Chapter I

INTRODUCTION
From the Iirst breath at birth, the rate and depth oI our breathing are unconsciously
matched to our activity, whether studying, sleeping, talking, eating, or exercising. We can
voluntarily stop breathing, but within a Iew seconds we must breathe again. Breathing is a
characteristic oI liIe that, along with the pulse, it is one oI the Iirst things we check to determine
iI an unconscious person is alive.
Breathing is necessary because all living cells oI the body require oxygen and produce
carbon dioxide. The respiratory system allows the exchange oI these gases between the air and
the blood, and the cardiovascular system transports them between the lungs and the cells oI the
body. The capacity to carry out normal activity is reduced without healthy respiratory and
cardiovascular systems.
Respiration includes the Iollowing process: ventilation, or breathing, which is the
movement oI air into and out oI the lungs, exchange oI oxygen and carbon dioxide between the
air in the lungs and the blood, transport oI oxygen and carbon dioxide in the blood; and exchange
oI oxygen and carbon dioxide between the blood and the tissues. The term respiration is also
used in reIerence to cell metabolism.
Respiration is necessary because all living cells oI the body require oxygen and produce
carbon dioxide. Its Iunctions include gas exchange. The respiratory system and the
cardiovascular system work together to supply oxygen to all cells and to remove carbon dioxide.
It also helps in regulation oI the pH. The respiratory system can alter blood pH by changing
blood carbon dioxide levels. It is also responsible in voice production. Air movement past the
vocal Iolds makes sound and speech possible. The sensation oI smell occurs when airborne
molecules are drawn into the nasal cavity which is called olIaction. Another Iunction oI the
respiratory system is protection. The respiratory system provides protection against some micro
organisms by preventing their entry into the body and by removing them Irom the respiratory
surIaces.











NTOMY ND PHYSIOLOGY OF THE
RESPIRTORY SYSTEM


















The respiratory system consists oI the external nose, nasal cavity, the pharynx, the larynx,
the trachea, the bronchi, and the lungs. Although air Irequently passes through the oral cavity, it
is considered to be a part oI the digestive system instead oI the respiratory system. The upper
respiratory tract consists oI external nose, nasal cavity, pharynx and associated structures, and
the lower respiratory tract consists oI larynx, trachea, bronchi and the lungs.





The Nose or Nasal Cavity
As air passes through the nasal cavities it is
warmed and humidiIied, so that air that reaches
the lungs is warmed and moist. The Nasal
airways are lined with cilia and kept moist by
mucous secretions. The combination oI cilia and
mucous helps to Iilter out solid particles Irom the
air and moisten the air, which prevents damage to
the delicate tissues that Iorm the Respiratory
System. The moisture in the nose helps to heat
and humidiIy the air, increasing the amount oI
water vapor the air entering the lungs contains.
This helps to keep the air entering the nose Irom
drying out the lungs and other parts oI our
respiratory system. When air enters the
respiratory system through the mouth, much less Iiltering is done. It is generally better to take
in air through the nose.
O The .ilia Iilter the smaller particles oI dust and dirt.
O The moist 2:.o:s 2e2-rane also catches particles oI dirt. It also warms and moistens
the incoming air.
O The tiny -lood vessel inside the nose also warm and moisten the passing air.


The Pharynx
The pharynx is also called the throat. As we
saw in the digestive system, the epiglottis closes oII
the tra.hea when we swallow. Below
the epiglottis is the larynx or voi.e -ox. This
contains 2 vo.al .ords, which vibrate when air
passes by them. With our tongue and lips we convert
these vibrations into spee.h. The area at the top oI
the tra.hea, which contains the larynx, is called
the glottis.


The Larynx

From the pharynx, the clean air moves down to the
larynx. The Larynx is Iound at the lower end oI the pharynx. It is
the enlarged upper portion oI the trachea. It is also called the voice
box. The larynx contains the vocal cords that vibrate when air
passes through them. The vibration oI the vocal cords, together
with the movements oI the mouth and tongue, produces the sound
oI your voice.
The Tra.hea

The tra.hea or windpipe is made oI muscle and elastic Iibres with rings oI cartilage. The
cartilage prevents the tubes oI the trachea Irom collapsing. The trachea is divided
or -ran.hed into -ron.hi and then into smaller -ron.hioles. The -ron.hioles branch oII
into alveoli. The alveoli will be discussed later. Like the nasal passages, the inner wall oI the
trachea is lined with cilia. The cilia catch the dust particles that reach the windpipe. The dust
particles are then pushed out and up toward the throat and mouth Ior expulsion. This explains
why one coughs or sneezes when dirt gets into the upper respiratory tract. The lower end oI the
trachea branches into two large tubes called the -ron.hi.

The Bron.hi
The trachea divides into two tubes called bronchi,
one entering the leIt and one entering the right
lung. The leIt bronchi is narrower, longer and
more horizontal than the right. Irregular rings oI
cartilage surround the bronchi, whose walls also
consist oI s2ooth 2:s.le. Once inside the lung
the bronchi split several ways, Iorming tertiary
bronchi.
The Bron.hioles
Tertiary bronchi continue to divide and become
bronchioles, very narrow tubes, less than 1
millimeter in diameter. There is no cartilage
within the bronchioles and they lead to alveolar
sacs.
The lveoli
Individual hollow cavities contained within
alveolar sacs (or ducts). Alveoli have very thin
walls which permit the ex.hange of
gases Oxygen and Carbon Dioxide. They are
surrounded by a network oI .apillaries, into
which the inspired gases pass. There are
approximately 3 million alveoli within an average
adult lung.
The Diaphrag2
The diaphragm is a broad band oI muscle which sits underneath the lungs, attaching to the lower
ribs, sternum and lumbar spine and Iorming the base oI the thoracic cavity.

The L:ngs

The l:ngs are spongy structure where the exchange oI gases takes place. Each lung is
surrounded by a pair oI pleural membranes. Between the membranes is ple:ral fl:id, which
reduces Iriction while breathing. The bronchi are divided into about a million bronchioles. The
ends oI the bronchioles are hollow air sacs called alveoli. There are over 700 million alveoli in
the lungs. This greatly increases the surIace area through which gas exchange occurs.
Surrounding the alveoli are .apillaries. The lungs give up their oxygen to the capillaries through
the alveoli. Likewise, carbon dioxide is taken Irom the capillaries and into the alveoli.
The -ron.hioles and alveoli look like the branches oI a tree. The biggest branches are
the bronchi. Bronchi are covered by cilia and a thin Iilm oI mucus. Dust and pollen are trapped
by the mucus beIore they reach the alveoli.
Each oI the lungs contains about 300 million alveoli. Each alveolus is surrounded by tiny
blood vessels called .apillaries. The exchange oI oxygen andcarbon dioxide during the
breathing process takes place in the capillaries oI each alveolus.








SSESSMENT
PHARYAX and MOU1H
Inspect
O The nurse inspects these structures Ior color, symmetry, and evidence oI exudate,
ulceration, or enlargement.

1RACHEA
!alpate
O BY placing the thumb and index Iinger oI one hand on either side oI the trachea
just above the sterna notch.
O The trachea normally in the midline as it enters the thoracic inlet behind the
sternum, but it may be deviated by masses in the neck or mediastinum.
O !leural or pulmonary disorders, such as a pneumothorax, may also displace the
trachea.

Physi.al ssess2ent of the Lower Respiratory Str:.t:res and Breathing
1HORAX
Inspect
O The nurse observes the skin over the thorax Ior color and turgor and Ior evidence
oI loss oI subcutaneous tissue. It is important to note asymmetry, iI present.
Chest conIiguration
O Barrel Chest- occurs as a result oI overinIlation oI the lungs. There is an increase
in the anteroposterior diameter oI the thorax. In a patient with emphyserma, the
ribs are more widely spaced and the intercostals spaces tend to bulge on
expiration.
O Funnel Chest (!ectus Excavatum)- there is a depression in the lower portion oI
the sternum. This may compress the heart and great vessels, resulting in murmurs.
O !igeon Chest (!ectus Carinatum)- occurs as a result oI displacement oI the
sternum. There is an increase in the anteroposterior diameter. This may occur with
rickets, MarIan`s syndrome, or severe kyphoscoliosis.
O yphoscoliosis- characterized by elevation oI the scapula and a corresponding S-
shaped spine. This deIormity limits lung expansion within the thorax. It may
occur with osteoporosis and other skeletal disorders that aIIect the thorax.
Breathing patterns and Respiratory rates
Eupnea Normal, breathing at 12-18 bpm
Bradypnea Slower than normal rate (·10 bpm), with normal depths and
regular rhythms
Tachypnea Rapid, shallow breathing ~24 bpm
Hypoventilation Shallow, irregular breathing
hyperventilation Increased rate and depth oI breathing (called ussmaul`s
respiration iI caused by diabetic ketoacidosis)
Apnea !eriod oI cessation oI breathing. Time duration varies,
apnea may occur brieIly during other breathing disorders,
such as with sleep apnea. LiIe threatening iI sustained.
Cheyne-Stokes Regular cycle where the rate and depths oI breathing
increase, then decrease until apnea (usually about 20
seconds) occurs.
Biot`s respiration !eriods oI normal breathing (3-4 breaths) Iollowed by a
varying period oI apnea (usually 10-60 seconds)

1HORACIC PALPA1IOA
The nurse palpates the thorax Ior tenderness, masses, lesions, respiratory excursion and
vocal Iremitus.
Respiratory excursion
O Is an estimation oI thoracic expansion and may disclose signiIicant inIormation
about thoracic movement during breathing. The nurse assesses the patienIt Ior
range and symmetry oI excursion.
O Decrease chest excursion may be caused by chronic Iibrotic disease. Asymmetry
excursion may be due to splinting secondary to pleurisy, Iractured ribs, or
unilateral bronchial obstruction.
Tactile Fremitus
O Sound generated by the larynx travel distally along the bronchial tree to set the
chest wall in resonant motion.
O Normal Iremitus is widely varied. It is inIluenced by the thickness oI the chest
wall, especially iI that thickness is muscular.
O Lower pitched sounds travel better through the normal lung and produce greater
vibration oI the chest wall.
O The patient is asked to repeat 'ninety- nine¨ or 'one, two. Three,¨ or 'eee, eee,
eee¨ as the nurse`s hands move down the patient`s thorax. The vibrations are
detected with the palmar surIaces oI the Iingers and hands, or the ulnar aspect oI
the extended hands on the thorax.
O !atients with emphysema, which results Irom the rupture oI alveoli and trapping
oI air, exhibit almost no tactile Iremitus.
THORACIC PERCUSSION
The nurse uses percussion to determine whether underlying tissues are Iilled with air,
Iluid or solid materials. !ercussion also is used to estimate the size and location oI certain
structurs within the thorax.

So:nd Relative Intensity Relative Pit.h Relative D:ration
Flatness SoIt High Short
Dullness Medium Medium Medium
Resonance Loud Low Long
Hyperresonance Very loud Lower Longer
Tympany Loud High -

1HORACIC AUSCUL1A1IOA
Auscultation is useIul in assessing the Ilow oI air through the bronchial tree and in
evaluating the presence oI Iluid or solid obstruction oI the lungs.
The nurse places the diaphragm oI the stethoscope Iirmly against the chest wall as the
patient breathes slowly and deeply through the mouth.
Breath Sounds
D:ration of
So:nds
Intensity of
Expiratory
So:nd
Pit.h of
Expiratory
So:nd
Lo.ation
Where Heard
Nor2ally
Vesicular Inspiratory
sounds last
longer than
expiratory ones
SoIt Relatively low Entire lung Iield
except over the
upper sternum
and between the
scapulae
Bronchovesicular Inspiratory and
expiratory
sounds are
about equal
Intermediate Intermediate OIten in the 1
st

and 2
nd

interspaces
anteriorly and
between the
scapular
Bronchial Expiratory
sounds last
longer than
inspiratory ones
Loud Relatively high Over the
manubrium, iI
heard at all
Tracheal Inspiratory and
expiratory
sounds are both
equal
Very loud Relatively high Over the
trachea in the
neck












Abnormal (Adventitious) Breath Sounds
Breath So:nd Des.ription
Cra.les
Crackles in general

SoIt, high- pitched, discontinuous popping sound that
occur during inspiration
Coarse crackles Discontinuous popping sounds heard in early inspiration:
harsh, moist sound originating in the large bronchi
Fine crackles Discontinuous popping sounds heard in late inspiration;
sounds like hair rubbing together, originates in the alveoli
Wheezes
Sonorous wheezes (rhonchi)

Deep, low- pitched rumbling sounds heard primarily
during expiration: caused by air moving through narrowed
tracheobronchial passages
Sibilant wheezes Continuous, musical, high- pitched, whistle- like sounds
heard during inspiration and expiration caused by air
passing through narrowed or partially obstructed airways:
may clear with coughing
Fri.tion R:-s
!leural Iriction rub

Harsh, crackling sound, like two pieces oI leather being
rubbed together.
Heard during inspiration alone or during both inspiration
and expiration.
May subside when patient holds breath. Coughing may
not clear sounds.

Voice Sounds
O Bronchopony describes vocal resonance that is more intense and clearer than
normal.
O Egophony describes voice sounds that are distorted. It is best appreciated by
having the patient repeat the letter E. the distortion produced by consolidation
transIorms the sound into a clearly heard A rather than E.
O Whispered pectoriloquy is a very subtle Iinding, which is heard only in the
presence oI rather dense consolidation oI the lungs.








SSESSMENT
Health History:
YSPAEA
DiIIicult or labored breathing, breathlessness, shortness oI breath
Clinical signiIicance;
O Sudden dyspnea in a healthy person may indicate pneumothorax (air in the pleural
cavity), acute respiratory obstruction, or ARDS.
O In immobilized patients, sudden dyspnea may denote pulmonary embolism.
O Orthopnea (inability to breathe easily except in an upright position) may be Iound in
patients with heart disease and occasionally in patients with CO!D; dyspnea with an
expiratory wheeze occurs with CO!D.
O Noisy breathing may result Irom a narrowing oI the airway or localized obstruction oI a
major bronchus by a tumor or Ioreign body.
O The presence oI both inspiratory and expiratory wheezing usually signiIies asthma iI the
patient does not have heart Iailure.
O Other issues that are important in assessment oI dyspnea include the Iollowing: the
patient`s rating oI the intensity oI breathlessness, the eIIort required to breathe, and the
severity oI the breathlessness or dyspnea.
O Several scales are available to assess the severity oI dyspnea, including visual analog
scales that can be used to assess changes in its severity over time.
RelieI measures;
O !lacing the patient at rest with head elevated (high Fowler`s position).
O In severe cases, administering oxygen may do.

COUCH
Cough is a reIlex that protects the lungs Irom the accumulation oI secretions or the
inhalation oI Ioreign bodies, it can also be a symptom oI a number oI disorders oI the
pulmonary system or it can be suppressed in other disorders.
The cough reIlex may be impaired by weakness or paralysis oI the respiratory muscles,
prolonged inactivity, the presence oI a nasogastric tube, or depressed Iunction oI the
medullary centers in the brain.
Cough results Irom the irritation oI the mucous membranes anywhere in the respiratory
tract. The stimulus that produces cough may arise Irom an inIectious process or Irom an
airborne irritant, such as smoke, smog, dust, or a gas.
Clinical signiIicance;
To help determine the cause oI the cough, the nurse describes the cough: dry, hacking,
wheezing, loose or severe.
O A dry, irritative cough is characteristic oI an upper respiratory tract inIectionoI viral
origin or it may be a side eIIect oI ACE inhibitor therapy.
O Laryngotracheitis cause an irritative, high- pitched cough.
O Tracheal lesions produce a brassy cough.
O A severe or changing cough may indicate bronchogenic carcinoma.
O !leuritic chest pain that accompanies coughing may indicate pleural or chest wall
(musculoskeletal) involvement.
The time oI coughing is also noted.
O Coughing at night may herald the onset oI leIt sided heart Iailure or bronchial asthma.
O A cough in the morning with sputum production may indicate bronchitis.
O A cough that worsens when the patient is supine suggests postnasal drip (sinusitis).
O Coughing aIter Iood intake may indicate aspiration oI material into the tracheobronchial
tree.
O A cough oI recent onset is usually Irom an acute inIection.
RelieI measures;
O Cough suppressants must be used with caution, because they may relive the cough but do
not address the cause oI the cough. II used inappropriately, they may prevent the patient
Irom clearing mucus Irom the airways and results in delay in seeking indicated health
care.
O II the cough is a result oI irritation, smoking cessation strategies are indicated.
O Drinking warm beverages may relieve cough caused by throat irritation.
O &se oI Iirst- generation antihistamines with decongestant Ior treatment oI acute cough or
upper airway cough syndrome secondary to rhinosinus disease (postnasal drip syndrome).

SPU1UM PROUC1IOA
Sputum production is the reaction oI the lungs to any constantly recurring irritant.
Clinical signiIicance;
O A proIuse mount oI purulent sputum (thick and yellow, green, or rust- colored) or a
change in color oI the sputum is a common sign oI a bacterial inIection.
O Thin, mucoid sputum Irequently results Irom viral bronchitis.
O A gradual increase oI sputum over time may indicate the presence oI chronic bronchitis
or bronchiectasis.
O !ink- tinged mucoid sputum suggests a lung tumor.
O !roIuse, Irothy, pink material, oIten welling up into the throat, may indicate pulmonary
edema.
O Foul- smelling sputum and bad breath point to the presence oI a lung abscess,
bronchiectasis, or an inIection, caused by Iusospirochetal or other anaerobic organisms.
RelieI measures;
O Adequate hydration
O Inhalation oI aerosolized solutions
O Smoking is contraindicated with excessive sputum production
O Encourages adequate oral hygiene
O Encourages wise selection oI Iood to stimulate the appetite
O Encouraging the patient to drink citrus juices at the beginning oI the meal may increase
the palatability oI the rest oI the meal, because these juices cleanse the palate oI the
sputum taste.

CHES1 PAIA
Chest pain or discomIort may be associated with pulmonary or cardiac disease. Chest
pain associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it
may be dull, aching and persistent.
Clinical signiIicance;
O Chest pain may occur with pneumonia, pulmonary embolism with lung inIarction, and
pleurisy. It also may be a late symptom oI bronchogenic carcinoma.
O In carcinoma, the pain may be dull and persistent because the cancer has invaded the
chest wall, mediastinum, or spine.
O !leuritic pain Irom irritation oI the parietal pleura is sharp and seems to 'catch¨ on
inspiration: patients oIten describe it as 'like the stabbing oI a kniIe¨. !atients are more
comIortable when they lie on the aIIected side, because this splints the chest wall limits
expansion and contraction oI the lung and reduces the Iriction between the injured or
diseased pleurae on that side.
O The nurse assesses the quality, intensity, and radiation oI pain and identiIies and explores
precipitating Iactors and their relationship to the patient`s position.
O In addition, it is important to assess the relationship oI pain to the inspiratory and
expiratory phases oI respiration.
RelieI measures;
O Analgesics
O Nonsteroidal anti inIlammatory drugs (NSAIDs)
O A regional anesthetic block may be perIormed to relieve extreme pain.

HEEZIAC
Wheezing is oIten the major Iinding in a patient with bronchoconstriction or airway
narrowing.
It is a high pitched, musical sound heard m mainly on expiration.
Oral or inhalant bronchodilator medications reverse wheezing in most instances.

CLUBBIAC OF FIACERS
Clubbing oI Iingers is a sign oI lung disease that is Iound in patients with chronic hypoxic
conditions, chronic lung inIections, or malignancies oI the lung.
This Iinding may be maniIested initially as sponginess oI the nai8l bed and loss oI the
nail bed angle.


HEMOP1YSIS
Expectoration oI blood Irom the respiratory tract.
A symptom oI both pulmonary and cardiac disorder.
The onset oI hemoptysis is usually sudden, and it may be intermittent or continuous.
Signs, which may vary Irom blood-stained sputum to a large, sudden hemorrhage, always
merit investigation. The most common causes are:
O !ulmonary inIection
O Carcinoma oI the lungs
O Abnormalities oI the heart or blood vessels
O !ulmonary artery or vein abnormalities
O !ulmonary embolus and inIarction
The nurse considers the Iollowing points:
O Bloody sputum Irom the nose or the nasopharynx
O Blood Irom the lung is usually bright red, Irothy, and mixed with sputum.

CYAAOSIS
Cyanosis, a bluish coloring oI the skin, is a very late indicator oI hypoxia.
A patient with anemia rarely maniIests cyanosis, and a patient with polycythemia may
appear cyanotic even iI adequately oxygenated.
Assessment oI cyanosis is aIIected by room lightning, the patient`s skin color, and the
distance oI the blood vessels Irom the surIace oI the skin.
In the presence oI a pulmonary condition, central cyanosis is assessed by observing the
color oI the tongue and lips. This indicates a decrease in oxygen tension in the blood.
!eripheral cyanosis results Irom decreased blood Ilow to a certain area oI the body, as in
vasoconstriction oI the nail beds or earlobes Irom exposures in cold, and does not
necessarily indicate a central systemic problem.

!hysical Assessment oI the &pper Respiratory Structure
AOSE and SIAUSES
Inspect
External nose
O For lesions, asymmetry or inIlammation

Internal structure oI the nose
O Color oI the mucosa
O Swelling
O Exudates
O Bleeding
O The nasal mucosa is normally redder than the oral mucosa.
O It may appear swollen and hyperemic iI the patient has a common cold, but
allergic rhinitis the mucosa appears pale and swollen.
Septum
O For deviation, perIoration or bleeding.
O Most people have a slight degree oI septal deviation, but actual displacement oI
the cartilage into either right or leIt side oI the nose may produce nasal
obstruction.
InIerior and middle turbinates
O In chronic rhinitis, nasal p0olyps may develop between the inIerior and middle
turbinates; they are distinguished by their gray appearance. &nlike the turbinates,
they are gelatinous and Ireely movable.
!alpate
Frontal and maxillary sinuses
O For tenderness it suggest inIlammation
O It is also can be inspected by transillumination (passing a strong light through a
bony area, such as sinuses). II the light Iails to penetrate, the cavity contains likely
Iluid or pus.






















Diagnosti. Eval:ation

P:l2onary F:n.tion Test

!ulmonary Function Tests are perIormed to assess respiratory Iunction and to
detect and determine the extent oI the abnormality. Such tests include measurements oI
lung volumes, ventilator Iunction, and the mechanics oI breathing, diIIusion, and gas
exchange.
!ulmonary Function Tests generally perIormed by a technician. They require a
spirometer that has a volume collecting device attached to a recorder that demonstrates
volume and time simultaneously.

rterial Blood Gas St:dies

Measurements oI blood pH and oI arterial oxygen and carbon dioxide tensions are
obtained when managing patients with respiratory problems and in adjusting oxygen
therapy as needed. Arterial blood gas studies aid in assessing the degree to which the
lungs are able to provide adequate oxygen and remove carbon dioxide and the degree to
which the kidneys are able to reabsorb or excrete bicarbonate ions to maintain normal
body pH.

P:lse Oxi2etry

!ulse oximetry is a non invasive method oI continuously monitoring the oxygen
saturation oI hemoglobin (SaO2). It is an eIIective tool to monitor the patient Ior subtle or
sudden changes in oxygen saturation.

C:lt:res

Throat cultures may be perIormed to identiIy organisms responsible Ior
pharyngitis. It may assist in identiIying organisms responsible Ior inIection oI the lower
respiratory tract. Nasal swabs may also be perIormed Ior the same purpose.

Sp:t:2 St:dies

Sputum is obtained Ior study to identiIy pathologic organisms and determine
whether or not malignant cells are present. It may also used to assess Ior hypersensitivity
states.


IMGING STUDIES

a. Chest X-ray St:dies

Normal pulmonary tissue is radiolucent; thereIore, densities produced by Iluid,
tumors, Ioreign bodies and other pathologic conditions can be detected by means oI x-ray
examination. A chest x-ray Iilm may reveal an extensive pathologic process in the lungs
in the absence oI symptoms.

-. Co2p:ted To2ography

Computed Tomography is an imaging method in which the lungs are scanned in
successive layers by a narrow-beam x-ray. The images produced provide a cross-
sectional view oI the chest.

.. Magneti. Resonan.e I2aging

An MRI (or magnetic resonance imaging) scan is a radiology technique that uses
magnetism, radio waves, and a computer to produce images oI body structures. The MRI
scanner is a tube surrounded by a giant circular magnet. The patient is placed on a
moveable bed that is inserted into the magnet. The magnet creates a strong magnetic Iield
that aligns the protons oI hydrogen atoms, which are then exposed to a beam oI radio
waves.

d. Fl:oros.opy

It is used to assist with invasive procedures, such as a chest needle biopsy or
trans-bronchial biopsy, in identiIying lesions. It also maybe used to study the movement
oI the chest wall, mediastinum, heart, and diaphragm.

e. P:l2onary ngiography

Is the rapid injection oI a radiopaque medium into the vasculature oI the lungs Ior
radiographic study oI the blood vessels.

f. Radioisotope Diagnosti. Pro.ed:res (L:ng S.an)

3 types:
1. Perf:sion L:ng S.an is perIormed by injecting a radioactive agent (
technetium) into a peripheral vein and then obtaining a scan oI the chest
and body to detect radiation.
. Ventilation S.an is perIormed aIter the perIusion scan. The patient takes
a deep breath oI a mixture oI oxygen and radioactive gas (xenon, krypton)
which diIIuses throughout the lungs
3. Inhalation S.an is perIormed by administering droplets oI radioactive
material by positive-pressure ventilator.

ENDOSCOPIC PROCEDURES

a. Bron.hos.opy

Bronchoscopy is the direct inspection and examination oI the larynx, trachea, and
bronchi through either a Ilexible Iiberopropic bronchoscope or a rigid bronchoscope. The
Iiberoptic scope is used more Irequently in current practice.

The p:rposes of diagnosti. -ron.hos.opy:

1. To examine tissues or collect secretions
2. To determine the location and extent oI the pathologic process and to obtain a
tissue sample Ior diagnosis
3. Determine whether or not a tumor can be resected surgically
4. Diagnose bleeding site

Pro.ed:re:

The Iiberoptic bronchoscope is a thin, Ilexible bronchoscope that can be directed
into the segmental bronchi. Because oI its smaller size, Ilexibility and excellent optical
system, it allows increased visualization oI the peripheral airways and is ideal Ior
diagnosing pulmonary lesions.

N:rsing Interventions:

O InIormed consent
O N!O Ior 6 hours beIore the procedure
O !reoperative Medications (atropine, sedative, opioid)
O Contact lenses, dentures, and other prosthesis are removed
O Topical anesthetics may be sprayed (Lidocaine)
O AIter the procedure, the patient is given nothing by mouth until the cough
reIlex returns.
-. Thora.os.opy

Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined
with an endoscope. Small incisions are made into the pleural cavity in an intercostals
space; the location oI the incision depends on clinical and diagnostic Iindings. It indicates
evaluation oI pleural eIIusions, pleural disease and tumor staging.

Thora.entesis

A thin layer oI pleural Iluid normally remains in the pleural space. A sample oI
this Iluid can be obtained by thoracentesis or tube thoracotomy.

Biopsy

a. Ple:ral Biopsy accomplished by needle biopsy oI the pleura or by pleuroscopy,
which is a visual exploration through a Iiberoptic bronchoscope inserted into the
pleural space.

-. L:ng Biopsy

3 nons:rgi.al l:ng -iopsy te.hniq:es:

1. Trans.atheter -ron.hial -r:shing a Iiberoptic bronchoscope is
introduced into the bronchus under Iluoroscopy
. Per.:taneo:s needle -iopsy may be accomplished with cutting needle
or by aspiration with spinal-type needle that provides a tissue specimen
Ior histologic studies.
3. Trans-ron.hial L:ng -iopsy uses cutting Iorceps introduced by
Iiberoptic bronchoscope.

.. Ly2ph Node Biopsy

The scalene lymph nodes are enmeshed in the deep cervical pad oI Iat
overlying the scalenus anterior muscle. They drain lungs and mediastinum and
may show histologic changes due to intrathoracic disease.












Chapter II
Upper irway Infe.tions
&pper airway inIections are the most common cause oI illness and aIIect most people on
occasion. Some inIections are acute, with symptoms that last several days; others are chronic,
with symptoms that last a long time or recur. !atients with these conditions seldom require
hospitalization. However, nurses working in the community settings or long term care Iacilities
may encounter patients who have these inIections. ThereIore, it is important Ior the nurse to
recognize the signs and symptoms and to provide appropriate care.
InIections oI the upper airway are also known as upper respiratory tract inIection (&RIs);
the common cold is the most Irequently occurring example. &RIs occur when micro organism
such as viruses and bacteria are inhaled. There are many causative micro organisms, and people
are susceptible throughout liIe. &RIs is the most common reason Ior seeking health care and Ior
absences Irom school and work.

RHINITIS
Rhinitis is a group oI disorders characterized by inIlammation and irritation oI the
mucous membranes oI the nose. These conditions can have a signiIicant impact on quality oI liIe
and contribute to sinus, ear and sleep problems and learning disorder. Rhinitis oIten coexists with
other respiratory disorders such as asthma. Rhinitis may be acute or chronic; non- allergic or
allergic.
PTHOPHYSIOLOGY
Rhinitis may be caused by variety oI Iactors, including change in temperature or
humidity; odors; inIection; age; systemic disease; use oI over the counter drugs and prescribed
nasal decongestant; and the presence oI a Ioreign body. Allergic rhinitis may occur with
exposure to allergens such as Ioods, medications and particles in the indoor and outdoor
environment. The most common cause oI no allergic rhinitis is common cold. Drug induced
rhinitis may occur with anti hypertensive agent such as ACE inhibitor and beta blockers.

CA&SE









The mucous membrane lining the nasal
passage becomes inIlamed, congested, and
edematous.
The swollen nasal conchae block the sinus
openings and mucus discharged Irom the
nostrils.
CUSE
a. Vasomotor
Idiopathic
Abuse oI nasal decongestant
!sychological stimulation
Irritants
b. Mechanical
Tumor
Deviated septum
Crusting
Hypertrophied turbinates
Foreign body
CSF leak

CLINICL MNIFESTTIONS
O Rhinorrhea (excessive nasal drainage, runny nose)
O Nasal congestion
O Nasal discharge
O Sneezing
O !ruritus oI the nose
O Headache
MEDICL MNGEMENT
O In allergic rhinitis, test may be perIormed to identiIy possible allergens.
O In viral rhinitis, medications are given to relieve symptoms
O !atients with septaldeIormitis or nasal polyps may be reIerred to an ear, nose and throat
specialist.
PHRMCOLOGIC MNGEMENT
O Anti histamines Ior sneezing, pruritus and rhinorrhea
Diphenhydramine (Benadryl)
Chlorpheniramine( Chlor- trimeton)
Brompheniramine
O Second generation anti histamines
Loratadine( Alavert, Claritin)
FexoIenadine (Allegra)
Cetirizine( Zytrec)
NURSING MNGEMENT
O Instruct patient with allergic rhinitis to avoid exposure to allergens.
O !atient education when assisting the patient in the use oI all medication.
O To prevent possible drug interactions, the patient is cautioned to read drug labels
beIore taking OTC medication.
O Saline nasal spray or aerosols may be helpIul in soothing mucous membrane,
soItening crusted secretions and removing irritants.
O To achieve maximal relieI, the patient is instructed to blow the nose beIore
applying any medication to nasal cavity. The patient is taught to keep the head
upright; spray quickly and Iirmly into each nostril away Irom nasal septum and
wait at least 1 minute beIore administering the second spray.

VIRL RHINITIS
The common cold, also called viral rhinitis, is one oI the most common inIectious
diseases in humans. The inIection is usually mild and improves without treatment. Because oI
the large number oI people who get the common cold, this illness results in nearly 26 million
days oI missed school and 23 million days oI absence Irom work every year in the &nited States.
The average American has one to three colds per year.
The common cold is an upper respiratory inIection that is caused by several Iamilies oI
viruses. Within these virus Iamilies, more than 200 speciIic viruses that can cause the common
cold have been identiIied. The virus Iamily that causes the most colds is called rhinovirus.
Rhinoviruses cause up to 40 percent oI colds, and this virus Iamily has at least 100 distinct virus
types in its group. Other important upper respiratory virus Iamilies are named coronavirus,
adenovirus and respiratory syncytial virus. Since so many viruses can cause cold symptoms,
development oI a vaccine Ior the common cold has not been possible.
Rhinoviruses cause most colds in the early Iall and spring. Other viruses tend to cause
winter colds and their symptoms can be more debilitating. There is no evidence that going out in
cold or rainy weather makes you more likely to catch a cold.
CLINICL MNIFESTTIONS
O Nasal congestion
O Rhinorrhea
O Sneezing
O Tearing watery eyes
O Scratchy or sore throat
O eneral malaise
O Low grade Iever
O Chills
O Headache
O Muscle ache

TRETMENTS
Although medical therapies can improve the symptoms oI the common cold, they do not
prevent, cure or shorten the illness. Drink enough Iluids, get plenty oI rest, and treat your
symptoms to keep yourselI as comIortable as possible. argling warm salt water can soothe a
sore throat. Inhaling steam may improve nasal congestion temporarily. Over-the-counter cold
remedies that contain a decongestant will help to dry secretions and relieve congestion. These
remedies may also relieve cough, iI the cough is triggered by mucus in the throat. Antihistamines
may improve the symptoms oI runny nose and watery eyes, but they should be used with care
because over-the-counter versions cause sedation. Over-the-counter cough suppressants do not
have a proven beneIit, but some people Ieel that they are helpIul. It is important to keep in mind
that antibiotics do not cure the common cold or shorten the length oI time that symptoms last.
Vitamin C, zinc and echinacea (a Irequently used herbal therapy) have been widely rumored to
decrease the likelihood oI developing the common cold and to shorten symptoms, but no
conclusive research has demonstrated that this is true.




NURSING MNGEMENT
Hand washing remains the most eIIective measure to prevent transmission oI organisms.
The nurse teaches the patient how to break the chain oI inIection with appropriate hand washing
or hand hygiene and the use oI tissue to prevent the spread oI virus with coughing and sneezing.



























CUTE PHRYNGITIS
Acute pharyngitis is a sudden painIul inIlammation oI the pharynx, the back portion oI the throat
that includes the posterior third oI the tongue, soIt palate, and tonsils. It is commonly reIerred to
as a sore throat. Viral pharyngitis spreads easily in the droplets oI coughs and sneezes and
unclean hands that have been exposed to the contaminated Iluids.
PTHOPHYSIOLOGY
Viral inIection causes most cases oI acute pharyngitis. Responsible viruses include the
adenovirus, inIluenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial inIection
accounts Ior the remainder oI cases. Ten percent oI adults with pharyngitis have group A beta-
hemolytic streptococcus, which is commonly reIerred to as group A streptococcus (AS) or
streptococcal pharyngitis. When AS causes acute pharyngitis the body responds by triggering
an inIlammatory response in the pharynx. Resulting to pain, Iever, vasodilation, edema, and
tissue damage, maniIested by redness and swelling in the tonsillar pillars, uvula and soIt palate.
Other bacterial organisms implicated in acute pharyngitis include Mycoplasma pneumonia,
Neisseria gonorrhea and H. inIluenza type B.
CLINICL MNIFESTTIONS
O Fiery-red pharyngeal membrane and tonsils
O Lymphoid Iollicles that are swollen and Ilecked with white-purple exudates
O Enlarged and tender cervical lymph nodes
O Fever
O Malaise
O Sore throat
O Heaache
O Myalgia
Occasionally, patients with AS pharyngitis may exhibit:
O Vomiting
O Anorexia
O Scarlatina-Iorm rash with urticaria (known as scarlet Iever)
DIGNOSTIC FINDINGS
O The most dependable method to determine the cause is trough swab specimens obtained
Irom posterior pharynx and tonsils.
O Rapid streptococcal antigen test newer and more rapid diagnostic test. However, its
accuracy varies widely depending on the person perIorming the test.






MEDICL MNGEMENT
O II the cause s bacterial, penicillin is usually the treatment oI choice. !enicillin V
potassium given Ior 5 days is the regimen oI choice.
O Erythromycin may also be given
O Cephalosporins and macrolides (clarithromycin and azithromycin) may be used iI there is
any allergy or resistance to penicillin and erythromycin.
O Analgesics may also be prescribed to relieve severe sore throats.
O Some patients may Iind salt-water gargling to be soothing. In severe cases, gargles with
benzocaine may relieve symptoms.
O Liquid or soIt diet is provided during the acute stage oI the disease.
O Cool beverages, warm liquids and Ilavored Irozen desserts may also be soothing.
NURSING MNGEMENT
O Initiation and correct administration oI prescribed antibiotic therapy.
O Instruct patient to seek medical assistance iI dyspnea, drooling, inability to swallow, and
inability to Iully open the mouth occur.
O Instruct patient to have bed rest during the Iebrile stage oI illness and to rest Irequently
once up and about.
O Instruct patient to dispose used tissues properly to prevent spread oI inIection.
O Examine skin once or twice daily because acute pharyngitis may lead to some other
communicable disease (e.g. rubella)
O Ice collar to relieve severe sore throats.
O !roper mouth care to prevent the development oI Iissures oI the lips and oral
inIlammation when bacterial inIection is present.
CHRONIC PHRYNGITIS
It is a persistent inIlammation oI the pharynx. It is common in adults who work in dusty
surroundings, use their voice to excess, suIIer Irom chronic cough or habitually use alcohol or
tobacco.
3 types:
O Hypertrophic: characterized by general thickening and congestion oI the pharyngeal
mucous membrane.
O Atrophic: !robably a late sign oI the Iirst type ( the membrane is thin, whitish, glistening,
and at times wrinkled)
O Chronic granular (clergyman`s sore throat): Characterized by numerous swollen lymph
Iollicles on the pharyngeal wall.

CLINICL MNIFESTTION
O Constant sense oI irritation or Iullness in the throat
O Mucus that collects in the throat and can be expelled by coughing
O DiIIiculty swallowing


MEDICL MNGEMENT
Treatment oI chronic pharyngitis is based on relieving symptoms, avoiding exposure to irritants,
and correcting any upper respiratory, pulmonary, gastrointestinal or cardiac condition that might
be responsible Ior a chronic cough.
O Nasal congestion may be relieved by short-term use oI nasal sprays or medications
containing ephedrine sulIate or phenylephrine HCl
O For adults with chronic pharyngitis tonsillectomy is an eIIective option.
NURSING MNGEMENT
O Instruct patient to avoid contact with others until the Iever subsides to prevent the spread
oI inIection.
O Instruct to avoid alcohol, tobacco, secondhand smoke, and exposure to cold or
environmental or occupational pollutants.
O Instruct patient to wear disposable mask to minimize exposure to pollutants.
O Encourage patient to drink plenty oI water
O argling with warm saline solution may relieve throat discomIort.
O Lozenges keep the throat moistened.



















PERITONSILLR BSCESS
Peritonsillar abscess also called 6:insy is the most common major suppurative complication Ior
sore throat. This collection oI purulent exudate between the tonsillar capsule and the surrounding
tissues, including the soIt palate may develop aIter an acute tonsillar inIection those progresses
to a local cellulitis and abscess.
The most common causative organism is Cro:5 A Beta-Hemolytic Stre5tococci (CABHS).
CLINICL MNIFESTTIONS
O Severe sore throat
O Fever
O Trismus (inability to open the mouth)
O Drooling
O DiIIiculty oI swallowing the saliva because oI pain
O !atient`s breath smells rancid
O Raspy voice
O Odynophagia (severe sensation oI burning, squeezing pain while swallowing)
O Dysphagia (diIIiculty in swallowing)
O Otalgia (pain in the ear)
O Enlarged cervical lymph nodes
SSESSMENT and DIGNOSTIC FINDINGS
O Intraoral ultrasound
O Transcutaneous cervical ultrasound
MEDICL MNGEMENT
` Antimicrobial agents and corticosteroid thera5y are used Ior treatment oI peritonsillar abscess.
Antibiotics(usually 5enicillin are extremely eIIective in controlling the inIection and iI they are
prescribed early in the course oI the disease, the abscess may resolve without needing to be
incised.
SURGICL MNGEMENT
Treatment choices include:
Aeedle as5iration- may be preIerred over a more extensive procedure due to high
eIIicacy, low cost and patient tolerance.
- the mucus membrane over the swelling is Iirst sprayed with topical anesthetic
and then injected with a local anesthetic.

Incision and drainage :nder local or general anesthesia
- patient is in sitting position to make it easier to expectorate the blood and pus
that accumulate in the pharynx.
- it is also eIIective but more painIul than needle aspiration

rainage of the abscess with sim:ltaneo:s tonsillectomy
- there is a risk oI hemorrhage





NURSING MNGEMENT

The nurse encourage the use oI prescribed topical anesthetic agents and assists with throat
irrigations or the Irequent use oI mouthwashes or gargles with the use oI saline or alkaline
solutions at a temperature oI 40.6 °C to 43.3 °C.

argle gently at intervals oI 1 to 2 hrs Ior 24 to 36 hours..

Liquids that are cool are usually tolerated. Adequate Iluids must be provided to treat
dehydration and prevent its reoccurrence.

Encourage Ior continuation oI good oral hygiene.



















CUTE SINUSITIS
Acute sinusitis (acute rhinosinusitis) causes the cavities around your nasal passages (sinuses) to
become inIlamed and swollen. This interIeres with drainage and causes mucus to build up.
With acute sinusitis, it may be diIIicult to breathe through your nose. The area around your eyes
and Iace may Ieel swollen, and you may have throbbing Iacial pain or a headache.
Acute sinusitis is most oIten caused by the common cold. Other triggers include bacteria,
allergies and Iungal inIections. Treatment oI acute sinusitis depends on the cause. In most cases,
home remedies are all that's needed. However, persistent sinusitis can lead to serious inIections
and other complications.
Acute sinusitis symptoms oIten include:
O Drainage oI a thick, yellow or greenish discharge Irom the nose or down the back oI the throat
O Nasal obstruction or congestion, causing diIIiculty breathing through your nose
O !ain, tenderness, swelling and pressure around your eyes, cheeks, nose or Iorehead
O Aching in your upper jaw and teeth
O Reduced sense oI smell and taste
O Cough, which may be worse at night
Other signs and symptoms can include:
O Ear pain
O Headache
O Sore throat
O Bad breath (halitosis)
O Fatigue
O Fever
When to see a do.tor
II you have mild symptoms oI sinusitis, try selI-care.
Conta.t yo:r do.tor iI you have any oI the Iollowing:
O Symptoms that don't improve within a Iew days or symptoms that get worse
O A persistent Iever
O A history oI recurrent or chronic sinusitis

See a do.tor i22ediately iI you have signs or symptoms that may indicate a serious inIection:
O !ain or swelling around your eyes
O Swollen Iorehead
O Severe headache
O ConIusion
O Double vision or other vision changes
O StiII neck
O Shortness oI breath
Causes:
When you have sinusitis, the mucous membranes oI your nose, sinuses and throat (upper
respiratory tract) become inIlamed. Swelling obstructs the sinus openings and prevents mucus
Irom draining normally, causing Iacial pain and other sinusitis symptoms.
Blocked sinuses create a moist environment that makes it easier Ior inIection to take hold.
Sinuses that become inIected and can't drain become pus Iilled, leading to symptoms such as
thick, yellow or greenish discharge and other symptoms oI inIection.
Acute sinusitis can be caused by:
O Viral infe.tion. Most cases oI acute sinusitis are caused by the common cold.
O Ba.terial infe.tion. When an upper respiratory tract inIection persists longer than seven to 10
days, it's more likely to be caused by a bacterial inIection than by a viral inIection.
O F:ngal infe.tion. You're at increased risk oI a Iungal inIection iI you have sinus abnormalities
or a weakened immune system.
Some health conditions can increase your risk oI getting a sinus inIection that causes sinusitis, or
can increase your risk oI getting sinusitis that isn't caused by an underlying inIection. These
conditions include:
O llergies s:.h as hay fever. InIlammation that occurs with allergies may block your sinuses.
O Nasal polyps or t:2ors. These tissue growths may block the nasal passages or sinuses.
O Deviated nasal sept:2. A crooked septum the wall between the nostrils may restrict or
block sinus passages.
O Tooth infe.tion. A small number oI cases oI acute sinusitis are caused by an inIected tooth.
O Enlarged or infe.ted adenoids in .hildren. Adenoids are located in the upper back part oI the
throat.
O Other 2edi.al .onditions. The complications oI cystic Iibrosis, gastroesophageal reIlux disease
(ERD) or immune system disorders may result in blocked sinuses or an increased risk oI
inIection.
Ris fa.tors
You may be at increased risk oI getting sinusitis iI you have:
O Hay fever or another allergi. .ondition that aIIects your sinuses
O nasal passage a-nor2ality, such as a deviated nasal septum, nasal polyps or tumors
O 2edi.al .ondition such as cystic Iibrosis, gastroesophageal reIlux disease (ERD), or an
immune system disorder such as immunoglobulin or antibody deIiciency
O Reg:lar expos:re to poll:tants such as cigarette smoke
Co2pli.ations
Acute sinusitis complications include:
O sth2a flare-:ps. Acute sinusitis can trigger an asthma attack.
O Chroni. sin:sitis. Acute sinusitis may be a Ilare-up oI a long-term problem known as chronic
sinusitis. Chronic sinusitis is sinusitis that lasts longer than 12 weeks.
O Meningitis. This occurs when inIection spreads to the lining oI the brain.
O Vision pro-le2s. II inIection spreads to your eye socket, it can cause reduced vision or even
blindness. This is a medical emergency that requires immediate treatment to prevent potentially
permanent damage.
O Ear infe.tion. Acute sinusitis may occur along with an ear inIection.

Tests and diagnosis
O Physi.al exa2. To look Ior the cause oI your symptoms, your doctor will Ieel Ior tenderness in
your nose or throat. Your doctor may use a tool to hold your nose open and apply medication
that constricts blood vessels in your nasal passages. This makes it easier to see inside your nasal
passages. Your doctor will then shine a light into your nasal passages to look Ior inIlammation or
Iluid. This visual inspection will also help rule out physical conditions that trigger sinusitis, such
as nasal polyps or other abnormalities.
O Nasal endos.opy. A thin, Ilexible tube (endoscope) with a Iiber-optic light inserted through your
nose allows your doctor to visually inspect the inside oI your sinuses.
O I2aging st:dies. Images taken using computerized tomography (CT) or magnetic resonance
imaging (MRI) can show details oI your sinuses and nasal area. These may identiIy a deep
inIlammation or physical obstruction that's diIIicult to detect using an endoscope.
O Nasal and sin:s .:lt:res. Laboratory tests are generally unnecessary Ior diagnosing acute
sinusitis. However, in cases in which the condition Iails to respond to treatment or is progressing,
tissue cultures may help pinpoint the cause, such as identiIying a bacterial cause.
O llergy testing. II your doctor suspects that the condition may be brought on by allergies, an
allergy skin test may be recommended. A skin test is saIe and quick, and can help pinpoint the
allergen that's responsible Ior your nasal Ilare-ups.
Treat2ents and dr:gs

Most cases oI acute sinusitis don't need treatment because they are caused by viruses that cause
the common cold. SelI-care techniques are usually the only treatment needed to speed recovery
and ease symptoms.
Treat2ents to relieve sy2pto2s
O Saline nasal spray, which you spray into your nose several times a day to rinse your nasal
passages.
O Nasal .orti.osteroids. These nasal sprays help prevent and treat inIlammation. Examples
include Iluticasone (Flonase), mometasone (Nasonex), budesonide (Rhinocort Aqua),
triamcinolone (Nasacort AQ) and beclomethasone (Beconase AQ).
O De.ongestants. These medications are available in over-the-counter (OTC) and prescription
liquids, tablets and nasal sprays. OTC oral decongestants include SudaIed, ActiIed and Drixoral.
Nasal sprays include phenylephrine (Neo-Synephrine, others) and oxymetazoline (AIrin, others).
These medications are generally taken Ior only a Iew days at most. Otherwise they can cause the
return oI more severe congestion (rebound congestion).
O Over-the-.o:nter pain relievers such as aspirin, acetaminophen (Tylenol, others) or ibuproIen
(Advil, Motrin, others). Aspirin has been linked with Reye's syndrome, so use caution when
giving aspirin to children or teenagers. Though aspirin is approved Ior use in children older than
age 2, children and teenagers recovering Irom chickenpox or Ilu-like symptoms should never
take aspirin. Talk to your doctor iI you have concerns.
nti-ioti.s
Antibiotics usually aren't needed to treat acute sinusitis.
O Antibiotics won't help when acute sinusitis is caused by a viral or Iungal inIection.
O Most cases oI bacterial sinusitis improve without antibiotics.
O Antibiotic treatment is generally needed only iI you have a bacterial inIection, especially iI the
inIection is severe, recurrent or persistent.
Antibiotics used to treat acute sinusitis caused by a bacterial inIection include amoxicillin
(Amoxil, Trimox, others), doxycycline (Doryx, Monodox, others) or the combination drug
trimethoprim-sulIamethoxazole (Bactrim, Septra, others). II the inIection doesn't go away or iI
the sinusitis comes back, your doctor may try a diIIerent antibiotic.
II your doctor does prescribe antibiotics, it's critical to take the entire course oI medication.
enerally, this means you'll need to take them Ior 10 to 14 days even aIter your symptoms get
better. II you stop taking them early, your symptoms may come back.
ntif:ngal 2edi.ations
Rarely, acute sinusitis is caused by a Iungal inIection, which can be treated with antiIungal
medication. The dose oI medication as well as how long you'll need to take it depends on
the severity oI your inIection and how quickly your symptoms improve.
I22:notherapy
II allergies are contributing to your sinusitis, allergy shots (immunotherapy) that help reduce the
body's reaction to speciIic allergens may help treat your symptoms.
Prevention
Take these steps to help reduce your risk oI getting acute sinusitis:
O void :pper respiratory infe.tions. Minimize contact with people who have colds. Wash your
hands Irequently with soap and water, especially beIore your meals.
O Caref:lly 2anage yo:r allergies. Work with your doctor to keep symptoms under control.
O void .igarette s2oe and poll:ted air. Tobacco smoke and other pollutants can irritate and
inIlame your lungs and nasal passages.
O Use a h:2idifier. II the air in your home is dry, such as it is iI you have Iorced-air heat, adding
moisture to the air may help prevent sinusitis. Be sure the humidiIier stays clean and Iree oI mold
with regular, thorough cleaning.
Pathophysiology
Failure oI normal mucus transport and decreasedsinusventilation are the major Iactors
contributing to the development oIsinusitis. Obstruction oI the sinus ostia occurs with mucosal
edema or any anatomic abnormality that interIeres with drainage. Bacterial
andviralinIectionsalso impair themucustransport system. The Irequency oI ciliary beats
(normally 700 per minute) decreases to less than 300 per minute during periods oI inIection.

InIlammation causes 30 percent oI the ciliated columnar cells to undergo metaplastic changes
to mucus-secreting goblet cells. The obstruction and decreased transport results in stagnation oI
secretions, decreased pH and lowered oxygen tension within the sinus, creating an excellent
culture medium Ior bacteria.
A number oI Iactors can contribute to the development oI sinusitis.The most common cause of
acute bacterial sinusitis is a viralupperrespiratoryinfection.&p to 0.5 percent oI upper
respiratory inIections in adults develop into documented sinusitis.Children experience six to
eight colds per year, and approximately 5 to 10 percent of these infections are complicated by
sinusitis.
Allergicrhinitishas also been considered a contributing Iactor to sinusitis; however, no causal
relationship has been proven, and it is now believed to be a rare initiating Iactor.Iatrogenic
factors include mechanical ventilation, nasogastric tubes, nasal packing and dental
procedures. !regnancy, hormone changes associated with puberty, and senile rhinorrhea may
be contributing Iactors.Anatomic variations include tonsillar and adenoid hypertrophy,
deviated septum, nasal polyps and cleft palate. Smoking and intranasal cocaine use also
predispose to sinusitis.
Computed tomographic (CT) scanning in humans has shown that most uncomplicated colds are
associated with some radiographic Iindings oI sinus involvement, the great majority oI which
do not progress to Ilorid sinusitis. Experimentally-produced rhinovirus inIections can generate
abnormalities oI the sinuses (as detected by MR imaging) accompanied by increased nasal
secretion but without any evidence Ior bacterial involvement.Thus, prophylactic antibiotics for
colds are never indicated, although they are frequently administered.
Viral &RI most common cause.
Nasotracheal or nasogastric tubes can predispose to sinusitis.
!rophylacticantibiotic not indicated.
The bacteria responsible Ior sinusitis vary with the clinical setting:
O The major causes oI typical acute bacterial sinusitis include Streptococcus pneumoniae,
HaemophilusinIluenzae, Streptococcus pyogenes, and (less oIten) Staphylococcus
aureus.
O !atients withchronicsinusitisare more likely to be inIected with obligate anaerobes which
are part oI the usual mouth Ilora.
O Nosocomial sinusitis involves bacteria and Iungi that enter the sinus aIter becoming part
oI the patient's respiratory tract Ilora. This includes methicillin-resistant S. aureus
(MRSA), various gram-negative bacilli (such as Escherichia coli
and!seudomonasaeruginosa), and yeasts such as Candida albicans.












CHRONIC SINUSITIS
Chronic sinusitis is a common condition in which the cavities around nasal passages
(sinuses) become inIlamed and swollen. Chronic sinusitis lasts 12 weeks or longer despite
treatment attempts.
Also known as chronic rhinosinusitis, this condition interIeres with drainage and causes
mucus to build up. II you have chronic sinusitis, it may be diIIicult to breathe through your nose.
The area around your eyes and Iace may Ieel swollen, and you may have throbbing Iacial pain or
a headache.
Chronic sinusitis may be caused by an inIection, but it can also be caused by growths in
the sinuses (nasal polyps) or by a deviated nasal septum. Chronic sinusitis most commonly
aIIects young and middle-aged adults, but it also can aIIect children.
Sy2pto2s

Chronic sinusitis and acute sinusitis have similar signs and symptoms, but acute sinusitis is a
temporary inIection oI the sinuses oIten associated with a cold. At least two oI the Iollowing
signs and symptoms must be present Ior a diagnosis oI chronic sinusitis:
O Drainage oI a thick, yellow or greenish discharge Irom the nose or down the back oI the throat
O Nasal obstruction or congestion, causing diIIiculty breathing through your nose
O !ain, tenderness and swelling around your eyes, cheeks, nose or Iorehead
O Reduced sense oI smell and taste
Other signs and symptoms can include:
O Ear pain
O Aching in your upper jaw and teeth
O Cough, which may be worse at night
O Sore throat
O Bad breath (halitosis)
O Fatigue or irritability
O Nausea
The signs and symptoms oI chronic sinusitis are similar to acute sinusitis, except they last longer
and oIten cause more signiIicant Iatigue. Fever isn't a common sign oI chronic sinusitis, as it
may be with acute sinusitis.

When to see a do.tor
You may have several episodes oI acute sinusitis, lasting less than Iour weeks, beIore developing
chronic sinusitis. You may be reIerred to an allergist or an ear, nose and throat specialist Ior
evaluation and treatment.
See a do.tor i22ediately if you have symptoms that may be a sign oI a serious inIection:
O !ain or swelling around your eyes
O A swollen Iorehead
O Severe headache
O ConIusion
O Double vision or other vision changes
O StiII neck
O Shortness oI breath
Ca:ses:

Common causes oI chronic sinusitis include:
O Nasal polyps or t:2ors. These tissue growths may block the nasal passages or sinuses.
O llergi. rea.tions. Allergic triggers include Iungal inIection oI the sinuses.
O Deviated nasal sept:2. A crooked septum the wall between the nostrils may restrict or
block sinus passages.
O Tra:2a to the fa.e. A Iractured or broken Iacial bone may cause obstruction oI the sinus
passages.
O Other 2edi.al .onditions. The complications oI cystic Iibrosis, gastroesophageal reIlux, or HIV
and other immune system-related diseases may result in nasal blockage.
O Respiratory tra.t infe.tions. InIections in your respiratory tract most commonly, colds
can inIlame and thicken your sinus membranes, blocking mucus drainage and creating conditions
ripe Ior growth oI bacteria. These inIections can be viral, bacterial or Iungal in nature.
O llergies s:.h as hay fever. InIlammation that occurs with allergies may block your sinuses.
O I22:ne syste2 .ells. With certain health conditions, immune cells called eosinophils can cause
sinus inIlammation.
Ris fa.tors
You're at increased risk oI getting chronic or recurrent sinusitis iI you have:
O nasal passage a-nor2ality, such as a deviated nasal septum or nasal polyps
O spirin sensitivity that causes respiratory symptoms
O 2edi.al .ondition, such as cystic Iibrosis or chronic obstructive pulmonary disease (CO!D)
O n i22:ne syste2 disorder, such as HIV/AIDS or cystic Iibrosis
O Hay fever or another allergi. .ondition that aIIects your sinuses
O sth2a about 1 in 5 people with chronic sinusitis have asthma
O Reg:lar expos:re to poll:tants such as cigarette smoke
Co2pli.ations
Chronic sinusitis complications include:
O sth2a flare-:ps. Chronic sinusitis can trigger an asthma attack.
O Meningitis, an inIection that causes inIlammation oI the membranes and Iluid surrounding your
brain and spinal cord.
O Vision pro-le2s. II inIection spreads to your eye socket, it can cause reduced vision or even
blindness that can be permanent.
O ne:rys2s or -lood .lots. InIection can cause problems in the veins surrounding the sinuses,
interIering with blood supply to your brain and putting you at risk oI a stroke.
Tests and diagnosis
To look Ior the cause oI your symptoms, your doctor will Ieel Ior tenderness in your nose or
throat. To make it easier to see inside your nasal passages, he or she may:
O &se a tool to hold your nose open
O Apply medication that constricts blood vessels in your nasal passages
O Shine a light into your nasal passages to look Ior inIlammation or Iluid
This visual inspection will also help rule out physical conditions that trigger sinusitis, such as
nasal polyps or other abnormalities.
Your doctor also may use several other methods to help screen Ior chronic sinusitis:
O Nasal endos.opy. A thin, Ilexible tube (endoscope) with a Iiber-optic light inserted through your
nose allows your doctor to visually inspect the inside oI your sinuses. This also is known as
rhinoscopy.
O I2aging st:dies. Images taken using computerized tomography (CT) or magnetic resonance
imaging (MRI) can show details oI your sinuses and nasal area. These may identiIy a deep
inIlammation or physical obstruction that's diIIicult to detect using an endoscope.
O Nasal and sin:s .:lt:res. Cultures are generally unnecessary Ior diagnosing chronic sinusitis.
However, in cases in which the condition Iails to respond to treatment or is progressing, tissue
cultures may help pinpoint the cause, such as identiIying a bacterial or Iungal pathogen.
O n allergy test. II your doctor suspects that the condition may be brought on by allergies, an
allergy skin test may be recommended. A skin test is saIe and quick and can help pinpoint the
allergen that's responsible Ior your nasal Ilare-ups.

Treat2ents and dr:gs
The goal oI treating chronic sinusitis is to:
O Reduce sinus inIlammation
O eep your nasal passages draining
O Eliminate the underlying cause
O Reduce the number oI sinusitis Ilare-ups you have

Treat2ents to relieve sy2pto2s
O Saline nasal spray, which you spray into your nose several times a day to rinse your nasal
passages.
O Nasal .orti.osteroids. These nasal sprays help prevent and treat inIlammation. Examples
include Iluticasone (Flonase), budesonide (Rhinocort Aqua), triamcinolone (Nasacort AQ),
mometasone (Nasonex) and beclomethasone (Beconase AQ).
O Oral or inje.ted .orti.osteroids. These medications are used to relieve inIlammation Irom
severe sinusitis, especially iI you also have nasal polyps. Examples include prednisone and
methylprednisolone. Oral corticosteroids can cause serious side eIIects when used long term, so
they're used only to treat severe asthma symptoms.
O De.ongestants. These medications are available in over-the-counter (OTC) and prescription
liquids, tablets and nasal sprays. Examples oI OTC oral decongestants include SudaIed and
ActiIed. An example oI an OTC nasal spray is oxymetazoline (AIrin). These medications are
generally taken Ior a Iew days at most; otherwise they can cause the return oI more severe
congestion (rebound congestion).
O Over-the-.o:nter pain relievers such as aspirin, acetaminophen (Tylenol, others) or ibuproIen
(Advil, Motrin, others). Because oI the risk oI Reye's syndrome a potentially liIe-threatening
illness never give aspirin to anyone younger than age 18.
O spirin desensitization treat2ent iI you have reactions to aspirin that cause sinusitis. However,
this treatment can have serious complications such as intestinal bleeding or severe asthma
attacks.
nti-ioti.s
Antibiotics are sometimes necessary Ior sinusitis iI you have a bacterial inIection. However,
chronic sinusitis is usually caused by something other than bacteria, so antibiotics usually won't
help.
Antibiotics used to treat chronic sinusitis caused by a bacterial inIection include amoxicillin
(Amoxil, others), doxycycline (Doryx, Monodox, others) or the combination drug trimethoprim-
sulIamethoxazole (Bactrim, Septra, others). II the inIection doesn't subside or iI the sinusitis
comes back, your doctor may try a diIIerent antibiotic.
II your doctor does prescribe antibiotics, it's critical to take the entire course oI medication.
enerally, this means you'll need to take them Ior 10 to 14 days or even longer even aIter
your symptoms get better. II you stop taking them early, your symptoms may come back.
I22:notherapy
II allergies are contributing to your sinusitis, allergy shots (immunotherapy) that help reduce the
body's reaction to speciIic allergens may help treat the condition.
S:rgery
In cases that continue to resist treatment or medication, endoscopic sinus surgery may be an
option. For this procedure, the doctor uses an endoscope, a thin, Ilexible tube with an attached
light, to explore your sinus passages. Then, depending on the source oI obstruction, the doctor
may use various instruments to remove tissue or shave away a polyp that's causing nasal
blockage. Enlarging a narrow sinus opening also may be an option to promote drainage.
Prevention
Take these steps to reduce your risk oI getting chronic sinusitis:
O void :pper respiratory infe.tions. Minimize contact with people who have colds. Wash your
hands Irequently with soap and water, especially beIore your meals.
O Caref:lly 2anage yo:r allergies. Work with your doctor to keep symptoms under control.
O void .igarette s2oe and poll:ted air. Tobacco smoke and air contaminants can irritate and
inIlame your lungs and nasal passages.
O Use a h:2idifier. II the air in your home is dry, such as it is iI you have Iorced hot air heat,
adding moisture to the air may help prevent sinusitis. Be sure the humidiIier stays clean and Iree
oI mold with regular, thorough cleaning.
Pathophysiology
The sinuses are normally sterile under physiologic conditions. Secretions produced in the sinuses
Ilow by ciliary action through the ostia and drain into the nasal cavity. In the healthy individual,
Ilow oI sinus secretions is always unidirectional (ie, toward the ostia), which prevents back
contamination oI the sinuses. In most individuals, the maxillary sinus has a single ostium (2.5
mm in diameter, 5 mm
2
in cross-sectional area) serving as the only outIlow tract Ior drainage.
This slender conduit sits high on the medial wall oI the sinus cavity in a nondependent position.
Most likely, the edema oI the mucosa at these 1- to 3-mm openings becomes congested by some
means (eg, allergy, viruses, chemical irritation) that causes obstruction oI the outIlow tract stasis
oI secretions with negative pressure, leading to inIection by bacteria.
Retained mucus, when inIected, leads to sinusitis. Another mechanism hypothesizes that because
the sinuses are continuous with the nasal cavity, colonized bacteria in the nasopharynx may
contaminate the otherwise sterile sinuses. These bacteria are usually removed by
mucociliaryclearance; thus, iI mucociliary clearance is altered, bacteria may be inoculated and
inIection may occur, leading to sinusitis. Data are available that support the Iact that healthy
sinuses are colonized. The bacterial Ilora oI noninIlamed sinuses were studied Ior aerobic and
anaerobic bacteria in 12 adults who underwent corrective surgery Ior septal deviation. Organisms
were recovered Irom all aspirates, with an average oI 4 isolates per sinus aspirate. The
predominant anaerobic isolates werePrevotella, Porphyromonas,
Fusobacterium and Peptostreptococcusspecies. The most common aerobic bacteria were S
pyogenes, S aureus, S pneumonia, and H influen:ae. In another study, specimens were processed
Ior aerobic bacteria only, and Staphylococcus species and alpha-hemolytic streptococci were
isolated.

Organisms were recovered in 20° oI maxillary sinuses oI patients who underwent
surgical repositioning oI the maxilla.
In contrast, another report oI aspirates oI 12 volunteers with no sinus disease showed no bacterial
growth.Jiang et al evaluated the bacteriology oI maxillary sinuses with normal endoscopic
Iindings.

Organisms were recovered Irom 14 (47°) oI 30 swab specimens and 7 (41°) oI 17 oI
mucosal specimens. ordts et al reported the microbiology oI the middle meatus in normal
adults and children.This study noted in 52 patients that 75° had bacterial isolates present, most
commonly coagulase-negative staphylococci (CNS) (35°), Corynebacterium species (23°),
and S aureus (8°) in adults. Low numbers oI these species were present. In children, the most
common organisms were H influen:ae (40°), M catarrhalis (34°), and S pneumoniae(50°), a
marked diIIerence Irom Iindings in adults. Nonhemolytic streptococci and Moraxella species
were absent in adults.
The pathophysiology oI rhinosinusitis is related to 3 Iactors:
O Obstruction oI sinus drainage pathways (sinus ostia)
O Ciliary impairment
O Altered mucus quantity and quality

O-str:.tion of sin:s drainage
Obstruction oI the natural sinus ostia prevents normal mucus drainage. The ostia can be blocked
by mucosal swelling or local causes (eg, trauma, rhinitis), as well as by certain inIlammation-
associated systemic disorders and immune disorders. Systemic diseases that result in decreased
mucociliary clearance, including cystic Iibrosis, respiratory allergies, and primary ciliary
dyskinesia (artagener syndrome), can be predisposing Iactors Ior acute sinusitis in rare cases.
!atients with immunodeIiciencies (eg, agammaglobulinemia, combined variable
immunodeIiciency, and immunodeIiciency with reduced immunoglobulin |Ig( and
immunoglobulin A |IgA(bearing cells) are also at increased risk oI developing acute sinusitis.
Mechanical obstruction because oI nasal polyps, Ioreign bodies, deviated septa, or tumors can
also lead to ostial blockage. In particular, anatomical variations that narrow the ostiomeatal
complex, including septal deviation, paradoxical middle turbinates, and Haller cells, make this
area more sensitive to obstruction Irom mucosal inIlammation. &sually, the margins oI the
edematous mucosa have a scalloped appearance, but in severe cases, mucus may completely Iill
a sinus, making it diIIicult to distinguish an allergic process Irom inIectious sinusitis.
Characteristically, all oI the paranasal sinuses are aIIected and the adjacent nasal turbinates are
swollen. Air-Iluid levels and bone erosion are not Ieatures oI uncomplicated allergic sinusitis;
however, swollen mucosa in a poorly draining sinus is more susceptible to secondary bacterial
inIection.
Hypoxia within the obstructed sinus is thought to cause ciliary dysIunction and alterations in
mucus production, Iurther impairing the normal mechanism Ior mucus clearance.

I2paired .iliary f:n.tion
Contrary to earlier models oI sinus physiology, the drainage patterns oI the paranasal sinuses
depend not on gravity but on the mucociliary transport mechanism. The metachronous
coordination oI the ciliated columnar epithelial cells propels the sinus contents toward the natural
sinus ostia. Any disruption oI the ciliary Iunction results in Iluid accumulation within the sinus.
!oor ciliary Iunction can result Irom the loss oI ciliated epithelial cells; high airIlow; viral,
bacterial, or environmental ciliotoxins; inIlammatory mediators; contact between 2 mucosal
surIaces; scars; and artagener syndrome.
Ciliary action can be aIIected by genetic Iactors, such as artagener syndrome. artagener
syndrome is associated with immobile cilia and hence the retention oI secretions and
predisposition to sinus inIection. Ciliary Iunction is also reduced in the presence oI low pH,
anoxia, cigarette smoke, chemical toxins, dehydration, and drugs (eg, anticholinergic
medications and antihistamines).
Exposure to bacterial toxins can also reduce ciliary Iunction. Approximately 10° oI cases oI
acute sinusitis result Irom direct inoculation oI the sinus with a large amount oI bacteria. Dental
abscesses or procedures that result in communication between the oral cavity and sinus can
produce sinusitis by this mechanism. Additionally, ciliary action can be aIIected aIter certain
viral inIections.
Several other Iactors can lead to impaired ciliary Iunction. Cold air is said to stun the ciliary
epithelium, leading to impaired ciliary movement and retention oI secretions in the sinus
cavities. On the contrary, inhaling dry air desiccates the sinus mucous coat, leading to reduced
secretions. Any mass lesion with the nasal air passages and sinuses, such as polyps, Ioreign
bodies, tumors, and mucosal swelling Irom rhinitis, may block the ostia and predispose to
retained secretions and subsequent inIection. Facial trauma or large inoculations Irom swimming
can produce sinusitis as well. Drinking alcohol can also cause nasal and sinus mucosa to swell
and cause impairment oI mucous drainage.
ltered q:ality and q:antity of 2:.:s
Sinonasal secretions play an important role in the pathophysiology oI rhinosinusitis. The mucous
blanket that lines the paranasal sinuses contains mucoglycoproteins, immunoglobulins, and
inIlammatory cells. It consists oI 2 layers: (1) an inner serous layer (ie, sol phase) in which cilia
recover Irom their active beat and (2) an outer, more viscous layer (ie, gel phase), which is
transported by the ciliary beat. !roper balance between the inner sol phase and outer gel phase is
oI critical importance Ior normal mucociliary clearance.
II the composition oI mucus is changed, so that the mucus produced is more viscous (eg, as in
cystic Iibrosis), transport toward the ostia considerably slows, and the gel layer becomes
demonstrably thicker. This results in a collection oI thick mucus that is retained in the sinus Ior
varying periods. In the presence oI a lack oI secretions or a loss oI humidity at the surIace that
cannot be compensated Ior by mucous glands or goblet cells, the mucus becomes increasingly
viscous, and the sol phase may become extremely thin, thus allowing the gel phase to have
intense contact with the cilia and impede their action. Overproduction oI mucus can overwhelm
the mucociliary clearance system, resulting in retained secretions within the sinuses.
.:te sin:sitis in the intensive .are setting
Acute sinusitis in the intensive care population is a distinct entity, occurring in 18-32° oI
patients with prolonged periods oI intubation, and is usually diagnosed during the evaluation oI
unexplained Iever. Cases in which the cause is obstruction are usually evident and can include
the presence oI prolonged nasogastric or nasotracheal intubation. Moreover, patients in an
intensive care setting are generally debilitated, predisposing them to septic complications,
including sinusitis. Finally, sinusitis in intensive care settings is associated with nasal catheter
placement.























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