Alterations in Oxygenation

Review of Anatomy and Physiology of the Respiratory SystemUpper Respiratory Tract-consists of nose, sinuses, nasal passages, pharynx, tonsils, adenoids, larynx and trachea.Nose- composed of an internal and external portionexternal portion- protrudes from the face supported by the nasal bones and cartilagesanterior nares- external openings of the nasal cavities

Review of Anatomy and Physiology of the Respiratory SystemParanasal sinuses- include four pairs of bony cavitites.-connected by a series of ducts that drain into the nasal cavitynamed by their location: frontal, ethmoidal,sphenoidal, and maxillary- fxn: resonating chambers in speech- common site of infection

Review of Anatomy and Physiology of the Respiratory SystemTurbinates(Bones)- also called conchae -increase the surface area of the mucous membrane in the nasal passages- As air enters the nostrils, it comes in contact with the mucous membrane to trap all the dust and microorganisms; air is moistened and warmed to body temperature

Review of Anatomy and Physiology of the Respiratory SystemInternal portion- hollow cavity separated into right and left nasal cavities by the nasal septumEach nasal cavity divided into 3 passageways by the projection of the turbinates(conchae) from the lateral walls-lined with highly vascular ciliated mucous membranes caleed the nasal mucosa

Review of Anatomy and Physiology of the Respiratory SystemPharynx- tubelike structure that connects the nasal and oral cavities to the larynx3 regions: nasopharynx- posterior to the nose and above the soft palateoropharynx- houses the palatine tonsilslaryngopharynx- extends from the hyoid bone to the cricoid cartilageEpiglottis- forms the entrance to the larynx

Review of Anatomy and Physiology of the Respiratory SystemLarynx- cartilaginous, epithelium lined structure that connects the pharynx and the trachea- major function: vocalization-consists of the following:*Epiglottis- flap of cartilage that covers the opening to the larynx during swallowing*Glottis- the opening between the vocal cords in the larynx*Thyroid cartilage- the largest of the cartilage structures; part of it forms the Adams apple*Cricoid cartilage- the only complete cartilaginous ring in the larynx(located below the Thyroid cartilage)*Arytenoid cartilages- used in vocal cord movement with the Thyroid cartilage*Vocal cords- ligaments controlled by muscular movements that produce sounds; located in the lumen of the larynx

Review of Anatomy and Physiology of the Respiratory SystemTrachea- a.k.a. windpipecomposed of smooth muscle with C-shaped rings of cartilage at regular intervalsThe cartilaginous rings are incomplete on the posterior surface and give firmness to the wall of the trachea to prevent it from collapsingServes as passage between the larynx and the bronchi

Review of Anatomy and Physiology of the Respiratory SystemLungs- paired elastic structures enclosed in the thoracic cage(airtight chamber with distensible walls)Ventilation- requires movement of the thoracic cage and diaphragm(Floor)Inspiration- air enters because of the negative pressure in the thoracic cageExpiration- air is forced out during lung recoilPassive process requiring little energyCOPD- expiration requires energy

Review of Anatomy and Physiology of the Respiratory SystemPleura- serous membrane lining the lungs(Visceral pleura) and the wall of the thorax(parietal pleura)-small amount of pleural fluid between the two membranes serve to lubricate the thorax and the lungs to permit smooth motion of the lungs within the thoracic cavity with each breathPleural friction rub-

Review of Anatomy and Physiology of the Respiratory SystemMediastinum- middle of the thorax between the pleural sacs that contain the two lungs-extends from the sternum to the vertebral column and contains all the thoracic tissue outside the lungs.Lobes-left lobe- consists of an upper and lower lobe-right lobe- consists of an upper, middle, and lower lobe*Each lobe further subdivided into two to five segments separated by fissures

Review of Anatomy and Physiology of the Respiratory SystemBronchi and bronchioles-lobar bronchi- 3 in the right and 2 in the leftLobar bronchi divide into:Segmental bronchi- 10 on the right and 8 on the left-structures identified when choosing the the most effective postural drainage position for a given patient.Segmental bronchi divide into:Subsegmental bronchi- surrounded by by connective tissue that contains arteries, lymphatics, and nervesSubsegmental bronchi then divide into:Bronchioles- no cartilage in their walls-patency depends on the elastic recoil of the surrounding smooth muscle and on the alveolar pressure*The bronchi and bronchioles are lined with cells that have cilia(propels mucus and foreign substances away from the lungstowards the larynx

Review of Anatomy and Physiology of the Respiratory SystemAlveoli- the lung is made of 300 million alveoli arranged in clusters of 15 to 20=70 sq. meters(tennis court)3 Types of alveolar cellsType1- epithelial cells that form the alveolar wallsType2- metabolically active(secrete surfactant which is a phospholipid that lines the inner surface to prevent alveolar collapseType3- large phagocytic cells that ingest foreign matter( bacteria, mucus)- acts a defense mechanism

Review of Anatomy and Physiology of the Respiratory SystemFunctions of RespirationOxygen transport- capillary-cell exchange Respiration- capillary-alveoli exchangeVentilation- inspiration from the trachea to the alveoliexpiration- alveolar gas travels in reverse

Review of Anatomy and Physiology of the Respiratory SystemAir Pressure Variances- Inspiration1.movement of the diaphragm and thoracic cavity2. enlarges the thoracic cavity3. lowers the pressure inside the thorax to a level below atmospheric pressure4. air is drawn into the alveoli

Review of Anatomy and Physiology of the Respiratory SystemAir pressure VariancesExpirationThe diaphragm relaxes and the lungs recoilDecrease in the size of the thoracic cavityAlveolar pressure exceeds atmospheric pressureAir flows from the lungs into the atmosphereAirway Resistancedetermined by the radius or size of the airway through which the air is flowing Eg. Changes in bronchial diameter- affects airway resistance and alters the rate of air flowEg. Bronchial asthma

Review of Anatomy and Physiology of the Respiratory SystemCauses of Increased airway Resistance:*contraction of bronchial smooth muscle- asthma*obstruction of the airway- mucus, tumor or foreign body*loss of lung elasticity- emphysema, characterized by connective tissue encircling the airways, keeping them open during inspiration and expiration

Review of Anatomy and Physiology of the Respiratory SystemCompliance- measure of the elasticity, expandability and distensibility of the lungsVolume-pressure relationship in the lungsHigh compliance- overdistended lungsLow or decreased- stiff lungseg. Pnemothorax, hemothorax, pleural effusion, pulmonary edema, pulmonary fibrosis, ARDS

Lung Volumes Tidal Volume-VT or TV- the volume of air inhaled and ehaled with each breath-normal value: 500 ml- Significance : the tidal volume may not vary even with severe disease

Lung Volumes Inspiratory Reserve Volume-IRV- the maximum volume of air that can be inhaled after a normal inspiration-normal value: 3000 ml

Lung Volumes Expiratory reserve VolumeERVThe maximum volume of air that can be exhaled forcibly after a normal exhalationNormal value: 1100 ml.Decreased with restrictive conditions such as obesity, ascites, pregnancy

Lung Volumes Residual VolumeRVThe volume of air remaining in the lungs after a maximum exhalationNormal value: 1200 mlIncreased with obstructive disease

Lung CapacitiesVital CapacityVCThe maximum volume of air exhaled from the point of maximum inspirationVC= TV+IRV+ERVNormal value: 4600 ml.Decreased VC may be found in neuromuscular disease, generalized fatigue, atelectasis, pulmonary edema, and COPD

Lung CapacitiesInspiratory CapacityICMaximum volume of air inhaled after normal expirationIC=TV+IRVNormal value: 3500 ml.Decreased IC in restrictive disease

Lung CapacitiesFunctional Residual CapacityFRCVolume of air remaining in the lungs after a normal expirationFRV= ERV+RVNormal value: 2300 ml.May be increased with COPDAnd decreased in ARDS

Lung CapacitiesTotal Lung capacityTLCThe volume of air in the lungs after a maximum inspirationNormal value: 5800 ml.May be decreased with restrictive disease ie. Atelectasis, pneumoniaIncreased in COPD

Diffusion and PerfusionDiffusion- process by which oxygen and carbon dioxide are exchanged at the air-blood interface(alveolar- capillary membrane)Pulmonary perfusion- actual blood flow to the pulmonary circulation

Ventilation and PerfusionVentilation- actual flow of gas in and out of the lungsPerfusion- filling of the pulmonary capillaries with bloodAdequate gas exchange depends on an adequate ventilation-perfusion ratio(V/Q)Imbalance occurs as a result of inadequate perfusion, inadequate ventilation or both

Ventilation/Perfusion Ratio (V/Q)Four possible V/Q statesNormal ratio-healthy lung-equal amount of blood passes an alveolus matched by an equal amount of gas- ratio is 1:1-ventilation matches perfusion

Ventilation/Perfusion Ratio (V/Q)Four possible V/Q statesLow ventilaton- perfusion ratio-also called shunt producing disorders-perfusion exceeds ventilation, a shunt exists-blood bypasses the alveoli but without gas exchange occuring- seen in distal airway obstruction ie. Pneumothorax, atelectasis, tumor, mucus plug

Ventilation/Perfusion Ratio (V/Q)Four possible V/Q statesHigh Ventilation-perfusion ratio (Dead Space)Ventilation exceeds perfusionAlveoli do not have adequate blood supply for gas exchange to occurPulmonary emboli, pulmonary infarction, cardiogenic, shock.

Ventilation/Perfusion Ratio (V/Q)Four possible V/Q statesSilent unitAbsence or limited ventilation and perfusionSeen in pneumothorax, severe ARDS

AssessmentHealth History- focuses on the physical and functional aspects of the patient and the effects of these problems on the patient, including activities of daily living.Reason the patient is seeking health care often related to DYSPNEA, HEMOPTYSISDyspnea- difficult or labored breathing is a common symptom in pulmonary and cardiac patientsMay be associated in neuromuscular disorders ie. Myasthenia gravis, Guillain-Barre syndrome, muscular dystrophyMay also occur after physical exercise in people without disease.Common at the end of life.Acute diseases of the lungs produce a more severe grade of dyspneaSudden dyspnea in a healthy person- pneumothorax, acute respiratory obstruction, or ARDSSudden dyspnea in immobilized patients- pulmonary embolismMay occur with other disorders: cardiac disease, anaphylactic reactions, severe anemia.

AssessmentOrthopnea- inability to breath easily except in the upright positionMay be found in patients with heart disease or COPD

Questions to ask in the HistoryHow much exertion triggers shortness of breathCough?Is dyspnea related to other symptoms?Was the onset sudden or gradualAt what time of the day or night does SOB occurWorse when flat in bedDoes it occur at rest? Exercise? Running? Climbing stairs?Is the SOB worse while walking? If so, when walking how far? How fastRelief measures: identify and correct cause, rest and high Fowlers position, Oxygen

AssessmentCough- reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodiesResults from the irritation of the mucous membrane anywhere in the resp. tractSymptom of a disorderCauses: airborne irritant, infection, cardiac disease, medications(ACE inhibitors), smoking, GERD(gastro-esophageal reflux disease)

AssessmentSputum production- reaction of the lungs to any constantly recurring irritantMay also be associated with nasal discharge.Bacterial infection- profuse, thick yellow, green or rusty colored sputumViral bronchitis- thin, mucoid sputumChronic bronchitis- gradual increase of sputum over timeLung abscess- foul smelling sputumRelief measures: hydration, aerosolized solutions

AssessmentChest Pain- in pulmonary conditions, pain is sharp, stabbing, intermittent, dull, aching or persistentMay occur with pneumonia, pulmonary embolism, lung infarctionWheezing- may be heard with or without a stethoscope.High pitched, musical sound heard mainly on expirationBronchodilators( oral or inhalants)

AssessmentClubbing of the fingers- sign of lung disease in patients with chronic hypoxic conditionsInitially manifested as sponginess of the nail bed and loss of nail bed angle.

AssessmentHemoptysis- expectoration of blood from the respiratory tractMay be sudden, intermittent or continuousMost common causes: pulmonary infection, carcinoma, pulmonary artery or vein abnormalities, pulmonary embolus and infarction, abnormalities of the heart and blood vessels.

AssessmentCyanosis- bluish coloring of the skinAssessmnet of cyanosis is affected by room lighting, skin color, and distance of the blood vessels from from the surface of the skin

Rates and Depths of RespirationEupnea- normal breathing at 12-18 breaths /minuteBradypnea- slower than normal(24 breaths/minHypoventilation- shallow,irregular breathingHyperventilation-increased rate and depth of breathing( Kussmauls respiration if caused by diabetic ketoacidosis)

Rates and Depths of RespirationApnea- period of cessation of breathing.Time duration varies-may occur with other breathing disorders ie. Sleep apneaCheyne- Stokes- regular cycle where the rate and depth of breathing increase, then decrease until apnea.Biots Respiration- periods of normal breathing(3-4 breaths) followed by a varying period of apnea( usually 10-60 seconds)

Physical AssessmentTactile Fremitus- detection of vibration on the chest wall by touch-sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion.Factors affecting fremitus:1. thickness of the chest wall2. obesity with increased subcutaneous tissue*lower pitched sounds travel better through the normal lung and produce greater vibration on the chest wall*more pronounced in men than in women because of deeper male voice*most palpable in the upper thorax anteriorly and posteriorly*patient is asked to repeat ninety nine, one-two-three, or eee, eee, or tres-tres.

FremitusAir does not conduct sound wellSolid substances such as tissue conduct sound wellEmphysema patients- decreased tactile fremitusPneumonia with lung consolidation- increased fremitus

Thoracic PercussionDetermines whether the underlying tissues are filled with air, fluid or solid materialEstimate the size and location of certain structures within the thorax( eg. Diaphragm, heart and liver)

Characteristics of Percussion SoundsFlatness----- Eg. Large pleural effusionlocation example: thighDullnes------Eg. Lobar pneumonialocation example: liverResonance-----eg. Simple chronic bronchitislocation example: normal lungHyperresonance--- Eg. Emphysema, pneumothoraxlocation example: noneTympany----- eg. Large pneumothoraxlocation example: gastric air bubble; puffed out cheek

Breath soundsVesicular- inspiratory sounds lasts longer than expiratory soundslocation- entire lung field over the upper sternum and between the scapulaBronchovesicular- inspiratory nd expiratory sounds are about equallocation: 1st and 2nd interspacesanteriorly and between the scapula( over the main bronchus)Bronchial- expiratory sounds lasts longer the inspiratory soundslocation: over the manubriumTracheal- inspiratory and expiratory sounds are about equallocation: over the trachea in the neck

Abnormal(Adventitious) soundsCrackles in general- discontinuous popping sounds that occur during inspirationetiol: fluid in the airways or alveoli or to opening of collapsed alveoli.coarse crackles- discontinuous popping sounds heard in early inspiration; harsh moist sounds originating in the large bronchietiol: obstructive pulmonary diseaseFine crackles- discontinuos poppping sounds heard in late inspiration; like hair rubbing together; originates in the alveolietiol: instertitial pneumonia, restrictive pulmonary disease(fibrosis), bronchitis, pneumoniaWheezessonorous wheezes(rhonchi)- deep low pitched rumbling sonds heard primarily during expiration;caused by air moving through narrowed tracheobronchial passagesetiol: secretions or tumor

Abnormal(Adventitious) soundsWheezessibilant wheezes- continuous, musical, high pitched, whistle like sounds heard during inspiration and expirationetiol: air passing through narrowed or partially obstructed airwayseg. Bronchospasm, asthmaFriction rubsPleural friction rubs- harsh crackling sound, like 2 pieces of leather rubbing together-heard during inspiration alone or during inspiration and expiration-may subside when patient holds breath. Coughing will not clear soundetiol: inflammation or loss of lubricating pleural fluid

Assessment Findings in Common Respiratory Disorders

DisorderTactile fremitusPercussionAuscultationConsolidation eg pneumoniaIncreasedDullBronchial breath soundsBronchitisNormal ResonantNormal to dec breath sounds, wheezesEmphysemaNormal to decreasedResonant to hyperresonantDec. intensity of breath sounds, usually with prolonged expirationAsthmaNormal to decreasedResonant to hyperresonantWheezes

Assessment Findings in Common Respiratory Disorders

DisorderTactile fremitusPercussionAuscultationPulmonary edemaNormalResonantCrackles at lung bases,possibly wheezesPleural effusionAbsentDull to flatDecreased to absent breath soundsPnemothoraxDecreasedHyperresonantAbsent breath soundsAtelectasisAbsentFlatDecreased to absent breath sounds

Diagnostic StudiesPulmonary function tests(PFTs)-routinely used in patients with chronic respiratory disorders-assesses respiratory function and determines the extent of destruction-monitors the course of the patient with an established respiratory disease and assesses response to therapy

Pulmonary Function Tests(PFTs)Forced Vital capacity-FVC-reduced in COPD because of air trapping-performed with a maximally forced expiratory effortForced Expiratory volume-FEV1-volume of air expired in the specified time during the performance of forced vital capacity; FEV1 is volume exhaled in 1 second-clue to the severity of airway obstruction

Arterial Blood Gas StudiesMeasurement of the blood pH and arterial oxygen and CO2 tensionsBlood obtained from arterial puncturesNsg. Responsibility: !!!!! Adequate hemostasisPaO2- indicates the degree of oxygenation of bloodPaCO2- indicates the adequacy of alveolar ventilationAid in assessing the ability of the lungs to provide adequate oxygen and remove CO2 and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pHSerial ABGs- explain to the patient the procedure

Arterial Blood Gas StudiesNormal ABG valuespH- 7.35- 7.45PaCO2- 35 -45 mm HgPaO2- 80- 100 mm HgHCO3- 22-26 meq/L

Pulse oximeterNon invasive method of continuously monitoring the oxygen saturation of hemoglobin(SaO2)Referred to as spO2 when oxygen saturation is measured by pulse oximetryEffective tool for monitoring for subtle or sudden changes in oxygen saturation.Probe may be attached to:finger tip, ear lobe, bridge of the nose, foreheadNormal spO2- 95-100%?Factors that affect SpO2 Valesdyes, vasoconstrictor medications, cardiac arrest and shock

CulturesCultures from the throat or nose- useful in identifying organisms responsible for causing the disease

Sputum StudiesObtained for analysis to identify the pathogenic organisms and to determine whether malignant cells are present.May also be used for hypersensitivity states to guide treatment.Expectoration is the usual method of collection

Sputum StudiesOther methods of collecting sputum1.Endotracheal aspiration2. bronchoscopic removal3. transtracheal aspirationNsg responsibility: 1. specimen should be delivered to the lab within 2 hours of collection

Imaging StudiesChest x-raynormal pulmonary tissue- radiolucentRoutine chest x-ray- 2 viewsPA view; lateral projectionusually taken with a full inspiration

X-ray: shows major contrasts between body densities such as bone, soft tissues, and air

Imaging StudiesComputed Tomography-imaging method where the lungs are scanned in successive layers by a narrow beam x-ray-provides a cross sectional view of the chest- may use contrast agentsNsg Responsibility:allergy to iodine or seafoodsBUN/Creatinine levels

Imaging StudiesMagnetic Resonance Imaging (MRI)-similar to CT scan except magnetic fields and radiofrequency are used instead of a narrow beam x-ray-yields more detailed images than a CT.

Imaging StudiesPulmonary Angiography- commonly used to investigate thromboembolic diseases of the lungs.eg. Pulmonary embolism,congenital abnormalities of the pulmonary vascular treeProcedure: rapid injection of a radiopaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels

Endoscopic ProceduresBronchoscopy- direct inspection and examination of the larynx, trachea, and bronchi through a flexible fiberoptic bronchoscopePurposes: Diagnostic1. determine the location and extent of the pathologic process2. examine tissues or collect secretions3. determine whether a tumor can be resected surgically4. obtain tissue sample for diagnosis5. diagnose bleeding sites

Endoscopic ProceduresBronchoscopyPurposes: Therapeutic1. remove foreign bodies from the tracheobronchial tree2. remove secretions when the patient cannot clear them3. treat post op atelectasis4. destroy and excise lesionsComplications of Bronchoscopy1. reaction to local anesthetic2. infection3. aspiration4. bronchospasm5. hypoxemia6. pnemothorax7. bleeding8. perforation

Endoscopic ProceduresBronchoscopy-Nursing Interventions1. consent2. withhold food and fluids 6 hours3. Preop meds- atropine- vagal stimulation and bradycardiaopioids- 4. remove dentures5. post op- nothing by mouth until cough reflex returns, then ice chips---fluids

Imaging StudiesThoracentesis-accumulation of pleural fluid may occur with some disorders of which a sample of this fluid can be obtained thoracentesis- aspiration of pleural fluid for diagnostic or therapeutic purposes-may be ultrasound guided- less complications-Studies include: Gram staining, C/S, acid fast staining and culture, differential cell count, cytology, pH, sp. Gravity, total protein, and lactic dehydrogenase

ThoracentesisNursing ActivitiesAscertain in advance- chest x-ray has been orderedAssess for allergy to the local anestheticAdminister sedation if prescribedInform the patient:1. remain immobile2. pressure sensations expected3. minimal discomfort after the procedurePosition: Upright- facilitates removal of fluid that localizes at the base of the thorax*sitting on the edge of the bed with the feet supported and arms and head on a padded over the bed table.

Imaging StudiesBiopsy- excision of a small amount of tissue for examination of cellsPleural Biopsy-accomplished by needle biopsy of the pleura or pleuroscopy(visual explorationthrough a fiberoptic bronchoscope inserted into the pleural space.-performed when there is pleural exudateof undetermined origin or when there is a need to stain or culture the tissue to identify tuberculosis or fungi.

Pulmonoray AngiographyUsed to investigate thromboembolic disease of the lungs eg. Pulmonary embolism, congenital abnormalities of the pulmonary systemProcedure- rapid injection of a radiopaque substance into a vein while simultaneously doing a radiographic study (CT Scan).

Upper Airway InfectionsRhinitis- inflammation and irritation of the mucous membranes of the nose-acute, chronic, non allergic, allergic-Allergic rhinitis- may be classified as seasonal (pollen seasons) Perennial(occurs throughout the year)Pathopyhysiology: environmental factorschanges in temp., odors, food, drugs such as cocaine and antihypertensive meds., infection.

RhinitisManagement1. H and P- ask for possible exposure to allergens- swollen and congested nasal mucosaMeds: decongestants/paracetamol corticosteroids desensitizing immunizations antibiotics antihistaminessaline spraysViral Rhinitis/common cold: rhinorrhea, nasal congestion, sneezing, headache, muscle pains- highly contagiousCause: rhinovirusother causes: adenovirus, Coronavirus, RSV, influenza virus***Each virus has many strains---vacccine is impossible

Acute SinusitisInflammation of the mucous membranes of the paranasal sinusesOften follows URIobstruction of the nasal cavities--- bacterial growth Most often caused by bacteria (60%)Other causes: abnormal structures of the nose, diving and swimming, traumaS/Sx: facial pain fatigue purulent nasal discharge fever, headache ear pain nasal obstruction sense of fullnessdecrease sense of smellsore throatsnoringperiorbital edema

Acute SinusitisAssessment1.tenderness to palpation of the sinus area2. tenderness on tapping of the sinus area3. transillumination with light- decrease transmission Complications: meningitis, abscess, osteomyelitis,Meds: same as in rhinitis

Acute SinusitisNsg. ManagementSteam inhalationWarm compressesAvoid- swimming, diving, air travelNasal decongestant- rebound congestionFollow recommended antibiotic regimenAdvise for signs of complications: nuchal rigidity, severe headache, fever

Chronic SinusitisSymptoms of sinusitis lasting more than 3 monthsPathopysiology: same as in Acute sinusitisS/sx: same as in acuteMedical mgt: same as in acute*surgery to correct to correct structural deformities eg. Excising nasal polyps, correcting deviated nasal septum

Acute PharyngitisSudden inflammation of the pharynxSore throat- primary symptomCauses: bacterial and viral(self limiting)Complications:1. sinusitis2. otitis media3. peritonsillar abscess4. pneumonia5. meningitis6. rheumatic fever (Group A B-hemolytic Streptococcus)8. nephritisS/Sx: swollen pharyngeal membrane and tonsils(exudate), lymphadenopathy

Chronic SinusitisPersistent inflammation Causes:-Common in adults, over use of voice, alcohol, tobaccoS/Sx: soreness /fulness of the throatdysphagiapostnasal dripManagement: antibiotics, antihistamines, decongestants

Tonsillitis/AdenoiditisAcute tonsillitis- can be confused with pharyngitisGroup A Beta hemolytic Sreptococcus- most common organism S/sx: fever, sore throat, snoring, mouth breathing, earache, May spread to the middle ears via Eustachian tubes otitis mediaManagement: increased fluid intake, salt water gargles, pain mends, PCN, Surgery: tonsillectomy/ adenoidectomy for repeated episodes

Tonsillitis/AdenoiditisPost op care in tonsillectomy1. immediate post op care- patient in prone position with head turned to the side2. ice collar to the neck3. frequent swallowing- warrants investigation- may suggest hemorrhage4. Vital signs- increasing heart rate (^Temp or decreasing BP)5. check for swallowing reflex- ice chips6. Advise: refrain from too much talking7. control coughing

Peritonsillar abscessCollection of purulent exudate between the tonsillar capsule and the surrounding tissuesCommon cause : Beta hemolytic streptococcusEdema can cause airway obstruction-life threateningS/Sx: fever, trismus, drooling, odynophagiaswelling of the soft palate, unilateral tonsillar hypertrophyMed Management: antibiotics(PCN)- effective-fine needle aspiration of the of pus or incision and drainage

LaryngitisResult from voice abuse, dust, chemicals, smoke, or as part of URI, allergiesS/Sx: hoarsenessaphoniasevere coughManagement: voice rest, antibiotics and steroids, dysphagia, hemoptysis

Obstruction and Trauma of the Upper Respiratory AirwaySleep Apnea1. excessive daytime sleepiness2. frequent nocturnal awakening3. insomnia4. loud snoring5. morning headaches6. intellectual deterioration7. irritabilty8. impotence9. dysrhythmias10. severe hypertension11. pulmonary hypertension12. polycythemia13. enuresis

Sleep ApneaManagementt1.avoid sleeping on the back2.avoid alcohol and meds that depress the upper airway3. weight loss4. CPAP or biPAP(bilevel positive airway pressure)5. surgery- uvulopalatopharyngoplasty6. Meds: Protryptiline increases the respiratory driveMedroxyprogesterone ?Acetazolamide(Diamox) ?

Epistaxis