a lab using the chemicals.
 Vapors are a form of gas given off by all liquids. Vapors usually irritate
your nose and throat before they affect the lungs.
 Mists or sprays from paints, hair spray, pesticides, cleaning products,
acids, oils, and solvents.

Symptoms of occupational lung disease

The following are the most common symptoms of lung diseases, regardless of
the cause. However, each individual may experience symptoms differently.
Symptoms may include:
 Cough
 Chest pain
 Chest tightness
 Dry, scratchy, or sore throat
 Fever
 Muscle or body aches
 breathing problems, such as shortness of breath

Types of occupational respiratory disease include:

 Asbestosis: This condition is caused when a person breathes in tiny
asbestos fibers. Over time, this leads to scarring of the lungs and stiff
lung tissue. It’s often linked with construction work. Asbestos is a
mineral fiber that was added in the past to certain products for
strengthening, heat insulation, and fire resistance. Most products today
are not made with asbestos. Normally safe when combined with other
materials, asbestos is hazardous to the lungs when the fibers become
airborne (such as when a product deteriorates and crumbles).
 Coal worker's pneumoconiosis or black lung disease: This disease is
caused by inhaling coal dust. It causes inflammation and scarring of the
lungs. This can cause permanent lung damage and shortness of breath.

52
  Silicosis: This condition is caused by breathing in airborne crystalline
silica. This is a dust found in the air of mines; foundries; blasting
operations; and stone, clay, and glass manufacturing facilities. It causes
scarring of the lungs. It can also increase the risk for other lung diseases.
 Byssinosis: This is caused by breathing in dust from hemp, flax, and
cotton processing. It is also known as Brown Lung Disease. The
condition is chronic and causes chest tightness and shortness of breath. It
affects textile workers, especially those who work with unprocessed
cotton.
 Hypersensitivity pneumonitis: This is an allergic lung disease caused by
a lung inflammation that happens from breathing in many different
substances including fungus spores, bacteria, animal or plant protein, or
specific chemicals. It can be caused by the inhalation of fungus spores
from moldy hay, bird droppings, and other organic dusts. The disease is
characterized by inflamed air sacs in the lungs, leading to fibrous scar
tissue in the lungs and abnormal breathing. There are variations of this
disease depending on the job.
 Occupational asthma: Occupational asthma is caused by breathing in
dusts, gases, fumes, and vapors. It causes asthma symptoms such as a
chronic cough and wheezing. This condition can be reversed if found
early. People that work in manufacturing and processing operations,
farming, animal care, food processing, cotton and textile industries, and
refining operations, are at higher risk of getting this illness.

 Bronchiolitis obliterans: Bronchiolitis obliterans, also known as

constrictive bronchiolitis or obliterative bronchiolitis is a respiratory
disease caused by injury to the smallest airways, called bronchioles. It has
been reported to occur from exposure to inhaled toxins and gases
including sulfur mustard gas, nitrogen oxides, diacetyl (used in many
food and beverage flavorings).

Measures used to diagnose occupational lung diseases

Occupational lung diseases, like other lung diseases, usually require an initial
chest X-ray or CT scan for a clinical diagnosis. In addition, various tests may
be performed to determine the type and severity of the lung disease, including:
 Pulmonary function tests: Diagnostic tests that help to measure the lungs'
ability to move air into and out of the lungs effectively. The tests are

53
 usually performed with special machines into which the person must
breathe.
 Microscopic examination from biopsy or autopsy of tissue, cells, and
fluids from the lungs
 Biochemical and cellular studies of lung fluids
 Examination of airway or bronchial activity

Ways of preventing occupational lung diseases

 Wear proper protective devices, such as facial masks, when around
airborne irritants and dusts.
 The best prevention for occupational lung diseases is avoidance of the
inhaled substances that cause lung diseases.
 Avoid smoking: Smoking can actually increase the risk for occupational
lung disease.
 Evaluate lung function with spirometry (an evaluation of lung function
performed in the doctor's office) as often as recommended by the doctor
to familiarize yourself with your lung function.
 Educate the workers concerning the risks of lung disease.
 Hire a specially-trained occupational health expert to investigate the work
environment for risks for occupational lung diseases.

Treatment of occupational lung diseases

There is no way to repair or regrow damaged lung tissue. The goal of treatment
is to;
 Prevent further exposure to the irritant
 Prevent worsening of the disease
 Manage symptoms
 Help the client stay active and healthy

Treatment will be determined by the doctor based on:

 The age, overall health, and medical history of the client
 Extent and type of lung disease
 The person’s tolerance for specific medications, procedures, or therapies
 Expectations for the course of the disease
 Client’s opinion or preference

54
 Special Procedures used in the Management of
Respiratory disorders

Tracheostomy

Tracheostomy is an opening surgically created through the neck between the

second and third tracheal ring (windpipe) to allow direct access to the breathing
tube and is commonly done in an operating room under general anesthesia. A
tube is usually placed through this opening to provide an airway and to remove
secretions from the lungs. Breathing is done through the tracheostomy tube
rather than through the nose and mouth.

Reasons for Tracheostomy

The main reason for tracheostomy is as a result of upper airway problem. The
doctor cuts below the injured or blocked part of the airway to get air to the
lungs.
You could need a tracheostomy because of:

 A tumor
 A spasm of your voice box (larynx)
 Injury to your windpipe or airway
 Swelling of your tongue, mouth, or airway
 Food or something else stuck in the airway
 Severe sleep apnea
 Burns
 Infections
 Other illnesses that cause breathing problems
 Surgery on your face or to take out the larynx (laryngectomy)
 Birth defects that affect the airways

Most times, tracheostomy can be planned in advance. But they sometimes need
to be done outside a hospital, such as at the scene of an accident. Emergency
tracheostomies can be hard and have a higher chance of complications.
In some cases, tracheostomy may not be as a result of airway blockage, but due
to serious illness preventing one from breathing normally. If this happens,
treatment usually starts with a tube that goes down into the airway through your
nose or mouth (intubation). But this can be uncomfortable and may lead to

55
injury, ulcers, and infection if it’s left in too long. So for people that need long-
term help with breathing, the doctor may suggest a tracheostomy. This can
happen with:
 Pneumonia
 A massive heart attack
 Stroke
 Damage to the chest wall
 Lung disease
 A spinal cord injury
 Coma
 A severe allergic reaction
 Problems with the muscle below your lungs that helps you breathe
(diaphragm)
 Paralysis or other conditions that make it hard to clear your airways

Risks associated with tracheostomy

Tracheostomies are generally safe, but they do have risks. Some complications
are particularly likely during or shortly after surgery. The risk of such problems
greatly increases when the tracheotomy is performed as an emergency
procedure.

Immediate complications include:

 Bleeding
 Damage to the trachea, thyroid gland or nerves in the neck
 Misplacement of the tracheostomy tube
 Air trapped in tissue under the skin of the neck (subcutaneous
emphysema), which can cause breathing problems and damage to the
trachea or food pipe (esophagus)
 Buildup of air between the chest wall and lungs (pneumothorax), which
causes pain, breathing problems or lung collapse
 A collection of blood (hematoma), which may form in the neck and
compress the trachea, causing breathing problems

Long-term complications include:

 Obstruction of the tracheostomy tube

 Damage, scarring or narrowing of the trachea

56
  Development of an abnormal passage between the trachea and the
esophagus (tracheoesophageal fistula), which can increase the risk of
fluids or food entering the lungs
 Development of a passage between the trachea and the large artery that
supplies blood to the right arm and right side of the head and neck
(tracheoinnominate fistula), which can result in life-threatening bleeding
 Infection around the tracheostomy or infection in the trachea and
bronchial tubes (tracheobronchitis) and lungs (pneumonia)
 Irritation, which can lead to an increase in mucus

For those that need a tracheostomy after leaving the hospital, they need to keep
regular scheduled appointments for monitoring possible complications such as:
 Bleeding at the tracheostomy site or from the trachea
 Difficulty breathing through the tube
 Pain or a change in comfort level
 Redness or swelling around the tracheostomy
 A change in the position of the tracheostomy tube

Tracheostomy procedure
A tracheotomy is most commonly performed in an operating room with general
anesthesia, which makes one unaware of the surgical procedure. A local
anesthetic to numb the neck and throat is used if the surgeon is worried about
the airway being compromised from general anesthesia or if the procedure is
being done in a hospital room rather than an operating room.
The type of procedure one undergoes depends on why they need a tracheostomy
and whether the procedure was planned. There are essentially two options:

 Surgical tracheotomy: This can be performed in an operating room or in

a hospital room. The surgeon usually makes a horizontal incision through
the skin at the lower part of the front of your neck. The surrounding
muscles are carefully pulled back and a small portion of the thyroid gland
is cut, exposing the windpipe (trachea). At a specific spot on the windpipe
near the base of your neck, the surgeon creates a tracheostomy hole.
 Minimally invasive tracheotomy (percutaneous tracheotomy: This is
typically performed in a hospital room. The doctor makes a small incision
near the base of the front of the neck. A special lens is fed through the
mouth so that the surgeon can view the inside of the throat. Using this

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 view of the throat, the surgeon guides a needle into the windpipe to create
the tracheostomy hole, then expands it to the appropriate size for the tube.
For both procedures, the surgeon inserts a tracheostomy tube into the hole. A
neck strap attached to the face plate of the tube keeps it from slipping out of the
hole, and temporary sutures can be used to secure the faceplate to the skin of
your neck.

After the procedure

The patient likely spends several days in the hospital as the body heals. During
that time, he learns the skills necessary for maintaining and coping with the
tracheostomy:

 Caring for your tracheostomy tube: A nurse will teach you how to
clean and change your tracheostomy tube to help prevent infection and
reduce the risk of complications. He will continue to do this as long as he
has a tracheostomy.
 Speaking: Generally, a tracheostomy prevents speaking because exhaled
air goes out the tracheostomy opening rather than up through your voice
box. But there are devices and techniques for redirecting airflow enough
to produce speech. Depending on the type of tube, width of the trachea
and condition of the voice box, the person may be able to speak with the
tube in place. If necessary, a speech therapist or a nurse trained in
tracheostomy care can suggest options for communicating and help the
patient to learn to use his voice again.
 Eating: While the incision is healing, swallowing will be difficult.
Nutrients are given through an intravenous (IV) line inserted into a vein
in the body, a feeding tube that passes through the mouth or nose, or a
tube inserted directly into your stomach. When the person is ready to eat
again, he may need to work with a speech therapist, who can help him
regain the muscle strength and coordination needed for swallowing.
 Coping with dry air: The air you breathe will be much drier because it
no longer passes through the moist nose and throat before reaching the
lungs. This can cause irritation, coughing and excess mucus coming out
of the tracheostomy. Putting small amounts of saline directly into the
tracheostomy tube, as directed, may help loosen secretions. Or a saline
nebulizer treatment may help. A humidifier or vaporizer adds moisture to
the air in a room.

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  Managing other effects: The health care team will teach the ways to care
for other common effects related to having a tracheostomy. For example,
they may learn how to use a suction machine to help clear secretions from
the throat or airway.

Tracheostomy tube
 A tracheostomy (trach) tube is a small tube inserted into the tracheostomy
to keep the stoma (opening) clear. Tracheostomy tubes are available in
several sizes and materials including semi-flexible plastic, rigid plastic or
metal. The tubes are disposable or reusable. They may have an inner
cannula that is either disposable or reusable.
 The obturator is used to insert a tracheostomy tube. It fits inside the tube
to provide a smooth surface that guides the tracheostomy tube when it is
being inserted.
 There are different types of tracheostomy tubes available and the patient
should be given the tube that best suits his/her needs.
 The tracheostomy tube may or may not have a cuff. Cuffed trach tubes
are generally used for patients who have swallowing difficulties or who
are receiving mechanical ventilation. Inflating the cuff during mechanical
ventilation makes sure that air is entering the lungs and not escaping
through the nose and mouth. The cuff also prevents aspiration of saliva in
patients who have trouble swallowing. Non-cuffed trach tubes are used to
maintain the patient’s airway when a ventilator is not needed. The choice
of tube is based on the patient’s condition, neck shape and size and
purpose of the tracheostomy.
 All trach tubes have an outer cannula (main shaft) and a neck-plate
(flange).
 The flange rests on the neck over the stoma (opening). Holes on each side
of the neck-plate allow you to insert trach tube ties to secure the trach
tube in place.
 The inner cannula is an inner tube inserted within the main outer
cannula of the tracheostomy tube, it acts as a liner. It is useful for
individuals who require secretion management. This liner can be removed
and cleaned to help prevent the build-up of mucus inside the trach tube.
The inner cannula locks into place to prevent accidental removal.
 Some tracheostomy tubes are fenestrated. (Fenestration is a hole in the
shaft of the tracheostomy tube, above the curvature, and therefore also

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 above the cuff of a cuffed trach tube. The purpose of a fenestration is to
allow for airflow upward and through the vocal cords).

Care of tracheostomy tube

Routine tracheostomy care should be done at least once a day after discharge
from the hospital.
Gather the following supplies:
 Two non-sterile gloves
 A clean basin (or sink)
 Hydrogen peroxide
 Clean fine mesh gauze pads
 Cotton swab
 Normal saline or tap water (Use distilled water if you have a septic tank
or well water)
 Clean pipe cleaners or small brush
 Clean washcloth
 Clean towel
 Trach tube ties
 Clean scissors

1. Wash your hands thoroughly with soap and water.

2. Stand or sit in a comfortable position in front of a mirror (in the bathroom
over the sink is a good place to care for your trach tube).
3. Put on the gloves.
4. Suction the trach tube. (the healthcare provider will provide information
about the suctioning procedure).
5. If your tube has an inner cannula, remove it. (If the trach tube does not
have an inner cannula, go to step 11.)
6. Hold the inner cannula over the basin and pour the hydrogen peroxide
over and into it. Use as much hydrogen peroxide as you need to clean the
inner cannula thoroughly.
7. Clean the inner cannula with pipe cleaners or a small brush.
8. Thoroughly rinse the inner cannula with normal saline, tap water or
distilled water (if you have a septic tank or well water).
9. Dry the inside and outside of the inner cannula completely with a clean
fine mesh gauze pad.
[Link] the inner cannula and lock it in place.
[Link] the soiled gauze dressing around your neck and throw it away.
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[Link] the skin around the stoma (opening) for redness, hardness,
tenderness, drainage or a foul smell. If you notice any of these conditions,
call your nurse or physician after you finish routine care.
[Link] the cotton swabs in a solution of half hydrogen peroxide and half
water. Use the swabs to clean the exposed parts of the outer cannula and
the skin around the stoma.
[Link] the wash cloth with normal saline, tap water or distilled water. Use
the wash cloth to wipe away the hydrogen peroxide and clean the skin.
Dry the exposed outer cannula and the skin around the stoma with a clean
towel.
[Link] the trach tube ties.
 Measure and cut a piece of tie long enough to go around your neck twice.
Cut the tie in such a way it is easier to insert the tie into the neck-plate.
 Untie one side of the old tie and remove that side from the neck-plate. Do
not completely remove the old tie until the new one is in place and is
securely fastened.
 Holding the trach tube in place, lace the tie through one hole of the neck-
plate, around the back of your neck, through the other hole of neck-plate,
and again around the back of your neck.
 Pull the tie snugly and tie a square knot on the side of your neck. There
should be enough space for no more than two fingers between the tie and
your neck.
 Cut, remove and discard the old tie. If you have a cuffed trach tube, be
careful not to cut the cuff balloon when removing the old trach tube tie.
[Link] fine mesh gauze under the tracheostomy tie and neck-plate by
folding it or cutting a slit in it.
[Link] your gloves and throw them away.
[Link] your hands with soap and warm water.
[Link] the basin and small brush with soap and warm water. Dry them and
put them away.
[Link] out the used washcloth and towel.
[Link] your hands again with soap and warm water.

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