Sinusitis
adults are infections and smoking.
Sinusitis is an inflammation or swelling of the tissue
lining the sinuses. Healthy sinuses are filled with air.
But when they become blocked and filled with fluid,
germs can grow and cause an infection.
Conditions that can cause sinus blockage include:
 The common cold
 Allergic rhinitis, which is swelling of the
lining of the nose
 Small growths in the lining of the nose called
nasal polyps
 A deviated septum, which is a shift in the nasal
cavity
Types
You may hear your doctor use these terms:
 Acute sinusitis usually starts with coldlike
symptoms such as a runny, stuffy nose and
facial pain. It may start suddenly and last 2-4
weeks.
 Subacute sinus inflammation usually lasts 4 to
12 weeks.
 Chronic inflammation symptoms last 12 weeks
or longer.
 Recurrent sinusitis happens several times a
year.
Who Gets It?
Lots of people. About 35 million Americans have
sinusitis at least once each year. It’s more likely if you
have:
 Swelling inside the nose like from a common
cold
 Blocked drainage ducts
 Structural differences that narrow those ducts
 Nasal polyps
 Immune system deficiencies or medications
that suppress the immune system
For children, things that can cause sinusitis include:
 Allergies
 Illnesses from other kids at day care or school
 Pacifiers
 Bottle drinking while lying on the back
 Smoke in the environment
The main things that make sinusitis more likely for
Acute Sinusitis Symptoms
The main signs include:
 Facial pain or pressure
 "Stuffed-up" nose
 Runny nose
 Loss of smell
 Cough or congestion
You may also have:
 Fever
 Bad breath
 Fatigue
 Dental pain
It may be acute sinusitis if you have two or more
symptoms, or thick, green, or yellow nasal discharge.
Chronic Sinusitis Symptoms
You may have these symptoms for 12 weeks or more:
 A feeling of congestion or fullness in your face
 A nasal obstruction or nasal blockage
 Pus in the nasal cavity
 Fever
 Runny nose or discolored postnasal drainage
You may also have headaches, bad breath, and tooth
pain. You may feel tired a lot.
Lots of things can cause symptoms like these. You'll
need to see your doctor to find out if you have sinusitis.
Treatment
If you have a simple sinus infection, your doctor may
recommend you use a decongestant and saline nasal
washes. You shouldn’t use an over-the-counter
decongestant more than 3 days, though, because it can
make you more congested.
If your doctor gives you antibiotics, you’ll probably take
them for 10 to 14 days. The symptoms usually disappear
with treatment.
Warm, moist air may help if you have chronic sinusitis.
You can use a vaporizer, or you can inhale steam from a
pan of warm water. Make sure the water isn't too hot.
There are some other things you can do yourself to help
with chronic sinusitis:
 Warm compresses can ease pain in the nose
and sinuses.
 Saline nose drops are safe to use at home.
 Over-the-counter decongestant drops or sprays
can help. Don’t take them longer than
recommended.
Rhinitis, which occurs most commonly as allergic
rhinitis, is an inflammation of the nasal membranes that
is characterized by sneezing, nasal congestion, nasal
itching, and rhinorrhea, in any combination. [1] Although
allergic rhinitis itself is not life-threatening (unless
accompanied by severe asthma or anaphylaxis),
morbidity from the condition can be significant.
Signs and Symptoms

In some cases, your doctor may prescribe steroids along History

with antibiotics.
Signs and symptoms of allergic rhinitis include the
Other Options following:

You also need to avoid any triggers linked to your  Sneezing

sinusitis. 
 Itching: Nose, eyes, ears, palate
If you have allergies,your doctor may recommend an
antihistamine.  Rhinorrhea

If a fungus is to blame, you’ll get a prescription for an

 Postnasal drip
antifungal medicine.

 Congestion
If you have certain immune deficiencies, your doctor
may give you immunoglobulin, which helps fight the
things your body reacts to.  Anosmia

Can I Prevent Sinusitis?  Headache

There is no sure-fire way to prevent sinusitis. But there  Earache

are some things that might help.
 Tearing
 Don’t smoke, and avoid other people's smoke. 
 Wash your hands often, especially during cold  Red eyes
and flu season, and try not to touch your face.
 Stay away from things you know you’re
allergic to.  Eye swelling

What Happens if Sinusitis Isn’t Treated?  Fatigue

You’ll have pain and discomfort until it starts to clear  Drowsiness

up. In rare cases, untreated sinusitis can lead to
meningitis, a brain abscess, or an infection of the bone.  Malaise
Talk to your doctor about your concerns.
Complications of this allergic rhinitis include the
Source: https://www.webmd.com/allergies/sinusitis- following:
and-sinus-infection#2
 Acute or chronic sinusitis

 Otitis media
Allergic Rhinitis

 Sleep disturbance or apnea

Practice Essentials
  Dental problems (overbite): Caused by
excessive breathing through the mouth
 Palatal abnormalities
 Eustachian tube dysfunction
Physical examination
Nasal features of allergic rhinitis can include the
following:
 Nasal crease: A horizontal crease across the
lower half of the bridge of the nose; caused by
repeated upward rubbing of the tip of the nose
by the palm of the hand
 Thin, watery nasal secretions
 Deviation or perforation of the nasal septum:
May be associated with chronic rhinitis,
although there can be other, unrelated causes
Manifestations of allergic rhinitis affecting the ears,
eyes, and oropharynx include the following:
 Ears: Retraction and abnormal flexibility of the
tympanic membrane
 Eyes: Injection and swelling of the palpebral
conjunctivae, with excess tear production;
Dennie-Morgan lines (prominent creases
below the inferior eyelid); and dark circles
around the eyes (“allergic shiners”), which are
related to vasodilation or nasal congestion
 Oropharynx: "Cobblestoning," that is, streaks
of lymphoid tissue on the posterior pharynx;
tonsillar hypertrophy; and malocclusion
(overbite) and a high-arched palate
See Clinical Presentation for more detail.
Diagnosis
Laboratory tests used in the diagnosis of allergic rhinitis
include the following:
 Allergy skin tests (immediate hypersensitivity
testing): An in vivo method of determining
immediate (IgE-mediated) hypersensitivity to
specific allergens
 Fluorescence enzyme immunoassay (FEIA):
Indirectly measures the quantity of
immunoglobulin E (IgE) serving as an
antibody to a particular antigen
 Total serum IgE: Neither sensitive nor specific
for allergic rhinitis, but the results can be
helpful in some cases when combined with
other factors
 Total blood eosinophil count: Neither sensitive
nor specific for the diagnosis, but, as with total
serum IgE, can sometimes be helpful when
combined with other factors
Imaging studies used in the diagnosis and evaluation of
allergic rhinitis include the following:
 Radiography: Can be helpful for evaluating
possible structural abnormalities or to help
detect complications or comorbid conditions,
such as sinusitis or adenoid hypertrophy
 Computed tomography scanning: Can be very
helpful for evaluating acute or chronic sinusitis
 Magnetic resonance imaging: Also can be
helpful for evaluating sinusitis
Management
The management of allergic rhinitis consists of the
following 3 major treatment strategies:
 Environmental control measures and allergen
avoidance: These include keeping exposure to
allergens such as pollen, dust mites, and mold
to a minimum
 Pharmacologic management: Patients are often
successfully treated with oral antihistamines,
decongestants, or both; regular use of an
intranasal steroid spray may be more
appropriate for patients with chronic symptoms
 Immunotherapy: This treatment may be
considered more strongly with severe disease,
poor response to other management options,
and the presence of comorbid conditions or
complications; immunotherapy is often
combined with pharmacotherapy and
environmental control
Background
Rhinitis is defined as inflammation of the nasal itching and more congestion and mucus production tend
membranes [2] and is characterized by a symptom to occur. [13] The late phase may persist for hours or days.
complex that consists of any combination of the
following: sneezing, nasal congestion, nasal itching, and Systemic effects, including fatigue, sleepiness, and
rhinorrhea. [1] The eyes, ears, sinuses, and throat can also malaise, can occur from the inflammatory response.
be involved. Allergic rhinitis is the most common cause These symptoms often contribute to impaired quality of
of rhinitis. It is an extremely common condition, life.
affecting approximately 20% of the population.
Second-generation antihistamines
Pathophysiology
Class Summary
Allergic rhinitis involves inflammation of the mucous
membranes of the nose, eyes, eustachian tubes, middle
Often referred to as the nonsedating antihistamines.
ear, sinuses, and pharynx. The nose invariably is
They compete with histamine for histamine receptor
involved, and the other organs are affected in certain
type 1 (H1) receptor sites in the blood vessels, GI tract,
individuals. Inflammation of the mucous membranes is
and respiratory tract, which, in turn, inhibits physiologic
characterized by a complex interaction of inflammatory
effects that histamine normally induces at the H1
mediators but ultimately is triggered by an
receptor sites. Some do not appear to produce clinically
immunoglobulin E (IgE)–mediated response to an
significant sedation at usual doses, while others have a
extrinsic protein. [7]
low rate of sedation. [82, 83, 84] Other adverse effects (eg,
anticholinergic symptoms) are generally not observed.
The tendency to develop allergic, or IgE-mediated,
reactions to extrinsic allergens (proteins capable of
Topical azelastine and olopatadine are nasal sprays
causing an allergic reaction) has a genetic component. In
antihistamines that effectively reduce sneezing, itching,
susceptible individuals, exposure to certain foreign
and rhinorrhea but also effectively reduces congestion.
proteins leads to allergic sensitization, which is [85, 86, 87]
Used twice per day, especially when combined
characterized by the production of specific IgE directed
with a topical nasal corticosteroid, azelastine is effective
against these proteins. This specific IgE coats the
at managing both allergic and nonallergic rhinitis.
surface of mast cells, which are present in the nasal
mucosa. When the specific protein (eg, a specific pollen
grain) is inhaled into the nose, it can bind to the IgE on -Cetirizine
the mast cells, leading to immediate and delayed release
of a number of mediators. [7, 8, 9] Levocetirizine, Loratadine (5mg/5ml)

The mediators that are immediately released include Decongestants

histamine, tryptase, chymase, kinins, and heparin. [8, 9]
The mast cells quickly synthesize other mediators,
including leukotrienes and prostaglandin D2. [10, 11, 12]
These mediators, via various interactions, ultimately
lead to the symptoms of rhinorrhea (ie, nasal congestion, Pseudoephedrine (Sudafed, Genaphed, Psudatabs,
sneezing, itching, redness, tearing, swelling, ear SudoGest, Suphedrine, Zephrex-D)
pressure, postnasal drip). Mucous glands are stimulated,
leading to increased secretions. Vascular permeability is
increased, leading to plasma exudation. Vasodilation
occurs, leading to congestion and pressure. Sensory
nerves are stimulated, leading to sneezing and itching. Stimulates vasoconstriction by directly activating alpha-
All of these events can occur in minutes; hence, this adrenergic receptors of the respiratory mucosa.
reaction is called the early, or immediate, phase of the Available OTC in the United States. Helpful for nasal
reaction. and sinus congestion.

Over 4-8 hours, these mediators, through a complex SOURCE: WEBMD.COM

interplay of events, lead to the recruitment of other
inflammatory cells to the mucosa, such as neutrophils, BRONCHITIS
eosinophils, lymphocytes, and macrophages. [13] This
results in continued inflammation, termed the late-phase
Bronchitis is when your bronchial tubes, which carry air
response. The symptoms of the late-phase response are
to your lungs, get inflamed and swollen. You end up
similar to those of the early phase, but less sneezing and
with a nagging cough and mucus.
There are two types:
 Acute bronchitis. This is more common.
Symptoms last for a few weeks, but it doesn’t
usually cause problems past that.
 Chronic bronchitis. This one is more serious.
It keeps coming back or doesn’t go away.
Bronchitis Symptoms
Symptoms of both acute and chronic bronchitis include
breathing problems, such as:
 Chest congestion, when your chest feels full or
clogged
 A cough that may bring up mucus that’s clear,
white, yellow, or green
 Shortness of breath
 A wheezing or a whistling sound when you
breathe
Symptoms of acute bronchitis also may include: 
 Body aches and chills
 Feeling “wiped out”
 Low fever
 Runny, stuffy nose
 Sore throat
Even after the other symptoms of acute bronchitis are
gone, the cough can last for a few weeks while your
bronchial tubes heal and the swelling goes down. With
chronic bronchitis, your cough lasts for at least 3 months
and comes back at least 2 years in a row.
Bronchitis Causes
Most often, the same viruses that give you a cold or
the flu cause acute bronchitis. But sometimes, bacteria
bring it on.
In both of these cases, as your body fights the germs,
your bronchial tubes swell and make more mucus. That
means you have smaller openings for air to flow
through, which can make it harder to breathe.
Chronic bronchitis causes include:
 Breathing in air pollution and other things that
bother your lungs, like chemical fumes or dust,
over time
 Smoking or breathing in secondhand smoke
for a long time
Bronchitis Risk Factors
You have a bigger chance of getting either kind of
bronchitis if:
 You smoke.
 You have asthma and allergies.
 You have a weaker immune system. This is
sometimes the case for older adults and people
with ongoing diseases, as well as for babies
and young children. Even a cold can make it
more likely, since your body’s already busy
fighting those germs.
Your risk of getting chronic bronchitis is higher if:
 You’re a female smoker. You may be more at
risk than a male smoker.
 You have a family history of lung disease.
Bronchitis Diagnosis
Your doctor usually can tell whether you have
bronchitis based on a physical exam and your
symptoms. They’ll ask about your cough, such as how
long you’ve had it and what kind of mucus comes up
with it. They’ll also listen to your lungs to see whether
anything sounds wrong, like wheezing.
Your doctor may need to do some tests, depending on
whether they think you have acute or chronic bronchitis.
These tests may include:
 Check the oxygen levels in your  blood . This
is done with a sensor that goes on your toe or
finger.
 Do a  lung function test . You’ll breathe into
a device called a spirometer to test
for emphysema (a type of COPD in which air
sacs in your lungs are destroyed) and asthma.
 Give you a chest X-ray. This is to check for
pneumonia or another illness that could cause
your cough.
 Order blood tests. These can identify signs of
infection or measure the amount of carbon
dioxide and oxygen in your blood.
 Test your mucus to rule out diseases caused
by bacteria. One of these is whooping cough,
also called pertussis. It causes violent coughing
that makes it hard to breathe. If your doctor
thinks you have this or the flu, they’ll also take
a nasal swab.
Bronchitis Treatments
Most of the time, acute bronchitis goes away on its own
within a couple of weeks.
If yours is caused by bacteria (which is rare), your
doctor may give you antibiotics. If you have asthma or
allergies, or you’re wheezing, they might suggest an
inhaler. This helps open your airways and makes it
easier to breathe.
To ease your acute bronchitis symptoms, you can:
 Drink a lot of water. Eight to 12 glasses a day
helps thin out your mucus and makes it easier
to cough it up.
 Get plenty of rest.
 Take over-the-counter pain
relievers. Aspirin, ibuprofen, or naproxen help
with pain. But avoid giving aspirin to children.
You can use acetaminophen to help with both
pain and fever.
 Use a humidifier or steam. A hot shower can
be great for loosening mucus.
 Take over-the-counter cough
medicines. You might take a medicine like
guaifenesin during the day to loosen your
mucus so it's easier to cough up. Your doctor
will call this an expectorant. Check with your
pediatrician before giving any cough medicine
to children.
Chronic bronchitis treatments target your symptoms and
include:
 Medications like antibiotics, anti-
inflammatories, and bronchodilators to help
open your airways.
 A mucus-clearing device to help you cough up
fluid more easily.
 Oxygen therapy so you can breathe better.
 Pulmonary rehab, an exercise program that can
help you breathe more easily and exercise
more.
Bronchitis Prevention
To lower your chances of getting acute bronchitis or a
flare-up of chronic bronchitis:  typically prescribe antibiotics only if they find
 Stay away from cigarette smoke.
 Get the flu vaccine since you can get
bronchitis from the flu virus.
 Make sure your pertussis vaccine is up to date.
 Wash your hands often.
 Wear a mask when you’re around things that
bother your lungs, such as paint fumes.
 Overview
 Most people with acute bronchitis recover after
a few days or weeks. Viral infections, such as
the cold or flu, are usually the cause of acute
bronchitis. Occasionally, acute bronchitis can
be caused by a bacterial infection.
SOURCE: https://www.nhlbi.nih.gov/health-
topics/bronchitis
 Chronic bronchitis is an ongoing cough that
lasts for several months and comes back two or
more years in a row. In chronic bronchitis, the
lining of the airways stays constantly inflamed.
This causes the lining to swell and produce
more mucus, which can make it hard to
breathe. Chronic bronchitis is often part of a
serious condition called chronic obstructive
pulmonary disease (COPD).
 Your risk for either type of bronchitis is higher
if you smoke cigarettes or have asthma or
allergies. Chronic bronchitis is most often
caused by smoking cigarettes, but it can occur
in non-smokers as well. Women who smoke
may be more at risk than men. Those who are
older, have been exposed to fumes or
secondhand smoke, have a family history of
lung disease, have a history of childhood
respiratory diseases, or have gastroesophageal
reflux disease (GERD), are also at higher risk
of getting chronic bronchitis.
 The most common symptom of bronchitis is
coughing associated with mucus production.
Other symptoms include wheezing or shortness
of breath, chest pain, or a low fever. To
diagnose bronchitis, your doctor will do a
physical exam and ask about your medical
history and symptoms. The doctor may also
order a blood test to look for signs of infection
or a chest X-ray to see if your lungs and
bronchial tubes look normal and rule out
pneumonia.
 Usually, acute bronchitis goes away on its
own, without treatment. Sometimes over-the-
counter medicines that loosen mucus or a non-
steroidal anti-inflammatory drug (NSAID)
such as ibuprofen can help manage acute
bronchitis. Taking a couple of teaspoons of
honey or using a humidifier may also reduce
the symptoms and help with comfort. Doctors
that you have a bacterial infection, which is
more common in young children. To prevent
acute bronchitis from recurring, your doctor
may recommend that you get a seasonal flu
vaccine, quit smoking, and avoid being around
secondhand smoke.
 The goal of treatment for chronic bronchitis is
to help you breathe better and control your
symptoms. Your doctor may recommend
 healthy lifestyle changes such as quitting
smoking; taking medicines to help clear your
airways or to prevent symptoms from getting
worse; or, in some cases, getting oxygen
therapy to help you breathe better. Pulmonary
rehabilitation can teach you breathing
techniques such as pursed-lip breathing and
help you prevent symptoms from worsening.
LEARNING ISSUES:
Pulmonary edema
Overview
Pulmonary edema is a condition caused by excess fluid
in the lungs. This fluid collects in the numerous air sacs
in the lungs, making it difficult to breathe.
In most cases, heart problems cause pulmonary edema.
But fluid can accumulate for other reasons, including
pneumonia, exposure to certain toxins and medications,
trauma to the chest wall, and visiting or exercising at
high elevations.
Pulmonary edema that develops suddenly (acute
pulmonary edema) is a medical emergency requiring
immediate care. Pulmonary edema can sometimes be
fatal, but the outlook improves if you get treated
quickly. Treatment for pulmonary edema varies
depending on the cause but generally includes
supplemental oxygen and medications.
Symptoms
Depending on the cause, pulmonary edema signs and
symptoms may appear suddenly or develop over time.
Sudden (acute) pulmonary edema signs and
symptoms
 Extreme shortness of breath or difficulty
breathing (dyspnea) that worsens with activity
or when lying down
 A feeling of suffocating or drowning that
worsens when lying down
 Wheezing or gasping for breath
 Cold, clammy skin
 Anxiety, restlessness or a sense of
apprehension
 A cough that produces frothy sputum that may
be tinged with blood
 Blue-tinged lips
 A rapid, irregular heartbeat (palpitations)
Long-term (chronic) pulmonary edema signs and
symptoms
 More shortness of breath than normal when
you're physically active
 Difficulty breathing with exertion
 Difficulty breathing when you're lying flat
 Wheezing
 Awakening at night with a cough or breathless
feeling that may be relieved by sitting up
 Rapid weight gain
 Swelling in your lower extremities
 Fatigue
High-altitude pulmonary edema (HAPE) signs and
symptoms
HAPE can occur when people travel to or exercise at
very high altitudes. Signs and symptoms are similar to
those that occur with acute pulmonary edema and
include:
 Shortness of breath after exertion, which
progresses to shortness of breath at rest
 Cough
 Difficulty walking uphill, which progresses to
difficulty walking on flat surfaces
 Fever
 Fatigue
 A cough that produces frothy sputum that may
be tinged with blood
 A rapid, irregular heartbeat (palpitations)
 Chest discomfort
 Headaches, which may be the first symptom
When to see a doctor
Pulmonary edema that comes on suddenly (acute
pulmonary edema) is life-threatening. Call 911 or
emergency medical assistance if you have any of the
following acute signs and symptoms:
 Shortness of breath, especially if it comes on
suddenly
 Trouble breathing or a feeling of suffocating
(dyspnea)
 A bubbly, wheezing or gasping sound when
you breathe
 Pink, frothy sputum when you cough
 Breathing difficulty along with profuse
sweating
 A blue or gray tone to your skin
 Confusion
  A significant drop in blood pressure resulting
in lightheadedness, dizziness, weakness or
sweating
 A sudden worsening of any of the symptoms
associated with chronic pulmonary edema or
high-altitude pulmonary edema
Don't attempt to drive yourself to the hospital. Instead,
call 911 or emergency medical care and wait for help.
Causes
Your lungs contain numerous small, elastic air sacs
called alveoli. With each breath, these air sacs take in
oxygen and release carbon dioxide. Normally, the
exchange of gases takes place without problems.
But in certain circumstances, the alveoli fill with fluid
instead of air, preventing oxygen from being absorbed
into your bloodstream. A number of things can cause
fluid to accumulate in your lungs, but most have to do
with your heart (cardiogenic pulmonary edema).
Understanding the relationship between your heart and
lungs can help explain why.
Chambers of the heart
Your heart is composed of two upper and two lower
chambers. The upper chambers (the right and left atria)
receive incoming blood and pump it into the lower
chambers. The lower chambers (the more muscular right
and left ventricles) pump blood out of your heart. The
heart valves — which keep blood flowing in the correct
direction — are gates at the chamber openings.
Normally, deoxygenated blood from all over your body
enters the right atrium and flows into the right ventricle,
where it's pumped through large blood vessels
(pulmonary arteries) to your lungs. There, the blood
releases carbon dioxide and picks up oxygen.
The oxygen-rich blood then returns to the left atrium
through the pulmonary veins, flows through the mitral
valve into the left ventricle and finally leaves your heart
through another large artery, the aorta.
The aortic valve at the base of the aorta keeps the blood
from flowing backward into your heart. From the aorta,
the blood travels to the rest of your body.
Heart-related (cardiogenic) pulmonary edema
Cardiogenic pulmonary edema is a type of pulmonary
edema caused by increased pressures in the heart.
This condition usually occurs when the diseased or
overworked left ventricle isn't able to pump out enough
of the blood it receives from your lungs (congestive
heart failure). As a result, pressure increases inside the
left atrium and then in the veins and capillaries in your
lungs, causing fluid to be pushed through the capillary
walls into the air sacs.
Medical conditions that can cause the left ventricle to
become weak and eventually fail include:
 Coronary artery disease. Over time, the
arteries that supply blood to your heart muscle
can become narrow from fatty deposits
(plaques). A heart attack occurs when a blood
clot forms in one of these narrowed arteries,
blocking blood flow and damaging the portion
of your heart muscle supplied by that artery.
The result is that the damaged heart muscle
can no longer pump as well as it should.
Sometimes, a clot isn't the cause of the
problem. Instead, gradual narrowing of the
coronary arteries can lead to weakness of the
left ventricular muscle. Although the rest of
your heart tries to compensate for this loss,
there are times when it's unable to do so
effectively. The heart can also be weakened by
the extra workload.
When the pumping action of your heart is
weakened, blood gradually backs up into your
lungs, forcing fluid in your blood to pass
through the capillary walls into the air sacs.
This is chronic congestive heart failure.
 Cardiomyopathy. When your heart muscle is
damaged, the condition is called
cardiomyopathy. Because cardiomyopathy
affects the function of the ventricles — your
heart's main pump — your heart may not be
able to respond to conditions that require it to
work harder, such as a surge in blood pressure,
a faster heartbeat with exertion, or consuming
too much salt in the diet that causes water
retention or infections. When the left ventricle
can't keep up with the demands that are placed
on it, fluid backs up into your lungs.
 Heart valve problems. In mitral valve disease
or aortic valve disease, the valves that regulate
blood flow in the left side of your heart may
not open wide enough (stenosis). Or, they don't
close completely, allowing blood to flow
backward through the valve (insufficiency or
regurgitation).
 When the valves are narrowed, blood can't
flow freely into your heart and pressure in the
left ventricle builds up, causing the left
ventricle to work harder and harder with each
contraction. The left ventricle also dilates to
allow greater blood flow, but this makes the
left ventricle's pumping action less efficient.
The increased pressure extends into the left
atrium and then to the pulmonary veins,
causing fluid to accumulate in your lungs. On
the other hand, if the mitral valve leaks, some
blood is backwashed toward your lung each
time your heart pumps. If the leakage develops
suddenly, you may develop sudden and severe
pulmonary edema.
 High blood pressure (hypertension).
Untreated or uncontrolled high blood pressure
can enlarge the heart.
Other conditions may lead to cardiogenic pulmonary
edema, such as high blood pressure due to narrowed
kidney arteries (renal artery stenosis) and fluid buildup
due to kidney disease or heart problems.
Non-heart-related (noncardiogenic) pulmonary
edema
High-altitude pulmonary edema
Pulmonary edema that isn't caused by increased
pressures in your heart is called noncardiogenic
pulmonary edema.
In this condition, fluid may leak from the capillaries in
your lungs' air sacs because the capillaries themselves
become more permeable or leaky, even without the
buildup of back pressure from your heart. Some factors
that can cause noncardiogenic pulmonary edema
include:
 Acute respiratory distress syndrome
(ARDS). This serious disorder occurs when
your lungs suddenly fill with fluid and
inflammatory white blood cells. Many
conditions can cause ARDS, including severe
injuries (trauma), systemic infection (sepsis),
pneumonia and severe bleeding.
 High altitudes. Mountain climbers and people
who travel to high-altitude locations run the
risk of developing high-altitude pulmonary
edema (HAPE).
This condition — which generally occurs at
elevations above 8,000 feet (about 2,400
meters) — can also affect hikers or skiers who
start exercising at higher altitudes without first
becoming acclimated, which can take from a
few days to a week or so. But even people who
have hiked or skied at high altitudes in the past
aren't immune.
Although the exact cause isn't completely
understood, HAPE seems to develop as a result
of increased pressure from constriction of the
pulmonary capillaries. Without appropriate
care, HAPE can be fatal, but this risk can be
minimized.
 Nervous system conditions. A type of
pulmonary edema called neurogenic
pulmonary edema can occur after some
nervous system conditions or procedures —
such as after a head injury or seizure — or
after brain surgery.
 Adverse drug reaction. Many drugs —
ranging from illegal drugs such as heroin and
cocaine to aspirin — are known to cause
noncardiogenic pulmonary edema.
 Negative pressure pulmonary edema.
Pulmonary edema can develop after a blockage
in the upper airway causes negative pressure in
the lungs from intense efforts to breathe
despite the blockage.
 Pulmonary embolism. Pulmonary embolism,
a condition that occurs when blood clots travel
from blood vessels in your legs to your lungs,
can lead to pulmonary edema.
 Viral infections. Pulmonary edema can be
caused by viral infections such as the
hantavirus and dengue virus.
 Exposure to certain toxins. These include
toxins you inhale as well as those that may
circulate within your own body, for example, if
you inhale (aspirate) some of your stomach
contents when you vomit. Inhaling toxins
causes intense irritation of the small airways
and alveoli, resulting in fluid accumulation.
 Smoke inhalation. Smoke from a fire contains
chemicals that damage the membrane between
the air sacs and the capillaries, allowing fluid
to enter your lungs.
 Near drowning. Inhaling water causes
noncardiogenic pulmonary edema that is
reversible with immediate attention.
Complications
If pulmonary edema continues, it can raise pressure in
the pulmonary artery (pulmonary hypertension), and
eventually the right ventricle in your heart becomes
weak and begins to fail. The right ventricle has a much
thinner wall of muscle than does the left side of your
heart because it is under less pressure to pump blood
into the lungs. The increased pressure backs up into the
right atrium and then into various parts of your body,
where it can cause:
 Lower extremity and abdominal swelling
 Buildup of fluid in the membranes that
surround your lungs (pleural effusion)
 Congestion and swelling of the liver
Left untreated, acute pulmonary edema can be deadly.
In some instances, it may be fatal even if you receive
treatment.
Prevention
Preventing conditions and situations that cause
pulmonary edema can help keep pulmonary edema from
developing. These measures can help reduce your risk.
Preventing cardiovascular disease
Cardiovascular disease is the leading cause of
pulmonary edema. You can reduce your risk of many
kinds of heart problems by following these suggestions:
 Control your blood pressure. High blood
pressure (hypertension) can lead to serious
conditions such as a stroke, cardiovascular
disease and kidney failure. In many cases, you
can lower your blood pressure or maintain a
healthy level by getting regular exercise;
maintaining a healthy weight; eating a diet rich
in fresh fruits, vegetables and low-fat dairy
products; and limiting salt and alcohol.
 Watch your blood cholesterol. Cholesterol is
one of several types of fats essential to good
health. But too much cholesterol can be too
much of a good thing. Higher than normal
cholesterol levels can cause fatty deposits to
form in your arteries, impeding blood flow and
increasing your risk of vascular disease.
But lifestyle changes can often keep your
cholesterol levels low. Lifestyle changes may
include limiting fats (especially saturated fats);
eating more fiber, fish, and fresh fruits and
vegetables; exercising regularly; stopping
smoking; and drinking in moderation.
 Don't smoke. If you smoke and can't quit on
your own, talk to your doctor about strategies
or programs to help you break a smoking habit.
Smoking can increase your risk of
cardiovascular disease. Also avoid secondhand
smoke.
 Eat a heart-healthy diet. Eat a healthy diet
that's low in salt, sugars and solid fats and rich
in fruits, vegetables and whole grains.
 Limit salt. It's especially important to use less
salt (sodium) if you have heart disease or high
blood pressure. In some people with severely
damaged left ventricular function, excess salt
may be enough to trigger congestive heart
failure.
If you're having a hard time cutting back on
salt, it may help to talk to a dietitian. He or she
can help point out low-sodium foods as well as
offer tips for making a low-salt diet interesting
and good tasting.
 Exercise regularly. Exercise is vital for a
healthy heart. Regular aerobic exercise, about
30 minutes a day, helps you control blood
pressure and cholesterol levels and maintain a
healthy weight. If you're not used to exercise,
start out slowly and build up gradually. Be sure
to get your doctor's OK before starting an
exercise program.
 Maintain a healthy weight. Being even
slightly overweight increases your risk of
cardiovascular disease. On the other hand,
even losing small amounts of weight can lower
your blood pressure and cholesterol and reduce
your risk of diabetes.
 Manage stress. To reduce your risk of heart
problems, try to reduce your stress levels. Find
healthy ways to minimize or deal with stressful
events in your life.
Preventing high-altitude pulmonary edema (HAPE)
If you travel or climb at high altitudes, acclimate
yourself slowly. Although recommendations vary, most
experts advise ascending no more than 1,000 to 1,200
feet (about 305 to 366 meters) a day once you reach
8,200 feet (about 2,500 meters).
Some climbers take prescription medications such as
acetazolamide or nifedipine (Procardia) to help prevent
signs and symptoms of HAPE. To prevent HAPE, start
taking the medication at least one day before ascent.
Continue taking the medication for about five days after
you've arrived at your high-altitude destination.
PATHOPHYSIOLOGY
Pulmonary Edema
Pulmonary edema occurs in the same way that edema
occurs elsewhere in the body. Any factor that increases
fluid filtration out of the pulmonary capillaries or that
impedes pulmonary lymphatic function and causes the
pulmonary interstitial fluid pressure to rise from the
negative range into the positive range will cause rapid
filling of the pulmonary interstitial spaces and alveoli
with large amounts of free fluid. The most common
causes of pulmonary edema are as follows:
1. Left-sided heart failure or mitral valve disease, with
consequent great increases in pulmonary venous
pressure and pulmonary capillary pressure and flooding
of the interstitial spaces and alveoli.
2. Damage to the pulmonary blood capillary membranes
caused by infections such as pneumonia or by breathing
noxious substances such as chlorine gas or sulfur
dioxide gas. Each of these mechanisms causes rapid
leakage of both plasma proteins and fluid out of the
capillaries and into both the lung interstitial spaces and
the alveoli. “Pulmonary Edema Safety Factor.”
Experiments in animals have shown that the pulmonary
capillary pressure normally must rise to a value at least
equal to the colloid osmotic pressure of the plasma
inside the capillaries before significant pulmonary
edema will occur. Remember that every time the left
atrial pressure rises to high values, the pulmonary
capillary pressure rises to a level 1 to 2 mm Hg greater
than the left atrial pressure. In these experiments, as
soon as the left atrial pressure rose above 23 mm Hg
(causing the pulmonary capillary pressure to rise above
25 mm Hg), fluid began to accumulate in the lungs. This
fluid accumulation increased even more rapidly with
further increases in capillary pressure. The plasma
colloid osmotic pressure during these experiments was
equal to this 25 mm Hg critical pressure level.
Therefore, in the human being, whose normal plasma
colloid osmotic pressure is 28 mm Hg, one can predict
that the pulmonary capillary pressure must rise from the
normal level of 7 mm Hg to more than 28 mm Hg to
cause pulmonary edema, giving an acute safety factor
against pulmonary edema of 21 mm Hg. Safety Factor
in Chronic Conditions. When the pulmonary capillary
pressure remains elevated chronically (for at least 2
weeks), the lungs become even more resistant to
pulmonary edema because the lymph vessels expand
greatly, increasing their capability of carrying fluid
away from the interstitial spaces perhaps as much as 10-
fold. Therefore, in patients with chronic mitral stenosis,
pulmonary capillary pressures of 40 to 45 mm Hg have
been measured without the development of lethal
pulmonary edema. Rapidity of Death in Persons with
Acute Pulmonary Edema. When the pulmonary capillary
pressure rises even slightly above the safety factor level,
lethal pulmonary edema can occur within hours, or even
within 20 to 30 minutes if the capillary pressure rises 25
to 30 mm Hg above the safety factor level. Thus, in
acute left-sided heart failure, in which the pulmonary
capillary pressure occasionally does rise to 50 mm Hg,
death may ensue in less than 30 minutes as a result of
acute pulmonary edema.
COUGH REFLEX
Cough Reflex The bronchi and trachea are so sensitive
to light touch that slight amounts of foreign matter or
other causes of irritation initiate the cough reflex. The
larynx and carina (i.e., the point where the trachea
divides into the bronchi) are especially sensitive, and
the terminal bronchioles and even the alveoli are
sensitive to corrosive chemical stimuli such as sulfur
dioxide gas or chlorine gas. Afferent nerve impulses
pass from the respiratory passages mainly through the
vagus nerves to the medulla of the brain. There, an
automatic sequence of events is triggered by the
neuronal circuits of the medulla, causing the following
effect. First, up to 2.5 liters of air are rapidly inspired.
Second, the epiglottis closes, and the vocal cords shut
tightly to entrap the air within the lungs. Third, the
abdominal muscles contract forcefully, pushing against
the diaphragm while other expiratory muscles, such as
the internal intercostals, also contract forcefully.
Consequently, the pressure in the lungs rises rapidly to
as much as 100 mm Hg or more. Fourth, the vocal cords
and the epiglottis suddenly open widely, so that air
under this high pressure in the lungs explodes outward.
Indeed, sometimes this air is expelled at velocities
ranging from 75 to 100 miles per hour. Importantly, the
strong compression of the lungs collapses the bronchi
and trachea by causing their noncartilaginous parts to
invaginate inward, so the exploding air actually passes
through bronchial and tracheal slits. The rapidly moving
air usually carries with it any foreign matter that is
present in the bronchi or trachea.
RESPIRATORY REFLEX CENTERS
A PNEUMOTAXIC CENTER LIMITS THE
DURATION OF INSPIRATION AND INCREASES
THE RESPIRATORY RATE A pneumotaxic center,
located dorsally in the nucleus parabrachialis of the
upper pons, transmits signals to the inspiratory area. The
primary effect of this center is to control the “switch-
off” point of the inspiratory ramp, thus controlling the
duration of the filling phase of the lung cycle. When the
pneumotaxic signal is strong, inspiration might last for
as little as 0.5 second, thus filling the lungs only
slightly; when the pneumotaxic signal is weak,
inspiration might continue for 5 or more seconds, thus
filling the lungs with a great excess of air. The function
of the pneumotaxic center is primarily to limit
inspiration, which has a secondary effect of increasing
the rate of breathing, because limitation of inspiration
also shortens expiration and the entire period of each
respiration. A strong pneumotaxic signal can increase
the rate of breathing to 30 to 40 breaths per minute,
whereas a weak pneumotaxic signal may reduce the rate
to only 3 to 5 breaths per minute.
VENTRAL RESPIRATORY GROUP OF NEURONS
—FUNCTIONS IN BOTH INSPIRATION AND
EXPIRATION Located in each side of the medulla,
about 5 millimeters anterior and lateral to the dorsal
respiratory group of neurons, is the ventral respiratory
group of neurons, found in the nucleus ambiguus
rostrally and the nucleus retroambiguus caudally. The
function of this neuronal group differs from that of the
dorsal respiratory group in several important ways: 1.
The neurons of the ventral respiratory group remain
almost totally inactive during normal quiet respiration.
Therefore, normal quiet breathing is caused only by
repetitive inspiratory signals from the dorsal respiratory
group transmitted mainly to the diaphragm, and
expiration results from elastic recoil of the lungs and
thoracic cage. 2. The ventral respiratory neurons do not
appear to participate in the basic rhythmical oscillation
that controls respiration. 3. When the respiratory drive
for increased pulmonary ventilation becomes greater
than normal, respiratory signals spill over into the
ventral respiratory neurons from the basic oscillating
mechanism of the dorsal respiratory area. As a
consequence, the ventral respiratory area contributes
extra respiratory drive as well. 4. Electrical stimulation
of a few of the neurons in the ventral group causes
inspiration, whereas stimulation of others causes
expiration. Therefore, these neurons contribute to both
inspiration and expiration. They are especially important
in providing the powerful expiratory signals to the
abdominal muscles during very heavy expiration. Thus,
this area operates more or less as an overdrive
mechanism when high levels of pulmonary ventilation
are required, especially during heavy exercise.
LUNG INFLATION SIGNALS LIMIT INSPIRATION
—THE HERING-BREUER INFLATION REFLEX In
addition to the central nervous system respiratory
control mechanisms operating entirely within the brain
stem, sensory nerve signals from the lungs also help
control respiration. Most important, located in the
muscular portions of the walls of the bronchi and
bronchioles throughout the lungs are stretch receptors
that transmit signals through the vagi into the dorsal
respiratory group of neurons when the lungs become
overstretched. These signals affect inspiration in much
the same way as signals from the pneumotaxic center;
that is, when the lungs become overly inflated, the
stretch receptors activate an appropriate feedback
response that “switches off” the inspiratory ramp and
thus stops further inspiration. This mechanism is called
the Hering-Breuer inflation reflex. This reflex also
increases the rate of respiration, as is true for signals
from the pneumotaxic center. In humans, the Hering-
Breuer reflex probably is not activated until the tidal
volume increases to more than three times normal
(>≈1.5 liters per breath). Therefore, this reflex appears
to be mainly a protective mechanism for preventing
excess lung inflation rather than an important ingredient
in normal control of ventilation.
Source: Guyton Textbook of Medical Physiology
DEMYELINATION OF NERVE FIBERS
A demyelinating disease is any condition that results in
damage to the protective covering (myelin sheath) that
surrounds nerve fibers in your brain, optic nerves and
spinal cord. When the myelin sheath is damaged, nerve
impulses slow or even stop, causing neurological
problems.
Multiple sclerosis
Multiple sclerosis (MS) is the most common
demyelinating disease of the central nervous system. In
this disorder, your immune system attacks the myelin
sheath or the cells that produce and maintain it.
This causes inflammation and injury to the sheath and
ultimately to the nerve fibers that it surrounds. The
process can result in multiple areas of scarring
(sclerosis).
Other causes
Other types of demyelinating disease and their causes
include:
 Optic neuritis — inflammation of the optic
nerve in one or both eyes
 Neuromyelitis optica (Devic's disease) —
inflammation and demyelination of the central
nervous system, especially of the optic nerve
and spinal cord
 Transverse myelitis — inflammation of the
spinal cord
 Acute disseminated encephalomyelitis —
inflammation of the brain and spinal cord
 Adrenoleukodystrophy and
adrenomyeloneuropathy — rare, inherited
metabolic disorders
MS and other demyelinating diseases most commonly
result in vision loss, muscle weakness, muscle stiffness
and spasms, loss of coordination, change in sensation,
pain, and changes in bladder and bowel function.
Treatment
No cures exist for demyelinating diseases and their
progression, and symptoms are different for everyone.
Getting treatment early is important. Treatment focuses
on:
 Minimizing the effects of the attacks
 Modifying the course of the disease
 Managing the symptoms
A variety of drug therapies are recommended depending
on your specific disorder. Strategies to treat symptoms
include physical therapy, muscle relaxing drugs, and
medications to reduce pain and fatigue. Talk with your
doctor about the best course of treatment for your
specific disorder.
PNEUMONIA
Pneumonia is an infection that inflames the air sacs in
one or both lungs. The air sacs may fill with fluid or pus
(purulent material), causing cough with phlegm or pus,
fever, chills, and difficulty breathing. A variety of
organisms, including bacteria, viruses and fungi, can
cause pneumonia.
Pneumonia can range in seriousness from mild to life-
threatening. It is most serious for infants and young
children, people older than age 65, and people with
health problems or weakened immune systems.
Symptoms
The signs and symptoms of pneumonia vary from mild
to severe, depending on factors such as the type of germ
causing the infection, and your age and overall health.
Mild signs and symptoms often are similar to those of a
cold or flu, but they last longer.
Signs and symptoms of pneumonia may include:
 Chest pain when you breathe or cough
 Confusion or changes in mental awareness (in
adults age 65 and older)
 Cough, which may produce phlegm
 Fatigue
 Fever, sweating and shaking chills
 Lower than normal body temperature (in adults
older than age 65 and people with weak
immune systems)
 Nausea, vomiting or diarrhea
 Shortness of breath
Newborns and infants may not show any sign of the
infection. Or they may vomit, have a fever and cough,
appear restless or tired and without energy, or have
difficulty breathing and eating.
When to see a doctor
See your doctor if you have difficulty breathing, chest
pain, persistent fever of 102 F (39 C) or higher, or
persistent cough, especially if you're coughing up pus.
It's especially important that people in these high-risk
groups see a doctor:
 Adults older than age 65
 Children younger than age 2 with signs and
symptoms
 People with an underlying health condition or
weakened immune system
 People receiving chemotherapy or taking
medication that suppresses the immune system
For some older adults and people with heart failure or
chronic lung problems, pneumonia can quickly become
a life-threatening condition.
Causes
Many germs can cause pneumonia. The most common
are bacteria and viruses in the air we breathe. Your body
usually prevents these germs from infecting your lungs.
But sometimes these germs can overpower your immune
system, even if your health is generally good.
Pneumonia is classified according to the types of germs
that cause it and where you got the infection.
Community-acquired pneumonia
Community-acquired pneumonia is the most common
type of pneumonia. It occurs outside of hospitals or
other health care facilities. It may be caused by:
 Bacteria. The most common cause of bacterial
pneumonia in the U.S. is Streptococcus
pneumoniae. This type of pneumonia can
occur on its own or after you've had a cold or
the flu. It may affect one part (lobe) of the
lung, a condition called lobar pneumonia.
 Bacteria-like organisms. Mycoplasma
pneumoniae also can cause pneumonia. It
typically produces milder symptoms than do
other types of pneumonia. Walking pneumonia
 is an informal name given to this type of
pneumonia, which typically isn't severe
enough to require bed rest.
 Fungi. This type of pneumonia is most
common in people with chronic health
problems or weakened immune systems, and in
people who have inhaled large doses of the
organisms. The fungi that cause it can be found
in soil or bird droppings and vary depending
upon geographic location.
 Viruses. Some of the viruses that cause colds
and the flu can cause pneumonia. Viruses are
the most common cause of pneumonia in
children younger than 5 years. Viral
pneumonia is usually mild. But in some cases
it can become very serious.
Hospital-acquired pneumonia
Some people catch pneumonia during a hospital stay for
another illness. Hospital-acquired pneumonia can be
serious because the bacteria causing it may be more
resistant to antibiotics and because the people who get it
are already sick. People who are on breathing machines
(ventilators), often used in intensive care units, are at
higher risk of this type of pneumonia.
Health care-acquired pneumonia
Health care-acquired pneumonia is a bacterial infection
that occurs in people who live in long-term care
facilities or who receive care in outpatient clinics,
including kidney dialysis centers. Like hospital-acquired
pneumonia, health care-acquired pneumonia can be
caused by bacteria that are more resistant to antibiotics.
Aspiration pneumonia
Aspiration pneumonia occurs when you inhale food,
drink, vomit or saliva into your lungs. Aspiration is
more likely if something disturbs your normal gag
reflex, such as a brain injury or swallowing problem, or
excessive use of alcohol or drugs.
Risk factors
Pneumonia can affect anyone. But the two age groups at
highest risk are:
 Children who are 2 years old or younger
 People who are age 65 or older
Other risk factors include:
 Being hospitalized. You're at greater risk of
pneumonia if you're in a hospital intensive care
unit, especially if you're on a machine that
helps you breathe (a ventilator).
 Chronic disease. You're more likely to get
pneumonia if you have asthma, chronic
obstructive pulmonary disease (COPD) or
heart disease.
 Smoking. Smoking damages your body's
natural defenses against the bacteria and
viruses that cause pneumonia.
 Weakened or suppressed immune system.
People who have HIV/AIDS, who've had an
organ transplant, or who receive chemotherapy
or long-term steroids are at risk.
Complications
Even with treatment, some people with pneumonia,
especially those in high-risk groups, may experience
complications, including:
 Bacteria in the bloodstream (bacteremia).
Bacteria that enter the bloodstream from your
lungs can spread the infection to other organs,
potentially causing organ failure.
 Difficulty breathing. If your pneumonia is
severe or you have chronic underlying lung
diseases, you may have trouble breathing in
enough oxygen. You may need to be
hospitalized and use a breathing machine
(ventilator) while your lung heals.
 Fluid accumulation around the lungs
(pleural effusion). Pneumonia may cause fluid
to build up in the thin space between layers of
tissue that line the lungs and chest cavity
(pleura). If the fluid becomes infected, you
may need to have it drained through a chest
tube or removed with surgery.
 Lung abscess. An abscess occurs if pus forms
in a cavity in the lung. An abscess is usually
treated with antibiotics. Sometimes, surgery or
drainage with a long needle or tube placed into
the abscess is needed to remove the pus.
Prevention
To help prevent pneumonia:
 Get vaccinated. Vaccines are available to
prevent some types of pneumonia and the flu.
Talk with your doctor about getting these
shots. The vaccination guidelines have
changed over time so make sure to review your
vaccination status with your doctor even if you
 recall previously receiving a pneumonia
vaccine.
 Make sure children get vaccinated. Doctors
recommend a different pneumonia vaccine for
children younger than age 2 and for children
ages 2 to 5 years who are at particular risk of
pneumococcal disease. Children who attend a
group child care center should also get the
vaccine. Doctors also recommend flu shots for
children older than 6 months.
 Practice good hygiene. To protect yourself
against respiratory infections that sometimes
lead to pneumonia, wash your hands regularly
or use an alcohol-based hand sanitizer.
 Don't smoke. Smoking damages your lungs'
natural defenses against respiratory infections.
 Keep your immune system strong. Get
enough sleep, exercise regularly and eat a
healthy diet.