The document provides an overview of lower respiratory tract infections, including pneumonia and pulmonary tuberculosis. It discusses various types of pneumonia such as community-acquired pneumonia, hospital-acquired pneumonia, and pneumonia in immunocompromised patients. For community-acquired pneumonia, it describes common causative agents and their characteristics. It also covers treatments for different types of pneumonia. The document additionally discusses pneumonia seen in immunocompromised individuals, including Pneumocystis pneumonia and fungal pneumonia.

1. LOWR RESPIRATORY TRACT DISORDERS
by Amanuel.O 1
7/27/2022

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

3. Overview of Anatomy & Physiology RS
 The respiratory system is composed of the upper and
lower respiratory tracts.
 The Upper airway structures consist of the:-
 nose and nasal passages
sinuses,
pharynx,
tonsils and adenoids
larynx and
trachea.
 URT warms and filters inspired air
BY A.O 3
7/27/2022

4. Overview of Anatomy & Physiology of RS
• The lower respiratory tract consists of the
 Lungs, which contain the bronchial and alveolar
structures.
• The LRT (the lungs) can accomplish gas exchange.
• Both URT & LRT are responsible for ventilation .
 The RS works in concert with the cardiovascular system.
 The RS is responsible for ventilation and diffusion &
 The CVS is responsible for perfusion.
BY A.O 4
7/27/2022

5. Overview of Anatomy & Physiology RS…
 The lungs and wall of the thorax are lined with a serous
membrane called the pleura.
 The pleural fluid is small amount of fluid found between
these two membranes serve as a lubricant.
 Lobes:-
 The left lung consists of an upper and lower lobes
 The right lung has an upper, middle, and lower lobe.
BY A.O 5
7/27/2022

6. Overview of Anatomy & Physiology RS…
 Bronchi and Bronchioles:
There are several divisions of the bronchi within each
lobe of the lung.
First are the lobar bronchi (3 in the right lung and 2 in
the left lung).
The bronchioles then branch into terminal bronchioles.
Terminal bronchioles then become respiratory
bronchioles
The respiratory bronchioles then lead into alveolar
ducts and alveolar sacs and then alveoli.
Oxygen and carbon dioxide exchange takes place in the
alveoli.
BY A.O 6
7/27/2022

7. Overview of Anatomy & Physiology of RS
 Alveoli: About 300 million alveoli are made the lung.
 Three different types of cells are found in the alvioli:-
Type I alveolar cells are epithelial cells that form
the alveolar walls.
Type II alveolar cells secrete surfactant that lines
the inner surface and prevents alveolar collapse.
Type III alveolar cells are large phagocytic cells
that ingest foreign matter (e.g, mucus, bacteria) and
act as an important defense mechanism.
7/27/2022 by Amanuel.O 7

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

9. I. PNEUMONIA
 Pneumonia is an inflammation of the lung parenchyma
caused by various microorganisms, including bacteria,
fungi, parasites, and viruses.
 Pneumonitis is a more general term that describes an
inflammatory process in the lung tissue that may
predispose or place the patient at risk for microbial
invasion.
by Amanuel.O 9
7/27/2022

10. Classification of Pneumonia
• Classically, there are four categories of pneumonia:
 Bacterial(typical= if s.pneumonie, H. influenzae,S. aureus)
 Atypical( if other bacterias and other causitive agents)
 Anaerobic/ cavitary, and
 Opportunistic.
• However, The more widely used classification are as
follow:
 Community-acquired pneumonia (CAP),
 Hospital-acquired (nosocomial)pneumonia (HAP),
 Pneumonia in the Immunocompromised host, and
 Aspiration pneumonia
by Amanuel.O 10
7/27/2022

11. 1. Community-Acquired Pneumonia
 CAP occurs either in the community setting or with the
normal social contact.
 Hospitalization for CAP depends on its severity.
 Causative agents are:
 S. pneumoniae, H. influenzae, Legionella,
 Pseudomonas aeruginosa, and other gram-negative rods.
 It is most prevalent during the winter and spring, when
URTIs are most frequent.
by Amanuel.O 11
7/27/2022

12. CAP
Streptococcal pneumonia (pneumococcal)
 Highest occurrence in winter months
 Incidence greatest in the:
 Elderly and
 Patients with COPD,
 Heart failure,
 Alcoholism, and after influenza.
 Death occurs in 14% of hospitalized adults with invasive
disease.
 Abrupt onset, toxic appearance, pleuritic chest pain
 Bacteremia in 15% to 25% of all patients
by Amanuel.O 12
7/27/2022

13. CAP…
 The organism colonizes the URT and can cause the
disseminated invasive infections:
 URTIs-otitis media and sinusitis
 Pneumonia and other LRTIs, and
 It may occur as a:
 Lobar or
 Broncho pneumonic form and may follow a recent
respiratory illness.
by Amanuel.O
13
7/27/2022

14. CAP
Treatment
 Penicillins
Alternative antibiotic therapy, such as
 Cefotaxime or
 Ceftriaxone;
 Antipseudomonal fluoroquinolones
 levofloxacin, gatifloxacin, moxifloxacin
by Amanuel.O 14
7/27/2022

15. CAP…
Mycoplasma pneumonia
 It is CAP, w/c is caused by M. pneumoniae
 It occurs most often in:
 Older children and
 Young adults
 It is spread by infected respiratory droplets through person-to-
person contact.
 It affects entire respiratory tract and has the characteristics of a
bronchopneumonia.
by Amanuel.O 15
7/27/2022

16. CAP
 Increase in fall and winter
 Responsible for epidemics of respiratory illness
 Most common type of atypical pneumonia
 Accounts for 20% of CAP
 Mortality rate:<0.1%
by Amanuel.O 16
7/27/2022

17. CAP
 Onset is usually insidious
 Patients not usually as ill as in other pneumonias
 Sore throat, nasal congestion, ear pain,
 headache, low-grade fever, pleuritic pain,
 Myalgias, diarrhea, Erythematous rash,
 Pharyngitis
 Interstitial infiltrates on chest x-ray.
by Amanuel.O 17
7/27/2022

18. CAP
Treatment of Mycoplasma pneumonia caused CAP
 Doxycycline,
 Macrolide : ERT,clarithromycin,azithromycin
 Fluoroquinolone
by Amanuel.O 18
7/27/2022

19. CAP
H. influenzae .
 Incidence greatest in:-
 Alcoholics,
 Elderly,
 Pts with DM or COPD, and
 children <5 years of age
 Accounts for 5–20% of CAP
 Mortality rate:30%
by Amanuel.O 19
7/27/2022

20. CAP
 Frequently insidious onset associated with URTI 2 to 6
weeks before onset of illness
 low-grade fever, chills, productive cough
 Usually involves one or more lobes
 Bacteremia is common
 Chest x-rays may reveal:
 Multi lobar,
 Patchy bronchopneumonia or
 Consolidation (alveoli tissue is solidified)
by Amanuel.O 20
7/27/2022

21. CAP
Treatment of H. influenzae caused CAP
 Ampicillin,
 Third Cephalosporin,
 Macrolides (Azithromycin, Clarithromycin),
 Fluoroquinolones
by Amanuel.O 21
7/27/2022

22. CAP
Viral pneumonia is another cause of CAP
 Influenza viruses types A, B
 Adenovirus, parainfluenza, CMV, Corona virus
 Incidence greatest in winter months.
 Epidemics occur every 2 to 3 years.
 Accounts for 20% of CAP
 Viruses are the most common cause of pneumonia in
infants and children.
by Amanuel.O 22
7/27/2022

23. CAP
 The chief causes of viral pneumonia In immunocompetent
adults: -
 Influenza viruses types A and B,
 Parainfluenza virus,
 Adenovirus, corona virus, and
 Varicella-zoster virus.
 The chief causes of viral pneumonia, In immuno
compromised adults:
 Cytomegalovirus is the leading
 HSV,
 Adenovirus, and respiratory syncytial virus
by Amanuel.O 23
7/27/2022

24. CAP
Chest X-ray
Patchy in filtrate,
small pleural effusion
Begins as an acute URTIs- in most patients
bronchitis,
pleurisy
by Amanuel.O 24
7/27/2022

25. CAP
Treatment of viral CAP
 Type A: Amantadine and Rimantadine
 Type A/B: zanamivir, oseltamivir phosphate
 Treated symptomatically
 Does not respond to treatment with currently available
antimicrobials
by Amanuel.O 25
7/27/2022

26. 2. Hospital-Acquired Pneumonia
 HAP, also known as nosocomial pneumonia, is defined as
the onset of pneumonia symptoms more than 48 hours
after admission in patients with no evidence of infection
at the time of admission.
 HAP accounts for 15% of hospital-acquired infections but
is the most lethal nosocomial infection.
by Amanuel.O 26
7/27/2022

27. HAP
 Ventilator-associated pneumonia is considered as a type of
nosocomial pneumonia
 It is bacterial pneumonia that develops in patients with
acute respiratory failure who have been receiving :-
 Mechanical ventilation for at least 48 hours or
 Endotracheal intubation
 Hands of health care personnel is also another potential
source of nosocomial infection.
by Amanuel.O 27
7/27/2022

28. HAP…
 HAP occurs when at least one of three conditions exists:
Inoculum of organisms reaches the LRT and
overwhelms the host's defenses, or
Presence of highly virulent organism
Impaired host defenses
 Immunocompromised patients are at particular risk.
by Amanuel.O 28
7/27/2022

29. HAP
Predisposing factors to HAP includes:
 Impaired host defenses (acute or chronic illness),
 A variety of co-morbid conditions
 Supine positioning and aspiration
 Coma
 Malnutrition
 Prolonged hospitalization
 Hypotension, and
 Metabolic disorders.
by Amanuel.O 29
7/27/2022

30. HAP
 HAP is associated with a high mortality rate because of:
The virulence of the organisms,
Their resistance to antibiotics, and
The patient's underlying disorder
 The common organisms responsible for HAP include:
 Enterobacter species, E. coli, H. influenzae, Klebsiella
species, Proteus, Serratia marcescens, P. aeruginosa,
Methicillin-sensitive/resistant-S.aureus & S.
pneumoniae
by Amanuel.O 30
7/27/2022

31. HAP
Staphylococcal pneumonia accounts for >30%cases of HAP
but <10% of cases of CAP.
• It can occur through inhalation or hematogenous route.
• It is often accompanied by bacteremia and positive
blood cultures.
• Its mortality rate is high
• Specific strains of staphylococci are resistant to all
available antimicrobial agents except vancomycin.
by Amanuel.O 31
7/27/2022

32. HAP
 Pseudomonal pneumonia accounts for 15% cases of HAP
and mortality rate:40–60%.
 It occurs:-
 In debilitated patients ,
 Altered mental status, and
 Prolonged intubation or with tracheotomy
by Amanuel.O 32
7/27/2022

33. Clinical manifestations of HAP…
 Cough and sputum production
 General malaise
 Fever, chills, productive cough, relative bradycardia,
Leukocytosis
 Pleural effusion,
 Diffuse consolidation on chest x-ray.
• Even with treatment, the mortality rate remains high(40-60%).
by Amanuel.O 33
7/27/2022

34. HAP
Treatments:
 Aminoglycoside And
 Antipseudomonal Pencillins (Ticarcillin, Piperacillin,
Mezlocillin)
 Ceftazidine
by Amanuel.O 34
7/27/2022

35. 3. Pneumonia in Immune compromised Host
 Pneumonia in Immunocompromised hosts includes:
 PCP, and other Fungal pneumonias
Mycobacterium tuberculosis.
 The organism that causes PCP is now known as
Pneumocystis jiroveci instead of Pneumocystis carinii.
by Amanuel.O 35
7/27/2022

36.  Pneumonia in the immunocompromised host occurs
with:
 Immunosuppressive agents
 Use of corticosteroids or
 Chemotherapy
 Nutritional depletion,
 Use of broad-spectrum antimicrobial agents,
 HIV/AIDS
 long-term advanced life-support technology
(mechanical ventilation).
by Amanuel.O 36
7/27/2022

37. Pneumonia in an Immunocompromised…
 Immune compromised Patients commonly develop
pneumonia from organisms of low virulence.
 Patients with impaired defenses develop HAP from gram-
negative bacilli (Klebsiella, Pseudomonas, E. coli,
Enterobacteriaceae, Proteus, Serratia).
 Whether patients are immunocompromised or immuno
competent, the clinical presentation of pneumonia is
similar.
by Amanuel.O 37
7/27/2022

38. Pneumonia in an Immunocompromised…
PCP/Pneumocystis jiroveci
 Incidence greatest in patients with:
 AIDS and
 Immunosuppressive therapy for cancer, organ
transplantation
 Frequently seen with CMV infection
 Mortality rate 15–20% in hospitalized patients and fatal if
not treated.
by Amanuel.O 38
7/27/2022

39. Pneumonia in an Immunocompromised…
 Pulmonary infiltrates on chest x-ray
 Non-productive cough, fever, dyspnea
Treatment
 Trimethoprim/sulfamethoxazole (TMP-SMZ),
 Primequine plus clindamycin
by Amanuel.O 39
7/27/2022

40. Pneumonia in an Immunocompromised…
Fungal Pneumonia
 Incidence greatest in
 Immunocompromised and
 Neutropenic patients
 Mortality rate:15–20%
 Cough, hemoptysis,
 On chest x-ray-infiltrates and fungus ball
by Amanuel.O 40
7/27/2022

41. Pneumonia in an Immunocompromised…
Treatment
 Flucytosine with amphotericin B in non-neutropenic
patients,
 Amphotericin B, Itraconazole, ketoconazole
 Lobectomy for fungus ball
by Amanuel.O 41
7/27/2022

42. 4. Aspiration Pneumonia
 Aspiration pneumonia refers to pneumonia resulting from
entry of endogenous or exogenous substances into the
lower airway.
 The most common form of aspiration pneumonia is
bacterial infection from aspiration of bacteria that
normally reside in the upper airways.
 Common pathogens are S. pneumoniae, H. influenza,
and S. aureus.
by Amanuel.O 42
7/27/2022

43. Aspiration Pneumonia…
 Substances other than bacteria may be aspirated into the
lung, such as gastric contents, exogenous chemical
contents, or irritating gases.
 This type of aspiration or ingestion may:-
 Impair the lung defenses,
 Cause inflammatory changes, and
 Lead to bacterial growth and a resulting pneumonia.
by Amanuel.O 43
7/27/2022

44. Other Classification of Pneumonia
 lobar pneumonia- If a substantial portion of one or more
lobes is involved.
 Bronchopneumonia- is a pneumonia that is distributed in a
patchy fashion, and originated in one or more localized
areas within the bronchi and extending to the adjacent
surrounding lung parenchyma.
Bronchopneumonia is more common than lobar
pneumonia.
by Amanuel.O 44
7/27/2022

45. by Amanuel.O 45
.
Distribution of lung involvement in bronchial and lobar
pneumonia.
In bronchopneumonia patchy areas of consolidation occur.
In lobar pneumonia, an entire lobe is consolidated
7/27/2022

46. Clinical manifestation of pneumonia
 Rapidly rising fever (38.5° to 40.5°C) and
 pleuritic chest pain that is aggravated by deep breathing
and coughing.
 Marked tachypnea (25 to 45 breaths/min),
 shortness of breath,
 use of accessory muscles in respiration
 sudden onset of shaking chill in pneumococcal .
by Amanuel.O 46
7/27/2022

47. Assessment and Diagnostic Findings
consolidation of lung tissue, including increased tactile
fremitus.
crackles
percussion dullness
Egophony (secondary to consolidation)
by Amanuel.O 47
7/27/2022

48. Assessment and Diagnostic Findings
 History (recent RTI),
 Physical examination,
 Chest x-ray studies,
 Blood culture (bacteremia)
 Sputum examination.
by Amanuel.O 48
7/27/2022

49. Medical Management
 Administration of the appropriate antibiotic as
determined by the results of the Gram stain.
 However, an etiologic agent is not identified in 50% of
CAP cases and empiric therapy must be initiated.
 In suspected HAP pneumonia, empirical treatment is
usually initiated with a broad-spectrum IV antibiotic and
 May be mono therapy or combination therapy
 Cephalosporin groups or
 Anti staphylococcal penicillin could be used.
 If hypoxemia develops, oxygen is administered.
 Pulse oximetry-to determine the need for oxygen and
evaluate the effectiveness of the therapy.
by Amanuel.O 49
7/27/2022

50. Complications
Shock
respiratory failure
atelectasis and
 pleural effusion
Super infection and etc
by Amanuel.O 50
7/27/2022

51. II. TUBERCULOSIS (TB)
 Introduction :-
 TB is an infectious disease that primarily affects the lung
parenchyma
 It also may be transmitted to other parts of the body, including
the meninges, kidneys, bones, and lymph nodes
 TB is caused by mycobacterium tuberculosis, a rod-shaped
‘acid fast’ bacillus
 Occasionally ,the disease can also be caused by mycobacterium
bovis and africanum
7/27/2022 by Amanuel.O 51

52. Introduction…
 If Properly treated, tuberculosis caused by drug-
susceptible strains is curable in virtually all cases.
 If Untreated, the disease may be fatal
 Transmission: airborne spread of droplet nuclei produced
by patients with infectious pulmonary tuberculosis.
52
BY: A.O
7/27/2022

53. Routes of transmission
.
53
1) By inhalation of infected droplet nuclei. This is most
common MOT.
3000 droplet nuclei can be produced during a single
cough
Droplet nuclei are so small that they pass the defenses
of the bronchi and
multiplication and infection begin in to the terminal
alveoli of the lungs
BY: A.O
7/27/2022

54. Routes of transmission…
54
2) Consumption of raw milk containing M .bovine
It is much less frequent
The risk of infection is high with close, prolonged,
indoor, exposure to a person with sputum smear-positive
pulmonary TB.
BY: A.O
7/27/2022

55. Risk Factors
55
Household contact with a newly diagnosed smear
positive case
Age less than 5 years and elders
Immunosuppressive therapy
HIV infection ,Malnutrition ,Over crowding
 Poor living condition
Alcohol abuse & drug use
Co morbid condition(DM, Chronic Renal Failure, Ca).
BY: A.O
7/27/2022

56. Pathophysiology
Primary infection: occurs in people who have not had any
previous exposure to tubercle bacilli.
 Infection begins when person inhales droplet nuclei containing
tubercle bacilli that reach the alveoli(lungs).
 They are ingested by alveoli macrophages and the majority of
bacilli are inhibited.
 A small number of bacilli may multiply intracelulary &
released when macrophages die.
 A localized granulomatous inflammatory process occurs in the
lung & this is called the primary (Ghon) focus.
56
BY: A.O
7/27/2022

57. Pathophysiology…
 From the Ghon focus, bacilli drain via lymphatic to the
regional lymph nodes.
 The Ghon focus associated with regional lymphadenopathy
form the primary Ghon Complex.
 If alive, the bacilli may spread by lymphatic channel or via
blood stream from the primary complex to distant tissue or
organs.
 Then the future course depends on the dynamic balance b/n
the host immunity & the pathogen.
 At this level most of patients are asymptomatic.
57
BY: A.O
7/27/2022

58. Latent TB Infection (LTBI)
 The process of LTBI begins when extra cellular bacilli are
ingested by microphages & presented to other WBCs.
 This triggers the immune response in w/c WBCs kill or
encapsulate most of bacilli, leading to formation of a
granuloma.
 At this point, LTBI may be detected by using the tuberculin
skin test(TST) or Interferon gamma release assay(IGRA).
 It can take 2-8 wks after initial infection for body’s immune
system to be able to react to tuberculin & for the infection to
detected by TST & IGRA.
58
BY: A.O
7/27/2022

59. Signs and symptoms…
The commonest symptoms of pulmonary Tb are:
 Cough with or with out sputum production ,
 Chest pain, hemoptysis and mild dyspnea
 Fever, night sweats, anorexia, and decreased activity
Some infants and young children with bronchial obstruction have:
 localized wheezing or
 decreased breath sounds that may be accompanied by tachypnea
or,
 rarely, respiratory distress
59
BY: A.O
7/27/2022

60. Signs and symptoms…
60
These pulmonary symptoms and signs are occasionally
alleviated by antibiotics, suggesting bacterial super
infection.
Symptom of EPTB
•Bone TB; localized pain, swelling, muscle weakness, paralyzing
and stiffness of joint .
•Intestinal; loss appetite ,loss of weight, abdominal pain, diarrhea
and ascites.
•TB meningitis; headache , fever, neck stiffness ,and vomiting.
BY: A.O
7/27/2022

61. Classification of TB
1. Anatomical site of disease
2. Bacteriological results (including drug resistance)
3. History of previous treatment
4. HIV status of the patient
61
BY: A.O
7/27/2022

62. 1. Anatomical site of TB diseases
 In general recommended Rx regimens are similar,
irrespective of site.
A. Pulmonary Tuberculosis(PTB)
Refer to a case of TB involving the lung parenchyma.
62
BY: A.O
7/27/2022

63. 1. Anatomical site of TB diseases…
B. Extra pulmonary tuberculosis(EPTB)
 Refer to a case of TB involving organ other than lung
such as:
 Lymph nodes, Pleura, GUT, Bones and Joints, Meninges,
Peritoneum, and Pericardium.
Virtually all organ systems may be affected.
EPTB is seen more commonly in HIV-infected today than
in the past.
63
BY: A.O
7/27/2022

64. 2. Bacteriological classification
Refer to the smear status of pulmonary case and the
identification of MTB by culture or newer methods.
A. Smear PTB+ If a pt With :
 A t least two initial sputum smear +ve for AFB or
 One initial smear +ve for AFB and culture +ve or
 one initial smear +ve for AFB and radiographic
abnormalities
 Consistent with active TB as determined by a clinician.
64
BY: A.O
7/27/2022

65. 2. Bacteriological classification …
B. Smear- Negative PTB/PTB-ve
1. A suggestive symptoms of TB with at least 3 initial-ve
for AFB and No response to a course of broad spectrum
antibiotic
2. Again three smear AFB–ve and Radiological abnormality
consistent with pulmonary TB.
65
BY: A.O
7/27/2022

66. 2. Bacteriological classification …
C. Extra pulmonary TB(EPTB)
TB in organ other than the lung , proven by one culture
+ve specimen from an extra-pulmonary site or histo-
pathological evidence from a biopsy or
TB based on strong clinical evidence with active EPTB
and the decision by a physician to treat with a full course
of anti TB therapy.
66
BY: A.O
7/27/2022

67. 3. Hx of previous Rx pt registration group
 It is important to identify previously treated pt . B/c they
are high risk for drug resistance including MDR-TB.
New patient: A who never had Rx or have taken anti TB
for less than 1 month [New case (N)].
 Previously Treated patient: A patient who have received
1 month or more of anti TB drug in the past& may have
+ve or –ve bacterlogical and may be any diseases at an
anatomical site .
67
BY: A.O
7/27/2022

68. 3. Hx of previous Rx pt registration group…
 Relapse(R): Rx completed but who report back is now
found to be AFB +ve
 Rx after failure(F): pt while on Rx is smear +ve at end
of 5 month.
 Return after default (D): a pt record as default from Rx
and return with smear +ve.
 Transfer in (T): pt transfer into continue Rx after staring
Rx in to another Rx unit for at least 4 week.
 Other (O):Smear –ve PTB who returned after default
,EPTB return after default. 68
BY: A.O
7/27/2022

69. 4. HIV Status in HIV+ve individuals
Smear +ve PTB :
 One sputum smear +ve & HIV +ve/strong clinical evidence of HIV
infection.
Smear -ve PTB :
 Three septum smear-ve & radiological abnormality, or
 HIV +ve /strong clinical evidence of HIV infection & Decision by
clinician to Rx with Anti TB or
 A pt with AFB –ve & culture +ve.
EPTB:
 The definition is the same as HIV-ve TB cases
69
BY: A.O
7/27/2022

70. Diagnosis of Tuberculosis
 The key to the diagnosis of tuberculosis is a high index of
suspicion.
 Diagnosis is not difficult with a high-risk patient e.g., a
Homeless, alcoholic who presents with typical
symptoms and
A classic chest radiograph showing upper-lobe
infiltrates with cavities .
70
BY: A.O
7/27/2022

71. Diagnostic Method
A. bacteriological method
1.Direct light smear microscope/ Conventional
microscope.
2. fluorescent microscope
- sensitivity by 10%.
3. culture
7/27/2022 BY: A.O 71

72. Diagnostic Method…
B. Molecular test for TB Dx
1. Line probe Assay (LPA): show Rifampicin & INH drug
sensitivity & used for smear +ve only to check presence or
absence of a specific mutation.
2. Gene Xpert MTB/RIF :Shows Rifampicin resistance
only.
C. Histo-pathological examination
D. Radiological examination
72
BY: A.O
7/27/2022

73. Standard TB Case Definition
73
•Tuberculosis suspect
cough of 2weeks or more duration with SOB, chest
pain, hemoptysis & constitutional symptoms is TB
suspect.
•Case of tuberculosis
A definite case of TB or one a health worker has
diagnosed TB and has decided to Rx with a full course
of TB Rx .
•A definite/proven case of tuberculosis
A pt with two sputum smears +ve (one sputum +ve is
enough for HIV +ve pt )or
 culture +ve for mycobacterium tuberculosis .
BY: A.O
7/27/2022

74. Treatment of TB
The aim of TB treatment is:-
To cure the TB patient and restore QOL and productivity.
To prevent death from active TB or its late effects.
To Prevent relapse of TB.
To prevent the development and transmission of drug
resistance.
To decrease TB transmission to others.
To reduces the number of actively multiplying bacteria.
74
BY: A.O
7/27/2022

75. Drugs-used For TB
The drugs used for the TB treatment are safe and effective if
properly used:
First line drugs for the treatment of TB in Ethiopia include:
 Rifampicin (R)
 Ethambutol (E)
 Isoniazid (H)
 Pyrazinamide (Z)
 Streptomycin(S)
75
BY: A.O
7/27/2022

76. Drugs-used For TB…
The fixed dose combination(FDC) drugs available for
adult and adolescent:
RHZE 150/75/400/275mg
RHZ 150/75/400mg
RH 150/75mg
EH 400/150mg
76
BY: A.O
7/27/2022

77. Chemotherapy of TB
 TB drugs available as loose form:
Ethambutol 400mg
Isoniazid 300mg
Streptomycin sulphate vials 1 gm
 NB: streptomycin is administered by injection and the
other anti TB drugs are to be taken orally
All drugs should be taken together as a single ,daily
dose, preferably on an empty stomach.
77
BY: A.O
7/27/2022

78. Phases of medical therapy
.
78
1. Intensive phase:
 For new cases; a phase consists of combination of
four drugs for the first 8 weeks followed by two
drugs, to be taken for 4 months
 For re-treatment cases: with combination of five drugs
for the first 8 weeks followed by four drugs for the
next four weeks.
BY: A.O
7/27/2022

79. Phases of medical therapy …
79
2.Continuation phase
 This phase immediately follows the intensive phase and
is important to ensure cure or completion of treatment.
 Necessary to avoid relapse after completion of treatment.
 For new cases: treatment with a combination of two
drugs, to be taken for 4 months and
 For re-treatment cases : treatment with a combination
of four drugs for 4 months or three drugs for 5 months.
BY: A.O
7/27/2022

80. TB patient categories and how to select the
correct treatment regimen
80
Before putting patients on anti TB drugs:
Determine the type of TB: PTB+, PTB- and EPTB
Select based on the three standard treatment
regimen:
i. New patient regimen
ii. Previously treated patient regimen
iii. MDR-TB regimen
BY: A.O
7/27/2022

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

82. Recommended Dose of First-Line Anti-TB
Drugs for Adults
Drugs Recommended dose
Dose and range
(mg/kg Bwt)
Maximum
(mg)
Isoniazid 5(4-6) 300
Rifampicin 10(8-12) 600
Pyrazinamide 25(20-30) 2,000
Ethambutol 15(15-20) 1600
Streptomycin 15(12-18) 1000
82
BY: A.O
7/27/2022

83. Anti TB Drugs Dosage of New TB cases
83
Patient’s Weight in
Kgs
Treatment regimen and dose
Intensive phase
2RHZE
Continuation phase
4RH
20-29 1½ 1½
30-39 2 2
40-54 3 3
≥55 4 4
BY: A.O
7/27/2022

84. Anti TB Drugs dosage for previously treated cases
84
Patients'
weights in
kgs
Treatment regimen and dose
Intensive phase
2SRHZE/1RHZE
Continuation phase
5(RH)E
s* RHZE RH E
20-29 ½(0.5g) 1½ 1½ 1½
30-39 ½(0.5g) 2 2 1½
40-54 ¾(0.75g) 3 3 2
≥55 1g 4 4 3
BY: A.O
7/27/2022

85. Standard code for TB treatment regimen
 There is a standard code for writing out TB treatment
regimens.
 Each antituberculosis drug has an abbreviation.
 a M(X)DR-TB regimen consists of two phases:
1) The first phase is the period in which the injectable
agent is used and the second is after it has been stopped.
 For instance in Ethiopia standard treatment for
MDR-TB is 6E-Z-KM(AM)-LFX-Eto-Cs/12/E-Z-Lfx-Eto-Cs
85
BY: A.O
7/27/2022

86. 86
Grouping Drugs
Group 1:- first line oral agents Isoniazid (H) ; Rifampicin (R); Ethambutol
(E); pyrazinamide (Z); Rifabutin (Rfb)n
Group 2:- Inject able agents Kanamycin (Km); Amikacin (Am);
Capreomycine (Cm); Streptomycin (S)
Group 3:- Fluoroquinolones Moxifloxacilin (Mfx); Levofloxacilin (Lfx)
Group 4:- Oral bacteriostatic second line
agents
Ethionamide (Eto); Cycloserine (Cs); para-
aminosalicylic acid (PAS)
Group 5:- Agents with unclear role in DR-
TB treatment (not recommended by the
WHO for routine use in DR-TB patients)
Clofazimine (Cfz); Linezolid (Lzd);
Amoxicillin /clavulanate (Amx/Clv);
Thioacetazone (Thz); Imipenem/ciliastain
(Imp/Cln); High-dose isoniazid (High-dose
H)b; clarithromycin (Clr)
BY: A.O
7/27/2022

87. Standard MDR-TB Regimen
87
 MDR-TB patients susceptible to both Kanamycin and
Quinolone
Regimen: E-Z-KM (AM)-Lfx-Eto-Cs
 MDR-TB patients susceptible to both Kanamycin, but
resistant to Quinolone
Regimen: E-Z-KM (AM)-Mfx-Eto-Cs-PAS
 MDR-TB patients susceptible to Quinolone, but
resistant to Kanamycin
Regimen: E-Z-Cm-Lfx-Eto-Cs
XDR-TB cases (I.e. MDR-TB and resistance to
Quinolone
Regimen: E-Z-Cm -Mfx-Eto-Cs-PAS
BY: A.O
7/27/2022

88. 88
Promote air way clearance
Increase fluid intake promote systemic rehydration.
Pt understand that TB is communicable diseases and
taking the drag regular for prescribed and duration.
Instruct about important hygiene
Mouth care
Covering mouth and nose when cough and sneezing
Proper disposal of tissue property
Hand wash
Promote adduct nutrition
BY: A.O
7/27/2022

89. Prevention
89
General preventive measures (e.g. staying at home,
avoiding visitors, covering mouth during coughs with
hand ,opening window .
Vaccination:
The BCG vaccine, made from an attenuated strain of M.
bovis is given to > 80% of the world's children, primarily
in high-burden countries.
BY: A.O
7/27/2022

90. PELURAL DISORDERS
by Amanuel.O 90
7/27/2022

91. Introduction to Pleural disorder
 Pleural disorder is a disorder that involves:
The membranes covering the lungs (visceral pleura)
The surface of the chest wall (parietal pleura) or
The disorders affecting the pleural space.
7/27/2022 by Amanuel.O 91

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

93. 1. Pleurisy
 Pleurisy (pleuritis) refers to inflammation of both parietal
and visceral layers of the pleurae.
 Pathophysiology-Pleurisy may develop :
• In pneumonia, TB, or collagen disease
• After trauma to the chest,
• Pulmonary infarction, or pulmonary embolism;
• Primary and metastatic cancer; and
• After thoracotomy.
by Amanuel.O 93
7/27/2022

94. Pathophysiology…
 The parietal pleura has nerve endings; the visceral pleura
does not.
 When the inflamed pleural membranes rub together
during inspiration, the result is severe, sharp, knife like
pain.
by Amanuel.O 94
7/27/2022

95. Clinical Manifestations
 Taking a deep breath, coughing, or sneezing worsens the
pain, i.e a key characteristic of pleuritic pain.
 Pleuritic pain is restricted in distribution; usually occurs
only on one side.
 Pain may be localized or radiate to the shoulder or
abdomen.
 Latter, as pleural fluid develops , the pain decreases.
by Amanuel.O 95
7/27/2022

96. Assessment and Diagnostic Findings
 Pleural friction rub sound in the early period, but it
disappears later as little fluid accumulates.
 Chest x-rays
 Sputum examinations,
 Pleural fluid for examination via thoracentesis
 Pleural biopsy - less commonly done.
by Amanuel.O 96
7/27/2022

97. Management
 The objectives are:
 To treat the underlying condition causing the pleurisy
(pneumonia, infection)
To relieve the pain and
To monitor signs and symptoms of pleural effusion such
as: - Shortness of breath.
Assumption of a position that decreases pain, and
decreased chest wall excursion.
by Amanuel.O 97
7/27/2022

98. Medical Management
 NSAIDs: Indomethacin may provide pain relief during
deep breathing and coughing.
 Topical heat or cold applications may provide
symptomatic relief.
 Intercostals' nerve block may be required If the pain is
severe.
by Amanuel.O 98
7/27/2022

99. Nursing Management
 Turning the patient frequently onto the affected side to
splint the chest wall and reduce the stretching of pleurae.
 To enhance comfort and
 To reduce pain during inspiration.
 Teach about the use the hands or a pillow to splint the rib
cage while coughing.
by Amanuel.O 99
7/27/2022

100. 2. Pleural effusion
 Pleural effusion is a collection of fluid in the pleural space,
in response to injury, inflammation or both.
 It may represents a local response to disease or
manifestation of a systemic illness.
 Normally, pleural space contains (5 to 15 ml) of pleural
fluid, which acts as a lubricant that allows the pleural
surfaces to move without friction.
by Amanuel.O 100
7/27/2022

101. Causes of plural effusion
 Pleural effusion may be a complication of:
 Heart failure,
 TB,
 Pneumonia,
 Viral pulmonary infection
 Nephrotic syndrome,
 Connective tissue disease,
 Pulmonary embolism, and
 Bronchogenic carcinoma
by Amanuel.O 101
7/27/2022

102. Pathophysiology
 In certain disorders, fluid may accumulate in the pleural
space to a point where it becomes clinically evident.
 This always has pathologic significance.
 The effusion can be:-
 Clear fluid
 Bloody
 Transudates
 Exudates(may be purulent)
by Amanuel.O 102
7/27/2022

103. Pathophysiology…
 A transudate occurs when the formation and reabsorption
of pleural fluid are altered.
 Transudative effusion implies that the pleural membranes
are not diseased.
 The most common cause of a transudative effusion is
heart failure.
 An exudate usually results from inflammation by
bacterial products/tumors involving the pleural surfaces.
by Amanuel.O 103
7/27/2022

104. Clinical Manifestations
 If effusion is from Pneumonia :
fever, chills, and pleuritic chest pain,
 Malignant effusion :
dyspnea and coughing
 A large pleural effusion
shortness of breath
 When a small to moderate pleural effusion is present,
minimal or absence of dyspnea.
by Amanuel.O 104
7/27/2022

105. Assessment and Diagnostic Findings
 Physical examination
 Decreased or absent breath sounds in auscultation
 Decreased fremitus, and
 Dull, flat sound when percussed
 Acute respiratory distress- if extreme pleural effusion.
 Tracheal deviation away from the affected side
 Chest x-ray
 Chest CT scan
by Amanuel.O 105
7/27/2022

106. Assessment and Diagnostic Findings…
 Thoracentesis confirm the presence of fluid
 Pleural fluid analysis:- bacterial culture, Gram stain,
AFB stain, RBC and WBC counts,
 Chemistry studies(glucose, protein),
 Cytological analysis for malignant cells, and
 PH
 Pleural biopsy
by Amanuel.O 106
7/27/2022

107. Management
The objectives are:
To treat the underlying cause (e.g, heart failure,
pneumonia, lung cancer, cirrhosis)
To prevent re-accumulation of fluid, and
To relieve discomfort, dyspnea, and respiratory
compromise.
 If the pleural fluid is an exudate, more extensive
diagnostic procedures are performed to determine the
cause. by Amanuel.O 107
7/27/2022

108. Management…
 Thoracentesis is performed:
 To remove fluid, and to relieve dyspnea and respiratory
compromise.
 To obtain a specimen for analysis,
 Depending on the size of the pleural effusion, the patient
may be treated by:
 Removing the fluid by thoracentesis
 Inserting a chest tube connected to a water-seal drainage system or
 Suctioning to remove fluid and re-expand the lung.
by Amanuel.O 108
7/27/2022

109. Management
 Repeated thoracentesis result in:
 pain,
 depletion of protein and electrolytes, and
 pneumothorax.
If the underlying cause is a malignancy, however, the
effusion tends to recur within a few days or weeks.
Therefore surgical:-
 pleurectomy
 Pleurodesis may be performed.
by Amanuel.O 109
7/27/2022

110. Management…
 Pleurodesis is a medical procedure in which the pleural
space is artificially obliterated.
 It involves the adhesion of the two pleurae using
chemically irritating agents (e.g., bleomycin or talc) are
instilled in the pleural space.
by Amanuel.O 110
7/27/2022

111. Nursing Management
 Preparing and positioning for thoracentesis and offers
support throughout the procedure.
 Pain management is a priority, and in assuming positions
that are the least painful.
 Frequent turning and ambulation facilitate drainage.
 Analgesics as prescribed and as needed.
 Care of chest tube.
by Amanuel.O 111
7/27/2022

112. 3. Empyema
 An empyema refers to collection of pus inside the
pleural space (dead cells and infected fluid).
 Causes;-
Penetrating chest trauma,
Hematogenous infection of the pleural space,
Non-bacterial infections, or
Iatrogenic causes (after thoracic surgery or thoracentesis)
by Amanuel.O 112
7/27/2022

113. Causes….
 Complications of bacterial pneumonia or lung abscess are
the two commonest ways that bacteria get into pleural
space.
In order for empyema to occur:
 Bacteria,
 Fungi, or
 Chemicals must get into the pleural space and cause
inflammation, leading to the production of pus.
Bacteria can also get into the pleural space from medical
instruments that are used to do tests or operate the chest.
by Amanuel.O 113
7/27/2022

114. Risk for Empyema
The greatest risk factors for empyema are:
Pneumonia,
Medical procedures done in the lung and surrounding structures,
Chest trauma and
Pre-existing lung diseases (COPD and lung cancer).
 People who have pre-existing lung diseases who develop
empyema are more likely to die than those who don’t.
by Amanuel.O 114
7/27/2022

115. Clinical Manifestations
Fever, night sweats, pleural pain, cough, dyspnea.
SOB-E.g. Pneumonia
Fatigue, loss of appetite, and weight loss
Empyema associated with sepsis is the most severe.
 High fever, chills, tachypnea, tachycardia, and low B/P.
 Sepsis is life-threatening and requires emergency treatment.
by Amanuel.O 115
7/27/2022

116. Diagnostic Findings
 Blood cultures
 WBCs count
 X-ray (pneumonia, lung abscess)
 CT scan of the chest
 Thoracentesis for microscopic examination
 Thoracic ultrasound
 Chest auscultation: Decreased or absent breath sounds &
 Dullness on chest percussion & decreased fremitus.
by Amanuel.O 116
7/27/2022

117. Management
The objectives of treatment are to drain the pleural cavity
and to achieve full expansion of the lung.
 Draining the fluid
 large doses of appropriate antibiotics based on the causative
organism.
 Cephalosporins ,Metronidazole, and
 Penicillins with Beta lactamase (Ampicillin/
sulbactam).
 Sterilization of empyema requires 4 to 6 wks of antibiotics.
by Amanuel.O 117
7/27/2022

118. Management…
 Drainage of the pleural fluid is accomplished by the ff:
 Needle aspiration (Thoracentesis) or
 Tube thoracostomy (Chest drainage using a large-
diameter inter costal tube attached to water-seal
drainage.
by Amanuel.O 118
7/27/2022

119. Nursing Management
 Deep breathing exercises to restore normal respiratorion
 Provide care(e.g, needle aspiration, closed chest drainage).
 When a patient is discharged to home with a drainage tube
or system in place:
 instructs the patient and family on care of the drainage
system and drain site, measurement and
 observation of drainage, signs and symptoms of infection
by Amanuel.O 119
7/27/2022

120. CHRONIC OBSTRUCTIVE PULMONARY
DISEASE(COPD)
 COPD is a disease state characterized by airflow limitation
that is not fully reversible.
 COPD is the diseases that cause airflow obstruction (e.g,
emphysema, chronic bronchitis).
 COPD can coexist with asthma & both diseases have the
same major symptoms.
 Other diseases (bronchiectasis, and asthma) are now
classified as chronic pulmonary disorders.
by Amanuel.O 120
7/27/2022

121. Pathophysiology
 In COPD, the airflow limitation is associated with an
abnormal inflammatory response of the lungs to noxious
particles or gases.
 The inflammatory response occurs throughout the airways,
parenchyma, and pulmonary vasculature.
 Because of the chronic inflammation and the body’s
attempts to repair it, narrowing occurs in the small
peripheral airways.
by Amanuel.O 121
7/27/2022

122. Pathophysiology…
 Over time, this injury and repair process causes scar tissue
formation and narrowing of the airway lumen.
 Airflow obstruction may also be due to parenchymal
destruction as seen with emphysema, a disease of the
alveoli or gas exchange units.
by Amanuel.O 122
7/27/2022

123. Pathophysiology…
 Early in the course of COPD, the inflammatory response
causes pulmonary vasculature (thickening of vessel wall).
 These changes may result from:
 Exposure to cigarette smoke,
 Use of tobacco products, or
 Release of inflammatory mediators
by Amanuel.O 123
7/27/2022

124. Chronic Bronchitis
 Chronic bronchitis, a disease of the airways, is defined as
the presence of cough and sputum production for at least 3
months in each of two consecutive years.
 The causes are:
 Cigarette smoking or
Other environmental pollutants irritate the airways.
 This results in inflammation & hyper secretion of mucus.
by Amanuel.O 124
7/27/2022

125. Pathophysiology
 This constant irritation causes the mucus-secreting glands
and goblet cells to increase in number.
 Ciliary function is reduced, and more mucus is produced.
 The bronchial walls become thickened, the lumen narrows,
and mucus may plug the airway.
 Alveoli adjacent to the bronchioles may become damaged
and fibrosed,
 Resulting in altered function of the alveolar macrophages
that play role in destroying foreign particles (bacteria).
by Amanuel.O 125
7/27/2022

126. Pathophysiology…
 As a result, the patient becomes more susceptible to
respiratory infection.
 A wide range of viral, and bacterial infections can produce
acute episodes of bronchitis.
 Exacerbations of chronic bronchitis are most likely to
occur during the winter.
by Amanuel.O 126
7/27/2022

127. Risk Factors for COPD
Exposure to tobacco smoke accounts 80% to 90% of
COPD cases
Passive smoking
Occupational exposure
Deficiency of alpha1- antitrypsin.
by Amanuel.O 127
7/27/2022

128. Clinical Manifestations
 COPD is characterized by three primary symptoms:
 Cough,
 Sputum production, and
 Dyspnea on exertion is severe and often interferes with the
patient's activities.
 Chronic cough and sputum production often precede the
development of airflow limitation by many years.
 Weight loss is common, because dyspnea interferes with
eating and the work of breathing is energy-depleting.
by Amanuel.O 128
7/27/2022

129. Clinical Manifestations
 Often patients cannot participate in even mild exercise because of
dyspnea
 As COPD progresses, dyspnea occurs even at rest.
 As the work of breathing increases over time, the accessory muscles
are recruited in an effort to breathe.
 Patients with COPD are at risk for:
 respiratory insufficiency,
 respiratory infections, and
 increase the risk of respiratory failure.
by Amanuel.O 129
7/27/2022

130. Diagnostic Findings
 Exposure to risk factors
 Past medical history: asthma, allergy, sinusitis, nasal polyps,
history of RTIs.
 Family history of COPD
 Pattern of symptom development
 History of exacerbations or
 History of previous hospitalizations for RTIs.
 Presence of Co-morbidities
 Barrel chest
by Amanuel.O 130
7/27/2022

131. Medical Management
 Smoking cessation: is the single most effective
intervention to prevent COPD or slow its progression.
 Bronchodilators: Relieve bronchospasm and increase
oxygen distribution throughout the lungs and improving
alveolar ventilation.
 Corticosteroids: Inhaled and systemic may be used
 Oxygen therapy: prevent acute dyspnea.
by Amanuel.O 131
7/27/2022

132. Bronchodilators
 Beta-Adrenergic Agonist Agents
Salbutamol
Salmeterol
Terbutaline
 Anticholinergic Agents
Ipratropium bromide
Oxitropium bromide
 Methylxanthines
Aminophylline
Theophylline
by Amanuel.O 132
7/27/2022

133. Emphysema
 Emphysema is a destructive disease of the lung in which
the alveoli (small sacs) are destroyed.
 Emphysema is a pathologic term that describes an
abnormal distention of the air spaces with destruction of
the walls of the alveoli.
 In emphysema, impaired gas exchange results from
destruction of the walls of over distended alveoli.
by Amanuel.O 133
7/27/2022

134. Chronic Pulmonary Disorders
 Bronchiectasis is a chronic, irreversible dilation of the
bronchi and bronchioles.
 It may be caused by a variety of conditions:
Airway obstruction
Diffuse airway injury
Pulmonary infections and obstruction of the bronchus
Genetic disorders such as cystic fibrosis
Abnormal host defense (e.g, ciliary dyskinesia or
humoral immunodeficiency)
Idiopathic causes
by Amanuel.O 134
7/27/2022

135. Bronchiectasis….
A person may be predisposed to bronchiectasis as a result of
recurrent respiratory infections in early childhood:
 Measles,
 influenza,
 tuberculosis, and
 immunodeficiency disorders.
Bronchiectasis is usually localized, affecting a segment or
lobe of a lung, most frequently the lower lobes.
by Amanuel.O 135
7/27/2022

136. Bronchiectasis….
 Cigarette smoking impairs bronchial drainage by:
 Paralyzing ciliary action,
 Hyperplasia of the mucous glands,
 Increasing bronchial secretions, and
 Causing inflammation of the mucous membranes
by Amanuel.O 136
7/27/2022

137. by Amanuel.O 137
7/27/2022

138. Pathophysiology
 The inflammatory process associated with pulmonary
infections damages the bronchial wall and its supporting
structure
 This results in thick sputum that ultimately obstructs the
bronchi.
 The walls become permanently distended and distorted,
impairing muco ciliary clearance.
 The inflammation and infection extend to the
peribronchial tissues.
by Amanuel.O 138
7/27/2022

139. Pathophysiology
 The retention of secretions and subsequent obstruction
ultimately cause the alveoli distal to the obstruction to
collapse (atelectasis).
 Inflammatory scarring or fibrosis replaces functioning
lung tissue.
 There is ventilation–perfusion imbalance and hypoxemia.
by Amanuel.O 139
7/27/2022

140. Clinical Manifestations
Chronic cough & purulent sputum
Hemoptysis
Clubbing of the fingers =>b/c of respiratory insufficiency.
Repeated episodes of pulmonary infection
Even with modern treatment approaches, the mean age at
death is ~ 55 years.
by Amanuel.O 140
7/27/2022

141. Assessment and Diagnostic Findings
Bronchiectasis is not readily diagnosed because the
symptoms can mimic with chronic bronchitis.
 A definite sign is prolonged Hx of productive cough,
with sputum consistently negative for AFB.
CT scan: Demonstrates bronchial dilation.
by Amanuel.O 141
7/27/2022

142. Medical Management
 Treatment objectives are:
 To promote bronchial drainage
 To clear excessive secretions from the affected portion
of the lungs and
 To prevent or control infection.
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143. Medical Management
 Chest physiotherapy-percussion and postural drainage, is
important in secretion management.
 Smoking cessation
 Antimicrobial therapy: based on the results of sputum
culture & sensitivity.
 Surgical intervention: Diseased tissue is removed.
 a segment of a lobe (segmental resection),
 a lobe (lobectomy), or
 rarely an entire lung (pneumonectomy).
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144. Asthma
 Asthma is a chronic inflammatory disease of the airways
that causes airway hyper responsiveness, mucosal edema,
and mucus production.
 This inflammation ultimately leads to recurrent episodes
of asthma symptoms:
Cough
Chest tightness
Wheezing and
Dyspnea
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145. Asthma…
 Status asthmaticus is severe and persistent asthma that
does not respond to conventional therapy and is
considered life-threatening.
The attacks can last longer than 24 hours.
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146. Asthma
 Asthma differs from the other obstructive lung diseases in
that it is largely reversible, either spontaneously or with
treatment.
 Patients with asthma may experience symptom-free
periods alternating with acute exacerbations.
 Asthma can occur at any age.
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147. Asthma…
 Chronic exposure to airway irritants, or allergens also
increases the risk for developing asthma.
 Allergy is the strongest predisposing factor for asthma.
 Common allergens can be seasonal (e.g, grass, tree, and
weed pollens) or perennial ,mold, dust, or animal dander.
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148. Common triggers
 Common triggers of symptoms and exacerbations of
Asthma:
 Air pollutants, cold, heat, weather changes, strong
odors or perfumes, smoke
Exercise
Stress or emotional upsets,
Medications, and
Gastro esophageal reflux
RTIs: viral RTI, sinusitis etc.
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149. Pathophysiology
 Asthma is a reversible and diffuse airway inflammation.
 Inflammation causes:
 Mucosal edema,
Increased mucus production which may entirely
plug to the bronchi &
Furtherly diminishes airway size or diameter.
 This leads to alveoli hyper inflation
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150. Pathophysiology…
 The cells that play a key role in the inflammation of
asthma are :
 Mast cells,
 Neutrophil,
 Eosinophils, and lymphocytes
 Mast cells is activated, released several chemicals
mediators (Histamine, Bradykinin, Prostaglandins, and
Leukotrienes).
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151. Pathophysiology…
These chemicals perpetuate the inflammatory response,
Vasodilatation – occurs after transient vasoconstriction
(lasting only for seconds),
Results in locally increased blood flow
Fluid leak from the vasculature,
Attraction of WBCs to the area, and
Broncho constriction.
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152. Pathophysiology…
 Further stimulation of alpha and beta2-adrenergic
receptors of the sympathetic NS are located in the bronchi.
 When the alpha adrenergic receptors are stimulated,
broncho constriction occurs.
 when the beta2 -adrenergic receptors are stimulated,
broncho dilation occurs.
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153. Pathophysiology…
 The balance between alpha and beta2 receptors is controlled
primarily by cyclic adenosine mono phosphate (cAMP).
 Alpha-adrenergic receptor stimulation results in a decrease in
cAMP, which leads to an increase of chemical mediators released
by the mast cells and bronchoconstriction.
 Beta2-receptor stimulation results in increased levels of cAMP,
which inhibits the release of chemical mediators and causes
bronchodilation.
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154. by Amanuel.O 154
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155. Clinical manifestations
 An asthma exacerbation may begin abruptly
 The three most common symptoms of asthma are
 Cough,
 Dyspnea, and
 Wheezing
 Asthma attacks often occur at night or early in the
morning.
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156. Clinical manifestations…
 Generalized chest tightness
 Expiration requires effort and becomes prolonged
 As the exacerbation progresses, diaphoresis, tachycardia,
and a widened pulse pressure along with hypoxemia and
central cyanosis (a late sign).
 The hypoxemia is 2 0 to a ventilation–perfusion mismatch
and readily responds to supplemental oxygenation.
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157. Clinical manifestations….
 Symptoms of exercise-induced asthma include:
 Maximal symptoms during exercise,
 Absence of nocturnal symptoms, and
 Sometimes only a sign of a “choking” sensation during
exercise.
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158. Diagnostic findings
A positive family Hx,
Occupational history
Environmental factors:
seasonal changes,
high pollen counts, mold,
Climate changes (particularly cold air), and
 Air pollution are primarily associated with asthma.
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159. Diagnostic findings…
 Occupation-related chemicals and compounds:
metal salts, wood and vegetable dust, medications (e.g,
ASA, Antibiotics, Piperazine, Cimetidine),
Industrial chemicals and plastics, (e.g, laundry
detergents),
Animal and insect dusts, secretions.
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160. Diagnostic findings…
Sputum and blood tests may disclose elevated levels of
eosinophils.
 Serum levels of IgE may be elevated if allergy is present.
 Arterial blood gas analysis and Pulse oximetry reveal
hypoxemia during acute attacks
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161. MEDICAL MANAGEMENT
Goals of Asthma Treatment
 Prevent chronic and troublesome symptoms
 Maintain near-normal pulmonary function
 Maintain normal activity levels (exercise and other
physical activity)
 Prevent recurrent exacerbations of asthma and minimize
the need for emergency OPD visits or hospitalizations
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162. MEDICAL MANAGEMENT
Long-Acting Medications:Corticosteroids:
Beclomethasone
Prednisone
Mast cell stabilizers:
cromolyn sodium (Intal),
Nedocromil sodium (Tilade)
Long-acting beta2-adrenergic agents
Salmeterol , formoterol fumarate
Xanthine derivatives: aminophylline, theophylline
Quick-Relief Medications: Short-acting
beta2-adrenergic agents:
Albuterol (Proventil), levalbuterol, pirbuterol , bitolterol.
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163. Complication
 Status asthmatics
 Respiratory failure
 Pneumonia
 Atelectasis.
 Hypoxemia
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164. Nursing management
 Monitoring the severity of symptoms, breath sounds, peak
flow , pulse oximetry, and vital signs.
 Obtain a history of allergic reactions to medications before
administering medications.
 Administer medications as prescribed and monitor the
patient’s responses to those medications
 Administer fluids if the patient is dehydrated.
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