RESPIRATORY

LEADING CAUSES OF DEATH

TRADITIONAL RANKINGS
1. Coronary heart disease / cerebrovascular diseases
2. Cancer (all causes)
3. Chronic Obstructive Pulmonary Disease (COPD)
CHANGES
1. Coronary heart disease / cerebrovascular diseases
2. Chronic Obstructive Pulmonary Disease (COPD)
particularly in women and due to smoking
3. Cancer (all causes)
RESPIRATORY SYSTEM
Pharynx
Nose
Larynx
Lung
Trachea
Alveoli
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Bronchus
Bronchioles
Important role in homeostasis:
Gas exchange
Regulation of blood pH
Determined by balance between
bicarbonate and carbon dioxide
(Bicarbonate Buffer System)
Important role in defence of the body
filtering, detecting & expelling invaders
and noxious substances by:
Cilia (tiny hairs), protective mucous
layer, intra cavity filters, vibrissae
FUNCTIONS
Nose
Filters air; removes foreign particles, humidifies & warms it to
37C
Smells & detects irritants in the nasal mucosa - triggers
sneezing.
Pharynx
Passageway for gas/air, food and liquid entering from the
mouth and for gas/air entering from the nasal cavities.
Larynx
Directs air and food into the proper channels.
Protects trachea from particles and foreign bodies; cough
reflex triggered to expel the substance
Houses vocal cords, which vibrate as air passes through
glottis (space between cords) as we breathe out for
sound/speech production; varied by changes to speed of air
and size of glottis

FUNCTIONS
Trachea
(Wind pipe), main passageway for air to the lungs.
Lungs
Fibrous elastic sacs designed to take in air for gas
exchange.
They expand and compress by movements of the rib
cage and diaphragm during breathing.
Water evaporates from lungs: important for fluid and
heat homeostasis
Alveoli
Blind-ended microscopic air sacs site of gas
exchange
Bronchi
Branches from the trachea delivering air to each
lung
Bronchioles
Branches from the bronchi - delivering air to the
aveoli

COMMON RESPIRATORY PROBLEMS
COPD eg
Emphysema / Bronchitis
Smoking biggest cause
other irritants:
pollutants, dust or
chemicals, may also
contribute
NO CURE
Asthma
Allergic component
Inflammation,
swelling / oedema
REVERSIBLE
COPD
Chronic bronchitis
inflammation of lungs,
causes a cough and
mucous production,
SOB - wheezing, and
chest tightness
Can be acute
eg infections
Emphysema
Damage to lungs' air
sacs (alveoli),
lack of oxygen / gas
exchange,
cough, hard to get
breath
COPD: VARIANTS
Chronic Bronchitis

Emphysema
Common names Blue Bloater
Lack of oxygen in the blood
and increased retention of
carbon dioxide gives the lips a
blue grey appearance.
Poss swollen legs or ankles
Pink puffer:
Reddish complexion
Puffing hyperventilation and
labored breathing
Aetiology (smoking
related)
Inflamed and hyper-reactive
bronchioles.
Excessive production of
mucus.
Airways thicken and loss of
cilia.
Walls within the alveolus are
damaged
So reduction in surface area
gas exchange and
Decreased ability to oxygenate
the blood.
Explain differences
in breathlessness
(dyspnoea)
Mild shortness of breath
compared to emphysema

Severe shortness of breath
than bronchitis
Explain the
differences in
mucous production
Cough, copious mucous
production,
Possible cough but with less
mucous compared to chronic
bronchitis

PATIENT / LIFESTYLE ADVICE
Stop smoking: never too late
20+ years of smoking can destroy 50% of lung function
Regular gentle exercise
Good diet
Breathing exercises
Disease education:
Conserve energy in advanced disease
Seek help to manage stress or depression etc
ASTHMA
Can commence at any age
Usually childhood
Some children will experience complete and
permanent loss of symptoms
ASTHMA
Affects smooth muscle of the bronchial tubes
Narrowed and inflamed
Airways narrow TOO easily and TOO much
Excess swelling and mucous production
Muscles relaxed
Lining normal
Lining swollen
Normal Bronchiole Bronchiole with
Asthma
Muscles;
relaxed
Muscles;
tightened
Lining:
normal
Lining:
swollen
Extra mucous
ASTHMA
Lining sore & tender
sensitive / hyperactive,
spasms / constriction
reduce air intake
wheezing, coughing,
chest tightness and
trouble breathing,
especially early in the
morning or at night
Reacts to allergens
eg dander, house-dust
mite
irritants, infections,
exercise & winter air
(temp changes), plus
NSAIDs, beta blockers
IN SUMMARY CURRENT BELIEFS
Chronic inflammatory disorder of the airways
Three Key features
bronchial smooth muscle constriction
inflammation
mucous production
INFLAMMATION RESULTS IN:
mucosal oedema
accumulation of leucocytes,
especially eosinophils in the mucosal surface & lumen
thickening of the basement membrane
leads to narrowing of the airway lumen and
bronchial hyper responsiveness
Trigger exposure further narrowing by smooth
muscle contraction
ASTHMA ATTACK (ACUTE)
Worsening of symptoms
Severe attack:
severe constriction & vital organs starved of
oxygen.
Death can occur
EARLY & LATE PHASE
ASTHMA REACTIONS
Early Asthma Reaction
! immediate reaction
! mainly due to release of mediators from
mast cells (histamine, leukotrienes)
! smooth muscle contraction
! wheeze & SOB
! responds to reliever meds
! reduced by preventer meds
Late Asthma Reaction
! begins 4-6 hours after exposure
! peaks at 12 hours
! mucosal swelling, oedema and
cellular infiltrates (especially
eosinophils)
! reduced/prevented by preventer
meds
IGE antibody
grabs
allergen
Chemical Mediators
released
Bronchoconstriction
Brain receives message
tight feeling in chest
Bronchodilator
used
Allergen breathed
in
Mast cell door
opens
Early phase reaction
Immediate reaction
Bronchoconstriction
Goblet cells produce
mucus
Brain receives message
tight feeling in chest
Bronchodilator
used
Afferent Nerve
Efferent Nerve
Vagus Nerve
Damage epithelium
Cause oedema of epithelium
Disturb the Afferent nerve
Release toxins to
control antigen &
chemical mediators
White Blood Cells arrive
Late phase reaction
4-6 hours after exposure
Peaks at 12 hours
Brain receives message
tight feeling in chest
IGE antibody
grabs allergen
Chemical Mediators
released
Bronchoconstriction
Goblet cells produce
mucus
Brain receives message
tight feeling in chest
Bronchodilator
used
Afferent Nerve
Efferent Nerve
Vagus Nerve
Damage epithelium
Cause oedema of epithelium
Disturb the Afferent nerve
Release toxins to
control antigen &
chemical mediators
White Blood Cells enters
Allergen breathed in
Mast cell door opens
Damage epithelium
Cause oedema of epithelium
Disturb the Afferent nerve
Goblet cells produce
mucus
Damage epithelium
Cause oedema of epithelium
Disturb the Afferent nerve
TREATMENTS
COPD
Smooth muscle relaxants
Need more air and
oxygen
(oxygen therapy)
Asthma
quick-relief medicines to
stop symptoms
preventative medicines;
to reduce inflammation
and progression
- for long-term control
TREATMENTS FOR ASTHMA / COPD (1)
Medicine Indication Action on the body
Theophylline
eg Nuelin
tablets
Asthma and
COPD
Relaxes bronchiole smooth muscle
and has some anti-inflammatory
effects even in smaller doses.
Long acting
beta 2 agonist
(LABA)
Eg salmeterol
(Serevent )
Moderate to
severe asthma
Stimulates B2 receptors. Relaxes
smooth muscle & opens
bronchioles.

Long acting beta agonist (LABA)
Combination
inhaler (LABA +
corticosteroid)
Eg Seretide
Moderate to
severe asthma
LABA as above + corticosteroid
which reduces airway inflammation
and mucous plugging

TREATMENTS FOR ASTHMA / COPD (2)
Medicine Indication Action on the body
Combination
inhaler (LABA +
corticosteroid)
Eg Seretide
Moderate to
severe asthma
LABA as above +
corticosteroid which reduces
airway inflammation and
mucous plugging
Ipratropium
(anticholinergic)

Eg Atrovent
COPD or
asthma
Prevents parasympathetic
induced bronchoconstriction.
Relaxes smooth muscle &
opens bronchioles.
Short acting
Tiotropium
(anticholinergic)
Eg Spiriva
(needs special
authority)
COPD or
asthma
Prevents parasympathetic
induced bronchoconstriction.
Relaxes smooth muscle &
opens bronchioles.
Long acting

TYPICAL TREATMENT FOR:
EXACERBATION OF COPD DUE TO INFECTION
Class Effect Common ADR Patient advice
Prednisone Corticosteroid Reduces
inflammation
Insomnia
decreased
appetite
Take as
instructed
Complete the
course
Take with food
after breakfast
Tiotropium Antimuscarinic
(amticholinergic)
Antagonises
muscarinic
receptors of
parasympathetic
system.
Dilating lungs by
relaxing smooth
muscle
Urinary retention
dry mouth
Throat irritation
Explain contents
of capsule
iinhaled via
specific
inhalation device
Take as
instructed by
doctor
Roxithromycin Macrolide
antibiotic
To treat bacterial
infection
(Inhibits synthesis
of bacterial wall
cell)
Vomiting and
diarrhoea
nausea
Take as
instructed by
doctor
Complete the
course.
Take 30 minutes
before food.

COMMON ASTHMA TREATMENTS
Ventolin
Salbutamol

Flixotide
Fluticasone
(beclomethasone earlier version)
Class /
action

Short-acting bronchodilator
works by stimulating !2
receptors (agonist)
Anti-inflammatory (corticosteroid)
Fluticasone long acting
Beclomethasone shorter acting
Used to:

Relieve symtoms (reliever) Prevent inflammation and
dampens down / disease process
(preventer)
Frequency
of use

PRN Use As required
only up to every 4 hours.
Use regularly regardless of
symptoms
Common
ADRs

Mainly cardiovascular due to
!1 stimulation
ie. Tachycardia and
palpitations
Hoarseness and thrush infections
of mouth or throat

BEST PRACTICE FOR
RESPIRATORY PATIENTS
ENSURE
Good inhaler technique and use of spacers
Patient comprehension: reliever vs preventer
Avoid excess use of salbutamol
Side-effects of inhaled steroids eg thrush:
minimised by:
large-volume spacer device
rinse mouth with water after inhalation
HAYFEVER
HAYFEVER - ALLERGY
SIGNS AND SYMPTOMS
Nasal
Itchy nose
Sneezing
Blocked nose and
congestion
Runny nose / post nasal
drip
Loss of smell sense
Throat & eyes
Itchy, sore, dry throat
Irritated, red eyes
ALLERGENS
Antigens that provoke a Type 1 hypersensitivity
reaction in a sensitised (allergic) individual
Many possible antigens / allergens
Pollens, molds, feathers, dander
House dust mite and dust
Dyes, cosmetics, medications and other chemicals
Certain foods
TREATMENT OPTIONS FOR ALLERGIES
CHOICE DEPENDENT UPON SYMPTOMS
Antihistamines
Oral (non-sedating / sedating)
Nasal spray
Eye drops
Sodium cromoglycate (mast cell stabilisers)
Eye drops
Corticosteroids
Nasal sprays
Decongestants
Nasal sprays / drops
Eye preparations
ANTIHISTAMINES - ADVICE
CAN BE USED PROPHYLACTICALLY
Oral Sedating type: Caution for possible drowsiness when
driving or operating machinery
Avoid alcohol
Nasal Occasionally may cause irritation of nasal mucosa
on initial applications.
Explain how to use see earlier assessments
Eye drops Remove contact lenses before use.
Discard contents 1 month after opening
Shake the bottle prior to use.

PREVENTERS / PROPHYLACTIC
Cromoglycate
Eye drops
Discard content 1 month after opening
May cause passing burning or stinging.
Remove soft contact lenses prior to use
Corticosteroid
Nasal spray

It will take several days (3 4 days) before
noticing the maximum effects.
Needs to be used every day to be effective.
If not relieved after 7 days, seek medical advice
Do not use continuously for more than 6 months
without medical advice
Discard contents 3 months after opening. Avoid
eyes with spray.

DECONGESTANTS
Oral: ADR include nervousness and insomnia.
(Should be used cautiously in patients with hypertension
(hypertension must be well controlled), heart disease,
hyperthyroidism, glaucoma and prostatic hypertrophy.
Nasal
spray
Do not use for more than 5 days
(rebound stuffiness in prolonged use)
Explain how to use. see earlier assessment
Wipe tip clean after each use. Use in both sides of nostril.
Eye
drops
Should be used for limited periods only
(i.e. Less than a week) or intermittently (3-4 doses per week)
because of the potential problems with rebound. Explain how
to use. see earlier assessment
Discard after 1 month of opening.
May cause burning or stinging at first.

DECONGESTANTS
Topical
Xylometazoline
Phenylephrine
Oxymetazoline
Oral
Pseudephedrine
(now restricted)
Phenylephrine
Phenylpropanolamine
Low therapeutic index
HAYFEVER
GENERAL AVOIDANCE ADVICE
Try not to rub eyes
Avoid contact lenses when using eye drops
Try wearing sunglasses
Commence treatment (if possible) prior to exposure
Avoid the allergen (if known)
Eg Sources of house dust mite are bedding, upholstered
furniture, fluffy toys and carpets.
Keep bedroom or home dust-free
(especially if have perennial rhinitis)
Pets, especially cats, should be kept outside
Avoid chemical irritants such as aspirin, smoke,
cosmetics, paints etc
COMMON COLD
COMMON COLD
SIGNS AND SYMPTOMS
START 1 -2 DAYS POST INFECTION
Nasal
Itchy nose, Sneezing
Stuffy or runny nose
Blocked nose and
congestion discharge
thickens after ~ 24hrs
Loss of smell sense
Headache
others
Itchy, sore, dry throat
Irritated, red eyes
General feeling of
unwell
HAYFEVER VS COLD
COMPARISON
Hayfever
Allergy (immune related)
Not infectious
Symptoms as described
Allergens can be:
Inhaled
Ingested
Injected
Touched etc
Lasts as long as exposure
Cold
Caused by a viral
infection widespread
Inflamed mucous
membranes:
Nose
Throat
Lungs
Infectious and
transmitted by coughing
& sneezing
Limited duration
TREATMENTS
Decongestants
Paracetamol
Throat lozenges,
sprays etc
Additional options
for coughs
Cough options
Suppressant tickly
unproductive coughs
Suppresses cough centre
in brain
Expectorants for
productive cough
Makes mucous thinner
and easier to cough up
Mucolytics eg
bromhexine
Also helps thin mucous
and break it up
SECONDARY CHEST INFECTION
Antibiotics - Amoxycillin broad spectrum
Care with OC
inhibits bacterial flora in intestines needed fore recycling of
oestrogen
Reduces effectiveness of OC (if used for short courses)
Need additional, non-hormonal treatment
Bronchodilators ease breathing
Inflammation of bronchioles closing them up
Salbutamol can help breathing