Nursing Interventions for Respiratory Disorder PDF

Nursing Interventions For a patient with Respiratory disorder By Aliye K. (Asst. professor) 1 5/15/2022 Anatomy and physiology of the respiratory system  The respiratory system is composed of the upper and lower respiratory tracts.  Together,...

Nursing Interventions For a patient with Respiratory disorder By Aliye K. (Asst. professor) 1 5/15/2022 Anatomy and physiology of the respiratory system  The respiratory system is composed of the upper and lower respiratory tracts.  Together, the two tracts are responsible for ventilation (movement of air in and out of the airways). 5/15/2022 2  theupper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange.  Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. 5/15/2022 3 ANATOMY OF THE UPPER RESPIRATORY TRACT  Upper airway structures consist of the ✓ nose ✓sinuses and nasal passages ✓ pharynx ✓ tonsils and adenoids ✓ larynx, and ✓ trachea. 5/15/2022 4  Nose  The nose is composed of an external and an internal portion.  The external portion protrudes from the face and is supported by the nasal bones and cartilage.  The internal portion of the nose is a hollow cavity separated into the right and left nasal cavities by a narrow vertical divider, the septum.  The nasal cavities are lined with highly vascular ciliated mucous membranes called the nasal mucosa. 5/15/2022 5 Cont…  Mucus, secreted continuously by goblet cells, covers the surface of the nasal mucosa and is moved back to the nasopharynx by the action of the cilia (fine hairs).  The nose serves as a passageway for air to pass to and from the lungs.  It filters impurities and humidifies and warms the air as it is inhaled.  It is responsible for olfaction (smell) because the olfactory receptors are located in the nasal mucosa.  This function diminishes with age. 5/15/2022 6 Paranasal Sinuses  The paranasal sinuses include four pairs of bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium.  These air spaces are connected by a series of ducts that drain into the nasal cavity. 5/15/2022 7  Cont…  The sinuses are named by their location: ✓Frontal ✓Ethmoidal ✓sphenoidal, and ✓maxillary. A prominent function of the sinuses is to serve as a resonating chamber in speech.  The sinuses are a common site of infection. 5/15/2022 8 Pharynx, Tonsils, and Adenoids  The pharynx, or throat, is a tube like structure that connects the nasal and oral cavities to the larynx.  It is divided into three regions: ✓ Nasal ✓ oral, and ✓ laryngeal.  The nasopharynx is located posterior to the nose and above the soft palate.  The oropharynx houses the faucial, or palatine, tonsils.  The laryngopharynx extends from the hyoid bone to the cricoid cartilage. 5/15/2022 9 Cont…  The epiglottis forms the entrance of the larynx.  The adenoids, or pharyngeal tonsils, are located in the roof of the nasopharynx.  The tonsils, the adenoids, and other lymphoid tissue encircle the throat.  These structures are important links in the chain of lymph nodes guarding the body from invasion by organisms entering the nose and the throat.  The pharynx functions as a passageway for the respiratory and digestive tracts. 5/15/2022 10 Larynx  The larynx, or voice organ, is a cartilaginous epithelium-lined structure that connects the pharynx and the trachea.  The major function of the larynx is vocalization.  It also protects the lower airway from foreign substances and facilitates coughing. 5/15/2022 11 Trachea  The trachea, or windpipe, is composed of smooth muscle with C-shaped rings of cartilage at regular intervals.  The cartilaginous rings are incomplete on the posterior surface and give firmness to the wall of the trachea, preventing it from collapsing.  The trachea serves as the passage between the larynx and the bronchi. 5/15/2022 12 ANATOMY OF THE LOWER RESPIRATORY TRACT: LUNGS  The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. 5/15/2022 13 Lungs  The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls.  Ventilation requires movement of the walls of the thoracic cage and of its floor, the diaphragm.  The effect of these movements is alternately to increase and decrease the capacity of the chest.  When the capacity of the chest is increased, air enters through the trachea (inspiration) because of the lowered pressure within and inflates the lungs. 5/15/2022 14  When the chest wall and diaphragm return to their previous positions (expiration), the lungs recoil and force the air out through the bronchi and trachea.  The inspiratory phase of respiration normally requires energy; the expiratory phase is normally passive.  Inspiration occurs during the first third of the respiratory cycle, expiration during the latter two thirds. 5/15/2022 15 PLEURA  The lungs and wall of the thorax are lined with a serous membrane called the pleura.  The visceral pleura covers the lungs; the parietal pleura lines the thorax.  The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. 5/15/2022 16 5/15/2022 17 MEDIASTINUM The mediastinum is in the middle of the thorax, between the pleural sacs that contain the two lungs.  It extends from the sternum to the vertebral column and contains all the thoracic tissue outside the lungs. 5/15/2022 18  LOBES  Each lung is divided into lobes.  The left lung consists of an upper and lower lobe, whereas the right lung has an upper, middle, and lower lobe.  Each lobe is further subdivided into two to five segments separated by fissures, which are extensions of the pleura. 5/15/2022 19  BRONCHI AND BRONCHIOLES  There are several divisions of the bronchi within each lobe of the lung.  First are the lobar bronchi (three in the right lung and two in the left lung).  Lobar bronchi divide into segmental bronchi (10 on the right and 8 on the left), which are the structures identified when choosing the most effective postural drainage position for a given patient.  Segmental bronchi then divide into subsegmental bronchi. 5/15/2022 20  ALVEOLI  The lung is made up of about 300 million alveoli, which are arranged in clusters of 15 to 20.  These alveoli are so numerous that if their surfaces were united to form one sheet, it would cover 70 square meters—the size of a tennis court.  There are three types of alveolar cells. 5/15/2022 21  Type I alveolar cells are epithelial cells that form the alveolar walls.  Type II alveolar cells are metabolically active. These cells secrete surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse.  Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter (eg, mucus, bacteria) and act as an important defense mechanism. 5/15/2022 22 FUNCTION OF THE RESPIRATORY SYSTEM  The cells of the body derive the energy they need from the oxidation of carbohydrates, fats, and proteins.  As with any type of combustion, this process requires oxygen.  Certain vital tissues, such as those of the brain and the heart, cannot survive for long without a continuing supply of oxygen. 5/15/2022 23 Cont…  However, as a result of oxidation in the body tissues, carbon dioxide is produced and must be removed from the cells to prevent the buildup of acid waste products.  The respiratory system performs this function by facilitating life-sustaining processes such as oxygen transport, respiration and ventilation, and gas exchange. 5/15/2022 24 Oxygen Transport  Oxygen is supplied to, and carbon dioxide is removed from, cells by way of the circulating blood.  Cells are in close contact with capillaries, whose thin walls permit easy passage or exchange of oxygen and carbon dioxide.  Oxygen diffuses from the capillary through the capillary wall to the interstitial fluid.  At this point, it diffuses through the membrane of tissue cells, where it is used by mitochondria for cellular respiration.  The movement of carbon dioxide occurs by diffusion in the opposite direction from cell to blood. 5/15/2022 25 Respiration  The oxygen concentration in blood within the capillaries of the lungs is lower than in the lungs’ air sacs (alveoli).  Because of this concentration gradient, oxygen diffuses from the alveoli to the blood.  Carbon dioxide, which has a higher concentration in the blood than in the alveoli, diffuses from the blood into the alveoli.  Movement of air in and out of the airways (ventilation) continually replenishes the oxygen and removes the carbon dioxide from the airways in the lung.  This whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body is called respiration. 5/15/2022 26 Gas exchange 5/15/2022 27 Assessment of the respiratory system Health history includes history of:  smoking  Previous personal or family hx.  Occupational hx  Allergens or environmental pollutants Examination of the thorax  Inspection  Palpation  Percussion and  Auscultation 5/15/2022 28 Physical Examination The posterior chest  Inspect the posterior chest.  Note the shape and configuration of the chest wall.  The spinous processes should appear in a straight line. 5/15/2022 29  The thorax and scapulae are symmetric.  The antero posterior diameter is less than the transverse diameter.  Abnormal – Antero posterior =Transverse diameter or ‘‘barrel chest’’ 5/15/2022 30 Palpate the posterior chest Symmetric Expansion  Confirm symmetric chest expansion by placing your warmed hands on the posterolateral chest wall with thumbs at the level of T9 to T10.  Slide your hands medially to pinch up a small fold of skin between your thumbs. 5/15/2022 31  Ask the person to take a deep breath.  As the person inhales deeply, your thumbs should move apart symmetrically.  Note any lag expansion 5/15/2022 32  Abnormal- unequal chest expansion occurs with marked atelectasis, pneumonia, fractured ribs or pneumothorax.  Pain accompanies deep breathing when the pleurae are inflamed. 5/15/2022 33 Tactile Fremitus  Assess tactile (or vocal) fremitus.  Fremitus is a palpable vibration.  Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall where you feel them as vibrations. 5/15/2022 34  Usethe palmar base of the fingers of one hand and touch the person’s chest while he/she repeats the words “ninety-nine” or “Arba-Arat”.  These are resonant phrases that generate strong vibrations. 5/15/2022 35  Start over the lung apices and palpate from one side to another.  Symmetry is important, the vibrations should feel the same in the corresponding area on each side.  Avoid palpating over the scapulae because bone damps out sound transmission 5/15/2022 36 Abnormal –  Decreased fremitus occurs when anything obstructs transmission of vibrations as obstructed bronchus, pnemothorax.  Increased fremitus with consolidation of lung tissue as lobar pneumonia. 5/15/2022 37  Using the fingers, gently palpate the entire chest wall to note any areas of tenderness, skin temperature and moisture.  Crepitus is a crackling sensation palpable over the skin surface. Ex. Subcutaneous emphysema-escape of air from the lung and enter subcutaneous tissue. 5/15/2022 38 Percuss the posterior chest  Start at the apices and percuss at the tops of the shoulders.  Then percussing in the interspaces, make a side- to side comparison all the way down. 5/15/2022 39  Avoid the damping effect of the scapulae and ribs.  Resonance predominates in healthy lung tissue.  A dull note signals abnormal density in the lungs as with pneumonia, pleural effusion or tumor. 5/15/2022 40 5/15/2022 41  Categorize what you hear as resonant, dull, or hyper resonant.  Practice your technique until you can consistently produce a "normal" percussion note on your partner before you work with patients. 5/15/2022 42 Auscultate the posterior chest  The passage of air through the tracheo-bronchial tree creates a characteristic set of noises audible through the chest wall.  These noises also may be modified by obstruction with the respiratory passage ways or by changes in the lung parenchyma, the pleura or chest wall. 5/15/2022 43 Breath sounds  Instruct the person to breathe through the mouth, a little bit deeper than usual.  Use the flat diaphragm end- piece of the stethoscope.  Listen to at least one full respiration and compare side to side.  Listen posteriorly from apices at C7to the bases (around T10). 5/15/2022 44 You should expect to hear three types of normal breath sounds. 5/15/2022 45  Bronchial (tracheal) is high pitched loud amplitude normally located on the trachea and larynx.  Broncho-vesicular is moderate pitch and amplitude normally located over major bronchi: Posterior between scapulae and anteriorly around upper sternum in the 1st and 2nd intercostal spaces. 5/15/2022 46  Vesicularis low pitched and soft amplitude located over peripheral lung fields where air flows through smaller bronchioles and alveoli. 5/15/2022 47  Abnormal – Decreased or absent breath sounds occur with obstruction of bronchial tree by secretions, in emphysema due to loss of elasticity or pleurisy, and pleural effusion 5/15/2022 48 Adventitious sounds  Note the presence of any adventitious sounds.  These are added sounds that are not normally heard in the lungs.  They are caused by moving air colliding with secretions in the tracheo bronchial passage ways and include crackles (rales) and wheeze (or rhonchi) 5/15/2022 49 Voice sounds  The spoken voice can be auscultated over the chest wall like tactile fremitus.  Ask the person to repeat a phrase while you listen over the chest wall.  Normal voice transmission is soft, muffled, and indistinct; 5/15/2022 50  You can hear sound through the stethoscope but cannot distinguish exactly what is being said.  Pathology that increases lung density enhances transmission of voice sounds.  Voice sounds are supplemented maneuvers that are performed if you suspect lung pathology for possible bronchophony, Egophony and Whispered pectoriloquy 5/15/2022 51 Technique Bronchophony  Ask the person to repeat ‘ninety nine” while you listen with the stethoscope over the chest wall.  Listen especially if you suspect pathology.  Normal findings- normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but can not distinguish exactly what is being said. 5/15/2022 52  Abnormal Findings pathology that increases lung density will enhance transmission of voice sounds.  You ausculate a clear “Ninety- Nine.”  The words are more distinct than normal and sound close to your ear. 5/15/2022 53 Egophony- (Greek: the voce of a goat)  Ausculate the chest while the person phonates a long “ee-ee-ee-ee” sound. Normally, you should hear “eeeeee” through your stethoscope.  Abnormal – over areas of consolidation or compression the spoken “eeee” sound changes to a bleating long “aaaaa” sound. If this is present record “E→A change” 5/15/2022 54 Whispered pectoriloquy –  ask the person to whisper a phrase like “one-two- three” as you auscultate.  The normal response is faint, Muffled and almost inaudible.  Abnormal with consolidation the whispered voice is transmitted very clearly and distinctly although still somewhat faint.  It sounds as if the person is whispering right into your stethoscope, “one-two- three’’ 5/15/2022 55 The Anterior chest- Inspect the anterior chest.  Note the shape and configuration of the chest wall.  The ribs are sloping downward with symmetric interspaces.  The costal angle is within 90 degrees. 5/15/2022 56 Cont… Signs and Symptoms  The major signs and symptoms of respiratory disease are dyspnea, cough, sputum production, chest pain, wheezing, clubbing of the fingers, hemoptysis, and cyanosis.  These clinical manifestations are related to the duration and severity of the disease. 5/15/2022 57 DIAGNOSTIC STUDIES  Arterial blood gas (ABG)  Determines – blood PH - 02 carrying capacity - Co2 and bicarbonate ions  sputum studies  Radiography - X –ray - CT scan  Endoscope - Bronchoscope - Laryngescopy - Mediastinoscopy 5/15/2022 58 Upper respiratory system infection 5/15/2022 59 TONSILLITIS  TONSILLITIS Inflammation or infection of the tonsils is medically termed as Tonsillitis. Tonsils are protective (lymph) glands that are situated on both sides in the throat. The tonsils constitute an important part of the body's immune system and are vital defense organs. They protect the body from bacteria and viruses by fighting these as soon as they enter the body (via the oral / nasal cavity).  ANATOMY In the normal state, tonsils are pink in color (similar to their surroundings tissues) and about the same size. The tonsils along with adenoids are said to form the 'first line of defense' against infective organisms. PATHOLOGY When the tonsils get inflamed, they become red swollen and may develop pus pockets that start exuding a discharge. PATHOLOGY… In cases with recurrent infections, the tonsils may become so swollen over a period of time so as to almost touch each other. Tonsillitis is very common amongst children. No particular gender predilection is seen in cases of tonsillitis. 5/15/2022 65 CAUSES Bacterial and viral infections can cause tonsillitis through droplet infection. A common cause is Streptococcus bacteria. Cause… Other common causes include: oAdenoviruses oInfluenza virus oEpstein-Barr virus oParainfluenza viruses oEnteroviruses oHerpes simplex virus 5/15/2022 68 TRIGGERING FACTORS Foods with artificial colors and preservatives. Peanuts. Cold foods, cold drinks, Ice creams. Changes of weather. Extremely cold climate, Damp weather. Exposure to a lot of pollution. Sour fruits, lemon, pineapple, grapes, oranges.  SIGNS ❖Red and swollen tonsils ❖White spots (specks or patches) on the tonsils ❖Enlarged lymph nodes in neck region ❖Bad and foul breath ❖Cough ❖Running Nose 5/15/2022 72  SYMPTOMS Soreness of throat Difficulty in swallowing or painful swallowing of food and drinks Pain / discomfort while swallowing saliva Change of voice Pain in the ears (due to common nerve supply of the back of the throat and ears) Headache Malaise, tiredness Difficulty in taking feeds in babies this may be the sole indicator in some cases of tonsillitis in infants  CATARRHAL TONSILLITIS When tonsils are inflamed as part of the generalised infection of the oropharyngeal mucosa it is called catarrhal tonsillitis.  MEMBRANOUS TONSILLITIS Some times exudation from crypts may merge to form a membrane over the surface of tonsil, giving rise to clinical picture membranous tonsillitis. of PARENCHYMATOUS TONSILLITIS When the whole tonsil is uniformly congested and swollen itis called acute parenchymatous tonsillitis DIAGNOSIS Examination of the throat in tonsillitis: Redness and swelling of the tonsils Pus pockets on the tonsils Discharge from the tonsils Diagnosis…  History and physical examination  The tonsillar site is cultured to determine the presence of bacterial infection.  In adenoiditis audiometric examination. 5/15/2022 78 Diagnosis…  Examination of the throat in tonsillitis: ◦ Redness and swelling of the tonsils ◦ Pus pockets on the tonsils ◦ Discharge from the tonsils ◦ In case of peritonsillar abscess, there may be a shift of the involved tonsil towards the center of the throat. ◦ The uvula may be shifted towards the opposite side (away from the affected tonsil) 5/15/2022 79 Diagnosis… Throat swab :This is used to get a sample of the secretion from the back of the throat.  Monospot test: A blood test can detect certain antibodies, which can help confirm that a person’s symptoms are due to mononucleosis. 5/15/2022 80 Diagnosis…  Epstein-Barr virus antibodies: If a monospot test is negative, antibodies in the blood against EBV might help diagnose mononucleosis.  Blood tests: This primarily includes a complete blood count (CBC) which is done to confirm the presence of infection. 5/15/2022 81  Management  bed rest + plenty of fluids  analgesia (Aspirin/NSAIDS)  Warm saline gurgle or Asprin gurgle  antimicrobial (Penicillin is the drug of choice) should be continued for 7 -10 days 5/15/2022 82 Medical Management …  Tonsillectomy is usually performed ◦ for recurrent tonsillitis ◦ when medical treatment is unsuccessful and there is severe hypertrophy, asymmetry, or ◦ peritonsillar abscess that occludes the pharynx, making swallowing difficult and endangering the airway (particularly during sleep). 5/15/2022 83  Enlargement of the tonsils is rarely an indication for their removal; most children normally have large tonsils, which decrease in size with age. 5/15/2022 84  Complications:  chronic tonsillitis with recurrent acute attacks  peritonsillar abscess  parapharyngeal abscess  cervical abscess  acute otitis media  rheumatic fever  acute golomerulonephritis  sub acute bacterial endocarditis  septicemia 5/15/2022 85 Chronic tonsillitis Repeated attack of inflammation of the tonsil 5/15/2022 86 Etiology:  may be complication of acute tonsillitis  subclinical infection of tonsils without acute attack  chronic infection of sinuses or teeth may be a predisposing factor 5/15/2022 87 Clinical features:  recurrent attacks of acute tonsillitis  chronic irritation in throat and cough  bad taste in mouth and foul breath (halitosis) 5/15/2022 88 Treatment:  conservative treatment: attention to diet, general health and treatment of coexisting infections of teeth, sinuses and nose.  tonsillectomy: if tonsils interfere with deglutition, speech, respiration or there is recurrent attacks of tonsillitis 5/15/2022 89 Adenoids (Nasopharyngeal tonsil) situated at the junction of the posterior wall and roof of the nasopharynx composed of lymphoid tissues covered by columnar epithelium 5/15/2022 90 Adnoiditis  Adenoiditis is the inflammation of the adenoid tissue usually caused by an infection 5/15/2022 91 Etiology:  Recurrent attacks of rhinitis, tonsillitis and sinusitis cause adenoid infection and hyperplasia 5/15/2022 92 Symptoms:  nasal obstruction  mouth breathing  nasal discharge  adenoid face: elongated face, dull expression, nasal discharge, open mouth, hitched-up upper lip, prominent and overcrowded upper teeth, high-arched palate 5/15/2022 93 5/15/2022 94 Adenoid Face 2 5/15/2022 95 Diagnosis:  nasopharyngoscopy  X-ray nasopharynx lateral view 5/15/2022 96 Treatment:  When symptoms are not severe, decongestant nasal drops and antihistamines is the treatment of choice  Marked symptoms, treatment is adenoidectomy 5/15/2022 97 Pharyngitis 5/15/2022 98 PHARYNGITIS  Pharyngitis can be ✓acute or ✓chronic 5/15/2022 99 5/15/2022 100 5/15/2022 101 5/15/2022 102 5/15/2022 103 Sign and symptom  is an acute inflammation or infection in the throat, usually causing symptoms of a sore throat.  Most cases of acute pharyngitis are caused by viral infection. 5/15/2022 104 Sign and symptom…  Pain  Dry cough  Fever  Lymph node enlargement  A fiery-red pharyngeal membrane and tonsils  malaise, and  sore throat also may be present 5/15/2022 105 5/15/2022 106 Medical Management  If Viral symptomatic treatment  Antibiotic if the cause is bacteria or secondary bacterial infection ◦ Doxycycline 100mg bid for 5 to 7 days ◦ Once daily Azithromycin may be given for only three days due to its long half life ◦ Five to ten days course of cephalosporin may be prescribed 5/15/2022 107 5/15/2022 108 Nutritional Therapy  Liquid or soft diet  Cool beverage, warm liquid  In sever situations IV fluid may be needed other wise the patient is encouraged to drink as much fluid as possible (2 to 3 liters a day 5/15/2022 109 CHRONIC PHARYNGITIS Chronic pharyngitis is a persistent inflammation of the pharynx.  It is common in adults who  work or live in dusty surroundings  use their voice too excess  suffer from chronic cough, and  habitually use alcohol and tobacco. 5/15/2022 110 Clinical Manifestations  Patients with chronic pharyngitis complain of ◦ a constant sense of irritation or fullness in the throat ◦ mucus that collects in the throat ◦ cough, and ◦ difficulty swallowing. 5/15/2022 111 Medical Management  Treatment of chronic pharyngitis is based on relieving symptoms like  avoiding exposure to irritants, and correcting any upper respiratory  pulmonary, or cardiac condition that might be responsible for a chronic cough. 5/15/2022 112  Nasal congestion may be relieved by short-term use of nasal sprays or medications containing ephedrine sulfate or phenylephrine hydrochloride. 5/15/2022 113  If there is a history of allergy, antihistamine  Aspirin or acetaminophen is recommended for its anti-inflammatory and analgesic properties. 5/15/2022 114 LARYNGITIS Laryngitis is an inflammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection.  It also may be caused by isolated infection involving only the vocal cords. 5/15/2022 115 Cont…  The cause of infection is almost always a virus.  Bacterial invasion may be secondary.  Laryngitis is usually associated with allergic rhinitis or pharyngitis.  The onset of infection may be associated with exposure to sudden temperature changes, dietary deficiencies, malnutrition, and an immunosuppressed state.  Laryngitis is common in the winter and is easily transmitted. 5/15/2022 116 Clinical Manifestations  Signs of acute laryngitis include hoarseness or aphonia (complete loss of voice) and severe cough.  Chronic laryngitis is marked by persistent hoarseness.  Laryngitis may be a complication of upper respiratory infections. 5/15/2022 117 Medical Management Management of acute laryngitis includes resting the voice, avoiding smoking, resting, and inhaling cool steam or an aerosol.  If the laryngitis is part of a more extensive respiratory infection due to a bacterial organism or if it is severe, appropriate antibacterial therapy is instituted. 5/15/2022 118  The majority of patients recover with conservative treatment; however, laryngitis tends to be more severe in elderly patients and may be complicated by pneumonia. 5/15/2022 119 MANAGEMENT OF PATIENT WITH LOWER RESPIRATORY TRACT DISORDERS 5/15/2022 120 ATELECTASIS  Atelectasis refers to closure or collapse of alveoli and often is described in relation to x-ray findings and clinical signs and symptoms.  Atlectasis can be acute or chronic.  The most commonly described atelectasis is acute atelectasis, which occurs frequently in the postoperative setting or in people who are immobilized and have a shallow, monotonous breathing pattern. 5/15/2022 121 Cont…  Excess secretions or mucus plugs may also cause obstruction of airflow and result in atelectasis in an area of the lung.  Atelectasis also is observed in patients with a chronic airway obstruction that impedes or blocks air flow to an area of the lung (eg, obstructive atelectasis in the patient with lung cancer that is invading or compressing the airways).  This type of atelectasis is more insidious and slower in onset. 5/15/2022 122 Clinical Manifestations  The development of atelectasis usually is insidious.  Signs and symptoms include cough, sputum production, and low-grade fever.  Fever is universally cited as a clinical sign of atelectasis, but there are few data to support this.  Most likely the fever that accompanies atelectasis is due to infection or inflammation distal to the obstructed airway. 5/15/2022 123  In acute atelectasis involving a large amount of lung tissue (lobar atelectasis), marked respiratory distress may be observed.  In addition to the above signs and symptoms, dyspnea, tachycardia, tachypnea, pleural pain, and central cyanosis 5/15/2022 124 Diagnostic Findings  Decreased breath sounds and crackles are heard over the affected area.  In addition, chest x-ray findings may reveal patchy infiltrates or consolidated areas.  Depending on the degree of hypoxemia, pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) or a lower-than-normal partial pressure of arterial oxygen (PaO2). 5/15/2022 125 Management  The goal in treating the patient with atelectasis is to improve ventilation and remove secretions.  The strategies to prevent atelectasis, which include frequent turning, early ambulation, lung volume expansion maneuvers (eg, deep- breathing exercises, incentive spirometry), and coughing also serve as the first-line measures to minimize or treat atelectasis by improving ventilation.  bronchoscopy may be used to improve the conditions. 5/15/2022 126 Bronchitis  Den: Bronchitis is an inflammation of the bronchi and can be acute or chronic 5/15/2022 127 Acute Bronchitis  Is an acute inflammation of the bronchial tree that often follows the URTI. 5/15/2022 128 cause Viral infection ☞ Influenza A or B, adenovirus, rhinovirus, para- influenzae, corona virus, Respiratory Syncytial Virus (RSV), human metapneumovirus Bacterial infection ☞Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis possible causes ☞Streptococcus pneumoniae and H. Influenziae usually only causative organisms if there is underlying lung disease 5/15/2022 129 Predisposing Risk Factors ✓ Chronic sinusitis ✓ Chronic Obstructive Pulmonary Disease (COPD) ✓ Asthma ✓ Bronchiectasis ✓ Immunocompromised (chronic asthma) ✓ Smoking ✓ Second hand smoke ✓ Air pollutants, environmental factors ✓ Alcoholism ✓ Gastro Esophageal Reflux Disease (GERD) ✓ Wood stoves ✓ Mould 5/15/2022 130 Clinical Manifestation  Fever, headache and general malaise  Mucoprulent sputum  Dry irritating cough  Wheezing  Inspiratory stridor 5/15/2022 131 Diagnostic procedure  History of the symptom and P/E  Culture of sputum  Chest X- ray 5/15/2022 132 Management  The treatment is largely symptomatic  Bed rest  Steam inhalation  Expectorants such as Beranthin cough syrup  Increase fluid intake  Antibiotic when the sputum is purulent 5/15/2022 133 Chronic Bronchitis  Is the presence of productive cough that lasts three months a year for two consecutive years.  The accumulated secretions in the bronchioles interfere with effective breathing  Patient with chronic bronchitis are more susceptible to recurrent LRTIs 5/15/2022 134 Pathophysiology  Constant irritation of the air way causes the mucous secreting cells and goblet cells increase in number.  Cilia function is reduced and more mucous is produced. 5/15/2022 135  As a result bronchi become narrow.  Bronchi near the alveoli may become damaged and fibrosed that leads to irreversible lung changes possibly resulting in emphysema and bronchiectasis. 5/15/2022 136 Clinical manifestation  Chronic productive cough which is exacerbated by cold whether and pulmonary irritants  Patient may have history of frequent respiratory infections. 5/15/2022 137 Diagnostic findings  History and physical examination  Chest x-ray  Sputum culture 5/15/2022 138 Management  Antibiotic based on culture result and sensitivity test  Bronchodilators  Encourage fluid intake 5/15/2022 139 PNEUMONIA  It is an inflammatory process of the lung parenchyma that is commonly caused by infections agent. 5/15/2022 140  Classification  Community-Acquired Pneumonia  Hospital Acquired Pneumonia, also known as nosocomial pneumonia  Pneumonia in the Immunocompromised Host  Aspiration Pneumonia 5/15/2022 141 Community-Acquired Pneumonia  CAP occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. 5/15/2022 142  The causative agents for CAP that requires hospitalization are most frequently  S. pneumoniae,  H. influenzae,  Legionella,  Pseudomonas aeruginosa, and  other gramnegative rods. 5/15/2022 143  S. pneumoniae (pneumococcus) is the most common cause of CAP in people younger than 60 years of age without comorbidity and in those 60 years and older with comorbidity 5/15/2022 144  H. influenzae causes a type of CAP that frequently affects elderly people and those with comorbid illnesses (eg, chronic obstructive pulmonary disease [COPD], alcoholism, diabetes mellitus). 5/15/2022 145  Viruses are the most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults.  In immunocompromised adults, ◦ cytomegalovirus is the most common viral pathogen, ◦ followed by herpes simplex virus, ◦ adenovirus, and ◦ respiratory syncytial virus. 5/15/2022 146 Hospital acquired pneumonia  HAP, also known as nosocomial pneumonia, is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission. 5/15/2022 147  Ventilator-associated pneumonia is considered a type of nosocomial pneumonia that is associated with endotracheal intubation and mechanical ventilation. 5/15/2022 148  The common organisms responsible for HAP include the pathogens  Enterobacter species  Escherichia coli,  H. influenzae,  Klebsiella species,  Proteus,  Serratia marcescens,  P. aeruginosa, methicillin-sensitive or methicillin-resistant Staphylococcus aureus (MRSA), and  S. pneumoniae. 5/15/2022 149  Most patients with HAP are colonized by multiple organisms.  Pseudomonal pneumonia occurs in patients who are debilitated, those with altered mental status, and those with prolonged intubation or with tracheostomy 5/15/2022 150  Staphylococcal pneumonia can occur through inhalation of the organism or spread through the hematogenous route.  It is often accompanied by bacteremia and positive blood cultures.  Its mortality rate is high. 5/15/2022 151  Overuse and misuse of antimicrobial agents are major risk factors for the emergence of these resistant pathogens.  Because MRSA is highly virulent, steps must be taken to prevent its spread.  Patients with MRSA are isolated in a private room, and contact precautions (gown, mask, glove, and antibacterial soap) are used. 5/15/2022 152 Pneumonia in the Immunocompromised Host  Pneumonia in immunocompromised hosts includes  Pneumocystis pneumonia (PCP)  fungal pneumonias, and  Mycobacterium tuberculosis.  The organism that causes PCP is now known as Pneumocystis jiroveci instead of Pneumocystis carinii.  The acronym PCP still applies because it can be read “Pneumocystis pneumonia 5/15/2022 153  Pneumonia in the immunocompromised host occurs with use of ◦ corticosteroids or other immunosuppressive agents ◦ Chemotherapy ◦ nutritional depletion ◦ use of broadspectrum antimicrobial agents, ◦ acquired immunodeficiency syndrome (AIDS), & ◦ genetic immune disorders, 5/15/2022 154  Pneumonia in immunocompromised hosts may be caused by the organisms also observed in CAP or HAP 5/15/2022 155 Aspiration Pneumonia  Aspiration pneumonia refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway.  The most common form of aspiration pneumonia is bacterial infection from aspiration of bacteria that normally reside in the upper airways 5/15/2022 156  Aspiration pneumonia may occur in the community or hospital setting.  Common pathogens are  S. pneumoniae,  H. influenzae, and  S. aureus.  Substances other than bacteria may be aspirated into the lung, such as ◦ gastric contents, ◦ exogenous chemical contents, or ◦ irritating gases. 5/15/2022 157 Risk factor for pneumonia  Heart faulure  Diabetes Mellitus  Alcoholism  COPD  AIDS 5/15/2022 158  Cigarette smoking  Upper respiratory tract infections  Corticosteroid therapy  Old age  Recent influenza infection  Pre-existing lung disease 5/15/2022 159 Clinical Manifestations  Pneumonia varies in its signs and symptoms depending on the  type,  causal organism, and  presence of underlying disease.  However, it is not possible to diagnose a specific form of pneumonia (CAP, HAP, immunocompromised host, or aspiration) by clinical manifestations alone. 5/15/2022 160  The patient with streptococcal (pneumococcal) pneumonia usually has a  sudden onset of chills,  rapidly rising fever (38.5 to 40.50C and  pleuritic chest pain that is aggravated by deep breathing and coughing. 5/15/2022 161  The patient is severely ill, with marked tachypnea (25 to 45 breaths/min), accompanied by other signs of respiratory distress (eg, shortness of breath, use of accessory muscles in respiration).  The pulse is rapid and bounding, and it usually increases about 10 bpm for every degree (Celsius) of temperature elevation. 5/15/2022 162  A relative bradycardia (a pulse– temperature deficit in which the pulse is slower than that expected for a given temperature) may suggest viral infection, mycoplasma infection 5/15/2022 163  Some patients exhibit an upper respiratory tract infection (nasal congestion, sore throat), and the onset of symptoms of pneumonia is gradual and nonspecific.  The predominant symptoms may be headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis 5/15/2022 164  The patient may exhibit orthopnea (shortness of breath when reclining),  Purulent sputum or slight changes in respiratory symptoms may be the only sign of pneumonia in patients with COPD 5/15/2022 165 Diagnosis Hx of recent RTI  P/E.  Chest x- ray  Blood culture  Sputum examination 5/15/2022 166 Medical Management  Pharmacologic Therapy  The treatment of pneumonia includes administration of the appropriate antibiotic as determined by the results of a Gram stain.  However, the causative organism is not identified in half of CAP cases when therapy is started. 5/15/2022 167  Guidelines are used to guide antibiotic choice; however, the resistance patterns, prevalence of causative organisms, patient risk factors, treatment setting (inpatient versus outpatient), and costs and availability of newer antibiotic agents must all be considered. 5/15/2022 168 Medical mgt  Appropriate antibiotic depending on the result of culture  Penicillin G for infection with streptococcus pneumonia. Other - Erythromycin - Cephalosporin - Other penicillin groups - Co -trmoxazole 5/15/2022 169  Mycoplasma pneumonia responds to Erythromycin, TTC and Doxycycline  Other atypical pneumonia are viral in origin and does not respond to antibiotics  Pneumocystic carni pneumonia responds to cotrimoxazole and fancider 5/15/2022 170 Nursing mgt  Oxygen administration if hypoxia  Promote rest and conserve energy  Promote fluid intake  Mechanical Ventilation  Administration of appropriate antibiotics and  Pain medications 5/15/2022 171  What is asthma?  Asthma is a chronic inflammatory disorder of the airways that is characterised by recurrent episodes of wheezing, breathlessness, chest tightness, and coughing’.  Increased air way responsiveness to a verity of stimuli 5/15/2022 172  Pathologically asthma can broadly be described as a chronic inflammatory disorder of the air way 5/15/2022 173 Factors contributing to development of asthma  Genetic factors  Obesity  Smoking mothers  Air pollution  Modern diets  Exposure to allergens  Exposure to tobacco  smoke 5/15/2022 174  Children: more common among boys  Adults: more common among women  Smoking during pregnancy however breast-feeding reduces risk  Respiratory infections as an infant  Occupational asthma -exposure to  certain substances in the workplace 5/15/2022 175 5/15/2022 176 Air pollution 5/15/2022 177 Asthma triggers  Allergens ◦ Dust mites, mold spores, animal dander, pollen, indoor and outdoor pollutant ◦ Irritant ( smokes, perfumes, cleaning agents)  Pharmacologic agents (ASA, Beta blockers)  Physical triggers( Exercise, cold air)  Physiologic agents(stress, viral and bacterial URTI 5/15/2022 178 5/15/2022 179 What causes asthma?  Cause not really known, though clear links to both genetics (family history) and environment. 5/15/2022 180 Pathophysiology 5/15/2022 181 5/15/2022 182 Airways become smaller or narrower, due to:  Underlying inflammation or swelling  Increased mucus production and  Contraction of muscles around the airways, or bronchospasm 5/15/2022 183 Classification  There are three type of asthma. They are: 1) Allergic asthma: asthma caused by known allergens. Eg. Dust, pollens, foods. Most allergens are air born and seasonal. Pt- usually has hx of eczema and allergic rhinitis. 5/15/2022 184 2) Idiopathic non- allergic asthma: Asthma not related to specific allergens. Common Cold, RTI, exercise and environmental Pollutants may trigger an attack 3) - Mixed asthma: Has characteristic of both allergic and idiopathic 5/15/2022 185 Clinical manifestation Three most common symptoms of asthma (cardinal symptoms of asthma are )  Cough  dyspnea and  wheezing 5/15/2022 186 5/15/2022 187 5/15/2022 188 Cont…  Symptoms are common during the night  Expiration is much more strenuous than inspiration  The asthma attack may last often 30 minute to several hours and May subside spontaneously  It is rarely fatal and produce continuous reaction called status- asthmaticus 5/15/2022 189  Diagnosis: - HX - including family, occupational& environment. - Skin test for allergy - Chest x- ray during acute episode, - Sputum examination - CBC - elevated eosinophil - Pulmonary function wheeze sound but normal b/n attacks. 5/15/2022 190 Diagnosing Asthma: Spirometry Test lung function when diagnosing asthma 5/15/2022 191 Medical mgt  Beta adrenergic – epinephrine, Aminophyline theophyline  Anticholenergic – Atropine  Corticosteroids - IV hydrocortisone - Oral predensolone - Inhalation (Dexamethason) 5/15/2022 192 5/15/2022 193  Prevention  Identify the substance that precipitate the attack and remove.  Re-consider pets in the home  Replace carpets with hard floors  Anti-allergenic bedding  Regular vacuuming/steam cleaning of mattresses and household furniture  Consider diet changes  Review medication regularly 5/15/2022 194 Complication of asthma  Status asthmaticus  Rib fracture  Pneumonia  Atelectasis  Polycythemia 5/15/2022 195 Mgt of status asthmaticus include:  Oxygen administration and  IV fluids for dehydration 5/15/2022 196 A Public Health Response to Asthma A call to action for organizations and people with an interest in asthma management to work as partners in reducing the burden of asthma within our nation’s communities. 5/15/2022 197 A Public Health Response to Asthma Education Education programs can be targeted to: ◦ People with asthma ◦ Parents of children with asthma ◦ Medical care providers ◦ School staff ◦ Public 5/15/2022 198 A Public Health Response to Asthma: Interventions  Medical management  Education  Environment  Schools 5/15/2022 199 A Public Health Response to Asthma: Medical Management Interventions Ensure people with asthma know about their disease and are empowered to demand appropriate management 5/15/2022 200 A Public Health Response to Asthma: Environmental Interventions  Help people create and maintain healthy home, school, and work environments.  Environmental interventions may consist of: ◦ Assessments to identify asthma triggers ◦ Education on how to remove asthma triggers ◦ Remediation to remove asthma triggers TUBERCULOSIS TUBERCULOSIS 5/15/2022 202 PULMONARY TUBERCULOSIS  Defn - It is a chronic infectious disease that primarily affects the lung parenchyma.  It may be transmitted to other parts of the body including meninges, kidney, bone and lymph nodes. 5/15/2022 203 Etiology  Mycobacterium tuberculosis ✓ It is acid fast aerobic (due to its staining characteristics in the laboratory) ✓ rode shaped that grow slowly and ✓ it is sensitive to heat and ultraviolet light.  Mycobacterium bovis 5/15/2022 204 Cont…  TB is a worldwide public health problem, and the mortality and morbidity rate continue to rises.  TB is closely associated with ✓Poverty ✓ malnutrition ✓Overcrowding ✓substandard housing and ✓inadequate health care. 5/15/2022 205 CLASSIFICATION Broadly classified in to two  Pulmonary tbc. =» accounts for 80% of all tb. Cases ✓ Smear +ve ptbc 75-80% of all pul. tbc cases ✓ Smear – ve ptbc 20-25% of all pul. tbc cases  Extra – pulmonary tbc (EPTB) ✓ Accounts for about 20% of all tbc cases 5/15/2022 206  TRANSMISSION & RISK FACTORS  Air borne (talking coughing , sneezing laughing)  Tuberculosis is most commonly transmitted by inhalation of infected droplet nuclei (the dried residua of larger respiratory droplets), which are discharged in the air when somebody with untreated sputum-positive pulmonary TB coughs or sneezes. 5/15/2022 207  Risk of infection depends on the extent of an individual‟s exposure to droplet nuclei and on susceptibility to infection.  Consumption of cow’s milk (raw milk) from infected cow 5/15/2022 208 Clinical manifestation  Low grade fever  fatigue  Anorexia  Wt- loss  Night sweating  Chest pain  Persistent cough for two weeks or more  Hemoptysis  Hx- of contact with pt-of smear +ve pul. Tb. 5/15/2022 209 Symptoms of extra-pulmonary TB:  In addition to the general symptoms of TB, patients with extrapulmonary TB present with features related to the pathology of the affected organ. 5/15/2022 210 Diagnostic study  History of clinical symptom  History of contact with patient with smear +ve PTB  History of previous TB infection  physical examination  Chest- x-ray  Histo- pathological examination, FNA for EPTB  Sputum Examination (2x sputum and one sputum +ve is diagnostic 5/15/2022 211 Cont…  Tuberculin test - is used to determine if the person has been infected with tbc bacillus  0.1ml PPD is injected and the result can be read 48-72 hrs after injection - 0 to 4mm not significant - 5mm or greater may be considered significant in individual who is considered at risk. - 10 mm or greater is usually considered as significant in individual who have normal or mildly impaired immunity 5/15/2022 212 DISEASE CLASSIFICATION 1) smear +ve pulmonary tuberculosis - At least one +ve direct microscopy or one direct microscopy plus culture +ve or one direct microscopy plus radio logic abnormality of the chest. 5/15/2022 213 2) Smear -ve pulmonary tuberculosis - Three initial smears are -ve and no cure with broad spectrum antibiotic and radio logic abnormality with PTb and smear +ve with culture. 5/15/2022 214 Cont… 3) Extra Pulmonary TB. - Tb With strong clinical evidence consistent with active EPTB and decision by physician to treat with full course of anti Tb or Tb in organ other than lungs proven by one culture +ve specimen 5/15/2022 215 Classification of TB  Cases of TB are also classified according to the: 1. anatomical site of disease; - Pulmonary - Extra pulmonary 5/15/2022 216 2. bacteriological results (including drug resistance); - Smear +ve pulmonary TB - Smear –ve pulmonary TB - Extrapulmonary proven by other culture positive 5/15/2022 217 3. history of previous treatment; - New - Relapse - Treatment failure - Return after default 5/15/2022 218 4. HIV status of the patient - HIV +Ve TB patient - HIV –Ve TB patient - HIV status unknown TB patient 5/15/2022 219 CASE CLASSIFICATION New case (N) – Patient who has never had Rx. For Tb. Or has been on anti Tb. For less than 4 weeks  Relapse ( R ) - Patient who has been declared cured or treatment completed of any form of Tb in past but reports back found smear +ve for AFB or culture tve. 5/15/2022 220 Cont…  Treatment Failure (F ) - patient who, while on treatment remains smear +ve at the end of the 5th month or later after completing treatment  Return after default (D) - patient who had recorded as defaulter from treatment and returns to health service with smear +ve sputum 5/15/2022 221 Cont…  Transfer (T) - Patient transferred to continue Rx.  Chronic case ( C ) - Patient remain +ve at the completion of retreatment  Other (O) - A patient who does not fit any of the above mentioned Categories 5/15/2022 222 Drugs used for the chemotherapy of TB First line drugs for the treatment of TB in Ethiopia include:  Rifampicin(R);  Ethambutol (E);  Isoniazid (H);  Pyrazinamide (Z) and  5/15/2022 223 Phases of chemotherapy 5/15/2022 224  The treatment of TB has two phases: 1. Intensive (initial) phase ✓It renders the patient non-infectious by rapidly reducing the load of bacilli in the sputum, usually within two weeks in majority of drug susceptible TB cases ✓The regimen in this phase consists of combination of four drugs for the first eight weeks for new cases 5/15/2022 225 Cont… 2. Continuation phase ✓ This phase aims to sterilize the remaining semi- dormant bacilli and is important to ensure cure/ completion of treatment and prevent relapse after completion of treatment. ✓regimen in this phase consists of combination of two drugs to be taken for 4 months for new cases ✓Continuation phase may be extended to 10 months if TB involves the CNS, bones and Osteoarticular space. 5/15/2022 226  Directly Observed Treatment (DOT) To ensure optimal administration of all doses of the TB treatment, patients are advised to be supported by trained person selected by the patient. This is called directly observed treatment- DOT. National control program recommends observation of the administration of each and every dose of TB treatment by either a health worker, Health extension worker or a community TB treatment supporter 5/15/2022 227 Standard TB treatment regimen in Ethiopia 5/15/2022 228 Treatment of TB in Special Situations  Pregnancy Ask female patients whether they are pregnant or not.  Most anti-TB drugs are safe for use in pregnancy with the exception of streptomycin. 5/15/2022 229 Do not give streptomycin to a pregnant woman because it can cause permanent deafness in the baby.  Pyridoxine supplementation is recommended for all pregnant women taking INH. 5/15/2022 230 Cont… Oral contraception  Rifampicin interacts with oral contraceptive medications with a risk of decreased protection against pregnancy.  5/15/2022 231  A woman who takes the oral contraceptive pill may choose between the following two options while receiving treatment with rifampicin: following consultation with a clinician, she could take an oral contraceptive pill containing a higher dose of estrogen.  Alternatively, she could use another form of contraception. 5/15/2022 232 Cont… Breastfeeding  A breastfeeding woman who has TB can be treated with the regimen appropriate for her disease classification and previous treatment.  The mother and baby should stay together and the baby should continue to breastfeed in the normal way. 5/15/2022 233  Give the infant a course of preventive therapy (INH). When preventive therapy is completed, give the infant BCG if not yet immunized.  Pyridoxine supplementation is recommended for all breast feeding women taking INH. 5/15/2022 234 5/15/2022 235 5/15/2022 236 5/15/2022 237 HIV patient on ART  Tb patient with HIV infection or HIV/AIDS may experience a temporary worsening of symptoms and sign after starting Tb. Treatment  In Tb patient infected with HIV treatment with ART may interact with treatment of TB, reducing the efficacy anti TB and ART drugs while increasing the risk of drug toxicity 5/15/2022 238 Drug resistant TB  Mono-resistant:- Resistant only to one first line anti Tb drugs  Poly- resistant:- Resistant to more than one first line anti Tb drugs but not to both isoniazid and rifampicin  MDR :- Resistant to at least isoniazid and rifampicin 5/15/2022 239 D. Extensive drug resistance (XDR-TB): resistance to any fluoroquinolone and to at least one of three second-line injectable drugs (Capreomycin, Kanamycin and Amikacin), in addition to multidrug resistance (- Isoniazid and Rifampicin). E. Rifampicin resistance (RR-TB): resistance to Rifampicin detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance to Rifampicin, whether mono-drug resistance, multi- drug resistance, poly-drug resistance or extensive drug resistance. 5/15/2022 240 PREVENTION AND CONTROL  Chemotherapy of cases  Chemoprophylaxis for contact with INH  BCG Vaccination  Proper disposal of sputum and covering mouth and nose While sneezing and coughing 5/15/2022 241 Cont…  Health education on - TBC - Mode of transmission - Improving standard of living - Adequate nutrition - Health housing / Ventilation - Environmental sanitation - Personal Hygiene - Active case finding and RX 5/15/2022 242 COPD.pptx 5/15/2022 243 Thank You 244 5/15/2022 5/15/2022 245 Thank You 246 5/15/2022