Lower Respiratory Tract Disorders

1 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumonia
 Pneumonia (from the Greek pneuma, “breath”) is a
potentially fatal infection and inflammation of the
lower respiratory tract (i.e., bronchioles and
alveoli) usually caused by inhaled bacteria and
viruses

 Is an inflammation of the lung parenchyma.

 Is a lung infection involving the alveoli (air sacs)

and can be caused by microbes, including bacteria,
viruses, or fungi.
 Pneumonitis
2 -- immune-mediated inflammation
By Dr.Mihiretu T( Bsc, MD) 11/21/2024 of
 Clinical Definition
Symptoms of acute LRT infection
a) Cough, sputum, chest pain
b) Fever, sweating, shiver, aches and pains
• New focal chest signs on examination OR
• New radiographic pulmonary infiltrates

3 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Classification of pneumonia
Based on causative agent
Bacterial -- typical pneumonia,
-- Atypical pneumonia
Viral pneumonia
Fungal pneumonia etc

4 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumonia
 Anatomic(morphological) classification
Lobar pneumonia- homogeneous consolidation of one
or more lung lobes
Broncho- pneumonia- multiple patchy shadows in a
localized or segmental area.

5 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Bronchopneumonia
 Infants + young children and the elderly.
 Usually secondary to other conditions
associated with local and general defense
mechanisms:
 Viral infections (influenza, measles)
 Aspiration of food or vomitus
 Obstruction of a bronchus (foreign body
or neoplasm)
 Inhalation of irritant gases
 Major surgery
 Chronic debilitating diseases,
6 malnutrition By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Lobar pneumonia:
S. pneumoniae.
Previously healthy individuals.
Abrupt onset.
Unilateral stabbing chest pain on
inspiration (due to fibrinous pleurisy).

7 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Types of Pneumonia
Community-acquired pneumonia(CAP)
 Infection of the pulmonary parenchyma
acquired from exposure in the community
 Occurs either in the community setting
or within the first 48 hours after
hospitalization or institutionalization.
 Infection usually spread by droplet
inhalation.
 Highest incidence in winter
 8 Smoking important risk factor
By Dr.Mihiretu T( Bsc, MD) 11/21/2024
“Typical” CAP:
 History
Previously healthy with sudden onset of fever
and shortness of breath

Presents with “typical” severe, acute infection

Infectious agent (usually S. Pneumonia or H. Flu)

is culturable/ identifiable

Responsive to cell-wall active antibiotics

9 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Physical signs and symptoms
Tachycardia

Tachypnea

Productive cough with purulent sputum and

possible hemoptysis
Pallor and cyanosis

10 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Typical CAP----

• localized:
− dullness to percussion
− decreased breath sounds
− crackles ,ronchi , egophony (“E” -to-”A” change)
 Investigations
• CXR showing lobar consolidation
• CBC showing leukocytosis w/ left shift
• Sputum sample contains neutrophil, RBCs; Gram
stain may be positiveBydepending
11 Dr.Mihiretu T( Bsc, on
MD) organism
11/21/2024
“Atypical” CAP
• History :
Previously healthy present which is usually sub-
acute, low grade fever, sore throat, and intractable
cough
Minimal sputum production
Able to continue to work
No sick contacts, recent travel, or evidence of
altered immune system
PE reveals a mildly ill-appearing patient with
diffuse wheezes on lung exam
Causative pathogens are difficult to culture/identify
by standard methods
Not responsive to penicillins
12 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Types Of Atypical Pneumonia.

 Mycoplasma pneumonia
 Caused by tiny bacteria mycoplasma
pneumoniae.
 It is generally milder than other types
 Children and adults who are infected often show
symptoms resembling those of a cold or flu,
such as coughing, sneezing, and a mild fever.
 Generally, not have to be hospitalized.

13 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Chlamydophila pneumonia.
 Caused by chlamydophila pneumoniae bacteria.
 School-age children at greatest risk for this type.
 Legionella pneumonia (legionnaires’ disease)
 Caused by legionella pneumophila bacteria.
 Not spread through person-to-person contact.
 Legionnaires’ disease tends to be more serious
than other types of atypical pneumonia.
 It can lead to respiratory failure and death in some
cases.
14 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Common causes Of CAP

 Thecausative agents for CAP that requires

hospitalization are:
 Previously
healthy individual: → S.
pneumoniae
 Pre-existing
viral infection → Staph. aureus
or S. pneumoniae
 Chronicbronchitis → Haemophilus influenzae
or S. pneumoniae

15 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 AIDS→ Pneumocystis carinii,
cytomegalovirus, TB
 Elderly
people and those with co
morbid illnesses → H. Influenzae
 Legionella,
pseudomonas Aeruginosa,
and other gram-negative rods.
 Viruses (infants and children)
 Atypical bacteria
16 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
The most common causes for viral
pneumonia are:
 Influenza
 Parainfluenza
 Adenovirus
 Respiratory syncytial virus (RSV)
 appears mostly in children
 Cytomegalovirus
 In immunocompromised hosts

17 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Features of Severe
Pneumonia
 ‘Core’ clinical adverse prognostic features
(CURB -65)
 Confusion* (1 point)
 Urea >20 mg/dL (7 mmol/L)** (1 point)
 Respiratory rate ≥30 breaths per minute (1
point)
 Low systolic (<90 mmHg) or diastolic (≤60
mmHg) Blood pressure (1 point)
 Age ≥65 years (1 point)
NOTE: Patients with 2 or more CURB are at high
risk of death
18 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Hospital-Acquired Pneumonia
 Also known as nosocomial pneumonia
 Is defined as the onset of pneumonia symptoms more than
48 hours after admission in patients with no evidence of
infection at the time of admission.
 Is an acute lower respiratory tract infection acquired after at
least 48 hours of admission to hospital and is not incubating
at the time of admission.
 Ventilator-associated pneumonia (VAP), is pneumonia
occurring more than 48 hours after endotracheal intubation .
19 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Predisposing factors
 Defense mechanisms are incompetent or
overwhelmed
 Decreased cough and epiglottal reflexes (may allow
aspiration)
 Mucociliary mechanism impaired
 Pollution
 Cigarette smoking
 Upper respiratory infections
 Tracheal intubation
 Aging
 Metabolic disorder
 Mechanical ventilation (VAP)
 Supine positioning and By
20 Dr.Mihiretu T( Bsc, MD) 11/21/2024
aspiration
 Pneumonia
The common organisms responsible for HAP
Enterobacter species,
Escherichia coli,
H. influenzae,
Klebsiella species,
Proteus, Serratia marcescens,
P. aeruginosa,
methicillin-sensitive or methicillin-resistant
Staphylococcus aureus (MRSA), and
S. pneumoniae

21 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumonia
Pneumonia in the Immunocompromised Host

Includes Pneumocystis pneumonia (PCP), fungal

pneumonias, and Mycobacterium tuberculosis.

Aspiration Pneumonia

Is the pulmonary consequences resulting from entry of

endogenous or exogenous substances into the lower
airway.

22 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Pathophysiology of Pneumonia
Pneumonia results from the proliferation of microbial
pathogens at the alveolar level and the host's response
to those pathogens
Their are three mechanisms by which pathogens reach
to the lungs
Inhalation,

Aspiration and
Hematogenous e.g. Tricuspid endocarditis

23 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Pathophysiology pneumonia----
Primary inhalation: when organisms
bypass normal respiratory defense
mechanisms or when the Pt inhales aerobic
GN organisms that colonize the upper
respiratory tract or respiratory support
equipment
Aspiration: occurs when the Pt aspirates
colonized upper respiratory tract secretions
Stomach: reservoir of GN that can ascend,
colonizing the respiratory tract.
Hematogenous: originate from a distant
source
24 and reach Bythe lungs
Dr.Mihiretu via11/21/2024
T( Bsc, MD) the blood
Pathology of lobar pneumonia
 Four stage of pathiophysiological change occur due to pneumonia

1. Congestion
 Lasts < 24 hours: Out pouring of fluid from
tissue to alveoli- b/se of inflammatory process.
 Alveoli filled with oedema fluid and bacteria.
 Only a few neutrophil are seen at this stage.

25 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Stage of pathiophysiological----
2. Red hepatization
 Lungs look like the liver
 Firm, 'meaty' and airless appearance of lung.
 Alveolar capillary dilatation.
 Strands of fibrin extending from one alveolus to another
via inter-alveolar pores of Kohn.
 Also neutrophil in alveoli.
 Pleura: Fibrinous exudate.
 Characterized microscopically by the presence of many
RBC, neutrophil, micro-organisms , fibrins in the
26 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
alveolar spaces
Stage of pathiophysiological---- …

3. Gray hepatization
Less hyperaemia.
Macrophages, neutrophil + fibrin
The lung is dry, friable and gray-brown to yellow
as a consequence of a persistent fibrino-
purulent exudates
 WBC and fibrin consolidate the alveoli and lung
 Second and third stages last for 2 to 3 days each
27 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Stage Of Pathiophysiological----
4. Resolution
 Lyses and removal of fibrin via sputum + lymphatics.
 Begins after 8-9 days (without antibiotics).
 Sudden improvement of patient's condition.
 Characterized by enzymatic digestion of the alveolar
exudate;
 Resorption, phagocytosis or coughing up of the residual
debris and
 Restoration of the pulmonary architecture.
28 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Clinical manifestations
Cough producing greenish or yellow sputum
High fever that may be accompanied by
shaking chills
Shortness of breath
Tachypnea
Pleuritic chest pain
 Headache

29 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Clinical manifestations…

Sweaty and clammy (moist) skin,

Loss of appetite
Fatigue
Blueness of the skin
Nausea, vomiting
Mood swings
Joint pains or muscle aches

30 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Investigations
 History

 Physical exam
 Chest x-ray
 Gram stain of sputum
 Sputum culture and sensitivity
 Pulse oximeter or ABGs
 CBC, differential, chemistry
 Blood cultures
Invasive diagnostic techniques
 Transtracheal aspiration
 Bronchoscopy with a protected brush catheter
31  Direct needle aspiration of the lung
By Dr.Mihiretu T( Bsc, MD) 11/21/2024
What are the differential diagnoses?
Alternative Supporting clinical feature(s)
diagnosis
Exacerbation of Known COPD, history of smoking, or industrial
COPD exposure to inorganic dust,Bilateral polyphonic
wheeze
Lack of focal chest signs

Exacerbation of History of asthma or atopy, Bilateral polyphonic

asthma wheeze
Lack of fever and focal chest signs

Pulmonary Features of left ventricular or biventricular failure

oedema (elevated jugular venous pressure, peripheral
oedema, fine bibasal crackles in the lung)
Bronchiectasis longer history,Finger clubbing
Chronic cough productive of purulent sputum
Bilateral crackles at the lung bases

Lung cancer Haemoptysis, weight and appetite loss, smoking

history
32 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Finger clubbing
 Medical management

EMPIRIC ANTIBIOTIC THERAPY

First line (Mild):Amoxicillin 1g PO TID #5-7days and if penicillin
allergy Clarithromycin 250gm PO BID #5-7days
(Moderate): Benztylpencillin 1.2g IM QID #7days
plus
Doxycycline100mg PO BID #7days
or
Clarithromycin 500gm PO BID #7days
If penicillin allergy Cefriaxone 1gm Iv daily #7days plus
Doxycycline100mg PO BID #7days or Clarithromycin 500gm PO BID
#7days
(Severe): Benztylpencillin 1.2g IM every 4hours
plus
Gentamycin IV daily plus
Azithromycin 500mg IV/PO daily
If 33
penicillin allergy :CefriaxoneBy1gm Iv daily
Dr.Mihiretu #7days
T( Bsc, plus Azithromycin
MD) 11/21/2024
 Pneumonia cont’d…
Medical management…
E.g. according to DACA
For community acquired ambulatory
pts (mild pneumonia):-
◦ Amoxicillin
OR
◦ Erythromycin
OR
◦ Doxycyciline

34 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumonia cont’d…
For community acquired hospitalized pts (severe
pneumonia):-
Non-Drug treatment:

Bed rest

Frequent monitoring of temperature, blood pressure and

pulse rate.

Give attention to fluid and nutritional replacements

Administer Oxygen

Analgesia for chest pain

35 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Pneumonia cont’d…
Drug treatment:

Benzyl penicillin PLUS Gentamicin

OR Ceftriaxon.

Pneumonia due to staphylococcus aureus:

Cloxacillin 1-2 gm, IV or IM QID for 10-14 days.

36 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumonia
HAP (nosocomial pneumonias)
Antimicrobials effective against gram-negative & gram-positive
should be given in combination. Suitable combination is:
Cloxacillin plus Gentamicin
OR
Ceftriaxone plus Gentamicin
Ciprofloxacin
Pneumocytis pneumonia responds to Trimethoprin +
Sulfamethoxazole
37 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Complications of Pneumonia
Abscess formation
Empyema
Failure of resolution ⇒ intra-alveolar scarring
('carnification') ⇒ permanent loss of Ventilatory
function of affected parts of lung.
 Bacteraemia:
 Infective endocarditis
 Cerebral abscess / meningitis
 Septic arthritis
Shock and Respiratory Failure
Pleural Effusion
Atelectasis
38 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Sample case scenarios
1. A 35-year-old male patient presented to Nekemte Specialized
hospital with fever and cough. He was well 3 days back, when
he suffered the onset of nasal stuffiness, mild sore throat, and a
cough productive of small amounts of clear sputum. On Physical
examination his temperature was 38.9°C , pulse 110 beats/min
and regular, and his respiratory rate is 18 breaths/min. The case
most likely?
2. A 65-year-old man presented to the emergency department a
few hours after the gradual onset of left-sided weakness and
expressive aphasia. On admission all Vital signs were normal.
However, On the fourth hospital day, Unfortunately, his
temperature increases to 39.3C with concomitant coughing that
sounds productive. Basilar rales are audible at the right lung
base. A chest radiograph reveals the presence of a new right
lower lobe infiltrate without an associated pleural effusion. The
case most likely?
39 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Chronic Obstructive Pulmonary Disease

 COPD is also known as:

 Chronic obstructive lung disease (COLD),
 Chronic obstructive airway disease (COAD),
 Chronic airflow limitation (CAL) and
 Chronic obstructive respiratory disease (CORD)
 It is pulmonary disease characterized by airflow limitation that is
not fully reversible.
 Refers to chronic bronchitis and emphysema, a pair of two
commonly co-existing diseases of the lungs in which the airways
become narrowed.
 This leads to a limitation of the flow of air to and from the lungs
causing shortness of breath

40 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 In COPD, less air flows in and out of the airways because of one or
more of the following:

The airways and air sacs lose their elastic quality.

The walls between many of the air sacs are

destroyed.

The walls of the airways become thick and inflamed.

The airways make more mucus than usual, which

tends to clog them.

41 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Causes
 Smoking
 Occupational exposures
 Air pollution
 sudden airway constriction in response to
inhaled irritants,
 Bronchial hyperresponsiveness, is a
characteristic of asthma.
 Genetics-Alpha 1-antitrypsin deficiency

42 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Pathophysiology of COPD

43 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Clinical features
Chronic cough
Sputum production
Wheezing
Chest tightness
Dyspnea on exertion
Wt.loss
Respiratory insufficiency
Respiratory infections
Barrel chest- chronic hyperinflation leads to
loss of lung elasticity
44 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
COPD includes

I. Bronchitis

II. Emphysema
45 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Bronchitis
 Bronchitis is a condition in which the bronchial tubes
become inflamed.
 Acute (short term) and chronic (ongoing).
 Infections or lung irritants cause acute bronchitis.
 Chronic bronchitis is an ongoing, serious condition.
 It occurs if the lining of the bronchial tubes is constantly
irritated and inflamed, causing a long-term cough with
mucus.
46 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Chronic bronchitis
Presence of recurrent or chronic productive cough for a minimum of 3
months for 2 consecutive years.

It is defined as the presence of cough and sputum production for at least

3 months.

Risk factors
 Bronchial irritants (e.g. cigarette smoke, exposure to pollution)
 Genetic predisposition (alpha-1 antitrypsin deficiency)
 Respiratory infections
47 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Chronic Bronchitis: Pathophysiology

Chronic inflammation

Hypertrophy & hyperplasia of bronchial glands that secrete

mucus

Increase number of goblet cells

Cilia are destroyed

Bronchial smooth muscle hyper reactivity

48 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Chronic Bronchitis:
Pathophysiology

Narrowing of airway
 airflow resistance
 work of breathing

Hypoventilation & CO2 retention  hypoxemia &

hypercapnea

49 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Chronic Bronchitis:
Pathophysiology
Bronchial walls thickened, bronchial lumen
narrowed, and mucus may plug in the airway

Alveoli become damaged and fibrosed,

Altered function of the alveolar macrophages.

The patient becomes more susceptible to

respiratory infection.

50 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Chronic Bronchitis: Pathophysiology

51 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Chronic Bronchitis: Pathophysiology

Mucus plug
Normal lumen

52 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Signs and symptom
Acute Chronic
sore throat,
fatigue coughing,
(tiredness), wheezing, and
fever, body aches,
stuffy or runny chest discomfort.
nose, The coughing may
vomiting, and produce large amounts
Diarrhea of mucus. This type of
persistent cough cough often is called a
cough may smoker's cough.
53 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
produce clear
Diagnosis
 History - medical history
 Whether you've recently had a cold or the flu
 Whether you smoke or spend time around others who
smoke
 Whether you've been exposed to dust, fumes, vapors, or
air pollution –
 Mucus -to see whether you have a bacterial infection
 chest x ray
 lung function tests,
 CBC
 ABG analysis

54 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

MEDICAL MANAGEMENT

Improve ventilation
 Broncho dilators like beta2agonists
(albuterol) ,anticholinergics(ipratropium
bromide-atrovent).
 Methylxanthines(theophylline,aminophyll
ine)
 Corticosteroids
 Oxygen administration
Remove bronchial secretion
Promote exercises
Control complications
55Improve general health
By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Surgical management
 BULLECTOMY
Bullae are enlarged airspaces that do not contribute to
ventilation but occupy space in the
 Lung volume reduction surgery: It involves the removal
of a portion of the diseased lung parenchyma.
 Lung transplantation

56 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Sample case scenarios
1. A 62-year-old auto mechanic who presents
with progressive shortness of breath for the
past several days. His problem began four days
ago when I got a cold. Initially, the cough was
dry but within 24 hours of onset, it produced
abundant yellow-green sputum that he stated ,
"I cough up a cup of this stuff every day." His
wife states that he "hack and spits up" every
morning when he gets up from bed. The case
most likely?

2. A 38 year old female presented to wollega

university referral hospital with chief complain
of mild, occasionally productive cough for the
past
57 3-4 months . Byshe hasT(been
Dr.Mihiretu Bsc, MD) smoking
11/21/2024 about
 Emphysema
 Is a pathologic term that describes an abnormal distention
of the airspaces beyond the terminal bronchioles and
destruction of the walls of the alveoli.
 Main types of emphysema, based on the changes taking
place in the lung
Panlobular (panacinar) type of emphysema, there is
destruction of the respiratory bronchiole, alveolar duct, and
alveolus.
Centrilobular (centroacinar) form, pathologic changes take
place mainly in the center of the secondary lobule,
preserving the peripheral portions of the acinus.
58 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Emphysema is defined as enlargement of
the air spaces distal to the terminal
bronchioles, with destruction of their
walls of the alveoli.
 Pathology :
 As the alveoli are destroyed the alveolar
surface area in contact with the
capillaries decreases.
 Causing dead spaces (no gas exchange
takes place)

59 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Classification
Centrilobular
The respiratory bronchiole (proximal and central part of the
acinus) is expanded.
The distal acinus or alveoli are unchanged.

Occurs more commonly in the upper lobes.

Pan lobular
The entire respiratory acinus from respiratory bronchiole to
alveoli, is expanded.
Occurs more commonly in the lower lobes, especially basal
segments, and anterior margins of the lungs.
60 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Emphysema….

61 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Emphysema….

 Clinical
Wheezing
manifestation
Chronic fatigue
 Early stages Difficult in sleeping
 Barell chest Hypoxia
 Central cyanosis Polycythemia

 Finger clubbing Cough & sputum

 Dyspnea
production
62 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Emphysema….
 Later stages
 Hypercapnea
 Purse-lip breathing
 Use of accessory muscles to breathe
 Underweight
No appetite & increase breathing workload

63 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Emphysema…..

64 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Emphysema

Use accessory muscle Pursed lips breathing

65 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

66 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Medical Management
Risk Reduction (smoking cessation)
Pharmacologic Therapy
 Bronchodilators

Beta2-Adrenergic Agonist Agents:- salbutamol, albuterol

Anticholinergic Agents:-Ipratropium bromide
Methylxanthines:- aminophylline ,theophylline
 Corticosteroids
 Other Medications(alpha1-antitrypsin augmentation therapy,
antibiotic agents, mucolytic agents, antitussive agents,
vasodilators, and narcotics.

67 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Medical Management …….
 Oxygen Therapy
 Surgical Management
 Lung Volume Reduction Surgery
 Pulmonary Rehabilitation
 Patient Education
 Breathing Exercises
 Activity Pacing
 Self-Care Activities
 Nutritional therapy
 Coping Measures

68 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Nursing Management
 Assessing the Patient
 Achieving Airway Clearance
 Improving Breathing Patterns
 Improving Activity Tolerance
 Monitoring and Managing Potential Complications
(respiratory insufficiency and failure)

69 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

70 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Asthma
Asthma is a chronic inflammatory disorder of the airways
that is characterized:
Clinically by recurrent episodes of wheezing,
breathlessness, chest tightness, and cough,
particularly at night/early morning.
 Physiologically by widespread, reversible
narrowing of the bronchial airways and a marked
increase in bronchial responsiveness to direct or
indirect stimuli and with chronic airway
inflammation
 Is a heterogeneous disease, usually characterized by
71 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
chronic airway inflammation
 The chronic inflammation is associated with airway
hyper‐responsiveness that leads to recurrent episodes of
wheezing , breathlessness, chest tightness and coughing
particularly at night or early morning.
 These episodes are usually associated with widespread,
but variable airflow obstruction within the lung that is
often reversible either spontaneously or with treatment
 Is a chronic inflammatory disease of the airways that causes:-
 Airway hyperresponsiveness
 Mucosal edema
72 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Mucus production
Asthma classification
 Asthma is divided into two main categories,
intrinsic and
extrinsic.
 Intrinsic
asthma is due to hypersensitivity of the
airways independent of antibodies.
 Thesesensitivities can include chemicals, exercise,
complement activation, cold air, infection, and
emotional stress.
 Extrinsic asthma is due to increased levels of IgE
in the plasma.

73 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Classification----
1. Atopic /extrinsic /allergic ( 70%)
 Due to increased levels of IgE in the plasma in responses
to environmental antigens.
 Genetically transmitted
 Childhood onset
2. Non-atopic/ intrinsic /non-allergic( 30%)
 Intrinsic asthma is due to hypersensitivity of the airways
independent of antibodies
 Triggered by non immune stimuli.
 Patients have negative skin test to common inhalant
allergens and normal serum concentrations of IgE.
 Asthma may be triggered by aspirin, pulmonary infections,
74 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
cold, exercise, psychological stress or inhaled irritants..
75 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Pathophysiology

Chronic inflammation

Airway Hyperresponsiveness

76 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Pathophysiology of Asthma
Non-modifiable Factors:
Modifiable Factors:
>Environmental Allergens
Gender >Emotional factors/Stress
Family History >GERD

Triggers airway
inflammation

Release of mast cells, eosinophils, histamine,

macrophages, and activated T lymphocytes

Increased Goblet cells

Acute Bronchoconstriction mucus production

Narrowing of the airway

passages
Cough
Difficulty Of Breathing
↓ Oxygenation Wheezing

chest Tightness Chest

77 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 ETIOLOGY
Allergy is the strongest predisposing factor for asthma.
 Common allergens can be
 Seasonal (grass, tree, and weed pollens) or
 Perennial (e.g., mold, dust, roaches, animal dander).
 Common triggers for asthma symptoms and exacerbations
 Airway irritants (e.g., air pollutants, cold, heat, weather
changes, strong odors or perfumes, smoke)
 Exercise, stress or emotional upset
 Rhino sinusitis with postnasal drip
 Medications

 Viral respiratory tract infections

78 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Clinical Manifestations
The three most common symptoms of asthma are
 Cough
 Dyspnea
 Wheezing

As the exacerbation progresses

 Diaphoresis
 Tachycardia
 Hypoxemia and central cyanosis (a late sign of poor
oxygenation)

79 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Status Asthmaticus
 The severe and prolonged asthma exacerbation with intensive
progressive respiratory failure, hypoxemia, hypercapnia,
respiratory acidosis, increased blood viscosity and the most
important sign is blockade of bronchial b2-receptors.
Stages:
1st - refractory response to b2-agonists (relaxation of the
smooth muscles)
2nd - “silent” lung because of severe bronchial obstruction and
collapse of small and intermediate bronchi;
3rd stage – the hypercapnic
80 coma. T( Bsc, MD)
By Dr.Mihiretu 11/21/2024
Asthma….
Assessment and Diagnostic Findings
Hx
Physical examination
Chest X-ray
Sputum increase viscosity
CBC- eosinophills
Lung Function Tests
Arterial blood gas analysis and pulse oximetry
81 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Asthma cont’d…

Medical management

There are two general classes of asthma medications:

 Quick-relief medications for immediate treatment of
asthma symptoms and exacerbations.
 Long acting medications to achieve and maintain control
of persistent asthma.

82 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

83 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Asthma cont’d…
According to DACA:

Initial treatment
 Salbutamol (metered dose inhaler MDI).

Alternatives
 Aminophylline, 5mg/kg by slow I.V. push over 5 minutes.
OR
 Adrenaline, 0.5ml sc.

84 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

85 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Asthma cont’d…
Persistent mild asthma
 Salbutamol, inhaler, 200 micro gram/puff 1-2 puffs to be
taken, as needed but not more than 3-4 times/day PLUS
 Beclomethasone, oral inhalation 1000mcg QD for two weeks

Alternative
 Ephedrine + Theophylline (11mg + 120mg), P.O. two to three times
a day PLUS
 Beclomethasone oral inhalation 1000mcg QD for two weeks.

86 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Asthma cont’d…
Persistent moderate asthma

Salbutamol, inhalation 200microgram/puff 1-2 puffs as

needed PRN not more than 3-4 times a day.

PLUS

Beclomethasone, 2000mcg, oral inhalation QD for two

weeks and reduce to 1000 mcg if symptoms improve.

87 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Asthma cont’d…
Severe persistent asthma
 Salbutamol, inhalation , 200 micro gram/puff 1-2
puffs not more than 3-4 times a day
PLUS
 Beclomethasone, 2000 mcg, oral inhalation daily

88 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Asthma….

Nursing management
 Assessing patients respiratory status
 The purpose and action of each medication Triggers to
avoid, and how to do so
 Proper inhalation technique

89 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Asthma….
Complications

Status asthmaticus

Respiratory failure

Pneumonia

Atelectasis

90 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Bronchiectasis
Is a chronic, irreversible dilation of the bronchi and
bronchioles.
Bronchiectasis may be caused :-
Airway obstruction
Diffuse airway injury
Pulmonary infections and obstruction of the bronchus or
complications of long-term pulmonary infections
Genetic disorders such as cystic fibrosis
Abnormal host defense (eg, ciliary dyskinesia or humoral
immunodeficiency)
Idiopathic causes
91 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
92 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Clinical Manifestations
Chronic cough
Production sputum(Copious and purulent and pools in
the dilated airways).
Hemoptysis.
Clubbing of the fingers also is common because of
respiratory insufficiency.
Wheezes and crackles
Repeated episodes of pulmonary infection

93 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Diagnostic tests
 History
 Sputum culture
 CT scan

94 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Medical management
Antibiotics may be used intermittently or for prolonged
periods.
Bronchodilators improve airway obstruction.
Mucolytic agents help thin secretions
Chest physiotherapy helps mobilize secretions
Oxygen is used if hypoxemia is present

95 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Nursing management
Encourage to stop smoking & other factors that increase
the production of mucus
Teaching the patient and family
How to perform postural drainage

Assess patients’ nutritional status/appetite

Teach the patient about early signs of respiratory

infection and the progression of the disorder.

96 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumothorax

Literally means “air in the chest”

 Is used to describe conditions in which air has entered the
pleural space outside the lungs.
TYPES
Simple Pneumothorax or spontaneous pneumothorax
occurs when air enters the pleural space through a breach of
either the parietal or visceral pleura.
It may be associated with diffuse interstitial lung disease and
severe emphysema.

97 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

98 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumothorax……
 Tension pneumothorax
 If a pneumothorax is closed, air, and therefore tension, builds up in the pleural
space.

 As tension increases, pressure is placed on the heart and great vessels, pushing
them away from the affected side of the chest.

 Heart and vessels are compressed, venous return to the heart is impaired, resulting
in reduced cardiac output symptoms of shock

 Is often related to the high pressures present with mechanical ventilation & it is a
medical emergency.

99 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumothorax……
 Clinical Manifestations
 Signs and symptoms associated with pneumothorax depend
on its size and cause
Pain(sudden & plueritic)
Dyspnea
Respiratory distress
Increased use of accessory muscles
Centeral cynosis
Expansion of chest decreased
Breath sound may diminished
Normal sounds or hyperresonance on percussion.
 100 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Pneumothorax……
 In a tension pneumothorax,
The trachea is shifted away from the affected side
Chest expansion may be decreased or fixed in a
hyperexpansion state.
Breath sounds are diminished or absent
Percussion to the affected side is hyperresonant.

101 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 HEMOTHORAX.
 It is the presence of blood in the pleural space.
 Can occur with or without accompanying pneumothorax.
 Cause:-
Traumatic injury (often).
Lung cancer,
Pulmonary embolism
Anticoagulant use.

102 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumothorax……
Diagnostic Tests
History
Physical examination
Chest x-ray examination
Arterial blood gases and oxygen saturation

103 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumothorax……
Medical Management
Depends on its cause and severity.
The goal of treatment is to evacuate the air or blood from
the pleural space.
A small pneumothorax :_
- May absorb with no treatment other than rest
-Trapped air may be removed with a small bore needle
inserted into the pleural space
Chest tubes connected to a water seal drainage system are
used to remove larger amounts of air or blood from the
pleural space.
104 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Pneumothorax……

If the pneumothorax is recurrent

Other treatments can be used to prevent additional episodes.

Sterile talc or certain antibiotics (such as tetracycline) can be

injected into the pleural space via thoracentesis, irritating the

pleural membranes and making them stick together,

-this is called pleurodesis or sclerosis.

105 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Pneumothorax……
Nursing management
Close monitoring & frequent assessment of:-
 Level of consciousness,
 Skin and mucous membrane color,
 Vital signs,
 Respiratory rate & depth
 Presence of dyspnea,
 Chest pain,
 Restlessness, or anxiety
 Lung sounds

106 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 EMPYEMA
An accumulation of thick, purulent fluid within the pleural
space, often with fibrin development and a loculated (walled-off)
area where infection is located.
Pathophysiology
Most empyemas occur as complications of bacterial pneumonia or
lung abscess.
Penetrating chest trauma, hematogenous infection of the pleural
space, nonbacterial infections, and iatrogenic causes (after thoracic
surgery or thoracentesis).
At first the pleural fluid is thin, with a low leukocyte count, but it
frequently progresses to a fibropurulent stage
Finally, to a stage where it encloses the lung within a thick
exudative membrane (loculated empyema).
107 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Clinical Manifestations
Fever
Night sweats
Pleural pain
Cough
Dyspnea
Anorexia
Weight loss

108 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Assessment and Diagnostic Findings
 Chest auscultation(decreased or absent breath
sounds over the affected area.
 Chest percussion there is dullness on as well as decreased
fremitus.
 The diagnosis is established by chest CT.
 Usually a diagnostic thoracentesis is performed, often
under ultra sound guidance

109 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Medical Management

The objectives of treatment are

 To drain the pleural cavity
 To achieve complete expansion of the lung.

Fluid is drained, and appropriate antibiotics (Sterilization of the

empyema cavity requires 4 to 6 weeks of antibiotics) are used.

110 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Drainage of the pleural fluid depends on the stage of the
disease and is accomplished by one of the following methods:
Needle aspiration (thoracentesis) with a thin percutaneous
catheter, if the volume is small and the fluid is not too purulent
or too thick.
Tube thoracostomy (chest drainage using a large diameter
intercostal tube attached to water-seal drainage.
Open chest drainage via thoracotomy, including potential rib
resection, to remove the thickened pleura, pus, and debris and
to remove the underlying diseased pulmonary tissue.
111 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Nursing management
 Instructs the patient in lung-expanding breathing exercises to
restore normal respiratory function.
 Provides care specific to the method of drainage of the
pleural fluid (eg, needle aspiration, closed chest drainage, rib
resection and drainage

112 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

PULMONARY TUBERCULOSIS
In 46o B.C. The Greek physician Hippocrates
described tuberculosis as an "almost always fatal disease
of the lungs.
Called phthisis from Greek term phthinein which
means wasting or decay.
In English, pulmonary TB was long known by the term
“consumption.”
German physician Robert Koch discovered and
isolated m tuberculosis in 1882.
113 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Tuberculosis (TB)-Definition
Neo-Latin word :
 Tubercle”-Round nodule/Swelling
 “Osis” – Condition
Tuberculosis (TB) :
 Is an infectious disease that primarily affects the

lung parenchyma.
 Is a potentially fatal contagious disease that can

affect almost any part of the body but is mainly

an infection of the lungs.
 Is a chronic bacterial infectious disease that

primarily affects the lungs, but can also infect

other organs in the body.
It also may be transmitted to other parts of the body,
including
114
the meninges, kidneys, bones, and lymph
By Dr.Mihiretu T( Bsc, MD) 11/21/2024
nodes.
 The primary infectious agent, M. tuberculosis, is
an acid-fast aerobic rod that grows slowly and is
sensitive to heat and ultraviolet light.
 Mycobacterium bovis and Mycobacterium avium
have rarely been associated with the development
of a TB infection
 Common causative bacilli:
 Mycobacterium tuberculosis (most cases)
 M. bovis – bovine tubercle bacillus
 M. Africana – West Africa
 M. Microti
115 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 M. Canetti
MODE OF TRANSMISSION
Airway droplets: the main mode of transmission from person infected
with pulmonary TB to others by respiratory droplets.
Ingestion: Less frequently transmitted by ingestion of mycobacterium
bovis found in unpasteurized milk products
Direct inoculation

TB spreads from person to person by airborne transmission.

An infected person releases droplet nuclei (usually particles 1 to 5 um in

diameter) through talking, coughing, sneezing, laughing, or singing.

Larger droplets settle; smaller droplets remain suspended in the air and are
inhaled by a susceptible person.

116 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Factors influence transmission
 The number of bacilli in the droplets,
 The virulence of the bacilli,
 Exposure of the bacilli to UV light,
 Degree of ventilation, and
 Occasions for aerosolization all influence
transmission

117 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

HIGH RISK FOR PROGRESSION
 Persons more likely to progress from LTBI to TB
disease includes:
 HIV infected persons
 Persons with a history of prior, untreated TB
or fibrotic lesions on CXR
 Recent TB infection (within the past 2 years)
 Injection drug users
 Age ( very young or very old)
 Patientswith certain medical conditions ( DM,
chronic renal failure, hemodialysis, solid
118
organ transplantation, cancer, malnourished
By Dr.Mihiretu T( Bsc, MD) 11/21/2024
patient, silicosis)
SPREAD OF TB TO OTHER PARTS OF
THE BODY
Spread if infection will take place by:
A. Local spread: to the surrounding lung tissue and
pleura
B. Lymphatic spread: along bronchi, leading to
tuberculous bronchopneumonia
C. Hematogenous spread: leading to:
 Lungs (85% of all cases)
 Pleura

 CNS

 Lymph nodes
 Genitourinary system
 Bones and joints
119 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Disseminated ( eg miliary)
Classification

Pulmonary TB Extra pulmonary

oPrimary Disease i. Lymph node TB
oSecondary ii. Pleural TB
Disease iii. TB of upper airways
iv. Skeletal TB
v. Genitourinary TB
vi. Miliary TB
vii. Pericardial TB
viii. Gastrointestinal TB
120
ix. Tuberculous Meningitis
By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Pathogenesis Bacteria
Aerosolizati reach the
Inhalation
Exposure to on of lung ,enter
the source droplet
of the
the
nuclei bacteria
macrophag
es
Bacteria Granulomato Bacteria
cease to us lesion multiply in
Reactivati
grow, begin to form the
on lesion caseous macrophag
calcify necrosis es

Spread
Lesion liquefies blood ,
organs
Bacteria
coughed up
in the
sputum Death
121 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Primary pulmonary TB
 Also called ghon’s complex or childhood tuberculosis.

 Is an infection of persons who have not had prior contact

with the tubercle bacillus

 The infection of an individual who has not been previously

infected or immunized

 Lesions forming after infection is peripheral and

accompanied by
hilar which may not be detectable on chest radiography.

 Inhaled bacilli are commonly deposited in alveoli

immediately beneath the pleura, usually in the lower part of
the upper lobes or the upper part of the lower lobes
122 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Macrophages ingest the bacilli and transport them to
Primary infection----
 The primary infection characteristically produces a "
Ghon complex" formed of:

 Ghon focus: small area of pneumonic consolidation

about 1-3 cm in diameter, sub pleural in location present
in the base of the upper lobe or apex of the lower lobe

 Tuberculous lymphangitis: of the draining

lymphatic channels

 Tuberculous lymphadenitis: of the tracheobronchial

nodes which are enlarged, matted together and their cut
surface show areas of caseous necrosis

123 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

MICROSCOPIC PICTURE
 The Ghon focus consists of a central area of pink caseous
necrosis surrounded by inflammatory infiltrate and walled of by
an area of granulation tissue containing multinucleated
Langhans giant cells
FATE OF PRIMARY TB
 This depends on:
 Virulence of the organism
 Dose of infection
 Degree of resistance of the host

 A. If the patient resistance is good and the organism is of low

virulence, Ghon complex undergo healing and over time usually
evolve to fibrocalcific nodules
 B.If the patient resistance is poor and/or the organism of high virulence,
progressive pulmonary tuberculosis will develop, the primary Ghon focus in
the lung enlarges rapidly, erodes the bronchial tree, and spread
124 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Secondary Tuberculosis
 Theinfection that individual who has been
previously infected or sensitized is called
secondary or post primary or reinfection or
chronic tuberculosis.

125 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Clinical Manifestations
 As the cellular processes tuberculosis develop
differently, according to the status of the patient’s
immune system.
 Stagesinclude latency, primary disease, primary
progressive disease, and extra pulmonary disease

Early infection
 Immune system fights infection
 Infection
generally proceeds without signs or
symptoms
 Patients
may have fever, paratracheal
lymphadenopathy, orBydyspnea
126 Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Early primary progressive (active)

 Immune system does not control initial infection

 Inflammation of tissues ensues Patients often
have nonspecific signs or symptoms (eg, fatigue,
weight loss, fever)
Nonproductive cough develops
 Diagnosis can be difficult: findings on chest
radiographs may be normal and sputum smears
may be negative for mycobacteria
Late primary progressive (active)
 Cough becomes productive
 More signs and symptoms as disease progresses
 Patients experience progressive weight loss,
rales, anemia
127 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Findings on chest radio - graph are normal
Latent

 Mycobacteria persist in the body

 No signs or symptoms occur
 Patients do not feel sick
 Patients are susceptible to reactivation of
disease
 Granulomatous lesions calcify and become
fibrotic, become apparent on chest radiographs
 Infection can reappear when
immunosuppression occurs

128 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

129 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

130 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

131 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Currently recommended diagnostic
methods
 Conventional Phenotypic Methods
• AFB Microscopy /ZN and FM Methods
• Culture Identification
• Culture-based drug susceptibility testing
(DST)
2. Molecular Genotypic Methods
• Line Probe Assay
• GeneXpert MTB/RIF

132 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Assessment and Diagnostic Findings
 History
 Physical examination
 Tuberculin skin test
 Chest x-ray(reveals lesions in the upper lobes)
 Acid-fast bacillus smear
 Sputum culture

133 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 MEDICAL MANAGEMENT
 The two aims of TB treatment are :-
To interrupt transmission by rendering patients
noninfectious and
To prevent morbidity and death by curing patients with
TB while preventing the emergence of drug resistance.
Four major drugs are considered the first-line agents for
the treatment of TB: isoniazid, rifampin, pyrazinamide,
and ethambutol.

134 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Standard short-course regimens are divided into an initial,
or bactericidal, phase and a continuation, or sterilizing,
phase.
During the initial phase, the majority of the tubercle bacilli
are killed, symptoms resolve, and usually the patient
becomes noninfectious.
The continuation phase is required to eliminate persisting
mycobacteria and prevent relapse.
The treatment regimen of choice for virtually all forms of
TB in adults consists of a 2-month initial phase of isoniazid,
rifampin, pyrazinamide, and ethambutol followed by a 4-
month continuation phase of isoniazid and rifampin
135 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
Recommended Antituberculosis Treatment Regimens
Initial Phase Continuation
Phase
Indication Duration, drugs Duration, drugs
months months

New smear- or culture-positive 2 HRZE 4 HR

cases

2 HRZE 4 HR
New culture-negative cases

HRE 7 HR
Pregnancy 2

Relapses and treatment default HRZES 5 HRE

3
(pending susceptibility testing)
Abbreviation:- E, ethambutol; H, isoniazid; R, rifampin; S, streptomycin Z,
pyrazinamide.

136 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

137 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Nursing Management

Promoting Airway Clearance (Increasing the fluid

intake promotes systemic hydration and serves as an
effective expectorant)

Advocating Adherence to Treatment Regimen

Promoting Activity and Adequate Nutrition

Preventing Spreading of Tuberculosis Infection

138 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Management of pt with respiratory disorder
Oxygen Therapy
 Is the administration of oxygen at a concentration greater than
that found in the environmental atmosphere
 The goal of oxygen therapy is to provide adequate transport of
oxygen in the blood while decreasing the work of breathing
and reducing stress on the myocardium
Indications
 Change in the patient’s respiratory rate or pattern( hypoxemia
or hypoxia)
 Need for oxygen is assessed by arterial blood gas analysis,
pulse oximetry, and clinical evaluation.
139 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Chest physiotherapy
 Includes postural drainage, chest percussion, and
vibration, and breathing retraining.
 The goals of CPT are to remove bronchial secretions,
improve ventilation, and increase the efficiency of the
respiratory muscles.

140 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Postural drainage
Allows the force of gravity to assist in the removal of
bronchial secretions.
The secretions drain from the affected bronchioles into
the bronchi and trachea and are removed by coughing or
suctioning.
Used to prevent or relieve bronchial obstruction caused by
accumulation of secretions.
Patient usually sits in an upright position, secretions are
likely to accumulate in the lower parts of the lungs.

141 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Nursing Management

 The nurse should be aware of:-

Patient’s diagnosis as well as the lung lobes or segments
involved
Cardiac status
Any structural deformities of the chest wall and spine
 Auscultating the chest before and after the procedure is used to
identify the areas that need drainage and assess the
effectiveness of treatment
 The nurse explores strategies that will enable the patient to
assume the indicated positions at home(use of objects readily
available at home, such as pillows, cushions, or cardboard
boxes
142 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 PD is usually performed two to four times daily, before
meals (to prevent nausea, vomiting, and aspiration) and at
bedtime
 The nurse makes the patient as comfortable as possible in
each position and provides an emesis basin, sputum cup,
and paper tissues.
 If the patient cannot cough, the nurse may need to
suction the secretions mechanically.

143 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Chest Percussion and Vibration

Thick secretions that are difficult to cough up may be loosened.

Help dislodge mucus adhering to the bronchioles and bronchi.
Percussion is carried out by cupping the hands and lightly
striking the chest wall in a rhythmic fashion over the lung
segment to be drained.
The patient uses diaphragmatic breathing during this
procedure to promote relaxation
percussion over chest drainage tubes, the sternum, spine, liver,
kidneys, spleen, or breasts (in women) is avoided.
Percussion is performed cautiously in the elderly (b/c of
increase incidence of osteoporosis and risk of rib fracture)
144 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 Vibration
 Is the technique of applying manual compression and
tremor to the chest wall during the exhalation phase of
respiration
 Helps increase the velocity of the air expired from the small
airways, thus freeing the mucus.
 After three or four vibrations, the patient is encouraged to
cough, contracting the abdominal muscles to increase the
effectiveness of the cough

145 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Nursing Management
 The nurse ensures that the patient is comfortable, is not
wearing restrictive clothing, and has not just eaten.
 Gives medication for pain, as prescribed, before
percussion and vibration and splints any incision and
 Provides pillows for support as needed.

146 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Deep Breathing and Coughing
Effective coughing can keep the airways clear of secretions.
An ineffective cough is exhausting and fails to bring up
secretions.
Instruct the patient to take two or three deep breaths, using
the diaphragm.
This helps get the air behind the secretions.
After the third deep inhalation, tell the patient to hold the
breath and cough forcefully.
This is repeated as necessary.
Good hydration can facilitate this process.
147 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
AIRWAY MANAGEMENT
 Adequate ventilation is dependent on free movement of air
through the upper and lower airways.
 In many disorders, the airway becomes narrowed or blocked
as a result of disease, bronchoconstriction (narrowing of
airway by contraction of muscle fibers), a foreign body, or
secretions.
 Endotracheal intubation
 involves passing an endotracheal tube through the mouth or
nose into the trachea.

148 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 It is a means of providing an airway for patients who cannot
maintain an adequate airway on their own
 Comatose patients,
 Patients with upper airway obstruction),
 For patients needing mechanical ventilation,
 For suctioning secretions from the pulmonary tree

149 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Tracheotomy
 is a surgical procedure in which an opening is made into the trachea.
 The indwelling tube inserted into the trachea is called a tracheostomy
tube
 It may be either temporary or permanent.

Equipment
 Sterile gloves
 Hydrogen peroxide
 Normal saline solution or sterile water
 Cotton-tipped applicators
 Dressing
 Twill tape
 Type of tube prescribed, if the tube is to be changed
150 By Dr.Mihiretu T( Bsc, MD) 11/21/2024
 A tracheotomy is used
To bypass an upper airway obstruction,
To allow removal of tracheobronchial secretions,
To permit the long-term use of mechanical ventilation,
To prevent aspiration of oral or gastric secretions in the
unconscious or paralyzed patient (by closing off the
trachea from the esophagus)
To replace an endotracheal tube

151 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

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

152 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

Preventing Complications Associated With
Endotracheal and Tracheostomy Tubes
 Administer adequate warmed humidity.
 Maintain cuff pressure at appropriate level.
 Suction as needed per assessment findings.
 Maintain skin integrity.
 Change tape and dressing as needed or per protocol.
 Auscultate lung sounds.
 Monitor for signs and symptoms of infection, including
temperature and white blood cell count.

153 By Dr.Mihiretu T( Bsc, MD) 11/21/2024

 Administer prescribed oxygen and monitor oxygen
saturation.
 Monitor for cyanosis.
 Maintain adequate hydration of the patient.
 Use sterile technique when suctioning and performing
tracheostomy care.

154 By Dr.Mihiretu T( Bsc, MD) 11/21/2024



THANK YOU

155 By Dr.Mihiretu T( Bsc, MD) 11/21/2024