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  • 19/11/10
  • 19/11/10
  • 19/11/10
  • 19/11/10
  • Anatomy & Physiology in Health & Illness, Ross & Wilson, 1990, pg 128 19/11/10
  • Anatomy & Physiology in Health & Illness, Ross & Wilson, 1990, pg 130 19/11/10
  • Anatomy & Physiology in Health & Illness, Ross & Wilson, 1990, pg 130 19/11/10
  • 19/11/10
  • 19/11/10
  • 19/11/10
  • 19/11/10
  • 19/11/10
  • 19/11/10
  • 19/11/10 Medical Research Council. Lancet 1965

Transcript

  • 1.
  • 2.
  • 3. Anatomy of Respiratory System
    • Nose
    • Pharynx (throat)
    • Larynx (Voice box)
    • Trachea (Wind pipe)
    • Bronchi
    • Lungs
    • Muscles of Respiration :
    • Intercostal muscles
    • Diaphragm
  • 4. Upper Resp. Ttract Nose Pharynx Lower Resp. Tract Larynx Trachea Bronchi Lungs
  • 5.
  • 6.
  • 7.
  • 8. Respiratory Bronchiole Alveolar Sac Acinus Alveolar Duct Lower Respiratory Tract
  • 9. Respiratory Function: Air is warmed, moistened & filtered Olfactory function
  • 10.
    • Citated columar epithelium
    • Mucus secreting goblet cells
  • 11.
    • Nasal part
    • Oral Part
    • Laryngeal Part
    Functions of Pharynx: Respiratory: Air passes thru the nasal & oral parts. Air is further warned & moistened Digestive: Food passes thru, oral & laryngeal parts
  • 12. Principles of Anatomy & Physiology, Tortora, 1996, pg 708 Lies in front of pharynx. After puberty, grows larger in the male which explains the prominence of the ‘ Adam’s apple ’ and deeper voice.
  • 13. Speech consists of manipulation of sound produced by vocal cords, tongue, cheeks.
  • 14.
    • Passage way for air between pharynx & trachea (air further moistened, filtered, warmed)
    • Vocal cords produce sounds of various loudness & pitch
    • During swallowing larynx moves upwards occluding the opening into it from the pharynx
  • 15. Trachea : 12 cm long Diameter 2 .5 cm
  • 16.
    • Cartilages keep the air passages open, allowing for unobstructed passage of air
    • Sticky mucus lining the membranes filters air
    • Wave motion of cilia & lining membrane waft mucus and adherent particles towards the throat.
  • 17.
    • Contraction & relaxation of muscles in the wall regulate the volume of air entering the lungs
    • Cells (lymphocytes, plasma cells, PMNs, macrophages) protect against infection and inhaled foreign particles.
    • Air warmed (or cooled) and moistened
  • 18.
  • 19.
  • 20.
  • 21.
  • 22.
  • 23.
    • 15 times/ min
    • Inspiration
    • Expiration
    • Pause
  • 24. Diaphragam Intercostals
  • 25.
  • 26.
    • Coughing
    • Sneezing
    • Sighing
    • Yawning
    • Sobbing
    • Crying
    • Laughing
    • Hiccuping
  • 27.
    • The process of respiration is carried out by the help of a large number of muscles:
      • 1) Diaphragm
      • 2) Intercostal muscles
      • 3) Accessory muscles of respiration
  • 28. Structure of a Bronchiole Smooth Muscle Epithelium Sub-Mucosa Cilia Mucous Layer Mucus Gland Goblet Cell Mast Cells
  • 29.
    • Respiration:
    • External
    • Internal
    • Tissue
  • 30.
  • 31.
  • 32.
  • 33.
    • Pharyngitis: Inflammation of pharynx
    • Laryngitis: Inflammation of larynx
    • Tracheitis: Inflammation of trachea
    • Bronchitis Inflammation of bronchi
    • Bronchiolitis: Inflammation of bronchiole
    • Otitis Medium: Inflammation of middle ear
  • 34.
    • Common cold: Is associated with running nose i.e. rhinorrhoea, congestion, sneezing etc. It is the inflammation of the nasal mucus membrane
    • Cough: It is a protective and physiological reflex which is responsible for expelling any foreign matter entering the respiratory tract.
  • 35.
    • Bronchiectasis: Localised, chronic and irreversible dilatation of the bronchi.
    • Pneumonia: Inflammation and consolidation of the lung tissue (parenchyma).
    • Empyema: Accumulation of pus in pleural cavity.
  • 36.
    • Sinusitis: Inflammation of the mucus membrane lining the various sinus cavities in the skull.
    • Tonsillitis: Inflammation of the tonsils.
    • Lung abscess: Collection of pus in the lungs.
    • Adenitis: Inflammation of the adenoids.
  • 37.
    • Sinuses:
    • hollow cavities within the facial bones.
    • Sinus infections:
    • most frequently maxillary and frontal sinuses.
    Sinisitis
  • 38.
    • Nasal congestion,
    • Greenish nasal phlegm (discharge),
    • Night-time cough.
    • Fever, malaise (feeling ill), bad breath
    • Sore throat,
    • Facial and/or dental pain, eye pain, headache.
    Classic Symptoms of Acute Sinusitis
  • 39.
    • Runny nose , Nasal congestion
    • Sneezing
    • Sore throat , Cough
    • Muscle aches , Headache
    • Fever
    Common Cold - Symptoms
  • 40.
    • Cough: with or without mucus ,
    • Nasal discharge
    • Headache , muscle aches and stiffness
    • Shortness of breath
    • Stuffy, congested nose , nose - bleed
    • Sore throat
    Flu (influenza) - Symptoms
  • 41.
    • Cough: mucus (sputum), blood streaked
    • Shortness of breath
    • Frequent RTI(colds)
    • Wheezing
    • Fatigue, Headaches
    • Reddish mucous membranes
    Bronchitis- Symptoms
  • 42.
    • The presence of chronic
    • productive cough for 3 months,
    • In each of 2 successive years.
    • In a patient in whom other causes of chronic cough have been excluded.
    Chronic Bronchitis
  • 43.
    • Cough: mucus-like, greenish, or pus-like sputum
    • Fever: chills with shaking
    • Chest pain: sharp or stabbing, increased by deep breathing, increased by coughing
    • Headache
    • General discomfort: uneasiness / ill feeling (malaise)
    Pneumonia - Symptoms
  • 44.
    • Chronic cough: large amounts of foul-smelling sputum production
    • Coughing up blood
    • Cough worsened by lying on one side
    • Shortness of breath worsened by exercise
    • Wheezing
    • Weight loss ,Fatigue
    Brochiectasis - Symptoms
  • 45.
    • Sore throat: accompanied by fever, headache, swollen lymph nodes in the neck.
    • Viral Pharyngitis: associated with runny nose (rhinorrhea) and postnasal discharge
    • Severe Pharyngitis: accompanied by difficulty swallowing and difficulty breathing.
    Pharyngitis - Symptoms
  • 46.
    • Cough,
    • Wheezing, shortness of breath, or difficulty breathing,
    • Bluish skin due to lack of oxygen (cyanosis),
    • Rapid breathing (tachypnea),
    • Nasal flaring(swelling) in infants,
    • Fever.
    Bronchiolitis - Symptoms
  • 47. Normal Lung Bronchiolitis Bronchiolitis
  • 48.
  • 49. What is cough? Cough is a protective and physiological reflex aimed at maintaining an open airway. Cough involves rapid expulsion of air at high velocity from the respiratory airway which expel irritants and excessive secretions from respiratory tract. Cough
  • 50. Coughing is under voluntary and involuntary control and consists of 3 phases. Inspiratory : initiated by taking a deep breathe Phase and results in maximal dilation of the lungs. Compressive : closure of the glottis followed by phase contraction of thoracic and abdominal muscles against a fixed diaphragm. Expiratory : sudden glottis opening results in phase the explosive release air. Cough - Physiology
  • 51. Act of Coughing
  • 52. Cough - Aetiology (Causes) Cough Cancer Smoking Acute LVF Psychogenic Infections URTI, LRTI, TB Chemicals Drugs (ACEI) Dust Pollens Bronchial Asthma
  • 53. Classification of Cough: A cough can be classified by its - Duration , Character , Quality , and Timing. Classification as per the Duration of Cough: Acute (of sudden onset): Present < 3 weeks, Subacute : Present between 3 and 8 wks, Chronic : L asting > 8 weeks. Types of Cough
  • 54. 1. Acute Cough Cough which comes all of a sudden, 1. Dry cough 2. Productive cough 3. Bronchospastic / Asthmatic cough Most commonly relates to - 1. Viral – induced lower respiratory tract infections. 2. Post-nasal drip resulting from rhinitis or sinusitis. 3. Throat - clearing secondary to laryngitis or pharyngitis. Types of Cough
  • 55. Cough is present between 3 and 8 weeks . The most common causes: Post infectious Cough. Acute Sinusitis. Asthma . 2. Sub-acute Cough:
  • 56. Cough lasting for more than 3 weeks. Most Important Causes :
    • Smoking
    • Post-nasal Drip
    • Asthma
    • GERD
    • Chronic bronchitis
    • Bronchiectasis
    • Occupation environment
    • Psychogenic cough
    • LVF (left ventricular failure)
    • Tuberculosis
    • Lung Cancer
    • Intestinal lung disease
    3. Chronic Cough … cont.
  • 57.
    • Findings
    • Patient is a smoker
    • Purulent sputum
    • TB exposure
    • Wheezing
    • Cough worse at work
    • Cough after URTI
    • Facial / tooth pain
    • Wt loss
    • Possible Diagnosis
    • Tobacco induced bronchitis
    • Pneumonia, Bronchitis
    • Pulmonary TB
    • Asthma
    • Occupational cause
    • Postnasal drip
    • Sinusitis
    • Cancer, TB
    Chronic Cough: Diagnosis
  • 58.
    • Step 1 : Initial evaluation + Diagnosis + Rx. Cough = Symptomatic treatment
    • Step 2 : Treatment for postnasal drip.
    • Rx = Antihistamine + decongestant
    • Step 3 : Add treatment for Asthma. Cough= Symptomatic Rx + Bronchodilator
    • Step 4 : Lab. Investigations (x-ray, CT scan)
    • Rx = Cough formula till cough subsides.
    Chronic Cough: Treatment
  • 59.
    • Troublesome type of cough,
    • Tends to aggravate because of rapid flow of air, further irritating the trachea and pharyngeal mucosa.
    • There is no sputum or secretions are too thick and viscid.
    4. Dry cough
  • 60.
    • Patient spits out a lot of sputum.
    • Secretions may be thick or watery.
    • It is usually the result of an allergic response or RTI.
    • Productive cough are coughs that produce phlegm , in contrast to dry coughs.
    • Productive cough is associated with tuberculosis , bacterial pneumonia, and bronchitis .
    • The loose productive cough is a sign of chest congestion or infection due to colds or flu.
    5. Productive Cough
  • 61.
    • Associated with bronchospasm,
    • Common in asthma patients & chronic bronchitis.
    • It frequently wakes up the patient during the night or the early hours of the morning.
    6. Bronchospastic (Asthmatic) Cough
  • 62. Characteristics of Cough Originating at Various Levels of Respiratory Tract : Origin Causes Characteristics Pharynx Post nasal drip Usually Persistent. Larynx Laryngitis, tumor, whooping cough, croup Harsh, barking, painful, persistent, often associated with strider. Trachea Tracheitis Painful Bronchi Acute Bronchitis and COPD Asthma. Bronchial Carcinoma Dry or Productive, , worse in mornings. Dry or productive, worse at night. Persistent often with haemoptysis. Lung Parenchyma Tuberculosis Pneumonia Bronchiectasis Pulmonary edema Interstitial Fibrosis Productive, often with haemoptysis. Initially Dry, Productive later. Productive Often at night ( may be productive) Dry, irritant and distressing.
  • 63.
  • 64. Most Common Symptoms in …. Cough Running Nose, Nasal & Chest Congestion Breathlessness Sore Throat Sinusitis, Common Cold Influenza (Flu), Pharyngitis, Bronchitis Pneumonia, Bronchiolitis Bronchiectasis
  • 65.
    • Resp. Mucous Membrane:
    • Lined by respiratory epithelium
    • Ciliated columnar cells
    • Goblet cells
    • Cilia - propel foreign particles upwards
    Respiratory Tract Fluids
  • 66.
    • Water 95% - secreted by bronchial glands
    • Glycoproteins - thick mucopolysaccharides secreted by Goblet cells
    • Fats
    • Proteinaceous material is called mucus
    Respiratory Tract Fluids …cont.
  • 67. Together - Muco-ciliary blanket
    • It has two layers:
    • Sol layer : watery layer in which cilia bathe freely
    • Gel layer : above the sol layer contains mucus
    • relatively thicker and stickier
    Respiratory Tract Fluids …cont.
  • 68.
    • The respiratory tract fluid and muco-ciliary equilibrium:
    • Resp. Fluid gradually propelled upwards into the pharynx where it is swallowed without awareness.
    Respiratory Tract Fluids …cont.
  • 69.
    • Respiratory tract fluid - increases during infections
    • During RTIs or when lungs are exposed to foreign particles secretion increase in order to:
    • Dilute irritants, if any,
    • Drive away foreign bodies and unwanted particles,
    • Trap micro-organisms.
    Respiratory Tract Fluids
  • 70. When respiratory tract is contaminated by – Oropharyngeal cells, bacteria, food particles and saliva, … it is called sputum. What is Sputum? ⁺ Phlegm is a sticky material from patient ’ s mucous membranes in the respiratory system. During Cold it might be yellowish brown . During an infection, it might be greenish brown. Normal phlegm is usually clear .
  • 71.
  • 72. Drugs Used In Cough
  • 73. Centrally Acting: Excessive Cough Bouts - Central Antitussive Peripherally Action: Increased Respiratory Tract Fluid - Expectorant Breakdown Thick Mucus - Mucolytic Decreased Bronchoconstriction - Bronchodilator Decreased Congestion - Decongestant Decreased Allergy - Antihistamine Anti-Cough Drugs - Mechanism of Action
  • 74. Actions of Anti-Cough Preparations Mucolysis Mucokinesis Expectoration Breaking down of the long, complex, muco polysaccharide fibers to facilitate better expectoration. Upwards movement of the mucous (mainly, gel layer of the Respiratory Tract Fluid). Driving away of respiratory tract fluid, done by liquefying the secretions so that extraneous (foreign particles, bacteria and the line) material can easily be thrown out
  • 75.
    • Mucokinesis is responsible for removal of secretions from respiratory tract.
    • If defective :
      • Mucus retention occurs resulting in …
      • Impairment in the distribution of inspired air,
      • Worsening of gas exchange at alveoli,
      • Development of bronhcietasis and atelectasis,
      • Reduction in the ability of the lung to resist infection.
    How Important is Mucokinesis?
  • 76.
    • Drugs which suppress cough centre situated in the medulla. (Latin tussis = Cough).
    • There are two types of these drugs :
    • Narcotics
    • Non-Narcotics
    Anti-tussives
  • 77.
    • In addition to cough suppressing action, they have properties like -
    • Powerful analgesia ,
    • Sedation, and
    • Psychic effects,.
    • Codeine,
    • Hydrocodeine,
    • Ethylmorphine,
    • Dihydrocodeine,
    • Oxycodeine
    Anti-tussives (Narcotics) NOT the drugs of first choice because of addiction properties.
  • 78.
    • Nausea, vomiting, constipation, skin rashes, drowsiness, addiction, confusion, headache, palpitation, convulsions, sweating, vertigo, shock
    • Rarely : Respiratory failure and coma, leading to death
    • Reduce ciliary motility of respiratory tract.
    • Interact with alcohol, antipsychotics, anti-depressants, anti-histaminics and anti-cholinergics.
    • Contra-indicated in respiratory, liver, cerebral diseases and endocrine disorders.
    Anti-tussives (Narcotics) – Side Effects
  • 79. These are a group of centrally acting anti-tussives without the narcotic properties which include – Noscapine and Dextromethorphan . Non- Narcotic Anti- Tussive
  • 80. Drug Therapy of Cough Class Drug Name Action Antihistamines Cetirizine, Levocetrizine, Diphenhydramine, Chlorpheniramine maleate (CPM) Block effects of histamine in allergic cough. Anti-tussive (Cough suppressants) Codeine, Pholcodeine, Noscapine, Dextromethorphan To suppress the cough reflex. Demulcents (Soothing Agents) Lozenges, cough drops, linctuses containing syrup. (glycerin, liquorice), and menthol (local action) To sooth the respiratory mucosa. Expectorants Reflexly acting - Ammonium chloride (local action), Potassium chloride. Directly- Guaiphenesin (local action), Sodium and Potassium citrate, Potassium iodide. To increase mucus clearance. Mucolytics Bromhexine (local action), Carbocisteine to liquefy the respiratory secretions for easy expectoration. Decongestant Ephedrine, phenylephrine , and topical drugs like oxymetazoline, xylometazoline are widely used as decongestants. Phenylephrine HCL a synthetic sympathomimetic agent, Sympathomimetic agents are a vasoconstrictor and pressor drug chemically related to epinephrine and ephedrine.
  • 81.
    • Blocks H1 histamine receptor and thus inhibits the actions of histamine.
    • Prevents allergic manifestations of cough.
    • Well absorbed from GIT and penetrates the CNS.
    • Side Effects : drowsiness, nausea and vomiting.
    Antihistamines
  • 82.
    • Antihistamine, antagonises the actions of histamine at the receptor sites.
    • Reduces allergic reactions produced due to histamine in the respiratory tract.
    • Drowsiness and anticholinergic side effects are common.
    Antihistamines
  • 83. Decongestants
  • 84. Anti-pyretic - Analgesics
  • 85.
    • Menthol:
    • Soothening action, produces cooling sensation and has a mild anesthetic action
    • Side effects are mild hypersensitivity reactions
    Soothing Agents
  • 86.
  • 87.
    • Composition: Each 5 ml contains
    •  
    • Phenylephrine 5 mg
    • Paracetamol 250 mg
    • Chlorpheniramine Maleate (CPM) 1 mg
    • Menthol 1.25 mg
  • 88.
    • Synthetic sympathomimetic agent,
    • Stimulate  receptors,
    • Very minimal effect on  -receptor,
    • Vasoconstrictor,
    • Vaso-presser drug.
    • Phenylephrine (Decongestant)
  • 89.
    • Phenylephrine … cont.
    Powerful Vasoconstrictor Cardiac Safety Blood Vessels: Cutaneous, limb, kidney, spleen Coronary blood flow increased Pulmonary Blood vessels constricted In nasal mucosa: Very minimal effects on  -receptors of heart Stimulate  -receptors in the Blood vessels, which constricts & stop secretions. Complete lack of action on heart
  • 90.
    • Very potent decongestant,
    • Constricts (shrinks) blood vessels (veins and arteries),
    • Constriction leads to drainage of supplied areas,
    • Decreases congestion & swelling of mucus membrane,
    • Site of action: Nose & Sinuses.
    • Phenylephrine in RTI :
    • Opens airways
    • Decreases amount of fluid in RT
    • Make easier to breath
    Phenylephrine- Place in Therapy
  • 91.
    • Adults & adolescents > 12 yr.: 10-20 mg 4 hrly
    • Children 6 to 12 yr. : 10 mg 4 hrly
    • Children < 6 yr. : 5 mg 4 hrly
    Phenylephrine- Dosage & Administration
  • 92. 2. Paracetamol (Anti-Pyretic)
  • 93.
    • Histamine in Nature Present in:
      • Plants
      • Venom and stings
      • Synthesized by bacteria and certain fungi
    3. Chlorpheniramine Maleate (CPM)
      • Human Tissue:
      • 1. Cells: Mast cells, Basophils, Neurons, Cells in the stomach.
    • 2. Tissues: Skin, Lung, Gastrointestinal tract.
  • 94. CPM: Synthesis and Metabolism Histidine Histamine L-histidine carboxylase Methylhistamine N – methylimidazole acetic acid histamine methyl transferase
  • 95.
    • H-1: GI & bronchial SM contraction.
    • H-2: Cardiac stimulation, Gastric secretion.
    • H-1 & H-2: Dilation of arterioles and veins.
    • H-3: Mainly in the CNS,
      • Preterminal and autoreceptors,
      • Not considered further.
  • 96. Action Histamine Receptor Bronchial contraction
      • H-1
    GI contraction
      • H-1
    Heart
      • H-2, H-1 (AV node)
    large artery contraction
      • H-1
    Microvessel dilation
      • H-1 & H-2
    Venule permeability
      • H-1 & H-2 (?)
    Gastric acid secretion
      • H-2
    CNS arousal
      • H-1
  • 97. Smooth muscle antihistamines Histamine, PG’s, 5-HT, PAF Drug Protein IgE antibody IgE-Sensitized Cell Histamine Release from Mast Cells Mast Cell Allergen
  • 98.
    • H-1 blockers
      • 1 st generation or classical (older)
      • 2 nd generation or non-sedating (newer)
    • H-2 blockers
      • gastric acid blockers
  • 99.
    • 1. Block H-1 receptors competitively.
    • 2. Reduce local response to intradermal histamine.
    • 3. Antagonize the vasoconstrictor, and to a lesser extent, the vasodilator effects of histamine.
    • 4. Antagonize histamine-induced bronchospasm.
    • 5. Inhibit GI smooth muscle contractions.
  • 100.
    • Developed in France pre-WWII
    • More sedating
    • Penetrate the CNS and generally have CNS effects
    • Significant anticholinergic effects
    • Example:
    • CPM : Sedative action, available OTC.
    • Diphenhydramine:highly sedating, available OTC.
    • Hydroxyzine: used frequently for urticaria.
    • Promethazine (Phenergan):anti-motion sickness activity
      • used by NASA for space motion sickness
  • 101.
    • Less sedating - less CNS penetration.
    • Almost no anticholinergic effects.
    • Produce cardiac toxicity: Removed from the market (Terfenadine , Astemizole).
    • Loratidine – no apparent cardiac toxicity
    • Fexofenadine - active metabolite of Terfenadine, safer than parent compound
    • Cetirizine, Levocetrizine – Used for Non-sedative properties.
  • 102.
    • 1.Common cold: Symptomatic relief.
    • 2.Local allergic manifestations:
    • Urticaria, rhinitis, rhinorrhea.
    • 3. Motion sickness: Nausea and vomiting.
    • 4. Sedative/hypnotic: In sleep remedies (1st generation).
  • 103.
    • Soothing action, produces cooling sensation and has a mild anesthetic action.
    • Action: Stimulation of the mucous membranes cold receptors .
    • Produce a cooling effect when inhaled or come in contact with mucous membrane
    • Use: Relieve sore throat , or nasal congestion, headache, cold , or sore throat . Products that commonly contain menthol include toothpaste, cough syrups , lip balm, mouthwash, gum, and cigarettes.
  • 104.
    • Menthol in Cough Syrups often soothe and cool sore throats by relieving inflammation.
    • It can also help clear stuffy sinus passages and break up chest congestion.
    • This usually helps a person to cough less and breathe easier.
    • The combination of menthol in cough syrup is often an easy treatment that can be given to a person of almost any age.
  • 105. ZEDEX - Indications
  • 106. ZEDEX - Dosage and Administration
  • 107. Diagnosis URTI Flu (Influenza) Rhinitis Common cold0 Sinusitis Pharyngitis Coryza Sore throat Bronchitis Pneumonia Bronchitis Bronchiolitis Bronchiectasis Bronchopneumonia LRTI ZEDEX Rational
  • 108. Cough with sputum Most Common Symptoms Chronic coughing Shortness of breath Difficult to cough out sputum Sore throat Nose & Throat congestion Nasal Discharge Red & swollen mucus membrane
  • 109. Sinuses & Throat Pain (Paracetamol) Most Effective Treatment Fever (Paracetamol) Difficult to cough out sputum (Decongestant) Sore throat (Menthol) Nose & Throat congestion (Antihistamine + Decongestant Nasal Discharge (Antihistamine + Decongestant) Red & swollen mucus membrane (Antihistamine + Decongestant)
  • 110. Cough Formula Antihistamine (CPM) Decongestant (Phenylephrine) Anti-pyretic + Analgesic (Paracetamol) Soothing Agent (Menthol)
  • 111.  
  • 112. ZEDEX - Product Description Packaging Bottle Shipper pack Stockiest Price Retailer Price
  • 113.
    • Product Positioning :
    • Product Differential :
    ZEDEX - Marketing Aspects
  • 114. ZEDEX - Prescribers Profile
  • 115. ZEDEX – Target Doctors and Indications
  • 116. ZEDEX – Communication Strategy
  • 117. ZEDEX – Input Plans
  • 118.  
  • 119.
  • 120. Cold Cough Syrup – Brand Trends
  • 121. Thank You