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  1. Biphasic
    anaphylaxis
  2. Biphasic anaphylaxis is the recurrence of
    • symptoms within 72 hours with no further
    • exposure to the allergen. It occurs in
    • between 1‒20% of cases depending on the
    • study examined. It is managed in the same
    • manner as anaphylaxis.
  3. Anaphylactic
    shock
  4. Anaphylactic shock is anaphylaxis
    • associated with systemic vasodilation that
    • results in low blood pressure. It is also
    • associated with severe bronchoconstriction
    • to the point where the individual is unable to
    • breathe.
  5. Pseudoanaphylaxis
  6. The presentation and treatment of pseudoanaphylaxis
    • is similar to that of anaphylaxis. However, it does not
    • involve an allergic reaction but is due to direct mast
    • cell degranulation.[10] This can result from morphine,
    • radiocontrast, aspirin and muscle relaxants
  7. Active
    anaphylaxis
  8. Active anaphylaxis is what is naturally
    • observed. Two weeks or so after an animal,
    • including humans, is exposed to certain
    • allergens, active anaphylaxis (which is
    • simply called "anaphylaxis") would be elicited
    • upon exposure to the same allergens.
    • 4 4
    • Passive
    • anaphylaxis
    • Passive anaphylaxis is induced in native
    • animals that receive transfer of the serum
    • experimentally from sensitized animals with
    • certain allergens. Passive anaphylaxis would
    • be provoked in the recipient animals after
    • exposure to the same allergens.
    • 5 5
  9. Passive
    anaphylaxis
  10. Passive anaphylaxis is induced in native
    • animals that receive transfer of the serum
    • experimentally from sensitized animals with
    • certain allergens. Passive anaphylaxis would
    • be provoked in the recipient animals after
    • exposure to the same allergens.
  11. Signs and symptoms Anaphylaxis can present with many
    different symptoms due to the systemic effects of histamine
    release. These usually develop over minutes to hours. The
    most common areas affected include: skin (80% to 90%),
    respiratory (70%), gastrointestinal (30% to 45%), heart and
    vasculature (10% to 45%), and central nervous system
    (10% to 15%)
  12. CausesAnaphylaxis can occur in response to any allergen. Common triggers include insect bites or stings,
    • foods, medication, and latex rubber. FoodMany foods can trigger anaphylaxis. The most common are
    • peanuts, wheat, tree nuts, shellfish, fish, milk, and eggs.[9] Severe cases are usually the result of ingesting
    • the allergen. MedicationAny medication may potentially trigger anaphylaxis. The most common to do so
    • include antibiotics (β-lactam antibiotics in particular), aspirin, ibuprofen, and other analgesics.[9] Some drugs
    • (polymyxin, morphine, x-ray contrast and others) may cause an "anaphylactoid" reaction (anaphylactic-like
    • reaction) on the first exposure.[17] This is usually due to a toxic reaction, rather than the immune system
    • mechanism that occurs with "true" anaphylaxis. The symptoms, risk for complications without treatment, and
    • treatment are the same, however, for both types of reactions. Some vaccinations are also known to cause
    • "anaphylactoid" reactions. VenomVenom from stinging or biting insects such as Hymenoptera or Hemiptera
    • may induce anaphylaxis in susceptible people
  13. PathophysiologyAnaphylaxis is a severe, whole-body
    allergic reaction. After an initial exposure "sensitizing dose"
    to a substance like bee sting toxin, the person's immune
    system becomes sensitized to that allergen. On a
    subsequent exposure "shocking dose", an allergic reaction
    occurs. This reaction is sudden, severe, and involves the
    whole body.
  14. Classified as a type I hypersensitivity, anaphylaxis is triggered when an
    • antigen binds to IgE antibodies on mast cells based in connective tissue
    • throughout the body, which leads to degranulation of the mast cells (the
    • release of inflammatory mediators).[19] These immune mediators cause
    • many symptoms, including common symptoms of allergic reactions, such as
    • itching, hives, and swelling. Anaphylactic shock is an allergic reaction to an
    • antigen that causes circulatory collapse and suffocation due to bronchial and
    • tracheal swelling.
  15. Acute respiratory
    distress syndrome
    (ARDS),
  16. is a severe lung disease caused by a variety of direct and indirect issues. It is
    • characterized by inflammation of the lung parenchyma leading to impaired
    • gas exchange with concomitant systemic release of inflammatory mediators
    • causing inflammation, hypoxemia and frequently resulting in multiple organ
    • failure. This condition is often fatal, usually requiring mechanical ventilation
    • and admission to an intensive care unit. A less severe form is called acute
    • lung injury (ALI).
  17. Arterial blood
    gas
  18. is a blood test that is performed using blood from an artery.
    • It involves puncturing an artery with a thin needle and
    • syringe and drawing a small volume of blood. The most
    • common puncture site is the radial artery at the wrist, but
    • sometimes the femoral artery in the groin or other sites are
    • used. The blood can also be drawn from an arterial
    • catheter.
  19. Aspiration
    pneumonia
  20. is bronchopneumonia that develops due to the entrance of
    • foreign materials that enter the bronchial tree,[1] usually oral
    • or gastric contents (including food, saliva, or nasal
    • secretions). Depending on the acidity of the aspirate, a
    • chemical pneumonitis can develop, and bacterial pathogens
    • (particularly anaerobic bacteria) may add to the
    • inflammation.
  21. Pneumonia
  22. is an inflammatory condition of the lung, especially of the
    • alveoli (microscopic air sacs in the lungs) or when the lungs
    • fill with fluid (called consolidation and exudation).[1][2]
    • There are many causes, of which infection is the most
    • common. Infecting agents can be bacteria, viruses, fungi, or
    • parasites.[3] Chemical burns or physical injury to the lungs
    • can also produce pneumonia.[4]
  23. Viral
    pneumonia
  24. Viruses have been found to account for between 18̶28% of pneumonia in a
    • few limited studies.[12] Viruses invade cells in order to reproduce. Typically,
    • a virus reaches the lungs when airborne droplets are inhaled through the
    • mouth and nose. Once in the lungs, the virus invades the cells lining the
    • airways and alveoli. This invasion often leads to cell death, either when the
    • virus directly kills the cells, or through a type of cell controlled self-destruction
    • called apoptosis. When the immune system responds to the viral infection,
    • even more lung damage occurs. White blood cells, mainly lymphocytes,
    • activate certain chemical cytokines which allow fluid to leak into the alveoli.
    • This combination of cell destruction and fluid-filled alveoli interrupts the
    • normal transportation of oxygen into the bloodstream.
  25. Bacterial
    pneumonia
  26. Bacteria are the most common cause of community acquired pneumonia with Streptococcus pneumoniae
    • the most commonly isolated bacteria.[13] Another important Gram-positive cause of pneumonia is
    • Staphylococcus aureus, with Streptococcus agalactiae being an important cause of pneumonia in newborn
    • babies. Gram-negative bacteria cause pneumonia less frequently than gram-positive bacteria. Some of the
    • gram-negative bacteria that cause pneumonia include Haemophilus influenzae, Klebsiella pneumoniae,
    • Escherichia coli, Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in the
    • stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical" bacteria which cause
    • pneumonia include Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila
  27. Fungal
    pneumonia
  28. Fungal pneumonia is uncommon, but it may occur in individuals with immune
    • system problems due to AIDS, immunosuppressive drugs, or other medical
    • problems. The pathophysiology of pneumonia caused by fungi is similar to
    • that of bacterial pneumonia. Fungal pneumonia is most often caused by
    • Histoplasma capsulatum, blastomyces, Cryptococcus neoformans,
    • Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most
    • common in the Mississippi River basin, and coccidioidomycosis in the
    • southwestern United States.
  29. Parasitic
    pneumonia
  30. A variety of parasites can affect the lungs. These parasites typically enter the
    • body through the skin or by being swallowed. Once inside, they travel to the
    • lungs, usually through the blood. There, as in other cases of pneumonia, a
    • combination of cellular destruction and immune response causes disruption
    • of oxygen transportation. One type of white blood cell, the eosinophil,
    • responds vigorously to parasite infection. Eosinophils in the lungs can lead to
    • eosinophilic pneumonia, thus complicating the underlying parasitic
    • pneumonia. The most common parasites causing pneumonia are
    • Toxoplasma gondii, Strongyloides stercoralis, and Ascariasis
  31. Idiopathic interstitial
    pneumonia
  32. Idiopathic interstitial pneumonias (IIP) are a class of diffuse
    • lung diseases. While this group is called idiopathic, which
    • means that the cause is unknown, in some types of
    • pneumonia classified as IIPs the cause is known and the
    • name of the group is misleading. For example,
    • desquamative interstitial pneumonia is classified as an IIP,
    • but it is caused by smoking. Many types of IIP, such as
    • usual interstitial pneumonia do not have a known cause.
  33. Chest tube
  34. A chest tube (chest drain or tube thoracostomy in British medicine or
    • intercostal drain) is a flexible plastic tube that is inserted through the side of
    • the chest into the pleural space. It is used to remove air (pneumothorax) or
    • fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic
    • space. It is also known as a Bülau drain or an intercostal catheter.
    • ContraindicationsContraindications to chest tube placement include
    • refractory coagulopathy, lack of cooperation by the patient, and
    • diaphragmatic hernia. Additional contraindications include scarring in the
    • pleural space (adhesions)
  35. Bronchiolitis
    obliterans
  36. is a rare and life-threatening form of non-reversible obstructive lung disease
    • in which the bronchioles (small airway branches) are compressed and
    • narrowed by fibrosis (scar tissue) and/or inflammation. Bronchiolitis
    • obliterans is also sometimes used to refer to a particularly severe form of
    • pediatric bronchiolitis caused by adenovirus.Signs and symptoms
    • Bronchiolitis obliterans is a lung disease characterized by fixed airway
    • obstruction. Inflammation and scarring occur in the airways of the lung,
    • resulting in severe shortness of breath and dry cough. shortness of breath,
    • wheezing. The symptoms can start gradually, or severe symptoms can occur
    • suddenly
  37. Emphysema
  38. is a long-term, progressive disease of the lungs that primarily causes
    • shortness of breath. In people with emphysema, the tissues necessary to
    • support the physical shape and function of the lungs are destroyed. It is
    • included in a group of diseases called chronic obstructive pulmonary disease
    • or COPD (pulmonary refers to the lungs). Emphysema is called an
    • obstructive lung disease because the destruction of lung tissue around
    • smaller sacs, called alveoli, makes these air sacs unable to hold their
    • functional shape upon exhalation. It is often caused by smoking or long-term
    • exposure to air pollution.
  39. Epiglottitis
  40. is an inflammation of the epiglottis - the flap that sits at the
    • base of the tongue, which keeps food from going into the
    • trachea (windpipe). Due to its place in the airway, swelling
    • of this structure can interfere with breathing and constitutes
    • a medical emergency. The infection can cause the epiglottis
    • to either obstruct or completely close off the windpipe.
  41. Sleep apnea
  42. a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing,
    • during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may
    • occur 5 to 30 times or more an hour.[1] Similarly, each abnormally low breathing event is called a hypopnea.
    • Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram, or "sleep study".There are
    • three forms of sleep apnea: central (CSA), obstructive (OSA), and complex or mixed sleep apnea (i.e., a
    • combination of central and obstructive) constituting 0.4%, 84% and 15% of cases respectively.[2] In CSA,
    • breathing is interrupted by a lack of respiratory effort; in OSA, breathing is interrupted by a physical block to
    • airflow despite respiratory effort, and snoring is common.
  43. Hyperventilation
  44. is the state of increased respiratory rate in a person,[1] being inappropriately high in regard to the respiratory
    • drive from carbon dioxide,[2] or causing inappropriate decrease of it.[3] It can result from a psychological
    • state such as a panic attack, from a physiological condition such as metabolic acidosis, or can be brought
    • about by lifestyle risk factors or voluntarily as in the yogic practice of Bhastrika. It often occurs together with
    • labored breathing, which, in contrast, can also be a response to increased carbon dioxide levels.
    • Hyperventilation can, but does not necessarily always cause symptoms such as numbness or tingling in the
    • hands, feet and lips, lightheadedness, dizziness, headache, chest pain, slurred speech, nervous laughter,
    • and sometimes fainting, particularly when accompanied by the Valsalva maneuver.
  45. Hypocapnia
  46. Hypocapnia or hypocapnea also known as
    • hypocarbia, sometimes incorrectly called acapnia, is a
    • state of reduced carbon dioxide in the blood.
    • Hypocapnia usually results from deep or rapid
    • breathing, known as hyperventilation. Hypocapnia is
    • the opposite of hypercapnia
  47. Pertussis
  48. is a highly contagious bacterial disease caused by Bordetella pertussis.
    • Symptoms are initially mild, and then develop into severe coughing fits, which
    • produce the namesake high-pitched "whoop" sound in infected babies and
    • children when they inhale air after coughing.[1] The coughing stage lasts for
    • approximately six weeks before subsiding. In some countries, this disease is
    • called the 100 days' cough or cough of 100 days. Prevention via vaccination
    • is of primary importance as treatment is of little clinical benefit to the person
    • infected.[3] Antibiotics, however, do decrease the duration of infectiousness
    • and are thus recommended.[3] The disease currently affects 48.5 million
    • people yearly, resulting in nearly 295,000 deaths.
  49. Pleurisy
  50. Pleurisy (also known as pleuritis) is an inflammation of the
    • pleura,[1] the lining of the pleural cavity surrounding the
    • lungs. Among other things, infections are the most common
    • cause of pleurisy. The inflamed pleural layers rub against
    • each other every time the lungs expand to breathe in air.
    • This can cause severe sharp pain with inhalation (also
    • called pleuritic chest pain).
  51. Pleural
    effusion
  52. Pleural effusion is excess fluid that
    • accumulates in the pleura, the fluid-filled
    • space that surrounds the lungs. Excessive
    • amounts of such fluid can impair breathing
    • by limiting the expansion of the lungs during
    • respiration.
  53. Pneumonia
  54. is an inflammatory condition of the lung, especially of the alveoli (microscopic air sacs in the lungs) or when
    • the lungs fill with fluid (called consolidation and exudation).[1][2] There are many causes, of which infection
    • is the most common. Infecting agents can be bacteria, viruses, fungi, or parasites.[3] Chemical burns or
    • physical injury to the lungs can also produce pneumonia Typical symptoms include cough, chest pain, fever,
    • and difficulty in breathing.[5] Diagnostic tools include x-rays and examination of the sputum.[6][7] Treatment
    • depends on the cause of pneumonia; bacterial pneumonia is treated with antibiotics Pneumonia is a
    • common disease that occurs in all age groups. It is a leading cause of death among the young, the old, and
    • the chronically ill.[8] Vaccines to prevent certain types of pneumonia are available. The prognosis depends
    • on the type of pneumonia, the treatment, any complications, and the person's underlying health.
  55. Pulmonary
    edema
  56. is fluid accumulation in the lungs.[1] It leads to impaired gas
    • exchange and may cause respiratory failure. It is due to
    • either failure of the heart to remove fluid from the lung
    • circulation ("cardiogenic pulmonary edema") or a direct
    • injury to the lung parenchyma ("noncardiogenic pulmonary
    • edema").[2] Treatment depends on the cause, but focuses
    • on maximizing respiratory function and removing the cause.
  57. Pulmonary
    embolism
  58. is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from
    • elsewhere in the body through the bloodstream (embolism). Usually this is due to embolism of a thrombus
    • (blood clot) from the deep veins in the legs, a process termed venous thromboembolism. A small proportion
    • is due to the embolization of air, fat or amniotic fluid. The obstruction of the blood flow through the lungs and
    • the resultant pressure on the right ventricle of the heart leads to the symptoms and signs of PE. The risk of
    • PE is increased in various situations, such as cancer and prolonged bed rest Symptoms of pulmonary
    • embolism include difficulty breathing, chest pain on inspiration, and palpitations. Clinical signs include low
    • blood oxygen saturation and cyanosis, rapid breathing, and a rapid heart rate. Severe cases of PE can lead
    • to collapse, abnormally low blood pressure, and sudden death.
  59. Pulmonary
    hypertension
  60. In medicine, pulmonary hypertension (PH) is an increase in blood pressure in
    • the pulmonary artery, pulmonary vein, or pulmonary capillaries, together
    • known as the lung vasculature, leading to shortness of breath, dizziness,
    • fainting, and other symptoms, all of which are exacerbated by exertion.
    • Pulmonary hypertension can be a severe disease with a markedly decreased
    • exercise tolerance and heart failure. It was first identified by Dr. Ernst von
    • Romberg in 1891.[1] According to the most recent classification, it can be
    • one of five different types: arterial, venous, hypoxic, thromboembolic or
    • miscellaneous
  61. Pneumothorax
  62. is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may
    • occur spontaneously in people without chronic lung conditions ("primary") as well as in those with lung
    • disease ("secondary"), and many pneumothoraces occur after physical trauma to the chest, blast injury, or
    • as a complication of medical treatment The symptoms of a pneumothorax are determined by the size of the
    • air leak and the speed by which it occurs; they may include chest pain in most cases and shortness of
    • breath in many. The diagnosis can be made by physical examination in severe cases but usually requires a
    • chest X-ray or computed tomography (CT scan) in milder forms. In a small proportion, the pneumothorax
    • leads to severe oxygen shortage and low blood pressure, progressing to cardiac arrest unless treated; this
    • situation is termed tension pneumothorax Small spontaneous pneumothoraces typically resolve by
    • themselves and require no treatment, especially in those with no underlying lung disease. In larger
    • pneumothoraces or when there are severe symptoms, the air may be aspirated with a syringe, or a one-way
    • chest tube is inserted to allow the air to escape. Occasionally, surgical measures are required, especially if
    • tube drainage is unsuccessful or someone has repeated episodes. Various treatments, usually involving
    • pleurodesis (sticking the lung to the chest wall), may be used if there is a significant risk of repeated
    • episodes of pneumothorax
  63. Rheumatoid
    lung disease
  64. is a disease of the lung associated
    • with rheumatoid arthritis. It is
    • estimated that about one quarter of
    • people with rheumatoid arthritis
    • develop Rheumatoid Lung Disease.[1]
  65. Rheumatoid
    arthritis
  66. is a chronic, systemic inflammatory disorder that may affect many tissues
    • and organs, but principally attacks synovial joints. The process produces an
    • inflammatory response of the synovium (synovitis) secondary to hyperplasia
    • of synovial cells, excess synovial fluid, and the development of pannus in the
    • synovium. The pathology of the disease process often leads to the
    • destruction of articular cartilage and ankylosis of the joints. Rheumatoid
    • arthritis can also produce diffuse inflammation in the lungs, pericardium,
    • pleura, and sclera, and also nodular lesions, most common in subcutaneous
    • tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity
    • plays a pivotal role in both its chronicity and progression, and RA is
    • considered a systemic autoimmune disease
  67. Sinusitis
  68. is inflammation of the paranasal sinuses, which may
    • be due to infection, allergy, or autoimmune issues.
    • Most cases are due to a viral infection and resolve
    • over the course of 10 days. It is a common condition
    • with more than 24 million cases occurring in the
    • United States annually.
  69. Status
    asthmaticus
  70. is an acute exacerbation of asthma that does not respond to standard
    • treatments of bronchodilators and steroids. Symptoms include chest
    • tightness, rapidly progressive dyspnea (shortness of breath), dry cough, use
    • of accessory muscles, labored breathing and extreme wheezing. It is a
    • life-threatening episode of airway obstruction considered a medical
    • emergency. Complications include cardiac and/or respiratory arrest The lung
    • failure means that oxygen can no longer be provided, carbon dioxide can no
    • longer be eliminated, which leads to acidosis
  71. Prednisone

    Brand names: Meticorten, Deltasone, Sterapred
    Classification: Corticosteroid (immunosuppressant and Anti-inflammatory) and antiasthmatic.
    5-60mg QD
    COPD, asthma, and allergic disorders.

    Prednisone is a corticosteroid that inhibits accumulation of leukocytes at the site of inflammation and increases capillary permeability; thus reduces swelling and pain associated with the injury. Decrease in leukocytes and lymphatic system activity also suppresses immune response due to allergic reaction.
    Salt and fluid retention, hypertension and increase ICP. Muscle weakness and osteoporosis. Peptic ulcer, esophagitis and abdominal distention. Impaired wound healing and glaucoma. Endocrine disorders requiring higher insulin dose or irregular menstruation.
    Use of hepatic enzyme drugs could lower the effectiveness. It can both mask as well as make prone to new infection. Immunization vaccines should be carefully considered. Precaution in patients with herpes due to risk for cornmeal perforation.
    Do not stop taking suddenly, withdrawal should be done gradually. Take with or after meals, but not on empty stomach. Monitor daily input and output along with BP. Can cause unusual, bad taste.
  72. Atrovent

    Generic: Ipratorpium
    Classification: Anticholinergics
    2 puffs of MDI QID

    500mcg/neb Q6-8hr
    COPD, bronchitis, emphysyma and symptomatic relief of rhinorrhea. It dilates the bronchial smooth muscle by blocking the concentration of cGMP and cholinergic action of acetylcholine. It also decrease the secretion by nasal glands.
    Blurred vision, sore throat, epistaxis and nasal irritation. Bronchospasm/cough. Hypotension, GI upset and UTI.
    Maintenance treatment rather than for acute episodes. Aerosol sprays cautioned with glaucoma and bladder neck obstruction. Contraindicated when hypersensitive to atropine.
    Assess respiration. Check for history of allergies to anticholinergic drugs. If giving concurrently with adrenergics, give atrovent next and corticosteroids last.
  73. Ventolin

    Generic Name: Albuterol
    Classification: adrenergics
    2 puffs of MDI Q4-6hr

    2-4mg PO TID-QID
    COPD and bronchodilator. It binds to beta2 adrenergic receptors which eventually decrease the intracellular calcium to relax smooth muscles.
    CNS effects of nervousness, restlessness and tremor. Cardiovascular actions rise higher. Hyperglycemia. Hypokalemia associated with fluid and electrolyte balances from vomiting and nausea and such.
    Contraindicated when hypersensitivity to adnergics and fluorocarbons (in some inhalers). Beta blockers will negate the effect. Concurrent use with MAO can cause hypertensive problem.
    Assess lung sounds and other vital signs before administration. Observe for paradoxical bronchospasm. Do not use more than recommended. When missed, take as soon as remember.
  74. Theo-dur

    Brand Name: (Theophylline)
    Classification: bronchodilators/ xanthines
    0.4mg/kg/hr IV PO dose-divide by 4 and give every 6 hours
    COPD, chronic asthma and bronchitis. It relaxes smooth muscles as well as suppresses the responsiveness of the airways to the histamine and allergen stimuli.
    Irritability, flushing, palpitations, convulsions, hair loss, and frequent urination.
    Contraindicated in peptic ulcer and coronary artery disease.
    Tablets shouldn’t be crushed or chewed. Serum concentration should be measured before making a dose increase.
  75. Guaifenesin

    Brand Names: Mucinex and Robitussin
    Classification: expectorants
    300-600mg Q 4 hours

    PRN (max 2400)
    COPD and cough associated with viral upper respiratory infection. It loosens the viscosity of the phlegm and increase the mobilization of respiratory fluid.
    Side effects are dizziness, excitability, nausea, weakness, insomnia and rash.
    Contraindicated in patients with hypersensitivity and consuming alcohol products with intolerance.
    Do not chew, crush or break extended release tablets. Take with water and as prescribed. Drink plenty of water to relieve congestion.
  76. Insoniazid (INH)

    Nydrazid as Brand name.
    5mg/kg (max 300mg/d ) IM 300mg PO QD (may be in divided doses)
    TB, first line therapy for active TB. It inhibits the cell wall synthesis of mycobacterium and interferes with metabolism.
    Hypertension, tachycardia, pscyhosis, vision problems, anorexia, slurred speech, hyperglycemia, metabolic acidosis, peripheral neuropathy and anemia.
    Caution with patients who have kidney or liver disease and malnourished. Inhibits the metabolism of phenytoin and concurrent use of pyridoxine may prevent neuropathy.
    Lab test of ALT, AST and albumin is necessary to evaluate the toxicity. The missed dose should be taken as soon as possible. Alcohol should also be avoided to prevent hepatic toxicity.
  77. Rifampin
    600mg IV QD
    TB and elimination of meningococcal carriers.
    Stomach upset, nausea, heartburn, dizziness, sore throat, yellow skin or eyes, dark urine or reddish orange colored,
    Contraindicated with delavirdine. It can cause liver dysfunction.
    Take on empty stomach 1 or 2 hours before or after meals with water. Rifampin can enhance the metabolism of adrenal and thyroid hormones and the vitamin D.
  78. Streptomycin

    Classifcation: anti-infectives
    15mg/kg (up to 1000mg/d) IM QD

    Geriatric dose: 10mg/kg (max 750mg)
    TB and other bacterial infections. It works by inhibiting the protein synthesis necessary for these pathogens to survive.
    GI distress, fever, weird skin sensation around face, fever, swelling, rash, hearing loss, drowsiness and muscle weakness.
    Do not use with nondepoliarizing muscle relaxant. It can also interact with loop diuretics causing cranial nerve damage.
    Can only be administerd via IM injection. Do no discontinue until through with the regimen. Drink extra fluids while taking it.
  79. Ethambutol

    Brand name: myabutol
    Classification: antibiotic
    15mg/kg PO QD
    TB. It prevents the growth of tuberculosis bacteria along with other drugs.
    GI distress, red-green color blindness, myocarditis, fever, confusion, rash, acute gout, nephritis and hyperurecemia.
    Contraindicated with optic neuritis condition. Caution with renal and hepatic disorder. Decreased absorption with aluminium hydroxide.
    Ethambutol is always prescribed along with another antibiotic, whether it is initial treatment or the retreatment. Often the tests include opthalmoscopy, color testing and finger perimetry.
  80. Pyrazinamide (PZA)

    Classification: anti- tuberculosis
    20-25mg/kg QD
    TB. It is converted to pyrazinoic acid which lowers the pH of the mycobaterium environment and produce bacteriostatic action.
    GI distress, malaise, hepatoxicity, dysuria, gout, photosensitivity and anemia.
    Cross sensitivity to isoniazid, niacin or nicotinic acid may exist. Caution when diabetic and active gout is present. Concurrent use with rifampin can cause severe hepatic toxicity.
    Test baseline liver function and monitor serum uric acid level. Take as prescribed and for the full course.
  81. Vitamin B6

    Generic name: pyridoxine
    Classification: water soluble vitamins
    50-10mg QD
    TB and neuropathy from isoniazid, penicillamine, or hydrolazine therapy. Also for synthesis of neurotransmitters serotonin and norepinephrine and for myelin formation.
    Sensory neuropathy, poor coordination, numbness, ticking and burning sensation of the feet, weakness, sore mouth, irritability and confusion.
    Vitamin B6 breaks down Dilantin, levodopa and phenobarbital and makes them less effective. So use cautiously in Parkinson’s disease treatment.
    Do not take more than prescribed. Store in a container at room temperature away from excess moisture or heat.
  82. Epinephrine

    Classification: adrenergics
    0.3-1mg, initial dose, repeat PRN
    Asthma Staticus, rapid relieve of hypersensitivity reactions and mucosal congestions. It stimulates beta adrenergic receptors to produce smooth muscle relaxation.
    GI distress, tremor, weakness, pale skin, dizziness, vasoconstriction, increase aqueous secretion and decrease production, tachycardia, and anxiety.
    Caution when using with drugs that can sensitize arrhythmias such as digitalis. Potentiation occurs when used with tricyclic antidepressant or monoamine oxidase inhibitors.
    Assess lung sounds and vital signs before administration. Monitor for chest pain and other toxicity symptoms. Epi is sensitive to light and air.
  83. Singulair

    Generic name: montelukast
    Classification: leukotrine antagonist
    4-10mg QD
    COPD-Asthma and management of seasonal allergy rhinitis. Singulair inhibits leukotrines that are released when our body experiences allergens, which causes tightening of lungs and airway passages.
    GI distress, heartburn, toothache, weakness, sore throat, stuffy nose, dizziness, and hallucination.
    Use caution in acute attacks of asthma and hepatic impairment.

    Effects decreased by phenobarbital and rifampin use.
    Assess respiratory functions prior to use. Lab test for AST and ALT. Do not double dose but always take as prescribed in the evening.
  84. Flovent/ Flonase

    Classification: corticosteroids
    Initially, 200mcg (2 sprays in each nostril once a day or 1 spray in each nostril Q 12hours). Maintenance, 1 spray in each nostril QD
    COPD-Asthma, immunosuppressant and anti-inflammatory.

    It acts locally.
    Weakness, rash, blurred vision, seeing halos around lights, wheezing, upper respiratory infection, rhinitis, dry eye, increased intraocular pressure and easily glaucoma.
    Flovent doesn’t work fast enough to prevent asthma attack. May produce corticosteroid related adverse effects such as that of prednisone.
    Rinse the device with water to prevent yeast infection. Do not use extra dose to compensate for the missed dose. Monitor for (hypothalamic pituitary adrenal) suppression.
  85. There are three common types of oxygen cylinders, which allow at-home oxygen therapy. These devices are called oxygen delivery systems and are used to transport oxygen into the body.
  86. Compressed Oxygen Cylinders
  87. Compressed oxygen cylinders come in a tank, which stores oxygen as gas. Attached to the tank is a flow meter and a regulator, which are used to adjust the flow of oxygen. Compressed oxygen cylinders come in various sizes ranging from large stationary tanks to small tanks, which can be transported. These tanks are generally home delivered and stored in a secure corner of a room. A key is needed to turn the tanks on or off and must be replaced when the tank becomes empty.
  88. Liquid Oxygen Systems
  89. Liquid oxygen systems consist of a large silver main tank and one or two portable tanks. Portable tanks are used for travel outside of the house and can be refilled from the main tank. The portable tanks generally weigh about 8 to 10 lbs., and can be carried with a cart or a shoulder strap. If the tank is not used frequently, the liquid oxygen will evaporate, so it is suggested that you fill the portable units right before use.
  90. Oxygen Concentrators
  91. Oxygen concentrators concentrate oxygen from the air and deliver it to the body. These tanks are not portable, however, a smaller portable tank will be delivered along with the device as a backup for power failure and for transport. This device is generally used for patients that only use oxygen at night, but they may be used 24 hours a day.
  92. What is Oxygen Therapy?
    • Oxygen therapy is usually delivered as a gas via an oxygen source such as a cylinder or oxygen concentrator. The oxygen is breathed by the patient through a nasal cannula (nasal prongs) or through a mask that covers the mouth and nose. A nasal cannula is a two-pronged device inserted in the nostrils and is connected to the tubing carrying the oxygen. The tubing can rest on the ears or be attached to eyeglass frames.
    • Once your physician has made the determination that you should receive oxygen, he or she will test you to find the right amount of oxygen for your requirements. Oxygen therapy is prescribed to increase the level of oxygen in the blood and is based on the fact that all human cells, tissue and organs need oxygen to function properly. The lack of oxygen on the cellular level can lead to a vast array of maladies. The human body is receiving oxygen and releasing carbon dioxide constantly. When this vital process is interrupted, oxygen in the blood decreases, often requiring supplemental oxygen supply.
  93. Heliox
    • Heliox is a breathing gas composed of a mixture of helium (He) and oxygen (O2).
    • Heliox has been used medically since the 1930s, and although the medical community adopted it initially to alleviate symptoms of upper airway obstruction, its range of medical uses has since expanded greatly, mostly because of the low density of the gas.[1][2] Heliox is also used in saturation diving and sometimes during the deep phase of technical dives. In medicine heliox generally refers to a mixture of 21% O2 (the same as air) and 79% He, although other combinations are available.
    • Heliox generates less airway resistance than air and thereby requires less mechanical energy to ventilate the lungs.[5] "Work of Breathing" (WOB) is reduced. It does this by two mechanisms:

    • increased tendency to laminar flow;
    • reduced resistance in turbulent flow.
    • Heliox has a similar viscosity to air but a significantly lower density (0.5 g/l versus 1.2 5g/l at STP). Flow of gas through the airways comprises laminar flow, transitional flow and turbulent flow. The tendency for each type of flow is described by the Reynolds number. Heliox's low density produces a lower Reynolds number and hence higher probability of laminar flow for any given airway. Laminar flow tends to generate less resistance than turbulent flow.
  94. The Heart
    • A basic understanding of cardiac anatomy allows for correlation of physical exam finding with the unseen anatomy of the heart. The adult heart is about the size of a closed fist and sits in the thorax on the left side of the chest in front of the lungs. The heart is designed as a pump with four chambers - right atrium (RA), right ventricle (RV), left atrium (LA), and left ventricle (LV). The two atria are the smaller, upper chambers of the heart and the two ventricles are the larger, lower chambers of the heart. The hear is oriented in the chest rotated about 30 degrees to the left lateral side such the right ventricle is the most anterior structure of the heart. The left ventricle is generally about twice as thick as the right ventricle because it needs to generate enough force to push blood through the entire body while the right ventricle only needs to generate enough force to push blood through the lungs.
    • The heart also has four valves. The tricuspid valve is between the right atrium and right ventricles. The pulmonary valve is between the right ventricle and the pulmonary artery. The mitral valve is between the left atrium and the left ventricle and the aortic valve is between the left ventricle and the aorta. The valves, under normal conditions, insure that blood only flows in one direction in the heart.
  95. The Cardiovascular System
    In order to pump blood through the body, the heart is connect to the vascular system of the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of the body and remove carbon dioxide and metabolic waste products from the body. The cardiovascular system is actually made up of two major circulatory systems, acting together. The right side of the heart pumps blood to the lungs through the pulmonary artery (PA), pulmonary capillaries, and then returns blood to the left atrium through the pulmonary veins (PV). The left side of the heart pumps blood to the rest of the body through the aorta, arteries, arterioles, systemic capillaries, and then returns blood to the right atrium through the venules and great veins.
  96. Basic Cardiac Physiology
    • A basic understanding of cardiac physiology is also essential to interpreting the physical finding during a cardiac exam. Each pump or beat of the heart consists of two parts or phases - diastole and systole. During diastole the ventricles are filling and the atria contract. Then during systole, the ventricles contract while the atria are relaxed and filling. A more detailed understanding of the of cardiac physiology can be obtained by examining in detail the simultaneous pressure characteristics in the aorta, left atrium (atrium) and left ventricle (ventricle) through one cardiac cycle.
    • For the purposes for this discussion of cardiac physiology, we will focus on the physiology associated with the heart sounds S1, S2, S3, and S4. S1 occurs near the beginning of (ventricular) systole with the closing of the tricuspid and mitral valves. The closing of these two valves with increasing pressure in the ventricles as they begin to contract should be simultaneous. Any splitting in which the closing of the two valves are heard separately should be considered pathological. S2 occurs near the end of (ventricular) systole with the closing of the pulmonary and aortic valves. The closing of these two valves occurs with beginning of backward flow in the pulmonary artery and aorta respectively as the ventricles relax. The two valves can occur simultaneously or with slight gap between them under normal physiologic circumstances. S3 occurs at the end of the rapid filling period of the ventricle during the beginning of (ventricular) diastole. An S3, if heard should occur 120-170 msec after S2. S4 occurs, if heard coincides with atrial contraction at the end of (ventricular) diastole.
    • Be sure you can correlate what you feel and what you hear in the cardiac exam with the underlying physiology. The top tracing is the standard EKG (electrocardiogram) with underlying blue line indicating diastole and the red line indicating systole. The second tracing indicates what you should hear in with your stethoscope, with the underlying colors indicating the cardiac physiology associated with each sound (mitral valve closure = purple (associated with S1), tricuspid valve closure = green (associated with S1), aortic valve closure = orange (associated with S2), pulmonic closure = blue (associated with S2), and if present ventricular wall tensing = yellow (associated with S3)).
    • The bottom tracing indicates the peripheral pulse wave felt when taking the pulse while auscultating, which is the recommended method. Notice that the pressure wave begins near the end of systole and continues through the beginning and middle of diastole. The green tabs underneath this tracing indicates when the pulse should be felt by the examiner. This technique of simultaneously listening and feeling the pulse (generally radial) is especially helpful to avoid confusion between S1 and S2. Palpation of the peripheral pulse should correspond with S2.
  97. The Respiratory System
  98. A person can live for weeks without food and a few days without water but only a few minutes without oxygen. Every cell in the body needs a constant supply of oxygen to produce energy to grow, repair or replace itself, and maintain vital functions. The oxygen must be provided to the cells in a way that they can use. It must be brought into the body as air that is cleaned, cooled or heated, humidified, and delivered in the right amounts.
    • The respiratory system is the body's link to this supply of life-giving oxygen. It includes the diaphragm and chest muscles, the nose and mouth, the pharynx and trachea, the bronchial tree, and the lungs, each of which is discussed below. (See Figure 1-1. The Respiratory System.) The bloodstream, the heart, and the brain are also involved. The bloodstream takes oxygen from the lungs to the rest of the body and returns carbon dioxide to them to be removed. The heart creates the force to move the blood at the right speed and pressure throughout the body. The smooth functioning of the entire system is directed by the brain and the autonomic nervous system.
    • A person at rest breathes about 6 liters of air a minute. Heavy exercise can increase the amount to over 75 liters per minute (3). During an 8-hour work day of moderate activity, the amount of air breathed may be as much as 8.5 m3 (300 cubic feet). The skin, with its surface area of approximately 1.9m2 (20 sq. ft.) is commonly thought to have the greatest exposure to air of any body part. However, in reality the lungs have the greatest exposure, with a surface area exposed to air of 28 m2 (300 sq. ft.) at rest and up to 93 m2 (1,000 sq. ft.) during a deep breath (4).
    • The respiratory system is susceptible to damage caused by inhaled toxic materials and irritants because the surface area of the lungs exposed to air is so large and the body's need for oxygen so great. The ability of the respiratory system to function properly has a great impact on the body. Disease in any one of its parts can lead to disease or damage to other vital organs. For example, occupational lung disease can also cause heart disease.
  99. Mechanics of Respiration
  100. The trachea, main bronchi, and approximately the first dozen divisions of smaller bronchi have either rings or patches of cartilage in their walls that keeps them from collapsing or blocking the flow of air. The remaining bronchioles and the alveoli do not have cartilage and are very elastic. This allows them to respond to pressure changes as the lungs expand and contract.
    • Blood vessels from the pulmonary arterial system accompany the bronchi and bronchioles. These blood vessels also branch into smaller and smaller units ending with capillaries, which are in direct contact with each alveolus. Gas exchange occurs through this alveolar-capillary membrane as oxygen moves into and carbon dioxide moves out of the bloodstream. (See Figure 1-3. A Close-Up View of Alveoli and Capillaries.) Although the 300 million alveoli found in the lungs are microscopic, they have a total surface area equivalent to the size of a tennis court (6).
    • Diffusing capacity measures the ease with which gas exchange takes place between the alveoli and capillaries. Certain lung diseases affecting the alveoli and capillary walls can interfere with diffusion and reduce the amount of oxygen reaching the bloodstream. Spirometry does not measure diffusing capacity, but it can be measured in a pulmonary function laboratory using an instrument which cost $20,000 to $40,000.
    • The movement of air into and out of the lungs is called ventilation. The contraction of the inspiratory muscles (principal inspiratory muscle is the diaphragm) causes the chest cavity to expand, creating a negative pressure. The resulting flow of air into the lungs is called inspiration. During a maximal inspiration, the diaphragm contracts forcing the abdominal contents downwards and outwards (See Figure 1-1). The external intercostal muscles, found between the ribs, are also involved. These muscles contract and raise the ribs during inspiration, thus increasing the diameter of the chest cavity. In addition to these muscles, the scalene muscle and the sternomastoid muscle in the neck may be employed during extreme ventilation or in conditions of respiratory distress.
  101. Mechanisms for Protecting the Lungs against Airborne Hazards
  102. Airborne contaminants can be in the form of gases (vapors), liquids (mists), or solids (smokes and dusts). (See Appendix B. An Overview of Occupational Lung Hazards for a discussion of common types of lung hazards seen in the occupational setting.) Toxic chemicals or irritating materials that are inhaled can damage the tracheo-bronchial tree or the lungs. These substances can cause harm in other parts of the body as well because the lungs provide an important route of exposure.
    • In order for a hazardous substance to affect the lungs, it must first pass through the bronchial tree and reach the alveoli. The body's defensive mechanisms prevent all but the smallest respirable particles from reaching the alveoli. The average person can see with the naked eye particles as small as 50 microns in diameter. (The symbol "Fm" is the abbreviation for micron.) To put this in perspective, there are 25,400 microns in an inch or 10,000 microns in a centimeter. Smaller particles can sometimes be seen if a strong light is reflected from them (such as specks that can be seen in the air when sunlight streams through a window). Particles of respirable size are less than 10 microns and cannot be detected without a microscope.
    • The size, shape, and mass of particles affect where they are deposited in the respiratory system. Particles bigger than 5 microns usually do not remain airborne long enough to be inhaled or they are trapped by the nose. Heavier particles also settle out quickly and are easily removed if they are inhaled. Particles of intermediate size (1-5 microns) are more likely to deposit in the trachea and bronchi. Small particles (0.01-1 micron) are more likely to reach the bronchioles, alveolar ducts, and alveoli. Fibrous or irregularly shaped particles tend to become caught at bronchiole branching points. However, some fibers and small particles travel readily to the alveoli because of their aerodynamic properties.
    • The lungs have several mechanisms to protect themselves from contamination by particles and infectious agents. The fine hairs in the nose provide the front-line barrier by filtering out large dust particles and other materials. However, when individuals exercise or work hard, they need to breathe through their mouths to get enough air, and the nasal filtering system is bypassed.
    • The cough reflex clears foreign material from the trachea and main bronchi. Whenever irritating materials touch the walls of these airways, the chest and lungs quickly contract. As a result, air is rapidly forced out of the lungs, which usually expels the irritant.
    • The trachea, bronchi, and larger bronchioles are lined with fine, hair-like ciliary cells. These are covered with a thin layer of mucous that catches foreign material. The cilia rhythmically beat and move the mucous-trapped material up to the throat where it can be swallowed or spit out, and thus eliminated from the body. This process is called the mucociliary escalator
  103. MUCOCILIARY ESCALATOR
  104. The tracheal lining showing ciliated and goblet cells and the mucous layer. This is called the "mucociliary escalator."
    • From E.P. Horvath Jr., S.M. Brooks, and J.L. Hankinson [1981]. Manual of Spirometry in Occupational Medicine, U.S. Department of Health and Human Services, Cincinnati, p. 9. (6)
    • Alveolar macrophages are specialized cells that mobilize to destroy bacteria and viruses. In healthy lungs, the production of macrophages and mucous increase as needed to remove foreign matter and then return to normal levels.
    • Coughing usually removes irritating particles instantly and the mucociliary escalator may take only a few hours to expel foreign materials. However, the innermost areas of the lungs can take considerably longer to clear out foreign matter (7). Lungs that receive prolonged or repeated exposure to air contaminants eventually cannot keep up with the rate of deposition and/or the constant irritation. As a result, the contaminants accumulate, contributing to the development of occupational lung diseases.
  105. Smoking and Occupational Lung Disease
  106. Smoking contributes to lung disease in several ways. It impairs the lungs' natural defense mechanisms by irritating the airways and inhibiting the work of macrophages and the mucociliary escalator. In itself, it is a leading cause of serious lung and heart disease and certain types of cancer. It also has a synergistic effect with other pulmonary carcinogens, such as asbestos, chromium and uranium compounds, and arsenic. Synergistic means that the combined effect of two or more substances is greater than the effects of each added together. Smoking increases the risk of lung cancer by 15%, chronic asbestos exposure by 4%, but together they produce a 60% increase in risk, not a 19% increase (8). As a result, smokers who receive prolonged occupational exposures to other airborne contaminants develop heart and lung disease and cancer more readily than do nonsmokers with comparable exposures, and these diseases progress more rapidly because of the extra burden on the lungs created by smoking.
  107. Occupational Lung Diseases
  108. Spirometry is used to detect lung abnormalities that show obstructive or restrictive patterns, or a combination of the two. (See Appendix C. Overview of Occupational Lung Disease for descriptions of some of the better known occupational lung diseases. Also see Appendix D. Respiratory Surveillance Programs for information on the role of spirometry in the medical surveillance of occupational lung disease.) Obstructive diseases or abnormalities interfere with the flow of air into and out of the lungs. The underlying disease process frequently alters the diameter or integrity of the airways, causing increased airflow resistance from bronchospasm, mucosal edema, and increased production of secretions. Emphysema is one form of obstructive disease. When individuals with emphysema exhale (especially if they exhale forcefully) the airways narrow further or collapse. Asthma and chronic bronchitis are other common obstructive diseases. Restrictive diseases, such as asbestosis and silicosis, are caused by fibrotic tissue changes that reduce the ability of the lungs to expand (i.e., they have low compliance) but do not necessarily affect air flow. Disorders that affect the neuromuscular functioning of the chest wall may also produce a restrictive pattern. Other lung diseases, such as pneumonia, may show both obstructive and restrictive patterns.
  109. Spirometry
    The simplest pulmonary function study that is used to measure lung function is spirometry. This test measures the total amount of air that can be exhaled and how quickly that air can be forced out. This is a very valuable tool for trending chronic lung disease such as asthma, chronic bronchitis, cystic fibrosis and muscular dystrophy. This test is also used to diagnose asthma.

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