Research Articles Base: Respiratory Disorder Case Studies

Diagnosis and Treatment of Most Respiratory Disorders

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malignant diseases of the respiratory tract.   INTRODUCTION             The diagnosis and treatment of most respiratory disorders depend heavily on understanding the basic physiologic principles of respiration and gas exchange. Some respiratory diseases result from inadequate ventilation, whereas others result from abnormalities of diffusion through the pulmonary membrane or abnormal transport in the blood from the lungs to the tissues. The therapy is often entirely different for these diseases, so it is no longer satisfactory simply to make a diagnosis of “respiratory insufficiency” (Guyton & Hall, 2000). In the normal respiratory system, the volume and pattern of ventilation are determined by the neural output from the respiratory center located near the ventrolateral surface of the medulla. This output is influenced by afferent information from several sources, including higher centers in the brain, peripheral chemoreceptors, central chemoreceptors, and neural impulses from moving tendons and joints.             Deviation from the normal range, and consequent respiratory insufficiency, can result from malfunction of the respiratory system at any point in the respiratory pathway. It is important to appreciate this when ordering and interpreting pulmonary function tests. Disturbances of different points can usually be measured specifically when the tests available and the patterns of pathophysiologic disturbances are understood.             Diagnosis and management of pulmonary disorders requires a history, a physical examination, and usually chest x-rays. Pulmonary function testing, arterial blood gas analysis, chemical or microbiologic tests, or special studies (eg, endoscopy, bronchoalveolar lavage, biopsy, radionuclide scanning) may be needed.             Among the most fundamental of all tests of pulmonary performance are determinations of the blood PO2, CO2 and pH. Several simple and rapid methods have been developed to make these measurements within a few minutes, using no more than a few drops of blood (Guyton & Hall, 2000).             Blood pH is measured using a glass of pH electrode of the type used in all chemical laboratories. However, the electrodes used for this purpose are miniaturized. A glass electrode pH meter can also be used to determine blood CO2. The concentration of oxygen in a fluid can be measured by a technique called polarography. Electric current is made to flow between a small negative electrode and the solution (Guyton & Hall, 2000). Non malignant respiratory diseases that will be discussed in this paper will include pulmonary hypertension, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, cystic fibrosis, and allergic pulmonary diseases. The importance of histology, cytology and immunohistochemistry in the diagnosis and management of these non-malignant diseases of the respiratory tract will be discussed.   PULMONARY HYPERTENSION             Primary pulmonary hypertension is a rare disease of unknown etiology, whereas secondary pulmonary hypertension is a complication of many pulmonary, cardiac and extrathoracic conditions. Chronic obstructive pulmonary disease, left ventricular dysfunction and disorders associated with hypoxemia frequently result in pulmonary hypertension. Regardless of the etiology, unrelieved pulmonary hypertension can lead to right-sided heart failure. Signs and symptoms of pulmonary hypertension are often subtle and nonspecific. The diagnosis should be suspected in patients with increasing dyspnea on exertion and a known cause of pulmonary hypertension (Stites, 2001).             All patients with documented pulmonary hypertension should undergo a comprehensive laboratory evaluation to clarify the etiology. The goal is to identify or exclude treatable causes. Initial tests include complete blood count, prothrombin time, partial thromboplastin time, hepatic profile and autoimmune panel (Stites, 2001). HIV testing should be considered in all patients, especially those with a compatible history or risk factors. Treatment of pulmonary hypertension is directed at the underlying etiology. For example, patients with emphysema should be treated with long-term oxygen therapy, bronchodilators and steroids to reduce the pulmonary artery pressure. Afterload reduction and diuretics are part of the therapy in patients with left ventricular dysfunction causing pulmonary venous disease. A patient with mitral valve disease may need valve repair or replacement to reduce the chronically elevated left atrial pressure. A patient with chronic thromboembolic pulmonary hypertension will need to be treated indefinitely with anticoagulation therapy, an inferior vena cava filter and a thromboendarterectomy to open the lumen (Brooke Huffman, 2001).   CHRONIC OBSTRUCTIVE PULMONARY DISEASE             Chronic obstructive pulmonary disease (COPD) is a disease state characterized by the progressive development of airflow limitation that is not fully reversible. The airflow limitation is associated with an abnormal inflammatory response of the lungs to noxious particles or gases (Daryanani, 2004). COPD is an umbrella term for two diseases, chronic bronchitis and emphysema, both of which are characterized by irreversible obstruction to air flow on exhalation. Asthma is another obstructive lung disease; however, it is classified separately from COPD because the person with asthma usually has periods during which air flow returns to normal. While many persons with COPD also have some degree of airway reactivity (or bronchospasm) and are thus said to have an asthmatic component to their disease, their air flow never returns to normal. Both COPD and asthma are also inflammatory processes; however, inflammation in COPD differs markedly from that seen in asthma, with different cells, mediators, and responses to treatment (Locke, 2004). In COPD, definite diagnosis depends on (1) demonstration of physiologic evidence of airways obstruction which persists despite intensive and maximum medical management, and (2) exclusion of any specific disease as a cause of this physiologic abnormality. Individuals with a family history of lung disease and those with an early onset of emphysema should be tested for α1-antitrypsin deficiency to determine the serum levels. Phenotyping should be done if the level is low. The normal phenotype is constituted by the MM genetic pattern. The most common abnormal phenotype associated with α1-antitrypsin deficiency is the ZZ pattern. Persons with the MZ phenotype are carriers of the disease, but do not appear to have an increased risk of developing COPD (Locke, 2004). β-2 agonists, corticosteroids, anticholinergics, and methylxanthines have been the mainstay of COPD therapy. New agents, classes, and combinations of drugs are being developed for the treatment of COPD. In February 2004, tiotropium, a long-acting anticholinergic bronchodilator, was approved by FDA. Three combination products are available: ipratropium/albuterol as a metered-dose inhaler (MDI); ipratropium/albuterol as a solution for inhalation via a nebulizer; and fluticasone/salmeterol, in the 250/50 mcg strength for the treatment of COPD associated with chronic bronchitis (Daryanani, 2004). Phosphodiesterase-4 (PDE4) inhibitors are a newer class of drugs under investigation for the treatment of COPD that may also be available in the near future. With the growing number of pharmacologic options for the treatment of COPD, it is important to use evidence-based clinical data to determine which agents are most beneficial.   Emphysema             In the degenerative and potentially fatal pulmonary disease called emphysema, the lungs lose their elasticity as a result of disruption of elastic tissue and the walls between the alveoli break down so that the alveoli are replaced by large air sacs.             The most common cause of emphysema is excessive cigarette smoking. The smoke causes an increase in the number of pulmonary alveolar macrophages, and these macrophages release a chemical substance that attracts leukocytes to the lungs. The leukocytes in turn release proteases including elastase, which attacks the elastic tissue in the lungs. At the same time, α1-antitrypsin, a plasma protein that normally inactivates elastase and other proteases, is itself inhibited (Ganong, 2001). The α1-antitrypsin is inactivated by oxygen radicals, and these are released by the leukocytes. The final result which can be seen in biochemical and histological tests is a protease-antiprotease imbalance with increased destruction of lung tissue.   Chronic Bronchitis             Chronic bronchitis is an inflammatory condition clinically defined as a chronic cough that exists for 3 months of the year for 2 consecutive years. While the diagnosis of bronchitis is based on clinical criteria, distinctive pathologic features of the airways are associated with the hypersecretion of mucus (Locke, 2004). Again, as in emphysema, certain proteases are involved. In chronic bronchitis, these proteases are potent stimulants of mucus secretion as the size and number of mucus-secreting goblet cells in the airway epithelium increase. Mucosal inflammation is characterized by edema, which further narrows the airways. These inflammatory airway changes occur secondary to chronic stimulation from irritants such as cigarette smoke. The presence of thick and tenacious mucus in the airways also promotes adherence of bacteria, which can reproduce rapidly in this environment. Impaired ciliary function, caused by cigarette smoking, further compromises the lung’s defense mechanisms and increases the patient’s susceptibility to infection (Locke, 2004).   ASTHMA             Asthma is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Three abnormalities are present: airway obstruction that is at least partially reversible, airway inflammation, and airway hyper-responsiveness to a variety of stimuli. A link to allergy has long been recognized, and plasma IgE levels are often elevated as found out in biochemical tests. The sputum in a patient with uncomplicated asthma is highly distinctive. Grossly, it is tenacious, rubbery and whitish. In the presence of infection, particularly in adults, the sputum may be yellowish. Examination of the blood and the sputum of a patient with asthma commonly shows eosinophilia regardless of whether allergic factors can be shown to have an etiologic role in the disease. Blood eosinophilia > 250 to 400 cells/cu mm is the rule; in many asthmatics, the degree of the eosinophilia may correlate with the severity of the asthma. The extent to which blood eosinophilia can be suppressed with corticosteroids has been used as an index of the therapeutic efficacy of these agents. Proteins released from eosinophils in the inflammatory reaction may damage the airway epithelium and contribute to the hyper-responsiveness. Leukotrienes are released from eosinophils and mast cells, and leukotrienes cause bronchoconstriction. Numerous other amines, neuropeptides, chemokines, and interleukins have effects on bronchial smooth muscle or produce inflammation, and they may be involved in asthma (Ganong, 2001).             Many eosinophils are found histologically, frequently arranged in sheets; large numbers of histiocytes and polymorphonuclear leukocytes are also present. Eosinophilic granules from disrupted cells may be seen throughout the sputum smear. Elongated dipyramidal crystals (Charcot-Leyden) originating from eosinophils are commonly found. When infection is present, and particularly when there is a bronchotic element, polymorphonuclear leukocytes and bacteria predominate. In uncomplicated asthma, sputum cultures rarely reveal pathogenic bacteria.             In the treatment of asthma, inhibitors of leukotriene synthesis such as zilueton and CysLT1 receptor blockers such as montelukast are found to be effective. β-Adrenergic receptors mediate bronchodilation, and treatment with inhaled β-Adrenergic agonists is a standard therapy for asthma.   PNEUMONIA             In diagnosing lower respiratory tract infections, histology and immunohistochemistry are important. Most of the clinical manifestations of the various pneumonias overlap. Some investigators demonstrated that chest radiography is not helpful for differentiating bacterial from nonbacterial pneumonia. Therefore, microbiologic means should be used to identify the causative agent in pneumonia (Thomson, 1991). Identification of the causative agent and knowledge of its antimicrobial susceptibility are important in determining the approach to treatment. Consequently, gram stain and culture of lower respiratory secretions should be performed.             Immunologic diagnosis of community-acquired pneumonia in adults can be attempted using methods that detect bacterial antigen in tissue fluids and microorganism-specific antibody (IgM or IgG) in serum. Detection of Haemophilus influenzae and Streptococcus pneumoniae antigens has been evaluated using counter-immunoelectrophoresis, latex agglutination, coagglutination and enzyme immunoassay (Thomson, 1991). The following tests can help with diagnosis and treatment of pneumonia: (1) Chest X-ray, indicated for anyone with suspected pneumonia to aid diagnosis, gain insight into the cause and severity of pneumonia, detect associated lung diseases, and assess the patient’s response to treatment. (2) Blood work, including complete blood cell count and differential; serum creatinine, urea nitrogen, glucose, electrolyte, bilirubin, and liver enzyme levels; possibly HIV status; Sao^sub 2^ levels; and blood cultures. (3) Sputum tests, including Gram’s stain, culture and sensitivity, and possibly tuberculosis and Legionella testing. Negative results help confirm the presence of viral pneumonia. (4) Thoracentesis with culture and stain, pH, white blood cell count and differential, and possibly cytologic testing (Schultz, 2002).  The goal of empiric therapy is to choose a regimen that will be effective against the most likely pathogen. When rapid diagnostic techniques are not available, therapy should be started based on the knowledge of the susceptibility pattern of the common respiratory pathogens in the community. A reasonable attempt should be made to obtain a Gram stain of respiratory secretions before antimicrobial therapy is started (Thomson, 1991).             With the aid of the Gram stain results, the physician can initiate treatment based on a suspected pathogen. When gram-positive cocci in chains or pairs are found as the predominant organism, S. pneumoniae is the most likely causative organism. When the smear indicates gram-positive cocci in clusters, staphylococcal infection must be considered. The finding of gram-negative coccobacilli in the smear is compatible with H. influenzae. Gram-negative diplococci suggest M. catarrhalis, and gram-negative rods are indicative of Enterobacteriaceae, Pseudomonas and anaerobic organisms. When mixed gram-positive and gram-negative organisms are seen, aspiration of oral flora should be suspected (Thomson, 1991).   CYSTIC FIBROSIS             Cystic fibrosis is another condition that leads to repeated pulmonary infections and progressive, eventually fatal destruction of the lungs. In this congenital recessive disorder, a Cl- channel in the apical membrane of airway epithelial cells is not activated in a normal fashion by cyclic adenosine monophosphate (cAMP).             Histologically, the gene that is abnormal in cystic fibrosis is located in the long arm of chromosome 7. This gene encodes a Cl- channel called the cystic fibrosis transmembrane conductance regulator (CFTR) (Ganong, 2001). Functional abnormalities in the CFTR protein result in a paucity of salt and water in secretions from epithelial cells. Consequently, airway secretions are tenacious and difficult to clear, leading to airway obstruction and subsequent bacterial infection. Recurrent bacterial infections and subsequent inflammation damage the lungs and account for much of the irreversible pulmonary disease in patients with cystic fibrosis (Worth, 1996). Sweat testing (using pilocarpine iontophoresis) is a standard quantitative test in the diagnosis of cystic fibrosis. A chloride level greater than 60 mEq per L is a positive test. False-negative and false-positive results are rare, but they do occur. A positive sweat test in combination with typical pulmonary manifestations, pancreatic malabsorption or a history of cystic fibrosis in the immediate family is considered diagnostic (Worth, 1996). Similarly, eosinophilia and elevated serum Ige levels lend confirmatory evidence but cannot establish the diagnosis. This test is usually performed at age 1 to 2 weeks when cystic fibrosis is suspected at birth, but can be done at any age. A complete microbiological assessment of expectorated sputum, including antibiotic susceptibility testing, should be performed at least on an annual basis, and preferably on a quarterly basis. Oropharyngeal swab cultures, which are commonly obtained from children who do not produce sputum, have not been fully studied in adults. Multiply-resistant Gram-negative organisms, such as Burkholderia cepacia, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans, are found in up to one third of adults with cystic fibrosis (David, 2004).             ALLERGIC PULMONARY DISEASES             Hypersensitivity (allergic) diseases of the lungs include hypersensitivity pneumonitis (extrinsic allergic alveolitis), allergic bronchopulmonary aspergillosis, and many drug reactions. Other eosinophilic pneumonias and the pulmonary granulomatoses are of suspected allergic origin.              Most data suggest that Th1 responses are required for viral clearance but Th1 cytokines such as interferon-[gamma] can also enhance the inflammatory response. Allergic airway responses are characterized by Th2 cytokines, increased production of total and allergen-specific IgE, tissue eosinophilia, and elevated exhaled nitric oxide (NO) in the lower airway, and are thought to be ineffective against viral infection and perhaps even detrimental (Varner, 2002).             Inhaled corticosteroids are the primary treatment for rhinitis and are thought to suppress Th2-like inflammation but not Th1 responses. Yet, nondiscriminate suppression of Th2 responses leads to a reduction in eosinophils, anti-inflammatory Th2 cytokines, and exhaled NO, and thus may enhance susceptibility to or severity of viral infection. Indeed, inhaled steroids are less effective against viral-induced wheezing than other triggers of asthma exacerbations and increase adverse sequelae of viral infection, such as otitis media in children, when used in the upper airway (Varner, 2002).   SUMMARIZATION/CONCLUSION             There are already significant advancements in the diagnosis and management of non-malignant diseases of the respiratory tract. These advancements are in the field of histology, cytology and immunohistochemistry.             Most non-malignant diseases of the respiratory tract can be diagnosed using cell and tissue specimens of respiratory organs. Cytological and histological examinations would be helpful in diagnosing these diseases. Diseases usually show abnormal patterns and characteristics in cell and tissue cultures that will be examined.             Histology, cytology and immunohistochemistry can help in confirming diseases, as sometimes chest X-rays and other procedures are not totally exact in diagnosing non-malignant diseases of the respiratory tract.               REFERENCES   Brooke Huffman, G. 2001, Pulmonary Hypertension: Diagnosis and Treatment, American Family Physician. Daryanani, A.A. 2004, Treatment Options for the Management of Chronic Obstructive Pulmonary Disease, Formulary. David, R. 2004, Cystic Fibrosis Adult Care: Consensus Conference Report, Chest. Ganong, W. 2001, Review of Medical Physiology 20th Edition, McGraw-Hill, USA. Gargiulo, R.F. 2000, Postobstructive Pulmonary Edema, American Family Physician. Guyton, A. and Hall, J. 2000, Textbook of Medical Physiology 10th Edition, Harcourt Asia Pte Ltd, Singapore. Locke, D.L. 2004, Update on Chronic Obstructive Pulmonary Disease, MedSurg Nursing. Schultz, T.R. 2002, Pinpointing a Diagnosis, Nursing. Stites, S.W. 2001, Diagnosis and Treatment of Pulmonary Hypertension. American Family Physician. Thomson, R.B. 1991, Ambulatory Management of Lower Respiratory Tract Infections, American Family Physician. Varner, A.E. 2002, The Increase in Allergic Respiratory Disease: Survival of the Fittest? Chest. Credit:ivythesis.typepad.com

Diagnosis and Treatment of Most Respiratory Disorders

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malign...

Critically evaluate the relevant importance of histology, cytology and immunohistchemistry in the diagnosis and management of non-malignant diseases of the respiratory tract

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malignant diseases of the respiratory tract.   INTRODUCTION             The diagnosis and treatment of most respiratory disorders depend heavily on understanding the basic physiologic principles of respiration and gas exchange. Some respiratory diseases result from inadequate ventilation, whereas others result from abnormalities of diffusion through the pulmonary membrane or abnormal transport in the blood from the lungs to the tissues. The therapy is often entirely different for these diseases, so it is no longer satisfactory simply to make a diagnosis of “respiratory insufficiency” (Guyton & Hall, 2000). In the normal respiratory system, the volume and pattern of ventilation are determined by the neural output from the respiratory center located near the ventrolateral surface of the medulla. This output is influenced by afferent information from several sources, including higher centers in the brain, peripheral chemoreceptors, central chemoreceptors, and neural impulses from moving tendons and joints.             Deviation from the normal range, and consequent respiratory insufficiency, can result from malfunction of the respiratory system at any point in the respiratory pathway. It is important to appreciate this when ordering and interpreting pulmonary function tests. Disturbances of different points can usually be measured specifically when the tests available and the patterns of pathophysiologic disturbances are understood.             Diagnosis and management of pulmonary disorders requires a history, a physical examination, and usually chest x-rays. Pulmonary function testing, arterial blood gas analysis, chemical or microbiologic tests, or special studies (eg, endoscopy, bronchoalveolar lavage, biopsy, radionuclide scanning) may be needed.             Among the most fundamental of all tests of pulmonary performance are determinations of the blood PO2, CO2 and pH. Several simple and rapid methods have been developed to make these measurements within a few minutes, using no more than a few drops of blood (Guyton & Hall, 2000).             Blood pH is measured using a glass of pH electrode of the type used in all chemical laboratories. However, the electrodes used for this purpose are miniaturized. A glass electrode pH meter can also be used to determine blood CO2. The concentration of oxygen in a fluid can be measured by a technique called polarography. Electric current is made to flow between a small negative electrode and the solution (Guyton & Hall, 2000). Non malignant respiratory diseases that will be discussed in this paper will include pulmonary hypertension, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, cystic fibrosis, and allergic pulmonary diseases. The importance of histology, cytology and immunohistochemistry in the diagnosis and management of these non-malignant diseases of the respiratory tract will be discussed.   PULMONARY HYPERTENSION             Primary pulmonary hypertension is a rare disease of unknown etiology, whereas secondary pulmonary hypertension is a complication of many pulmonary, cardiac and extrathoracic conditions. Chronic obstructive pulmonary disease, left ventricular dysfunction and disorders associated with hypoxemia frequently result in pulmonary hypertension. Regardless of the etiology, unrelieved pulmonary hypertension can lead to right-sided heart failure. Signs and symptoms of pulmonary hypertension are often subtle and nonspecific. The diagnosis should be suspected in patients with increasing dyspnea on exertion and a known cause of pulmonary hypertension (Stites, 2001).             All patients with documented pulmonary hypertension should undergo a comprehensive laboratory evaluation to clarify the etiology. The goal is to identify or exclude treatable causes. Initial tests include complete blood count, prothrombin time, partial thromboplastin time, hepatic profile and autoimmune panel (Stites, 2001). HIV testing should be considered in all patients, especially those with a compatible history or risk factors. Treatment of pulmonary hypertension is directed at the underlying etiology. For example, patients with emphysema should be treated with long-term oxygen therapy, bronchodilators and steroids to reduce the pulmonary artery pressure. Afterload reduction and diuretics are part of the therapy in patients with left ventricular dysfunction causing pulmonary venous disease. A patient with mitral valve disease may need valve repair or replacement to reduce the chronically elevated left atrial pressure. A patient with chronic thromboembolic pulmonary hypertension will need to be treated indefinitely with anticoagulation therapy, an inferior vena cava filter and a thromboendarterectomy to open the lumen (Brooke Huffman, 2001).   CHRONIC OBSTRUCTIVE PULMONARY DISEASE             Chronic obstructive pulmonary disease (COPD) is a disease state characterized by the progressive development of airflow limitation that is not fully reversible. The airflow limitation is associated with an abnormal inflammatory response of the lungs to noxious particles or gases (Daryanani, 2004). COPD is an umbrella term for two diseases, chronic bronchitis and emphysema, both of which are characterized by irreversible obstruction to air flow on exhalation. Asthma is another obstructive lung disease; however, it is classified separately from COPD because the person with asthma usually has periods during which air flow returns to normal. While many persons with COPD also have some degree of airway reactivity (or bronchospasm) and are thus said to have an asthmatic component to their disease, their air flow never returns to normal. Both COPD and asthma are also inflammatory processes; however, inflammation in COPD differs markedly from that seen in asthma, with different cells, mediators, and responses to treatment (Locke, 2004). In COPD, definite diagnosis depends on (1) demonstration of physiologic evidence of airways obstruction which persists despite intensive and maximum medical management, and (2) exclusion of any specific disease as a cause of this physiologic abnormality. Individuals with a family history of lung disease and those with an early onset of emphysema should be tested for α1-antitrypsin deficiency to determine the serum levels. Phenotyping should be done if the level is low. The normal phenotype is constituted by the MM genetic pattern. The most common abnormal phenotype associated with α1-antitrypsin deficiency is the ZZ pattern. Persons with the MZ phenotype are carriers of the disease, but do not appear to have an increased risk of developing COPD (Locke, 2004). β-2 agonists, corticosteroids, anticholinergics, and methylxanthines have been the mainstay of COPD therapy. New agents, classes, and combinations of drugs are being developed for the treatment of COPD. In February 2004, tiotropium, a long-acting anticholinergic bronchodilator, was approved by FDA. Three combination products are available: ipratropium/albuterol as a metered-dose inhaler (MDI); ipratropium/albuterol as a solution for inhalation via a nebulizer; and fluticasone/salmeterol, in the 250/50 mcg strength for the treatment of COPD associated with chronic bronchitis (Daryanani, 2004). Phosphodiesterase-4 (PDE4) inhibitors are a newer class of drugs under investigation for the treatment of COPD that may also be available in the near future. With the growing number of pharmacologic options for the treatment of COPD, it is important to use evidence-based clinical data to determine which agents are most beneficial.   Emphysema             In the degenerative and potentially fatal pulmonary disease called emphysema, the lungs lose their elasticity as a result of disruption of elastic tissue and the walls between the alveoli break down so that the alveoli are replaced by large air sacs.             The most common cause of emphysema is excessive cigarette smoking. The smoke causes an increase in the number of pulmonary alveolar macrophages, and these macrophages release a chemical substance that attracts leukocytes to the lungs. The leukocytes in turn release proteases including elastase, which attacks the elastic tissue in the lungs. At the same time, α1-antitrypsin, a plasma protein that normally inactivates elastase and other proteases, is itself inhibited (Ganong, 2001). The α1-antitrypsin is inactivated by oxygen radicals, and these are released by the leukocytes. The final result which can be seen in biochemical and histological tests is a protease-antiprotease imbalance with increased destruction of lung tissue.   Chronic Bronchitis             Chronic bronchitis is an inflammatory condition clinically defined as a chronic cough that exists for 3 months of the year for 2 consecutive years. While the diagnosis of bronchitis is based on clinical criteria, distinctive pathologic features of the airways are associated with the hypersecretion of mucus (Locke, 2004). Again, as in emphysema, certain proteases are involved. In chronic bronchitis, these proteases are potent stimulants of mucus secretion as the size and number of mucus-secreting goblet cells in the airway epithelium increase. Mucosal inflammation is characterized by edema, which further narrows the airways. These inflammatory airway changes occur secondary to chronic stimulation from irritants such as cigarette smoke. The presence of thick and tenacious mucus in the airways also promotes adherence of bacteria, which can reproduce rapidly in this environment. Impaired ciliary function, caused by cigarette smoking, further compromises the lung’s defense mechanisms and increases the patient’s susceptibility to infection (Locke, 2004).   ASTHMA             Asthma is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Three abnormalities are present: airway obstruction that is at least partially reversible, airway inflammation, and airway hyper-responsiveness to a variety of stimuli. A link to allergy has long been recognized, and plasma IgE levels are often elevated as found out in biochemical tests. The sputum in a patient with uncomplicated asthma is highly distinctive. Grossly, it is tenacious, rubbery and whitish. In the presence of infection, particularly in adults, the sputum may be yellowish. Examination of the blood and the sputum of a patient with asthma commonly shows eosinophilia regardless of whether allergic factors can be shown to have an etiologic role in the disease. Blood eosinophilia > 250 to 400 cells/cu mm is the rule; in many asthmatics, the degree of the eosinophilia may correlate with the severity of the asthma. The extent to which blood eosinophilia can be suppressed with corticosteroids has been used as an index of the therapeutic efficacy of these agents. Proteins released from eosinophils in the inflammatory reaction may damage the airway epithelium and contribute to the hyper-responsiveness. Leukotrienes are released from eosinophils and mast cells, and leukotrienes cause bronchoconstriction. Numerous other amines, neuropeptides, chemokines, and interleukins have effects on bronchial smooth muscle or produce inflammation, and they may be involved in asthma (Ganong, 2001).             Many eosinophils are found histologically, frequently arranged in sheets; large numbers of histiocytes and polymorphonuclear leukocytes are also present. Eosinophilic granules from disrupted cells may be seen throughout the sputum smear. Elongated dipyramidal crystals (Charcot-Leyden) originating from eosinophils are commonly found. When infection is present, and particularly when there is a bronchotic element, polymorphonuclear leukocytes and bacteria predominate. In uncomplicated asthma, sputum cultures rarely reveal pathogenic bacteria.             In the treatment of asthma, inhibitors of leukotriene synthesis such as zilueton and CysLT1 receptor blockers such as montelukast are found to be effective. β-Adrenergic receptors mediate bronchodilation, and treatment with inhaled β-Adrenergic agonists is a standard therapy for asthma.   PNEUMONIA             In diagnosing lower respiratory tract infections, histology and immunohistochemistry are important. Most of the clinical manifestations of the various pneumonias overlap. Some investigators demonstrated that chest radiography is not helpful for differentiating bacterial from nonbacterial pneumonia. Therefore, microbiologic means should be used to identify the causative agent in pneumonia (Thomson, 1991). Identification of the causative agent and knowledge of its antimicrobial susceptibility are important in determining the approach to treatment. Consequently, gram stain and culture of lower respiratory secretions should be performed.             Immunologic diagnosis of community-acquired pneumonia in adults can be attempted using methods that detect bacterial antigen in tissue fluids and microorganism-specific antibody (IgM or IgG) in serum. Detection of Haemophilus influenzae and Streptococcus pneumoniae antigens has been evaluated using counter-immunoelectrophoresis, latex agglutination, coagglutination and enzyme immunoassay (Thomson, 1991). The following tests can help with diagnosis and treatment of pneumonia: (1) Chest X-ray, indicated for anyone with suspected pneumonia to aid diagnosis, gain insight into the cause and severity of pneumonia, detect associated lung diseases, and assess the patient’s response to treatment. (2) Blood work, including complete blood cell count and differential; serum creatinine, urea nitrogen, glucose, electrolyte, bilirubin, and liver enzyme levels; possibly HIV status; Sao^sub 2^ levels; and blood cultures. (3) Sputum tests, including Gram’s stain, culture and sensitivity, and possibly tuberculosis and Legionella testing. Negative results help confirm the presence of viral pneumonia. (4) Thoracentesis with culture and stain, pH, white blood cell count and differential, and possibly cytologic testing (Schultz, 2002).  The goal of empiric therapy is to choose a regimen that will be effective against the most likely pathogen. When rapid diagnostic techniques are not available, therapy should be started based on the knowledge of the susceptibility pattern of the common respiratory pathogens in the community. A reasonable attempt should be made to obtain a Gram stain of respiratory secretions before antimicrobial therapy is started (Thomson, 1991).             With the aid of the Gram stain results, the physician can initiate treatment based on a suspected pathogen. When gram-positive cocci in chains or pairs are found as the predominant organism, S. pneumoniae is the most likely causative organism. When the smear indicates gram-positive cocci in clusters, staphylococcal infection must be considered. The finding of gram-negative coccobacilli in the smear is compatible with H. influenzae. Gram-negative diplococci suggest M. catarrhalis, and gram-negative rods are indicative of Enterobacteriaceae, Pseudomonas and anaerobic organisms. When mixed gram-positive and gram-negative organisms are seen, aspiration of oral flora should be suspected (Thomson, 1991).   CYSTIC FIBROSIS             Cystic fibrosis is another condition that leads to repeated pulmonary infections and progressive, eventually fatal destruction of the lungs. In this congenital recessive disorder, a Cl- channel in the apical membrane of airway epithelial cells is not activated in a normal fashion by cyclic adenosine monophosphate (cAMP).             Histologically, the gene that is abnormal in cystic fibrosis is located in the long arm of chromosome 7. This gene encodes a Cl- channel called the cystic fibrosis transmembrane conductance regulator (CFTR) (Ganong, 2001). Functional abnormalities in the CFTR protein result in a paucity of salt and water in secretions from epithelial cells. Consequently, airway secretions are tenacious and difficult to clear, leading to airway obstruction and subsequent bacterial infection. Recurrent bacterial infections and subsequent inflammation damage the lungs and account for much of the irreversible pulmonary disease in patients with cystic fibrosis (Worth, 1996). Sweat testing (using pilocarpine iontophoresis) is a standard quantitative test in the diagnosis of cystic fibrosis. A chloride level greater than 60 mEq per L is a positive test. False-negative and false-positive results are rare, but they do occur. A positive sweat test in combination with typical pulmonary manifestations, pancreatic malabsorption or a history of cystic fibrosis in the immediate family is considered diagnostic (Worth, 1996). Similarly, eosinophilia and elevated serum Ige levels lend confirmatory evidence but cannot establish the diagnosis. This test is usually performed at age 1 to 2 weeks when cystic fibrosis is suspected at birth, but can be done at any age. A complete microbiological assessment of expectorated sputum, including antibiotic susceptibility testing, should be performed at least on an annual basis, and preferably on a quarterly basis. Oropharyngeal swab cultures, which are commonly obtained from children who do not produce sputum, have not been fully studied in adults. Multiply-resistant Gram-negative organisms, such as Burkholderia cepacia, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans, are found in up to one third of adults with cystic fibrosis (David, 2004).             ALLERGIC PULMONARY DISEASES             Hypersensitivity (allergic) diseases of the lungs include hypersensitivity pneumonitis (extrinsic allergic alveolitis), allergic bronchopulmonary aspergillosis, and many drug reactions. Other eosinophilic pneumonias and the pulmonary granulomatoses are of suspected allergic origin.              Most data suggest that Th1 responses are required for viral clearance but Th1 cytokines such as interferon-[gamma] can also enhance the inflammatory response. Allergic airway responses are characterized by Th2 cytokines, increased production of total and allergen-specific IgE, tissue eosinophilia, and elevated exhaled nitric oxide (NO) in the lower airway, and are thought to be ineffective against viral infection and perhaps even detrimental (Varner, 2002).             Inhaled corticosteroids are the primary treatment for rhinitis and are thought to suppress Th2-like inflammation but not Th1 responses. Yet, nondiscriminate suppression of Th2 responses leads to a reduction in eosinophils, anti-inflammatory Th2 cytokines, and exhaled NO, and thus may enhance susceptibility to or severity of viral infection. Indeed, inhaled steroids are less effective against viral-induced wheezing than other triggers of asthma exacerbations and increase adverse sequelae of viral infection, such as otitis media in children, when used in the upper airway (Varner, 2002).   SUMMARIZATION/CONCLUSION             There are already significant advancements in the diagnosis and management of non-malignant diseases of the respiratory tract. These advancements are in the field of histology, cytology and immunohistochemistry.             Most non-malignant diseases of the respiratory tract can be diagnosed using cell and tissue specimens of respiratory organs. Cytological and histological examinations would be helpful in diagnosing these diseases. Diseases usually show abnormal patterns and characteristics in cell and tissue cultures that will be examined.             Histology, cytology and immunohistochemistry can help in confirming diseases, as sometimes chest X-rays and other procedures are not totally exact in diagnosing non-malignant diseases of the respiratory tract. Credit:ivythesis.typepad.com

Critically evaluate the relevant importance of histology, cytology and immunohistchemistry in the diagnosis and management of non-malignant diseases of the respiratory tract

Critically evaluate the relevant importance of histology, cytology and immunohistochemistry in the diagnosis and management of non-malign...

Sample Respiratory Disorder Case Study on Chronic Ostructive Pulmonary Disease (COPD) in which complications have taken place before the release and risks that a patient might encounter with regards to the treatment

Introduction   The condition of chronic obstructive pulmonary disease (COPD), nothing like a good number other illnesses, is growing in incidence globally. This boost, at least to some extent, is probably as a result of the population surviving much longer generally and increasing cigarette use in developing nations. Moreover, even though contact to cigarette fumes is by a long way the foremost identifiable origin of COPD. Similarly contact to specific occupational dirt and chemicals have also been deemed to be another cause of COPD. On the other hand, exposures in the home like being exposed to the smoke used for cooking and heating are also liable causes. Furthermore, one could not discount the genetic predisposition which might have triggered the illness among the casualties. This paper will look into the condition of a geriatric patient admitted for COPD exacerbation in which complications have taken place before his release. For clarity and coherence of the paper, the discussions and assessment on the stated case will be divided into several parts. One part will be discussing the probable questions that could help the assessment on making out the complications that the patient has acquired. The subsequent part will be discussing the body systems that will be involved in the assessment of the case. It is in this part where the respiratory system and the heart are to be discussed. Specifically, the parts in which the complications might have been involved in the case of the patient is to be taken into consideration. The third part is going to look into the factors in which the patient might encounter risk with regards to the treatment. And finally, after the discussions regarding the situation, a conclusion will be provided with regards to the condition of the patient and concerns with COPD in general.   Questions Providing Essential Information   In the case study, the patient is admitted in the hospital for exacerbated COPD with complications like pneumonia. An exacerbation of COPD is described by a boost in cough, with an alteration in color or amount of sputum or a worse condition of dyspnea. (Shelley and Salpeter, 2003) Before the patient is discharged, he complained of a pain in the left part of his chest and shortness of breath.    o       Does the patient have a family history of heart problems? o       Does he have a hypertension and high cholesterol in his medical history? o       Has the patient totally stopped smoking tobacco? o       Does the patient feel emotionally strained? o       Is the pain felt underneath the breastbone? o       Is the pain characterized by a prickly, intense, or constricting feeling? o       Does the pain start after a walk or if he leaves his bed? o       Is the pain relieved when the patient gets enough rest? In looking in the response of the patient based on the case, one could suspect that the patient is experiencing an episode of angina. Moreover, if the medical history of the patient is taken into account, one could also presume the existence of a case of chronic heart failure.     Body Systems Included in the Assessment   The condition of the elderly patient with COPD is actually possible in terms of acquiring heart diseases. Patients with COPD are at bigger danger of acquiring heart illnesses as compared to asthmatics. (Shelley and Salpeter, 2003) Nevertheless, they similarly possess more severe airway impediments such that they may possibly be more susceptible to small alterations in forced expiratory volume at 1 second. (FEV1) In a study of Shelley and Salpeter (2003) they noted that these patients would make the most from the employment of ß blockers.   In a study of Cilli, Uslu, Ozdemir (2004), they noted that patients with chronic obstructive pulmonary disease (COPD) have a bigger possibility of fatality from reasons other than COPD. The most frequent comorbid illnesses include hypertension (22%), coronary heart disease (8.9%), diabetes mellitus (7.4%), cancer (6.4%), heart failure (4.9%) and cerebrovascular disease (2%). Whereas the most the said sicknesses were stated to be the most frequent comorbid factor, FEV1, heart failure and cancer were related components with bigger threat of death from COPD.   On the other hand, it was stated that the case may possibly be complicated by a heart condition on the part of the patient, it is important to take a look at the possibility of the patient having a chronic heart failure. Left-sided chronic heart failure (CHF) takes place in patients with COPD for the reason of a concurrent cardiac disorder like coronary artery disease or hypertension. (Wilbert and Aronow, 2003) This is apparently present in the case of the elderly patient considering he had a history of hypercholesterolemia and poorly controlled hypertension. It should be treated in concurrence with the COPD, however, on grounds of financial problems with the patient, it was ceased. Moreover, according to the work of Wilbert and Aronow (2003) it is important to establish whether the patient really has stopped smoking. If he did stop, it must be established whether he has been constantly exposed to other probable sources of COPD, like secondary cigarette smoke or chemical dusts.   Another system to be checked is the respiratory tract. (Wilbert and Aronow, 2003) It should be checked if it is infected. If it is infected, it might lead to RV failure. This means that it should be treated quickly. To look if the tract is indeed infected,   the secretions of the sputum should be monitored to establish whether there is a need to employ mucolytic agents to address this condition.     Risk Factors in the Patient’s Condition   This part will be discussing the risk factors involved in the condition of the patient. Particularly, those related to the lifestyle choices, medications, and conditions are going to be pointed out in this context.     Conditions The patient might have exacerbated his condition because of his being bed-ridden for several days caused by his COPD exacerbation. This might have triggered the heart condition that has been caused by his previous illnesses GERD, hypercholesterolemia, and hypertension over and above his exposure to smoking. His old age has also added the risk of the heart condition. Having a geriatric patient lessens the capability and speed of recovery because of the slower metabolism of the patient. Similarly, the inactivity of the patient might have also triggered the disease since he has been confined for several days already. This inactivity might have slowed down his already slow metabolism rate and might have triggered the illness along with the help of the COPD.     Lifestyle choices There are two lifestyle choices that should be looked into in taking into account the risk factors present in the patient’s condition. First is the existence of alcohol abuse or withdrawal. Alcohol consumption is associated with a favorable lipid profile. (Mozaffarian et al, 2004) On the other hand, greater intake is associated with brain atrophy. Another lifestyle choice is smoking. Cigarette smoking is a well recognized risk factor for illnesses among adolescent and grown-up populations. Older adults who have ceased smoking have inferior risk than those who carry on smoking. (Mozaffarian et al, 2004) However, continuous exposure to cigarette smokes such that of second hand smoke may still trigger the risk factor. Medications Early methods for the management of COPD are in a lot of aspects considerably unlike from current recommendations. At first, the amount of pharmacologic agents accessible to take care of COPD was inadequate. Antibiotics, mucolytics, and nonselective sympathomimetics were the key agents provided for COPD management. (Petty, 2002) Paradoxically, oxygen and working out, a couple of the most common elements of treatment today were deemed harmful.   Antibiotics have been accessible to take care of patients with COPD for years and frequently were controlled consistently in patients with obstructive lung disease. Even though patients with COPD are more vulnerable to pulmonary illnesses than are patients with no COPD and management of these agents is an essential element of the management of infection connected with COPD, antibiotic treatment must be employed more prudently nowadays than it was in the past. Antibiotic resistance formerly was recognized in the 1970s and has been growing progressively in commonness. (Faulkner and Hilleman, 2002) On account of this occurrence, patients nowadays are monitored more cautiously for antibiotic requirement. (Saint et al, 2001)   On the other hand, mucolytic drugs are deemed to boost the expectoration of sputum by lessening its thickness. (Faulkner and Hilleman, 2002) More than a few years ago, mucolytic treatment with an oral mixture of potassium iodide was provided to dilute the mucus of patients with COPD. (Petty, 2002) Nowadays, it would be atypical to see this agent employed in such ability in view of its possibly harmful implications in individuals with thyroid disease, and for the reason that other mucolytic agents are readily obtainable. In addition, the effectiveness of mucolytic agents for a good number of patients with COPD has been challenged. Merely lessening the thickness of mucus may possibly be useless with no general reduction in the quantity of mucus emitted. (Rogers, 2002)   Conclusion   Patients who are indicative with constant COPD have need of a range of interventions to optimize their way of life and continued existence. Conditional on their individual conditions, they may possibly take advantage from making the most of airflow, lessening and clearance of secretions, physical treatment, averting infections, and guaranteeing sufficient oxygenation. The different components can be brought in eventually with cautious inspection to establish which intercession has constructive (or adverse) consequences. Responsiveness of other disorders that are frequent among those with COPD will assist in early detection, cure, or prevention. Punctual acknowledgment and efficient administration of acute exacerbations of COPD are necessary. Moreover, facts from this study advocates that diet, physical activity, and smoking habits in the later part of a person’s life may have an effect with health risk. Corresponding to medical or surgical intercessions, such lifestyle alterations are comparatively low risk, low rate, and extensively pertinent. Consequently, even small alterations in risk because of these elements may possibly be important on a population level. Credit:ivythesis.typepad.com

Sample Respiratory Disorder Case Study on Chronic Ostructive Pulmonary Disease (COPD) in which complications have taken place before the release and risks that a patient might encounter with regards to the treatment

Introduction The condition of chronic obstructive pulmonary disease (COPD), nothing like a good number other illnesses, is growing in...

Sample Respiratory Case Study ASTHMA IN CHILDREN

ASTHMA IN CHILDREN             A. Description of Disease:  Textbook Manifestations Asthma is a serious and potentially life-threatening illness affecting many children. It is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Its morbidity and mortality are increasing, and its fundamental cause is still unknown despite intensive research. A child who is frequently coughing or has respiratory infections should be evaluated for asthma. Additionally, a child who coughs after running or crying may also have asthma. Recurrent night cough is common, as asthma is often worse at night (American Lung Association, 2006).   B. Possible Etiology/Epidemiology As mentioned, the basic cause of the lung abnormality in asthma is not yet known. However, three abnormalities are present in asthma: airway obstruction that is at least partially reversible, airway inflammation, and airway hyperresponsiveness to a variety of stimuli. Episodes of asthma often are triggered by some condition or stimulus. Common triggers of asthma are exercise, infections, allergy, irritants, and weather.   C. Implications on growth and development Asthma is one of the most pervasive chronic illnesses in the United States, and it disproportionately affects children from low-income, urban, and/or ethnic minority backgrounds. Pediatric research has provided evidence that children who have been diagnosed with asthma experience compromises in psychological, behavioral, and social. The results from one study of urban children indicate young kids with asthma often exhibit behavioral problems, and that in many cases, children with persistent asthma may struggle in more than one area of behavior (KidsHealth, 2006). However, some studies also have found that children with asthma fare as well as their healthy peers in terms of psychosocial functioning (Mitchell, 2005).   D. Pertinent normal and abnormal lab data and diagnostic tests with significance for nursing care Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, normal findings during periods of remission. Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease. Arterial blood gases (ABGs): Determined degree and severity of disease process, e.g., most often PaO2 is decreased, PaCO2 is often decreased, pH normal or acidotic, and mild respiratory alkalosis secondary to hyperventilation in asthma. Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases. Complete blood count and differential: Increased eosinophils in asthma. Sputum culture: Determines presence of infection, identifies pathogen. Cytologic examination: Rules out underlying malignancy or allergic disorder. Electrocardiogram (ECG): Right axis deviation and peaked P waves in severe asthma. Exercise, ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program. Children with congenital malformations of the vascular system and of the gastrointestinal and respiratory tracts may present with wheezing. The presence of other congenital malformations, special attention to cases in which symptoms begin before age 1 year, x-ray studies, and a high index of suspicion will lead to a diagnosis of congenital malformation as a cause of wheezing. Foreign-body obstruction must be considered, particularly in children with unilateral wheezing or sudden onset of wheezing with no prior history of respiratory symptoms. Opaque foreign bodies are readily visible on x-ray. Non-opaque foreign bodies are more of a problem, but the diagnosis can be reestablished by a history of sudden onset of cough and wheezing in a previously well child, combined with asymmetric diaphragmatic movement on inspiratory and expiratory chest x-rays. Viral infections of the upper respiratory tract involving the epiglottis, glottis, and subglottis generally cause signs and symptoms of croup (inspiratory stridor, high-pitched cough, and hoarseness) that are distinct from the lower airways signs and symptoms of asthma.   E. Management             Nursing priorities include (a) maintain airway patency, (b) assist with measures to facilitate gas exchange, (c) enhance nutritional intake, (d) prevent complications and slow the progression of asthma, and (e) provide information about disease process of asthma and the prognosis and treatment regimen.             An important component of any intervention model designed to mitigate the impact of asthma on inner city children is the ability to efficiently and reliably identify children who are likely to have poorly controlled asthma. Ideally, this process would identify children with previously diagnosed asthma who are not receiving adequate therapy as well as children with undiagnosed asthma. Schools have received increasing attention as strategic sites for this process. School-based case identification methods that have been tested include parental surveys and exercise challenge procedures (Hanley-Lopez, 2004).             A holistic approach to the nursing care of children is required and involvement of the family is essential. The role of the children’s nurse is multifaceted and continually evolving. It includes being the carer, health educator and health promoter, the researcher, empowerer and the advocate. Children’s nurses must harness their power and influence: by working collaboratively with policymakers, other clinicians and service users, they can strive to give children the priority they deserve. Policy developments, the shift in care from hospital to the community and the recognition given to family centred care mean that children’s nurses must increasingly address the wider issues that influence child health and family wellbeing (Ross, 2003).             Discharge goals include (a) ventilation/oxygenation adequate to meet self-care needs, (b) nutritional intake meeting caloric needs, (c) the infection treated or prevented, (d) disease process or prognosis and therapeutic regimen understood, and (e) plan in place to meet needs after discharge.   F. Prognosis             Children with asthma have acute episodes when the air passages in their lungs get narrower as a result f different triggers. Because of this, their breathing becomes more difficult. These problems are caused by an oversensitivity of the lungs and airways.             The allergic reaction that occurs in asthma is believed to occur in the following way: the child forms abnormally large amounts of IgE antibodies, and these antibodies cause allergic reactions when they react with the specific antigens that have caused them to develop in the first place. When the child breathes in pollen to which he or she is sensitive, the pollen reacts with the antibodies that are attached to mast cells and causes them to release several different substances. The combined effects of all these factors are to produce (1) localized edema in the walls of the small bronchioles, as well as secretion of thick mucus into the bronchiolar lumens, and (2) spasm of the bronchiolar smooth muscle (Guyton & Hall, 2000).   G. Health promotion activities, teaching/learning and discharge needs.             Given the age of the child, he or she could have deficient knowledge regarding condition, treatment, self-care and discharge needs. This learning need is usually due to lack of information/unfamiliarity with information resources, information misinterpretation, and lack of recall/cognitive limitation (Doenges et al, 2002), the last of which could be applicable to the child. The parents or the guardian of the child should therefore be present along with the child during health promotion activities and teaching/learning and discharge needs.             The desired outcomes for these activities are to (a) verbalize understanding of condition/disease process and treatment, (b) identify relationship of current signs/symptoms to the disease process and correlate these with causative factors, and (c) initiate necessary lifestyle changes and participate in treatment regimen. The health promotion activities and teaching of disease process and other needs is outlined below: 		Nursing Actions/Interventions 		Rationale Explain or 		reinforce explanations of individual disease process. The child as well 		as the parents or guardian are encouraged to ask questions. Decreases anxiety 		and can lead to improved participation in treatment plan. Instruct or 		reinforce rationale for breathing exercises, coughing effectively, and 		general conditioning exercises. Specific breathing 		exercises can strengthen the muscles of respiration, help minimize 		collapse of small airways, and provide the child with means to control 		dyspnea. General conditioning exercises increase activity tolerance, 		muscle strength, and sense of well being. Stress importance 		of oral care/dental hygiene. Decreases 		bacterial growth in the mouth, which can lead to pulmonary infections. Discuss importance 		of avoiding people with active respiratory infections. Stress the need 		for routine influenza/pneumococcal vaccinations. Decreases exposure 		to and incidence of acquired acute respiratory infections. Discuss individual 		factors that may trigger or aggravate condition like excessively dry 		air, wind, environmental temperature extremes, pollen, tobacco smoke, 		aerosol sprays, air pollution. Parents/guardians should be encouraged to 		explore ways to control these factors in and around the home, school or 		any environment which the child stays. These 		environmental factors can induce/aggravate bronchial irritation, leading 		to increased secretion production and airway blockage. Provide 		information about activity limitations and alternating activities with 		rest periods to prevent fatigue. Having this 		knowledge can enable parents of the child to make informed 		choices/decisions to reduce dyspnea, maximize activity level, perform 		most desired activities and prevent complications for the child. Upon discharge, 		discuss importance of medical follow-up care, periodic chest x-rays, and 		sputum cultures. Monitoring disease 		process allows for alterations in therapeutic regimen to meet changing 		needs and may help prevent complications. Instruct asthmatic 		patient in use of peak flow meter, as appropriate. Peak flow level 		can drop before the patient exhibits any signs/symptoms of asthma during 		the “first time” after exposure to trigger. Regular use of the peak flow 		meter may reduce the severity of the attack because of the earlier 		intervention. Provide 		information and encourage participation in support groups, e.g., 		American Lung Association, public health department. The child and the 		parents or guardian may experience anxiety, depression, and other 		reactions as they deal with asthma that will have an impact on their 		lifestyle. Support groups and/or home visits may be desired or needed to 		provide assistance, emotional support, and respite care. Refer for 		evaluation of home care if indicated. Provide a detailed plan of care 		and baseline physical assessment to home care nurse as needed on 		discharge from acute care. Provides for 		continuity of care. may help reduce frequency of rehospitalization. Discuss 		respiratory medications, side effects, adverse reactions. The child may be 		on several respiratory drugs that have similar side effects and 		potential drug interactions. It is important that the parents or the 		guardian of the child understand the difference between nuisance side 		effects and untoward or adverse side effects.     Website research   URL: http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22691             This website is maintained by the American Lung Association, an organization whose mission is to prevent lung disease and promote lung health. The American Lung Association exists outside the internet and is the oldest voluntary health organization in the United States. The association is geared on fighting lung disease in all forms, most especially asthma, tobacco control, and environmental health. A section on Asthma and Children is in the website which has been used as a reference for this paper. The site is appropriate for everyone who is concerned about their lung health and would like to know more about lung problems. Health care professionals and ordinary individuals concerned about lung health can use the site. The information provided in the website are useful, relevant and reliable. The facts presented agree with some which are found in textbooks and journals. This site can be trusted since this is maintained by a reputable health organization and is likely to be more impartial and trustworthy than one privately developed. However, the site presents a disclosure that all information contained in their website is not a substitute for medical advice or treatment, and they recommend consultation with a health care professional or a doctor. There was no specific date as to when the site has been updated but the year printed on the page is 2006.     URL: http://www.nlm.nih.gov/medlineplus/asthmainchildren.html             The name of the website is Medline Plus and is maintained by the U.S. government, specifically the U.S. National Library of Medicine and the National Institutes of Health. Regarding asthma, it contains links to other websites including that of the American Lung Association. The site provides health information regarding almost any kind of health issue, most are linked to other websites. Everyone could make use of the site, not just those who have children with asthma or lung problems. Although a section is dedicated to children with asthma, there are also other pages for adults with asthma. The website could be trusted that it provides useful and reliable information based on the fact that this is maintained by the government and includes information taken from other reliable websites. The site is last updated on November 3, 2006.   URL: http://kidshealth.org/research/asthma_behavioral.html             This is a link taken from the Medline Plus website and contains an article entitled “Behavioral Problems Often Present in Children with Asthma,” which is a review of a study. This website is called Kids Health for Parents. From the name of the website alone, one can tell that this site has parents of little children as its target audience. Aside from asthma, the website offers information regarding other health concerns of children. The information used in the article is reliable and useful since it is taken from a published study in the Pediatrics journal. The article mentioned has been reviewed in February 2006, suggesting that the website could be recently updated.   URL: http://pediatrics.about.com/cs/conditions/a/asthma.htm             This site, about.com, is a commercial organization offering information about virtually everything, not only about health concerns. The target audience of this site is everyone who wishes to know something about any topic. If one wishes to know about asthma, one could just click the link provided that would bring one to the page about asthma. A topic about Asthma in Children, created on November 20, 2003, is provided in one of its pages. The writer of this article is a doctor named Vincent Iannelli. Compared to the previous websites that have been mentioned, this one still contains information that is useful but less reliable.   URL: http://www.umm.edu/pediatric-info/asthma.htm             This is an educational institution website of the University of Maryland Medical Center. It provides various resources regarding medical issues, among them children’s health. The page on asthma in children was last reviewed on May 14, 2003 by a University of Maryland Medicine expert. Compared to commercial organizations, educational institutions can be more trusted regarding the content of their site. The target audience of this website could be medicine students and other health care professionals, but is not strictly limited only to them. Everyone could access the website and do research regarding issues in medicine. Credit:ivythesis.typepad.com

Sample Respiratory Case Study ASTHMA IN CHILDREN

ASTHMA IN CHILDREN A. Description of Disease: Textbook Manifestations Asthma is a serious and potentially life-threatenin...