Downloaded File 6

2013-2014
Respiratory Care
Training Program
Respiratory Care 2013-2014

nahdi-Pharmacy Training Department
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INTRODUCTION
Every working day, people come to the community pharmacy for advice about minor complaints. With increasing pressure on
doctors workload, it is likely that the community pharmacy will be even more widely used as a rst port of call for minor illness.
Customers present to the pharmacist in three ways:
Requesting advice about symptoms
Asking to purchase a named medicine
Requiring general health advice (e.g. about dietary supplements)
The pharmacists role in responding to symptoms and overseeing the sale of over-the-counter (OTC) medicines is essential and
requires a mix of knowledge and skills in the area of diseases and their treatment. The key skills that are required by the
pharmacist to manage OTC in right way:
Differentiation between minor and more serious symptoms
Listening skills
Questioning skills
Treatment choices based on evidence of effectiveness
The ability to pass these skills on by acting as a role model for other pharmacy staff
WORKING IN PARTNERSHIP WITH PATIENTS
In the past, the approach has been to see the pharmacist as expert and the patient as beneciary of the pharmacists information
and advice. But patients are not blank sheets or empty vessels. They are experts in their own and their childrens health. The
patient:
May have experienced the same or a similar condition in the past
May have tried different treatments already
Will have their own ideas about possible causes
Will have views about different sorts of treatments
May have preferences for certain treatment approaches
The pharmacist needs to take this into account in the consultation with the patient and to enable patients to participate by
actively eliciting their views and preferences and some of the patient want the pharmacist to simply make a decision on their
behalf.


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RESPONDING TO A REQUEST FOR HELP WITH SYMPTOMS
1. INFORMATI ON GATHERING
Most information required to make a decision and recommend treatment can be gathered from just listening to the patient.
Pharmacists need to develop a method of information seeking e.g. WHAM or ASMETHOD

NOTE
There is no right and wrong here, pharmacist can use any of those methods.
2. DECISION MAKING
Is referral for a medical opinion required? Or OTC medication will be enough to manage the patient complaints.
3. TREATMENT
The pharmacists background in pharmacology, therapeutics and pharmaceutics will guide him to pick the possible lines of
treatment considering the adverse effects and drug interactions that may arise.
4. OUTCOMES
It is the pharmacists responsibility to make sure that patients know what to do if they do not get better.
PRIVACY IN THE PHARMACY
The pharmacist should always bear the question of privacy in mind and, where possible, seek to create an atmosphere of
condentiality if sensitive problems are to be discussed. The pharmacist can look for signs of hesitancy or embarrassment on the
patients part and can suggest moving to a quieter part of the pharmacy or to the consultation area to continue the conversation.

W
H
A
M

W
Who is the patient and what are symptoms?
The person in the pharmacy might be there on
someone elses behalf
H
How long have the symptoms been present?
Duration of symptoms can be an important
indicator of whether referral to the doctor might
be required.
A
Action taken?
Any action taken by the patient like medication
used to treat this case or any herbal preparation
used
M
Medication being taken?
Any regular medications used by the patient, due
to any possible drug interaction or adverse effects
that may manifest these symptoms
A
S
M
E
T
H
O
D

A Age and appearance Age of the patient and his appearance may be ill, pale and flushed
S Self or someone else Asking advice for himself or someone else
M Medication Medication regularly taken, on prescription or OTC
E Extra medicines Extra medication tried to treat the current symptoms
T Time persisting Duration of symptoms
H History History of symptoms and medications
O Other symptoms Any symptoms patient did not mention
D Danger symptoms Symptoms need immediate referral

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RESPIRATORY SYSTEM INTRODUCTION
FUNCTIONAL ANATOMY OF RESPI RATORY TRACT
Respiratory tract is the anatomical structure through which air moves in and out. It includes nose, pharynx, larynx, trachea,
bronchi and lungs.
PLEURA
Each lung is enclosed by a bi-layered serous membrane called pleura or pleural sac. Pleura has two layers namely inner visceral
and outer parietal layers. Visceral layer is attached firmly to the surface of the lungs. At hilum, it is continuous with parietal layer,
which is attached to the wall of thoracic cavity.
INTRAPLEURAL SPACE OR PLEURAL CAVITY
Intrapleural space or pleural cavity is the narrow space in between the two layers of pleura.
INTRAPLEURAL FLUID
Intrapleural space contains a thin film of serous fluid called intrapleural fluid, which is secreted by the visceral layer of the pleura.
Functions of intrapleural fluid:
It functions as the lubricant to prevent friction between two layers of pleura.
It is involved in creating the negative pressure called intrapleural pressure within intrapleural space.
TRACHEOBRONCHIAL TREE
Trachea and bronchi are together called tracheobronchial tree. It forms a part of air passage.
COMPONENTS OF TRACHEOBRONCHIAL TREE:
1. Trachea bifurcates into two main or primary bronchi called right and left bronchi
2. Each primary bronchus enters the lungs and divides into secondary bronchi
3. Secondary bronchi divide into tertiary bronchi. In right lung, there are 10 tertiary bronchi and in left lung, there are eight
tertiary bronchi
4. Tertiary bronchi divide several times with reduction in length and diameter into many generations of bronchioles
5. When the diameter of bronchiole becomes 1 mm or less, it is called terminal bronchiole
6. Terminal bronchiole continues or divides into respiratory bronchioles, which have a diameter of 0.5 mm.
UPPER AND LOWER RESPIRATORY TRACTS
Generally, respiratory tract is divided into two parts:
Upper respiratory tract that includes all the structures from nose up to vocal cords; vocal cords are the folds of mucous
membrane within larynx that vibrates to produce the voice
Lower respiratory tract, which includes trachea, bronchi and lungs.


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RESPIRATORY UNIT
Parenchyma of lungs is formed by respiratory unit that forms the terminal portion of respiratory tract.
Respiratory unit is defined as the structural and functional unit of lung. Exchange of gases occurs only in this part of the
respiratory tract.
STRUCTURE OF RESPIRATORY UNIT
Respiratory unit starts from the respiratory bronchioles. Each respiratory bronchiole divides into alveolar ducts. Each alveolar duct
enters an enlarged structure called the alveolar sac. Space inside the alveolar sac is called antrum. Alveolar sac consists of a
cluster of alveoli. Few alveoli are present in the wall of alveolar duct also. Thus, respiratory unit includes:
1. Respiratory bronchioles
2. Alveolar ducts
3. Alveolar sacs
4. Antrum
5. Alveoli.
Each alveolus is like a pouch with the diameter of about 0.2 to 0.5 mm. It is lined by epithelial cells.
ALVEOLAR CELLS OR PNEUMOCYTES
Alveolar epithelium consists of alveolar cells or pneumocytes, which are of two types namely type I alveolar cells and type II
alveolar cells.
TYPE I ALVEOLAR CELLS
Type I alveolar cells are the squamous epithelial cells forming about 95% of the total number of cells. These cells form the site of
gaseous exchange between the alveolus and blood.
TYPE II ALVEOLAR CELLS
Type II alveolar cells are cuboidal in nature and form about 5% of alveolar cells. These cells are also called granular pneumocytes.
Type II alveolar cells secrete alveolar fluid and surfactant.
RESPIRATORY MEMBRANE
Respiratory membrane is the membranous structure through which the exchange of gases occurs. Respiratory membrane
separates air in the alveoli from the blood in capillary. It is formed by the alveolar membrane and capillary membrane. Respi ratory
membrane has a surface area of 70 square meter and thickness of 0.5 micron.
NON-RESPIRATORY FUNCTIONS OF RESPIRATORY TRACT
Besides primary function of gaseous exchange, the respiratory tract is involved in several non-respiratory functions of the body.
Particularly, the lungs function as a defense barrier and metabolic organs, which synthesize some important compounds.
Non-respiratory functions of the respiratory tract are:
1. OLFACTION
Olfactory receptors present in the mucous membrane of nostril are responsible for olfactory sensation.
2. VOCALIZATION
Along with other structures, larynx forms the speech apparatus. However, larynx alone plays major role in the process of
vocalization. Therefore, it is called sound box.

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3. PREVENTION OF DUST PARTICLES
Dust particles, which enter the nostrils from air, are prevented from reaching the lungs by filtration action of the hairs in nasal
mucous membrane. Small particles, which escape the hairs, are held by the mucus secreted by nasal mucous membrane. Those
dust particles, which escape nasal hairs and nasal mucous membrane, are removed by the phagocytic action of macrophages in
the alveoli. Particles, which escape the protective mechanisms in nose and alveoli are thrown out by cough reflex and sneezing
reflex.
4. DEFENSE MECHANISM
Lungs play important role in the immunological defense system of the body. Defense functions of the lungs are performed by
their own defenses and by the presence of various types of cells in mucous membrane lining the alveoli of lungs. These cells are
leukocytes, macrophages, mast cells, natural killer cells and dendritic cells.
I. LUNGS OWN DEFENSES
Epithelial cells lining the air passage secrete some innate immune factors called defensins and cathelicidins. These substances
are the antimicrobial peptides, which play an important role in lungs natural defenses.
II. DEFENSE THROUGH LEUKOCYTES
Leukocytes, particularly the neutrophils and lymphocytes present in the alveoli of lungs provide defense mechanism against
bacteria and virus. Neutrophils kill the bacteria by phagocytosis. Lymphocytes develop immunity against bacteria.
III. DEFENSE THROUGH MACROPHAGES
Macrophages engulf the dust particles and the pathogens, which enter the alveoli and thereby act as scavengers in lungs.
Macrophages are also involved in the development of immunity by functioning as antigen presenting cells. When foreign
organisms invade the body, the macrophages and other antigen presenting cells kill them. Later, the antigen from the organisms
is digested into polypeptides. Polypeptide products are presented to T lymphocytes and B-lymphocytes by the macrophages.
Macrophages secrete interleukins, tumor necrosis factors (TNF) and chemokines. Interleukins and TNF activate the general
immune system of the body. Chemokines attract the white blood cells towards the site of any inflammation.
IV. DEFENSE THROUGH MAST CELL
Mast cell is a large cell resembling the basophil. Mast cell produces the hypersensitivity reactions like allergy and anaphylaxis. It
secretes heparin, histamine, serotonin and hydrolytic enzymes.
V. DEFENSE THROUGH NATURAL KILLER CELL
Natural killer (NK) cell is a large granular cell, considered as the third type of lymphocyte. Usually NK cell is present in lungs and
other lymphoid organs. Its granules contain hydrolytic enzymes, which destroy the microorganisms. NK cell is said to be the first
line of defense in specific immunity particularly against viruses. It destroys the viruses and viral infected or damaged cell s, which
may form the tumors. It also destroys the malignant cells and prevents development of cancerous tumors. NK cells secrete
interferons and the tumor necrosis factors.
VI. DEFENSE THROUGH DENDRITIC CELLS
Dendritic cells in the lungs play important role in immunity. Along with macrophages, these cells function as antigen presenting
cells.
5. MAINTENANCE OF WATER BALANCE
Respiratory tract plays a role in water loss mechanism. During expiration, water evaporates through the expired air and some
amount of body water is lost by this process.
6. REGULATION OF BODY TEMPERATURE
During expiration, along with water, heat is also lost from the body. Thus, respiratory tract plays a role in heat loss mechanism.

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7. REGULATION OF ACID-BASE BALANCE
Lungs play a role in maintenance of acid-base balance of the body by regulating the carbon dioxide content in blood. Carbon
dioxide is produced during various metabolic reactions in the tissues of the body. When it enters the blood, carbon dioxide
combines with water to form carbonic acid. Since carbonic acid is unstable,
8. ANTICOAGULANT FUNCTION
Mast cells in lungs secrete heparin. Heparin is an anticoagulant and it prevents the intravascular clotting.
9. SECRETION OF ANGIOTENSIN-CONVERTING ENZYME
The angiotensin I into active angiotensin II, which plays an important role in the regulation of ECF volume and blood pressure.
10. SYNTHESIS OF HORMONAL SUBSTANCES
Lung tissues are also known to synthesize the hormonal substances, prostaglandins, acetylcholine and serotonin, which have
many physiological actions in the body including regulation of blood pressure.
RESPIRATORY PROTECTI VE REFLEXES
Respiratory protective reflexes are the reflexes that protect lungs and air passage from foreign particles. Respiratory process is
modified by these reflexes in order to eliminate the foreign particles or to prevent the entry of these particles into the respiratory
tract. The following are the respiratory protective reflexes:
1. COUGH REFLEX
Cough is a modified respiratory process characterized by forced expiration. It is a protective reflex and it is caused by i rritation of
respiratory tract and some other areas such as external auditory canal.
CAUSES
Cough is produced mainly by irritant agents. It is also produced by several disorders such as cardiac disorders (congestive heart
failure), pulmonary disorders (chronic obstructive pulmonary disease, COPD) and tumor in thorax, which may exert pressure on
larynx, trachea, bronchi or lungs.
MECHANISM
Cough begins with deep inspiration followed by forced expiration with closed glottis. This increases the intrapleural pressure
above 100 mm Hg. Then, glottis opens suddenly with explosiveoutflow of air at a high velocity. Velocity of the airflow may reach
960 km/hour. It causes expulsion of irritant substances out of the respiratory tract.
REFLEX PATHWAY
Receptors that initiate the cough are situated in several locations such as nose, paranasal sinuses, larynx, pharynx, trachea,
bronchi, pleura, diaphragm, pericardium, stomach, external auditory canal and tympanic membrane. Afferent nerve fibers pass
via vagus, trigeminal, glossopharyngeal and phrenic nerves. The center for cough reflex is in the medulla oblongata. Efferent nerve
fibers arising from the medullary center pass through the vagus, phrenic and spinal motor nerves. These nerve fibers activate
theprimary and accessory respiratory muscles.
2. SNEEZING REFLEX
Sneezing is also a modified respiratory process characterized by forced expiration. It is a protective reflex caused by irritation of
nasal mucous membrane.
CAUSES
Irritation of the nasal mucous membrane occurs because of dust particles, debris, mechanical obstruction of the airway and
excess fluid accumulation in the nasal passages.


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MECHANISM
Sneezing starts with deep inspiration, followed by forceful expiratory effort with opened glottis resulting in expulsion of irritant
agents out of respiratory tract.
REFLEX PATHWAY
Sneezing is initiated by the irritation of nasal mucous membrane, the olfactory receptors and trigeminal nerve endings present in
the nasal mucosa. Afferent nerve fibers pass through the trigeminal and olfactory nerves. Sneezing center is in medulla oblongata.
It is located diffusely in spinal nucleus of trigeminal nerve, nucleus solitarius and the reticular formation of medulla. Eff erent nerve
fibers from the medullary center pass via trigeminal, facial, glossopharyngeal, vagus and intercostal nerves. These nerve fibers
activate the pharyngeal, tracheal and respiratory muscles.
3. SWALLOWING (DEGLUTITION) REFLEX
Swallowing reflex is a respiratory protective reflex that prevents entrance of food particles into the air passage during swallowing.
While swallowing of the food, the respiration is arrested for a while. Temporary arrest of respiration is called apnea. Arrest of
breathing during swallowing is called swallowing apnea or deglutition apnea. It takes place during pharyngeal stage, i.e. second
stage of deglutition and prevents entry of food particles into the respiratory tract.


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COLD AND FLU
Thecoldandinuenzaexhibitsimilarsymptomsandareoftenconfusedbypatients
Common cold (infectious rhinitis) Flu (influenza)
Causes
A viral infection of the nose, nasopharynx (upper respiratory
tract)
Rhinoviruses (responsible for 40% of infections) and
Coronaviruses (10% of infections) are the most common
Transmission is via nasopharyngeal droplets, released by
sneezing and coughing,
Major sites of entry are the nasal mucosa and conjunctiva
An acute infection of the respiratory tract caused mainly by 2
types of Influenza A and B
A vaccine is available, which is reformulated each year to
keep up with antigenic shift in the viruses
Transmission is by droplet inhalation; it is highly contagious
Epidemiology
It is extremely common: on average adults 24 colds per year,
and children up to 12 colds per year
Incidence is mainly in autumn and winter, but it can occur at
any time of year
Up to 15% of the population may develop inuenza
It normally occurs in the winter months
Manifestations
Gradual, with initial discomfort in the eyes, nose and
throat
Mild fever in children but rare in adults
Onset
Rapid with Initial symptoms
Always fever (38C or higher)
Mild to moderate like sneezing, rhinorrhea (start as
clear and thin discharge then may turn thicker and
purulent)
Sore throat and cough are due to postnasal drip of
mucous and irritation of pharynx.
Cough starts dry and nonproductive and may evolve
into productive cough
Symptoms
Dry cough, nasal congestion (runny nose may
appear), sore throat, anorexia, depression, shivering,
headache, myalgia, vertigo and back pain
Recovery is usually within 7-14 days Duration
Severe symptoms last up to 45 days
Recovery in 7-10 days
laryngitis, sinusitis, otitis media and secondary
bacterial infection
Complications Secondary bacterial infection as Pneumonia
SYMPTOMS AND CI RCUMSTANCES FOR REFERRAL
1. Night cough in children and wheezing may indicate bronchial asthma in absence of cold symptoms.
2. Asthmatics.
3. Cough persisting for more than 2 weeks, or becoming worse over a shorter period.
4. Dyspnea ( ). It may indicate heart failure in elder patients.
5. Severe pain on coughing or inspiration may indicate pleurisy or pulmonary embolism.
6. Adverse drug reactions e.g. ACE inhibitors.
7. Colored sputum (yellow/green/brown) may indicate bacterial infection.
8. Blood-ecked sputum may indicate Tuberculosis, Carcinoma.
9. Persistent fever for more than 48 hrs.
10. Sore throat should be referred if:
a. More than 1 week, and/or persistent hoarseness, and/or dysphagia (pain or difculty in swallowing) may
indicate Carcinoma.
b. Dysphagia, and/or rash, and/or stiff neck may indicate meningitis or Glandular fever.
c. Suspected adverse drug reaction, as sore throat is an early sign of drug-induced blood dyscrasias (imbalance of
the constituents of the blood or bone marrow like agranulocytosis) e.g. Captopril, Carbimazole
11. Earache. Bacterial infection of middle ear (otitis media) usually in children.


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TREATMENT
GENERAL NOTES
1. Both are self-limiting conditions but patients prefer to use OTC preparations to relieve the symptoms.
2. Cold and flu are both viral infections and antibiotics have no rule here.
3. For influenza:
a. Prophylaxis
b. Vaccination is recommended for all risk groups and elderly over 65 years.
c. Oseltamivir and Zanamivir may be used for prophylaxis and treatment under certain conditions.
d. Antivirals like Zanamivir, Oseltamivir may reduce severity and duration but not a cure.
e. The adamantanes, Amantadine and Rimantadine are only active against influenza A.
4. The same OTC symptomatic treatment preparations are used for both cold and flu.
ANALGESICS AND ANTIPYRETICS (FOR FEVER AND MALAISE)
Paracetamol, Aspirin and Ibuprofen can be used to reduce fever, muscle pain, headache of influenza, sore throat pain
and the general discomfort of cold.
Paracetamol can be given to babies from 2 months of age and ibuprofen from 3 months.
Aspirin is contraindicated less than 19 years due to its association with Reyes syndrome (AAP, CDC, FDA, National Reyes
syndrome foundation)
NASAL SYMPTOMS TREATMENT
SYSTEMIC ANTIHISTAMINES
A. SEDATING ANTIHISTAMINES
For runny nose with anti-muscarinic side effects that cause drying for nasal secretions.
Usually formulated with sympathomimetics to decrease their sedating action and as a nasal decongestant.
Avoid use with closed-angle glaucoma, benign prostatic hypertrophy, liver diseases and epilepsy due to their
anticholinergic side effects.
e.g. Chlorphenamine, Diphenhydramine, Promethazine, others
B. NON-SEDATING ANTIHISTAMINES
Are less potent than non-sedating ones.
Used alone or in combination with nasal decongestants.
e.g. Loratadine, Cetirizine, Fexofenadine
NASAL DECONGESTANTS
A. SYSTEMIC
Constrict the swollen mucosa and dilated blood vessels of the nasal passages, and improve air circulation and mucus
drainage.
e.g. Pseudoephedrine and phenylephrine.
Precautions:
o Do not take before bedtime, as they are CNS stimulants.
o Contraindicated with cardiac, hypertensive, thyroid, BPH and diabetic patients.
o Drug-drug interaction may occur with MAOIs and beta-blockers (rise in blood pressure)


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B. LOCAL
Rapid and potent vasoconstricting effect.
e.g. Oxymetazoline, Xylometazoline and Phenylephrine.
Can be used for patients for whom systemic decongestant is contraindicated.
Spays are more preferred for patient over 6 years because the spray mist reaches large surface area.
For children under 6 years, drops are preferred because in young children the nostrils are still narrow.
Precautions:
o Drug-drug interaction may occur with MAOIs.
o Do not use for more than 3-5 days due to the rebound effect and may worsen congestion (Rhinitis
medicamentosa)
INHALANTS
Preparations contain volatile oils used directly or in steam devices to relief nasal congestions.
INTRANASAL SALINE
Used to moisten nasal membranes and assist in the removal of encrusted secretions.
Recommended for all patients especially pregnant women and infants.
May be in the form of isotonic solutions e.g. Sterimar, Ocean Spray OR Hypertonic solutions e.g. Sinoclear
NASAL STRIPS (BREATH RIGHT)
It is ideal for pregnancy and elder people who takes numerous medications or cannot take sympathomimetics.
SORE THROAT TREATMENT
DEMULCENTS
For producing saliva, soothing the inflamed tissues and washing the microbes off.
Lozenges or pastilles will do this e.g. Strepsils, Orofar
Lozenges that contain eucalyptus oil and menthol are highly recommended due to its action in relieving nasal congestion
and other symptoms of cold.
LOCAL ANESTHETICS
Benzocaine, phenol and menthol, Available in mouthwashes, lozenges and sprays.
ANTIBIOTICS
Systemic antibiotics are not effective against viral infection but it will be highly needed in case of secondary bacterial
infection like Tonsillitis.
Gargles are used for the mechanical wash for microbes but not of any antiviral activity.
COUGH PREPARATIONS
Will be discussed in later
IMMUNOSTIMULANTS
Echinacea and vitamin C may have a role in reducing severity and duration of infections.
Other immunostimulants e.g. Garlic, Siberian ginseng, Black seed


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PATIENT EDUCATION
TO REDUCE THE LIKELI HOOD OF CATCHING INFECTI ON
1. Stay away of people with colds and flu and avoid crowded places.
2. Do not touch eye or nose after physical contact with infected persons.
3. Wash hands after blowing the nose.
4. Ethanol-based hand sanitizers.
5. Through away tissue after use.
6. Keep room well aired.
7. Children less than 2 years cannot blow their nose; a rubber bulb nasal syringe (Otrivin) can be used to clear nose and
decrease cough caused by postnasal drip.
FOR COLD
1. There is no need to reduce daily activities.
2. Sleeping with the head on a high pillow may help breathing at night.
3. Avoid smoking as it irritates the throat and the nose.
FOR FLU
1. Stay in bed and get plenty of sleep.
2. Drink fluid as much as possible (due to fluid loss during fever).
3. Avoid smoking as it irritates the throat and the nose.
4. Consult a doctor if the symptoms have not gone after a week, or sooner if symptoms worsen.


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COUGH
Acute cough is a common symptoms associated with many diseases like cold, flu, asthma, allergic rhinitis, chronic bronchitis and
others. Pharmacists must be able to distinguish between a cough from a simple condition and one from a potentially more serious
cause and make appropriate referrals.
DEFINITION
Cough is a reex action to remove secretions or foreign material from the airways
CAUSES
In association with a URTI:
o Productive (wet or chesty cough). Large amounts of cohesive mucus are produced in the upper respiratory tract
as a defense against invading microbes.
o Dry cough (hacking). The inammation and irritation in the pharynx caused by infecting organisms are perceived
in the brain as foreign objects.
o Discharge from the nasal passages and sinuses owing down behind the nose into the throat (postnasal drip)
also causes reex coughing (now known as upper airway cough syndrome UACS).
PATHOGENESIS
Cough receptors in the epithelial layer of the pharynx and trachea are stimulated by excessive mucus or perceived
foreign body (virus) and impulses are transmitted to the cough center in the medulla oblongata of the brain.
Impulses are sent back to respiratory muscles of the diaphragm, chest wall and abdomen.
This contract, producing a deep inspiration followed by a forced expiration of air, forcing open the glottis and producing
the cough.
CLASSIFICATION
1. Acute cough, duration of less than 3 weeks (viral URTI, pneumonia, asthma, foreign body aspiration)
2. Subacute cough, duration of 3-8 weeks (postinfectious cough, bacterial sinusitis, asthma)
3. Chronic cough, duration of longer than 8 weeks (UACS, asthma, COPD, GERD, with ACEIs, Cancer, TB)
EPIDEMIOLOGY
Cough occurs in 4050% of symptomatic URTIs.
SYMPTOMS AND SIGNS OF ACUTE VIRAL COUGH
1. Associated with other symptoms of cold and flu.
2. Sudden onset.
3. Usually more troublesome in the evening.
4. Duration less than 2 weeks.
5. If there is phlegm or sputum, it will be colorless.


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DIFFERENTIAL DIAGNOSIS
Asthma. It is characterized by chest tightness and wheezing and increases at night especially in children.
Croup. A viral URTI occurring in infants and toddlers. The cough has harsh, barking quality caused by laryngeal
oedema and thick tenacious secretions that block the trachea and airways.
Whooping cough (pertussis) : a bacterial infection affecting babies and children. Initial symptoms resemble a
URTI, but paroxysmal coughing bouts develop which recur periodically for 68 weeks and sometimes for up to 4 months.
The cough has a characteristic whooping sound. Attacks may cause the child to vomit and leave the child ghting for
breath and exhausted afterwards, but between coughing spasms the child appears completely well.
Chronic bronchitis. Patients often have a history of acute chest infections that become more frequent and severe until
there is a permanent cough.
Heart failure. Productive cough with frothy, pink-tinged sputum and breathlessness.
Gastro-esophageal reux disease (GERD). Non-productive cough, especially when lying down and accompanied with
heartburn and sensation of acid regurgitation.
Adverse drug reactions. E.g. angiotensin-converting enzyme inhibitors (ACEIs control the breakdown of bradykinin and
other kinins in the lung, which can trigger a cough.
SYMPTOMS AND CI RCUMSTANCES FOR REFERRAL
1. Night cough in children. It may indicate Asthma.
2. Asthmatic patients, as viral infections may worsen the asthma.
3. Cough persistent for more than 2 weeks or become worse after short period.
4. Colored sputum (yellow, green, brown) that may indicate bacterial infection.
5. Blood-flecked sputum. It may indicate Tuberculosis and carcinoma.
6. Productive cough with pink, frothy sputum with dyspnea may indicate cardiac failure in elder patients.
7. Severe pain on coughing or inspiration may indicate pleurisy or pulmonary embolism.
8. Adverse drug reactions. E.g. angiotensin-converting enzyme inhibitors, non-steroidal anti-inammatory drugs and beta-
blocker.
9. Cough that may be associated with weight loss and/or fatigue.


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TREATMENT
Treatment is available for four types of cough:
1. Dry (nonproductive, irritating, hacking).
2. Wet (productive, chesty).
3. Wheezy and nonproductive cough (no mucous but feeling of chest tightness and bronchial congestion).
4. Wheezy and productive cough (mucous with bronchial congestion).
The active ingredients of cough remedies fall into 4 main categories:
1. Suppressants (antitussives).
2. Expectorants.
3. Decongestants for wheezy coughs.
4. Demulcents to soothe any kind of cough.
COUGH SUPPRESSANTS (ANTITUSSIVES) -DRY COUGH
Dry cough has no beneficial purpose so; it is easily suppressed by any antitussives with no bad outcomes.
They are classified into opioids and antihistamines.
OPIOIDS
Codeine and Dextromethorphan.
Act on the cough center in the brain to depress the cough reex and increase cough threshold.
Codeine is stronger than Dextromethorphan but with high level of adverse effects like respiratory depression.
Dextromethorphan is widely used in OTC cough preparations with little or no dependence and non-sedating with few
side effects.
Avoid use in productive cough unless it is necessary (due to risk of airway obstruction and 2ry bacterial infection of lower
respiratory tract).
ANTIHISTAMINES
Diphenhydramine, Promethazine and Triprolidine.
Sedative-type antihistamines, exerting a central and peripheral inhibitory action on neuronal pathways involved in the
cough reex.
Side effects like sedation, anticholinergic side effects (urine retention, dry mouth, constipation and blurred vision) and
sedation may be beneficial and aiding in cough treatment to help patient sleep and dry nasal and bronchial secretions.
Contraindicated in glaucoma, benign prostatic hypertrophy (BPH) and elder patients.
EXPECTORANTS AND MUCOLYTICS (PROTUSSIVES) -CHESTY COUGH
Guaifenesin, Ammonium chloride, Ipecacuanha, Squill, Ivy, ambroxol and bromhexin.
Also known as, mucolytic agents are used to loosen sputum and thin bronchial secretions by irritating the gastric mucosa
and stimulating secretions of respiratory tract.
In productive cough, mucus produced in the bronchial passages because of infection is moved upwards towards the
pharynx by ciliary action and is then expelled by coughing.
Here, the cough is of high benefit and helps to keep airways open so; it must not be suppressed.
Guaifenesin is the expectorant most frequently used.
DECONGESTANTS-WHEEZY COUGH
Pseudoephedrine is used as a decongestant and bronchodilator.
They shrink swollen mucosa and open up the airways.
Contraindicated with cardiac and hypertensive patients and in case of glaucoma.
Drug-drug interaction with MAOIs.


15
DEMULCENTS-ANY COUGH
Glycerol, liquid, glucose, syrup and honey are used.
Demulcents coat the mucosa of the pharynx and provide short-lived relief of the irritation that provokes reex coughing.
Pastilles (e.g. glycerin, lemon and honey) provide more prolonged soothing action and increase saliva.
Safe for children and pregnant women.
Honey is contraindicated under age of 1 year due to the risk of botulism.
COMBINATI ON PRODUCTS
Contain more than one component from the mentioned above.
PATIENT EDUCATI ON
For diabetic patients, in short-term acute conditions the amount of sugar in cough medicine is relatively unimportant as
diabetic control is often upset during infections and the additional sugar is now not considered to be a major problem
but patient may prefer to use the sugar free ones.
Steam inhalation (Humidifier) may help to liquefy lung secretions and provide comfort to patients especially if menthol or
eucalyptus is added to the boiling water.
Maintain high intake of fluid and hot drinks to hydrate the lung to be at least 2 Liters per day.
Reduce throat irritation by slowly dissolve nonmedicated lozenges in mouth.


16

SORE THROAT (PHARYNGITIS)
Most patients complaining from sore throat do not consult the doctor. About 90% of the cases are because of viral infection and
the rest may be due to bacterial one and Treatment with antibiotics is unnecessary in most cases.
DEFINITION
A sore throat is pain, scratchiness or irritation of the throat that often worsens when you swallow. It is the primary symptom of
pharyngitis inflammation of the throat (pharynx). However, the terms "sore throat" and "pharyngitis" are often used
interchangeably.
CAUSES
Viral infection
Common cold.
Flu.
Glandular fever (infectious mononucleosis).
Bacterial Infection
Strep throat, which is caused by a bacterium known as Streptococcus pyogenes, or group A streptococcus.
Others
Smoking, GERD, postnasal drip (sinusitis) and breathing through mouth.
SYMPTOMS AND SIGNS
Main symptoms like painful burning or scratching sensation in the back of the throat, pain when swallowing and
sometimes tenderness in the neck.
Other symptoms may accompany sore throat:
o Cough.
o Sneezing.
o Hoarseness (laryngitis).
o Runny nose.
o Mild fever.
o General fatigue.
o Swollen lymph nodes (glands) in the neck.
o Bad breath (Halitosis).


17
SYMPTOMS AND SIGNS FOR REFERRAL
More than 1 week, and/or persistent hoarseness, and/or dysphagia (pain or difculty in swallowing) may indicate
Carcinoma.
Dysphagia, and/or rash, and/or stiff neck may indicate meningitis or Glandular fever.
Suspected adverse drug reaction, as sore throat is an early sign of drug-induced blood dyscrasias (imbalance of the
constituents of the blood or bone marrow like agranulocytosis) e.g. Captopril.
Glandular fever (infectious mononucleosis): a viral infection, the features of which are sore throat, dysphagia, swollen
lymph glands fatigue and fever. It is more common in adolescents. Patients normally recover within 6 weeks without
treatment, but they may feel tired and depressed for several months afterwards (A severe sore throat may follow 1 or 2
weeks of general malaise and the throat may become very inamed with creamy exudates present).
Tonsillitis (Bacterial pharyngitis): inammation of the tonsils, usually caused by -haemolytic streptococcus, with a
purulent discharge (white spots, exudates or pus on the tonsils), fever and malaise.
Oral thrush (candidiasis): a yeast infection, causing sore throat and mouth, with white patches on the oral mucosa. It can
be a result of medication therapy like chemotherapy, antibiotics and corticosteroids inhalation.
Laryngitis (Hoarseness). An inammation of the vocal cords in the larynx (laryngitis) due to viral infection or if persistent
for more than 2-3 weeks it may indicate laryngeal cancer. If it appears in infants and children, it may indicate Croup
(acute laryngotracheitis) characterized by difficulty in breathing and stridor.
Drugs that can cause agranulocytosis through immunosuppression in which sore throat is an indicator e.g. Captopril,
Carbimazole, Cytotoxics, Clozapine and Co-trimoxazole.
TREATMENT
A) TREATMENT OF THE MAIN CAUSE
B) SYMPTOMATIC TREATMENT
1. ANALGESICS
2. GARGLESANDLOZENGES
PATIENT EDUCATI ON
Rest body and voice.
Stop smoking as it may cause mouth dryness and then sore throat.
Change the habit of mouth breathing.
Drink plenty of hot fluids especially if with honey.
Gargle saltwater, 1 teaspoon (5 grams) of table salt to 8 ounces (237 milliliters) of warm water.
Humidify the air.
Avoid irritants like cigarette smoke.


18
LARYNGITIS
DEFINITION
Laryngitis is an inflammation of the voice box (larynx).
CAUSES
Upper respiratory tract infection (cold, flu)
Chronic sinusitis.
Excessive talking, singing or shouting.
Chronic irritations of the vocal cords e.g. smoking and excess cough.
Reflux laryngitis (Due to GERD that may cause irritation of the vocal cords).
Tumors and thyroid enlargement.
Hoarseness more than 2-3 weeks as it may indicate cancer.
Dysphagia.
TREATMENT
1. Voice rest event not whisper as it may delay recovery.
2. Treat the main cause e.g. smoking cessation, GERD and excess shouting (in case of chronic laryngitis)
3. Symptomatic treatment:
a. Analgesics.
b. Volatile oil inhaling e.g. Tincture Benzoin, Vicks
c. Drink plenty of fluids (hot fluids).
d. Humidified air.
4. Short course of oral corticosteroids may be given in some cases like singers or actors to shorten the course of symptoms
and decrease inflammation.


19
TONSILLITIS (STREP THROAT)
DEFINITION
Tonsillitis is an inflammation of the tonsils.
SYMPTOMS AND SIGNS
Sore throat is the main symptoms and other symptoms may be accompanied like:
o Bad breath.
o Fever (38.3 C).
o Red, swollen tonsils with patches of pus (white spots).
o Swollen lymph nodes in front of the neck.
o Pain or difficulty swallowing.
o Loss of voice.
o Headache.
o If the adenoids are enlarged, breathing through the nose may be difficult and there will be:
o Breathing through the mouth, especially in kids.
o Snoring.
o Voice may be nasal-sounding.
Note
If sore throat is accompanied with symptoms of colds or flu (cough, sneezing, congestion and runny nose), the cause is
almost a viral infection and recovery will be within 2 week.
If sore throat is with sudden mild fever without upper respiratory tract infection, it may point to bacterial infection (Strep
throat).
Acute mononucleosis is caused by the Epstein-Barr virus, and can lead to a very severe throat infection that is
characterized by the rapid enlargement of the tonsils, adenoids, and lymph nodes of the neck. It also causes extreme
malaise and tiredness. The sore throat and gland swelling can last for one week to a month and does not respond to the
usually prescribed antibiotics.
COMPLICATIONS
Strep tonsillitis can cause secondary damage to the heart valves (rheumatic fever) and kidneys (glomerulonephritis). It
can also lead to a skin rash (scarlet fever), sinusitis, pneumonia, and ear infections.
Chronic Tonsillitis, a persistent infection of the tonsils. Repeated infections may cause the formation of small pockets
(crypts) in the tonsils, which harbor bacteria. Frequently, small, foul smelling stones are found within these crypts. These
stones (tonsilloliths) may contain high quantities of sulfa. When crushed, they give off the characteristic rotten egg smell,
which causes bad breath.
Peritonsillar Abscess, a collection of pus behind the tonsils that pushes one of the tonsils toward the uvula (the
prominent soft tissue dangling from the back of the upper throat). It is generally very painful and is associated with
decreased ability to open the mouth. If left untreated, the infection can spread deep in the neck causing life-threatening
complications and airway obstruction.
Enlargement of (Hypertrophic) Tonsils and Adenoids that may cause snoring and disrupted sleep that may lead to sleep
apnea.


20
TREATMENT
1. ANTIBIOTIC
In case of strep throat, a full course of antibiotic is a must to treat the infection e.g. Amoxiclave, Azithromycin
2. SYMPTOMATIC TREATMENT
Analgesic
Demulcents (gargles and lozenges)
3. SURGERY
(Tonsillectomy and adenoidectomy) is indicated in persons with repeated or persistent infections, particularly if they
interfere with everyday activities. The American Academy of Otolaryngology defines repeated infections in children as 7
episodes in one year, or 5 episodes in each of two years, or 3 episodes in each of three years.
Other complications like Obstructive sleep apnea, Breathing difficulty and swallowing difficulty may require surgery.
PATIENT EDUCATI ON
Rest.
Warm fluids.
Gargles e.g. salt water.
Avoid irritants e.g. smoking.
Lozenges as a demulcent.


21
ALLERGIC RHINITIS (HAY FEVER)
DEFINITION
An allergic hypersensitivity reaction in the nasal mucosa and the conjunctiva of the eye associated with the presence of poll ens in
the atmosphere and characterized by four symptoms, Rhinorrhea, Nasal Itching, Sneezing and Nasal Congestion (RISC).
CAUSES AND TYPES OF ALLERGI C RHINI TIS
Seasonal allergic rhinitis (SAR) is caused by exposure to pollen or other allergens that occur at certain times:
o Tree pollen in spring.
o Grass pollen in summer.
o Fungal spores in autumn.
Perennial allergic rhinitis (PAR) is caused by dust mites, molds and animal allergens.
Non-allergic rhinitis
o Hormonal (Pregnancy, puberty, thyroid disorders).
o Structural (Septum deviation, adenoid hypertrophy).
o Drug-induced (cocaine, -blockers, ACEIs, chlorpromazine, oral contraceptives, NSAID, overuse of topical
decongestants).
o Lesions (nasal polyps).
o Traumatic (recent facial or head trauma).
PATHOGENESIS
It consists of 4 phases:
1. Sensitization phase: Initial allergen exposure that stimulates IgE production.
2. Early phase: occur within minutes of allergen exposure, it consists of release of :
a. Performed mast cell mediators: histamine and proteases.
b. Additional mediators: kinins, leukotrienes, neuropeptides.
3. Cellular recruitment: circulating leucocytes and eosinophils are attracted to nasal mucosa releasing more mediators.
4. Late phase: begins 2-4 hrs after initial exposure and symptoms include mucus hypersecretion and congestion.
Note
Continued persistent inflammation may result in lowering the threshold for allergic and non-allergic mediated triggers
e.g. cold air, strong odors, exercise and hyperventilation.
Risk factors for allergic rhinitis:
o Family history of allergic disorders.
o Elevated serum IgE greater than 100 IU/mL before age 6.
o Higher socioeconomic class.
o Positive reaction to allergy skin tests.
CLASSIFICATION
1. Intermittent. Occurs less than 4 days/week or for less than 4 weeks.
2. Persistent. Occurs more than 4 days/week and for more than 4 weeks.
EPIDEMIOLOGY
Appear in 10% of children and 20-30% of adolescents.
2/3 of adults that suffer from hay fever are under age 30.


22
SYMPTOMS OF HAY FEVER
NASAL SYMPTOMS
EARLY PHASE
It is characterized by:
Rhinorrhea (nasal discharge), clear and watery with frequent blowing and wiping that may cause nose to sore
and sometimes cause infection.
Nasal pruritus (itching), intermittent or continuous.
Sneezing, long, repeated and disruptive bouts.
Itching sensation in the roof of the mouth.
LATE PHASE
It is characterized by:
Nasal congestion due to vasodilation of blood vessels that may be unilateral or bilateral that leads to mouth
breathing which is responsible for mouth dryness and bad breath. In addition, insomnia and loss sense of smell
may happen (anosmia).
Nasal congestion may cause frontal or sinus headaches and give rise to secondary infections such as sinusitis.
The Eustachian tubes may become blocked with mucus and infected, and otitis media may result.
Dark and bluish swelling, like a black eye (allergic shiner), develops around the eye caused by impaired nasal
venous outow.
EYE SYMPTOMS (ALLERGIC CONJUNCTIVITIS)
Clear and watery discharge.
Redness.
Itching.
Photophobia.
Skin folds or pleats develop parallel to the lower lid margin, extending from under the eye to the top of the
cheekbone.
SYSTEMIC SYMPTOMS
Fatigue, irritability, malaise, cognitive impairment and depression
NOTE
The following signs may result from persistent nasal pruritis:
Allergic salute, the constant upward rubbing of the nose with the palm of the hand.
Allergic crease, a visible transverse line appearing between the tip and the bridge of the nose caused by
constant rubbing.
Earache may indicate otitis media.
Facial pain or recurrent headache may indicate sinusitis.
Purulent eye discharge may indicate infection.
Bloody nasal discharge.
If no improvement after 1 week treatment with OTC preparations.

23
Allergic rhinitis

Common cold
Remain clear unless infection happens
Nasal
discharge
Initially clear, usually thickened then turns to purulent
Frequent and paroxysmal Sneezing Less frequent
Common (allergic salute) Nasal itching No
Common (allergic conjunctivitis)
Eye
symptoms
No
As long as allergen present Duration Usually or 4-7 days
Sudden Onset Gradual
Same time of the year or when allergen is in the air Occurrence Any time, but more usually in winter
No infection, only susceptible individuals Infection Highly contagious
TREATMENT
Pharmacotherapy is symptoms-specific and depends on the severity of the illness.
There is no single ideal medication, and combination of drug regimen is used.
AVOIDANCE OF THE ALLERGENS
It is considered the best treatment for Hay fever; but actually, it is so difficult.
SYSTEMIC TREATMENT
Histamine is the main chemical mediator responsible for the inammatory response of Hay fever.
Antihistamines act through competitive antagonism of histamine at the H1-receptors.
They control symptoms of Hay fever like sneezing, itching, rhinorrhea and allergic conjunctivitis.
For maximum effectiveness, antihistamines should be taken when symptoms are expected, rather than after they have
started.
They are classified into 2 groups:
o Sedating antihistamines.
o Non-sedating antihistamines.
SEDATING ANTIHISTAMI NES
Lipophilic in nature and can cross blood-brain barrier.
Can cause many side effects e.g. anticholinergic side effects like blurred vision, constipation, dry mouth and others.
E.g. chlorphenamine, clemastine, diphenhydramine, promethazine.
NON-SEDATING ANTIHISTAMI NES
Less lipophilic and do not reach the brain to a signicant extent.
Much less likely to cause central nervous system adverse effects.
E.g. loratadine, cetirizine, fexofenadine, desloratadine, levocetirizine.
COMBINATION PRODUCTS
These products are a combination of antihistamines (sedating and non-sedating) with sympathomimetics.
Adding sympathomimetics to these compounds are intended to relief nasal congestion that appears at the late-stage of
allergic rhinitis.


24
TOPI CAL TREATMENT
NASAL PREPARATION
Contains antihistamines, anti-inflammatory, decongestants and nasal saline
A. ANTIHISTAMINES
E.g. Levocabastine, azelastine.
Both are H1-receptor antagonists and treatment should be started 2-3 weeks before allergy starts.
B. ANTI-INFLAMMATORY
E.g. Fluticasone, Mometasone, Beclomethasone, Budesonide.
Corticosteroids have a wide range of inhibitory activities against multiple cell types (mast cell, eosinophils, neutrophils,
macrophages and lymphocytes) and mediators (histamine, leukotrienes and cytokinines)
They take some days to achieve optimum effect, and treatment should ideally be started at least 2 weeks before
symptoms are expected.
They can be used for patients 18 years and over for up to 3 months without consulting a doctor and can be repeated
each year.
C. TOPICAL DECONGESTANTS
E.g. Oxymetazoline, phenylephrine, xylometazoline.
To relief the congestion evolved at late-stage.
Should not be used more than 5 days.
D. NASAL SALINE (ISO OR HYPERTONIC)
Used to moisten nasal membranes and assist in the removal of encrusted secretions.
Can relieve the congestion.
Recommended for all patients especially pregnant women and infants.
EYE PREPARATIONS
Most symptoms are controlled by oral antihistamines by if symptoms are persistent, eye drops are effective.
These preparations may contain antihistamine like antazoline, cromoglicate or levocabastine alone or in combination
with decongestants like naphazoline.
PATIENT EDUCATI ON
Stay indoors and keep all windows closed.
Wear close-tting sunglasses when outside, and a mask if symptoms are severe.
Car windows and air vents should be kept closed while driving.
Avoid animal contact
Avoid perfumes and strong odors


25

SINUSITIS (RHINOSINUSITIS)
DEFINITION
Inflammation and swollen of the air cavities within the passages of the nose (paranasal sinuses)
CAUSES
1- Upper respiratory tract Infections:
a. Viral as caused by common cold.
b. Bacterial. URT infection for more than 10 days may cause bacterial sinusitis.
c. Fungal, due to decreased immunity.
2- Allergy (hay fever).
3- Nasal polyps and tumors.
4- Deviated nasal septum.
5- Tooth infection.
6- Enlarged or infected adenoids in children.
7- Medical conditions e.g. GERD and immunity disorders.
TYPES
According to time span of the problem:
o Acute: less than 30 days.
o Subacute: over 1 month but less than 3 months.
o Chronic: greater than 3 months.
According to type of inflammation:
o Infected sinusitis: viral, bacterial or fungal.
o Non-infected sinusitis: is caused by irritants and allergy.
SYMPTOMS AND SIGNS
Fever (mainly in acute sinusitis).
Drainage of a thick, yellow or greenish
discharge from the nose or down the back
of the throat (postnasal drip).
Nasal obstruction or congestion, causing
difficulty breathing through nose.
Pain, tenderness and swelling around your
eyes, cheeks, nose or forehead (headache
increased when lean forward).
Reduced sense of smell and taste.
Aching in upper jaw and teeth.
Cough, which may be worse at night.
Bad breath (halitosis).
Fatigue or irritability.
Sore throat.
Earache.
Sneezing and itching.


26
TREATMENT
1. ANTIBIOTICS
Antibiotic treatment is generally needed only if there is a bacterial infection, especially if the infection is severe,
recurrent or persistent (Bacterial infection of the sinuses is suspected when facial pain, nasal discharge
resembling pus, and symptoms persist for longer than a week and are not responding to OTC nasal medications).
Antibiotics used e.g. Amoxicillin, amoxicillin with clavulanic acid (For at least 10-14 days even after
disappearance of symptoms).
2. NASAL SALINE (ISO AND HYPERTONIC)
3. MUCOLYTICS
4. NASAL DECONGESTANT ( TOPICAL/ORAL)
5. ANALGESICS
6. NASAL CORTICOSTEROI D
PATIENT EDUCATI ON
Get plenty of fluid (hot is recommended) to dilute mucous secretion and promote drainage.
Rest.
Humidifier or steam vaporizer.
Apply warm compresses to the face.
Keep rinsing nasal passages with saline solutions.
Sleep with head elevated.


27
BRONCHITIS
DEFINITION
Bronchitis is an inflammation of the bronchial tubes (bronchi), the air passages that extend from the trachea into the small
airways (bronchioles) and alveoli.
CAUSES
For acute bronchitis, it is usually caused by viruses (the same viruses of colds and influenza).
For chronic bronchitis, the most common causes are smoking cigarettes, air pollution and dust.
TYPES
1- Acute bronchitis: it is manifested by cough and, occasionally, sputum production that last for no more than 3 weeks.
2- Chronic bronchitis: it is manifested by cough with sputum for at least 3 months a year during a period of 2 consecutive
years (associated with hypertrophy of the mucus-producing glands).
SYMPTOMS AND SIGNS
For both acute and chronic (Generally, bronchitis is a diagnosis made by exclusion of other conditions such as sinusitis, pharyngitis,
tonsillitis, and pneumonia)
Cough (it may last for weeks even after bronchitis resolves in the acute type).
Production of mucus (sputum), which can be clear, white, yellowish-gray or green in color.
Fatigue.
Slight fever and chills.
Chest discomfort.
If cough lasts for more than 3 weeks.
If cough is accompanied with blood.
If cough interferes with sleeping.
If there is wheezing or shortness of breath.
Asthma and COPD
Bronchiolitis.
Bronchiectasis.
Sinusitis.
Pharyngitis.
Influenza.
GERD.

28
COMPLICATIONS
Asthma, Bronchiectasis, Cystic fibrosis, TB, Sinusitis, Pneumonia, COPD and others
TREATMENT
1- Antibiotic: Bronchitis usually results from viral infection, but sometimes it may be indicated if there is a suspected
bacterial infection or there are many risk factors like smoking and age (elder patient or infants) e.g. Macrolides,
Levofloxacin.
2- Cough preparations especially mucolytics or expectorants to dissolve and remove excess mucus in combination of cough
suppressant like dextromethorphan.
3- Analgesics and antipyretics.
4- Immunostimulants e.g. echinacea.
5- Bronchodilators, anticholinergics and steroids inhalation are widely used in chronic bronchitis.
PATIENT EDUCATI ON
Bed rest.
Drink plenty of fluids.
Warm and moist air (humidifier or steam vaporizer).
Wash hands and use hand sanitizer.
Stop smoking especially in chronic bronchitis.
Avoid air dust and smokes (use facemasks outside home).
Vaccination for the high-risk individuals e.g. smokers, older adults, infants and young children whom with low resistance
(as many cases of acute bronchitis result from influenza virus).


29
BRONCHIAL ASTHMA
DEFINITION
Asthma is a chronic inflammation of the bronchial tubes (airways) causing swelling and narrowing (constriction) of the airways.
CAUSES
Environmental allergens (e.g. house dust mites; animal allergens, especially cat and dog; cockroach allergens; and fungi).
Viral respiratory tract infections.
Exercise, hyperventilation.
GERD.
Chronic sinusitis or rhinitis.
Aspirin or non-steroidal anti-inflammatory drug (NSAID) hypersensitivity, sulfite sensitivity.
Use of beta-adrenergic receptor blockers (including ophthalmic preparations).
Obesity.
Environmental pollutants, tobacco smoke.
Occupational exposure.
Irritants (e.g. household sprays, paint fumes).
Iinsects, plants, latex, gums, di-isocyanates, anhydrides, wood dust, and fluxes; associated with occupational asthma).
Emotional factors or stress.
Perinatal factors (prematurity and increased maternal age; maternal smoking and prenatal exposure to tobacco smoke;
breastfeeding has not been definitely shown to be protective.
PATHOPHYSIOLOGY
The pathophysiology of asthma is complex and involves the following components:
1- Airway inflammation.
o The first and most important factor causing narrowing of the bronchial tubes is inflammation.
o The bronchial tubes become red, irritated, and swollen.
o This inflammation increases the thickness of the wall of the bronchial tubes and thus results in a smaller
passageway for air to flow through.
o This irritation is a result from the action of chemical mediators (histamine, leukotrienes, and others).
o The inflamed tissues produce an excess amount of "sticky" mucus into the tubes that can clump together and
form "plugs" that can clog the smaller airways.
o Specialized allergy and inflammation cells (eosinophils and white blood cells), which accumulate at the site,
cause tissue damage.
2- Bronchospasm
o The muscles around the bronchial tubes tighten during an attack of asthma.
o Chemical mediators and nerves in the bronchial tubes cause the muscles to constrict.


30
3- Hyperreactivity (hypersensitivity)
o The chronically inflamed and constricted airways become highly sensitive, or reactive, to triggers such as
allergens, irritants, and infections.
Therefore, the combination of these three factors results in difficulty with breathing out, or exhaling. As a result, the air needs to
be forcefully exhaled to overcome the narrowing, thereby causing the typical "wheezing" sound. People with asthma also
frequently "cough" in an attempt to expel the thick mucus plugs. Reducing the flow of air may result in less oxygen passing into
the bloodstream, and if very severe, carbon dioxide may dangerously accumulate in the blood (as in COPD).
EPIDEMIOLOGY
Asthma predominantly occurs in boys in childhood, with a male-to-female ratio of 2:1 until puberty, when the male-to-
female ratio becomes 1:1. Asthma prevalence is greater in females after puberty, and the majority of adult-onset cases diagnosed
in persons older than 40 years occur in females. Boys are more likely than girls to experience a decrease in symptoms by late
adolescence.
Asthma prevalence is increased in very young persons and very old persons because of airway responsiveness and lower
levels of lung function. Two thirds of all asthma cases are diagnosed before the patient is aged 18 years. Approximately half of all
children diagnosed with asthma have a decrease or disappearance of symptoms by early adulthood.
SYMPTOMS
The following are the 4 major recognized asthma symptoms:
1- Shortness of breath, especially with exertion or at night.
2- Wheezing is a whistling or hissing sound when breathing out
3- Coughing may be chronic, is usually worse at night and early morning, and may occur after exercise or when exposed to
cold, dry air.
4- Chest tightness may occur with or without the above symptoms
Other Non-pulmonary symptoms:
1. Signs of atopy or allergic rhinitis.
2. Skin problems e.g. atopic dermatitis, eczema, or other manifestations of allergic skin conditions.
ASTHMA CLASSIFICATION
Asthma is classified according to the frequency and severity of symptoms, or "attacks," and the results of pulmonary (lung)
function tests.
1. Intermittent (less than 2 days a week)
2. Mild persistent (more than 2 days a week)
3. Moderate persistent (occur daily)
4. Severe persistent (during the day)

31
TREATMENT
The pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the
frequency and severity of the patient's symptoms change.
1. Step 1 - Intermittent asthma
The reliever medication is a short-acting beta-agonist (SABA).
2. Step 2 - Mild persistent asthma
The preferred controller medication is a low-dose inhaled corticosteroid. Alternatives include sodium cromolyn or a
leukotriene receptor antagonist (LTRA).
3. Step 3 - Moderate persistent asthma
The preferred controller medication is a low-dose inhaled corticosteroid plus a long-acting beta-agonist (LABA)
(combination medication preferred choice to improve compliance) or an inhaled medium-dose corticosteroid.
Alternatives include inhaled a low-dose ICS plus either a leukotriene receptor agonist, theophylline.
4. Step 4 - Moderate-to-severe persistent asthma
The preferred controller medication is an inhaled medium-dose corticosteroid plus a leukotriene receptor antagonist
(combination therapy). Alternatives include an inhaled medium-dose corticosteroid plus either a leukotriene receptor
antagonist, theophylline.
5. Step 5 - Severe persistent asthma
The preferred controller medication is an inhaled high-dose corticosteroid plus a leukotriene receptor agonist.
6. Step 6 - Severe persistent asthma
The preferred controller medication is a high-dose inhaled corticosteroid plus a leukotriene receptor agonist plus an oral
corticosteroid.
TYPES OF MEDICATION USED
1. Quick-relief (rescue) medications.
a. Short-acting beta agonists. E.g. albuterol, salbutamol, they can be used by inhaler or nebulizer.
b. Anticholinergic agents. Ipratropium (Atrovent) and Tiotropium bromide (Spiriva)
c. Oral and intravenous corticosteroids. E.g. prednisone and methylprednisolone, but only for short-term use.
2. Long-term asthma control medications (the cornerstone of asthma treatment)
a. Inhaled corticosteroids. E.g. Budesonide, ciclesonide, fluticasone, beclomethasone etc.
b. Leukotriene antagonist. E.g. Montelukast.
c. Antihistamine. E.g. Ketotifen (Zaditen)
d. Long-acting beta agonists. E.g. salmeterol, formoterol.
e. Combination inhalers. E.g. budesonide-formoterol (Symbicort), fluticasone-salmeterol (Seretide)
f. Theophylline.
OTHER USED MEDICATION
1. Cough preparations.
2. Omega-3 fatty acid (fish oil) as it has an anti-inflammatory effect especially in children.


32
PATIENT EDUCATI ON
1. Use air conditioner to lower humidity and decrease the airborne pollen from trees.
2. Decontaminate the home stuff as in bedroom (covers, pillows..).
3. Use dehumidifier (in areas of high humidification)
4. Avoid pets with fur and feathers.
5. Clean home at least once a week.
6. Wear a facemask on case of cold or dry air.
7. Regular exercise.
8. Eat fruits and vegetables.
9. Keep healthy weight.
10. Control heartburn and GERD.

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