Fluticasone

Skye H. Cheng, MD

• Clinical Professor
• Department of Radiation Medicine
• National Yang-Ming University
• Adjunct Associate Professor
• Department of Radiation Oncology
• Duke University Medical Center
• Durham, North Carolina
• Chief
• Department of Radiation Oncology
• Koo Foundation Sun Yat-Sen Cancer Center
• Taipei, Taiwan

When an epidemic has spread to include several areas worldwide asthma zone chart purchase fluticasone with american express, it is said to be pandemic asthma 3 rcp questions discount fluticasone 100 mcg on-line. When a disease suddenly occurs in unexpected numbers in a limited area and then subsides asthma symptoms after running order 500 mcg fluticasone free shipping, this is described as an outbreak asthma 3d animation purchase fluticasone 500 mcg on-line. Notifiable diseases are certain infectious diseases that physicians must report to the Centers for Disease Control and Prevention asthma treatment article cheap fluticasone 250 mcg visa. After these infections were classified as notifiable, it was discovered that the number of chlamydial infections surpassed gonorrhea. Chapter Three Infectious Diseases í 37 Transmission of Infectious Diseases the source of an infectious agent is known as a reservoir. For example, humans are the reservoir for the measles virus because it does not infect other organisms. People who harbor an infectious agent but do not have signs or symptoms are known as carriers. Horizontal transmission describes transmission of an infectious disease from a reservoir to a susceptible human. Direct transmission occurs when an individual is infected by contact with the reservoir. For example, some infections are transmitted by touching, kissing, or engaging in sexual contact with an infected person, or being bitten by an infected animal or insect. Transmission by direct contact also occurs when infectious agents are expelled in droplets produced by sneezing or coughing. These contaminated respiratory droplets can travel up to 3 feet and can cause an infection if inhaled. Indirect transmission occurs when a pathogen can withstand the environment outside its host for a long period of time before infecting another individual. Some infectious agents survive in tiny airborne droplets for prolonged periods and can travel more than 3 feet from the reservoir. Some of these pathogens can remain viable in the environment for some time before infecting another person. Contaminated inanimate objects are called fomites, and these can also transmit infection. The fecal­oral route of transmission occurs when food and beverages are contaminated and then ingested. For example, sewagecontaminated water is a source of infection if used for drinking, washing, or preparing foods. Gastrointestinal diseases such as cholera, rotavirus infection, and giardiasis are transmitted this way. The respiratory tract is among the most frequently used portals of entry for pathogens, including those that cause the common cold, influenza, and tuberculosis. Pathogens also use the gastrointestinal and genitourinary tracts as portals of entry. Punctures, injections, bites, and surgery can allow microorganisms to be deposited directly into the tissues below the skin. Nosocomial Infections Nosocomial, or hospital-acquired, infections are infections acquired in a health care facility. The most common are urinary tract infections, accounting for 32% of nosocomial infections; 22% are infections at the surgical site, 15% are lung infections such as pneumonia, and 14% are bloodstream infections (sepsis). Rates of nosocomial infections are markedly higher in developing countries as a result of poor infection control practices, limited resources, and overcrowding of hospitals. Because hospital stays are short, patients may be discharged before the infection becomes apparent. Health care facilities are a major reservoir for a variety of opportunistic pathogens that can cause nosocomial infections. A weakened patient 38 í Part I Mechanisms of Disease is an ideal target for an opportunistic pathogen. Burns, surgical wounds, injections, invasive diagnostic procedures, ventilators, intravenous therapy, and catheters increase the risk of infection. The 100 trillion microorganisms that are commonly present in and on our bodies comprise our normal flora or microbiota. Normal flora do not harm us and in some cases help us by preventing overgrowth of harmful microorganisms and by producing vitamins. Opportunists typically do not cause disease in their usual location in a healthy person but may cause disease in surgical wounds or if the host is weakened or immune-compromised. According to the Centers for Disease Control and Prevention, handwashing is the single most important means of preventing the spread of nosocomial infections. Education of health care facility staff and visitors about basic infection control measures, isolation of patients, sterilization of equipment, use of disposable materials, and prescription of antibiotics only when necessary can help control nosocomial infections. Respiratory etiquette controls the spread of influenza, cold, tuberculosis, and other respiratory diseases. Handwashing prevents foodborne illnesses as well as those transmitted by respiratory droplets. One must wash hands before and after preparing meals and after handling raw meat and eggs. Of all methods, vaccination may be the most effective way to protect personal and public health. Vaccination eliminated smallpox from Earth-the only method that has been able to completely eradicate an infectious disease. Vaccines are safe and effective and prevent some of the most serious diseases we know. Precise data are not available on the annual number of needlestick Control of Infectious Diseases Control of infectious diseases can be achieved by preventing transmission. Isolation of infected persons in hospitals and self-imposed isolation, such as when a person with influenza remains home in bed, can be effective. Quarantine is the separation of persons who may or may not be infected from healthy people until the period of infectious risk is passed. Disinfection of potentially infectious materials is necessary to prevent transmission. Medical and dental implements need disinfection to remove human pathogens after use. Handwashing According to the Centers for Disease Control and Prevention, handwashing is the single most important means of preventing the spread of infection. The standard provides for regular employee training and a system for communication of hazards in the workplace. Where bloodborne pathogens are likely to be encountered, a workplace must adopt the practice of Standard Precautions Table 3­2). Wear gown during procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated. Wear mask during procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, and secretions, especially suctioning, endotracheal intubation. Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene. Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas. Handle in a manner that prevents transfer of microorganisms to others and to the environment. Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container. Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection. Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible. Some viruses also have a lipid membrane surrounding their capsid that plays a role in host cell recognition and spikes that aid in attachment to cells. Viruses are not considered living organisms because they do not independently grow, metabolize, or reproduce. Signs and symptoms of infection result from the way these viruses reproduce in cells or from the way the immune system responds to viral infection. Other viruses sustain a latent infection, whereby the viruses insert themselves in cells, do not reproduce, and elicit no signs and symptoms. Later, a trigger-such as stress, infection with another pathogen, or a weakened immune defense-activates the viruses. Signs and symptoms of the disease then manifest themselves as the viruses reproduce. A simple structure (no nucleus or membranous organelles) and small size (1­10 m) differentiate bacteria from other single-celled organisms. Although often described as simple, they are far from primitive, for they have adapted to a wide variety of habitats and have evolved complex strategies for infecting and surviving in the human body. Bacteria have cell walls, a rigid layer of organic material surrounding their delicate cell membranes. The walls protect these cells; should walls be disrupted, cells are susceptible to bursting, or lysis. Penicillin interferes with correct cell wall construction of certain types of bacteria, causing them to lyse. Thickness and chemical composition of the cell wall accounts for the way certain cells stain during the gram stain procedure. Identification is critical to obtain an accurate diagnosis and effective treatment of an infection. Other bacteria that do not fit into the above categories of shape and gram stain properties include the chlamydias and rickettsias, which are intracellular parasites. Rickettsias are transmitted by ticks and cause diseases such as typhus and Rocky Mountain spotted fever. Endospores permit these bacteria to survive drying, lack of nutrients, and harsh conditions such as extreme heat. In favorable conditions, the dormant endospore germinates and produces a bacterial cell. Bacteria that produce endospores include the causes of tetanus, botulism, and anthrax. Some bacteria produce other types of toxins that interfere with normal physiology. For example, tetanus is caused by the toxin produced by the bacterium Clostridium tetani. The tetanus toxin interferes with the ability of muscle cells to relax, resulting in frozen, rigid muscles characteristic of the disease. Other toxins are enzymes that enable the bacteria to spread through tissues and to obtain nutrients. They are much larger than bacteria and have complex internal structures, including a nucleus and membranous organelles. Protozoa are found in nearly every habitat, and most do not cause disease; however, they may invade and destroy certain tissues, or they may provoke damaging inflammatory responses. Types of protozoa are described as amoeboids, flagellates, ciliates, and sporozoans. Amoeboids move by means of cell membrane extensions called pseudopodia (from Greek words meaning "false feet"). An amoeba of medical concern is Entamoeba histolytica, the cause of amoebic dysentery, an intestinal infection acquired from feces-contaminated food or water. Pathogens in this group include Trichomonas vaginalis, the cause of trichomoniasis, a sexually transmitted infection, and Giardia, the cause of giardiasis, an intestinal infection. Every year, more than 500 million people worldwide become severely ill with malaria and more than 1 million people die as a result. Malaria kills mostly infants, young children, and pregnant women, largely in Africa. Fungi Fungi are single-celled or multicelled organisms with cell walls that contain a polysaccharide called chitin. Fungi use specialized filaments called mycelia to absorb nutrients from their surroundings. Healthy human tissue is relatively resistant to fungal infections but may become susceptible under certain circumstances. For example, fungi can more easily infect damaged tissue than intact healthy tissue. Fungi cause disease by producing toxins, interfering with normal organ structure or function, or inducing inflammation or allergy. Candidiasis is an opportunistic infection of skin or mucous membranes caused by the yeast Candida albicans. Other mycoses include a variety of ringworm infections of the skin, hair, and nails. They often have well-developed reproductive systems capable of producing large numbers of offspring. Many helminths have also evolved complex life cycles and strategies for Chapter Three Infectious Diseases í 43 infecting new hosts. Ascariasis occurs worldwide, but the largest numbers of cases occur in tropical and subtropical regions. The eggs of the worm are found in soil contaminated by human feces or in uncooked food contaminated by soil. Prevention includes using toilet facilities, handwashing, safe stool disposal, protecting food from dirt and soil, and thorough washing of produce.

It is estimated that up to 50% of all fertilized ova die and are spontaneously aborted childhood asthma definition purchase 100 mcg fluticasone, usually before the woman knows she is pregnant asthma x ray order cheap fluticasone on-line. Among known pregnancies asthma symptoms sinusitis best order fluticasone, the rate of spontaneous abortion is approximately 15­20% and the occurrence is usually between the 7th and 12th weeks of pregnancy asthmatic bronchitis symptoms in adults discount fluticasone 100 mcg free shipping. Risk factors for spontaneous abortion include maternal age and previous miscarriage asthma xanax cheap 100 mcg fluticasone free shipping. Possible signs and symptoms of spontaneous abortion may include low back pain or abdominal pain that is dull, sharp, or cramping; vaginal bleeding; and tissue or clotlike material discharged from the vagina. About 20% of pregnant women have some vaginal bleeding during the first 3 months of pregnancy; approximately half of these women have a miscarriage. Other possible causes of spontaneous abortion include infection, physical problems in the mother, hormonal factors, immune responses, or serious systemic diseases of the mother such as diabetes or thyroid disease. Diagnosis of spontaneous abortion is based on pelvic examination, ultrasound, and pregnancy test. If all the pregnancy tissue does not exit the body, the woman may be given an Chapter Eleven Diseases and Disorders of the Reproductive System L 235 injection of a drug that stops embryonic cells from dividing and multiplying, or she may need surgery to eliminate the remaining tissue. Preeclampsia Preeclampsia is defined as high blood pressure and excess protein in the urine after 20 weeks of pregnancy in a woman who previously had normal blood pressure. Preeclampsia occurs in 6­10% of all pregnancies in the United States and is most often seen in first-time pregnancies, pregnant teens, and women over age 40. Risk factors include a history of high blood pressure before pregnancy, previous history of preeclampsia, obesity prior to pregnancy, carrying more than one baby, and a history of diabetes, kidney disease, lupus, scleroderma, and rheumatoid arthritis. Mild preeclampsia is characterized by high blood pressure and the presence of protein in the urine. Severe preeclampsia may also include headaches, blurred vision, and inability to tolerate bright light, upper abdominal pain, nausea, vomiting, dizziness, decreased urine output, and sudden weight gain. Diagnosis of preeclampsia is based on increased blood pressure and urine protein levels. However, if a woman has mild preeclampsia and is not close enough to term to be delivered, rest, frequent monitoring of blood pressure and urine, reduced salt intake, and increased water intake may be recommended. The normal pregnancy-induced elevation of stress hormones-such as cortisol, epinephrine, and glucagon-raises blood glucose. In a normal pregnancy, more insulin is secreted to compensate for these changes, but in some women insulin levels remain low as blood glucose continues to rise. Risk factors include a family history of type 2 diabetes, age, previous diagnosis of gestational diabetes or prediabetes, and being obese. Women at risk for developing gestational diabetes should be screened early and monitored throughout their pregnancy. Treatment consists of regular blood glucose monitoring, dietary control of blood glucose levels, weight control, exercise, and possibly insulin therapy. Untreated gestational diabetes puts the fetus at risk of premature delivery and respiratory distress syndrome, excessive birth weight, hypoglycemia, jaundice, and an increased risk for type 2 diabetes. Prevention of gestational diabetes includes eating a healthy diet, maintaining a healthy weight, not gaining too much weight during pregnancy, and engaging in exercise on a regular basis. Female Age-Related Diseases In older females, pubic hair thins and grays and the external reproductive genitalia acquire a wrinkled and sagging appearance due to a decrease in elasticity. Physical changes in the aging female include shrinking of internal reproductive organs, decrease in vaginal secretions and elasticity, and a decrease in breast tissue volume. The pH of vaginal secretions becomes more alkaline, making older women more susceptible to vaginal infections. Increased stimulation and lubrication may be necessary to facilitate sexual intercourse. Gestational Diabetes Mellitus Gestational diabetes is diabetes mellitus associated with pregnancy. Increased metabolic demands during pregnancy require higher insulin levels, but certain normal maternal physiological changes during pregnancy can result in insufficient insulin levels, which, if uncorrected, result in diabetes. As a woman ages, the ovaries produce less estrogen and progesterone, causing cessation of ovulation and menstruation. Common physical signs and symptoms of menopause include hot flashes, night sweats, trouble sleeping, mood swings, trouble focusing, hair loss or thinning, facial hair growth, and vaginal dryness. Hormone therapy may help with menopause signs and symptoms; however, each woman and her physician must weigh the benefits and risks of hormone therapy. Uterine prolapse is falling or sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal. Risk factors include age, one or more vaginal births, and giving birth to a large baby. Signs and symptoms may include feelings of heaviness in the pelvic area, urinary difficulties, and a feeling like you are sitting on a small ball. Uterine prolapse is caused by trauma to the fascia, muscle, and pelvic ligaments during pregnancy and delivery or atrophy of the pelvic floor muscles with age. The ligaments and muscles become so overstretched that they can no longer hold the uterus in place, so the uterus falls or sags downward. Treatment consists of strengthening the pelvic floor muscles (Kegel exercises), inserting a pessary (removable device placed in the vagina designed to support areas of pelvic organ prolapse) into the vagina to support the uterus, or surgery. Risk factors for cystocele include age, one or more vaginal births, and having a hysterectomy. Signs and symptoms may include pelvic pressure, urinary urgency and frequency, and incontinence. The etiology of cystocele includes trauma to the fascia, muscle, and pelvic ligaments during pregnancy and delivery, or atrophy of the pelvic floor muscles with age. Risk factors for rectocele include aging, one or more vaginal births, and obesity. The etiology of rectocele is trauma to the fascia, muscle, and pelvic ligaments during pregnancy and delivery, or atrophy of the pelvic floor muscles with age. Anatomy and Physiology of the Male Reproductive System the male reproductive system produces, transfers, and introduces sperm into the female reproductive tract. The loose skin covering the penis continues over the glans penis to form the prepuce or foreskin. Glands in the foreskin secrete a waxy substance called smegma that collects between the glans penis and the foreskin. During sexual arousal, these tissues fill with blood, causing the penis to enlarge and become erect. The testes reside outside the body because sperm production requires a temperature lower than the rest of the body. The tightly coiled seminiferous tubules are the sperm-producing factories within the testes. Sperm produced in the seminiferous tubules then travel via the male reproductive duct system (epididymis, ductus deferens, and urethra) to exit the body. Semen is a viscous, white secretion with a slightly alkaline pH that contains sperm and accessory gland secretions. A typical ejaculate contains about 1 teaspoon of semen and contains between 40 and 100 million sperm. The accessory glands including the seminal vesicles, the prostate gland, and the bulbourethral glands produce most of semen. The seminal vesicles are paired sacs located at the base of the bladder and produce roughly 65% of the fluid portion of semen. The seminal vesicles secrete a thick, yellowish fluid that nourishes and activates the sperm. The bulbourethral glands are tiny glands located below the prostate gland and produce roughly 5% of the fluid portion of semen. The bulbourethral glands secrete a clear fluid into the urethra during sexual arousal that serves as a lubricant for sexual intercourse and neutralizes the acidity of residual urine in the urethra. The prostate gland sits just below the bladder and encircles the urethra and produces roughly 30% of the fluid portion of semen. During the last 2 months of gestation testosterone normally causes the testes to descend into the scrotum. The increased production of testosterone promotes the development of secondary sex characteristics including pubic, axillary, and facial hair; darker and thicker skin; increased activity of oil and sweat glands; deepening of the voice; enlargement of skeletal muscles; and an increase in bone growth and density. Urodynamic testing assesses how well the bladder and urethra are storing and releasing urine. Other laboratory tests that may be performed include urinalysis and hormone testing. Diseases of the Male Reproductive System Prostatitis Prostatitis is inflammation or infection of the prostate gland. Over-the-counter pain relievers and several weeks of treatment with antibiotics are required for bacterial prostatitis. Prevention includes practicing good hygiene, maintaining adequate hydration, and early diagnosis and treatment for infections. Over-the-counter pain relievers, bed rest, and elevation and application of ice packs to the scrotum relieve symptoms and swelling. Prevention of epididymitis includes abstinence, monogamy, use of latex condoms, and early diagnosis and treatment for infections. Orchitis occurs in 20­35% of men with mumps, and in 10% of these cases, the condition exists in both testicles. Signs and symptoms may include testicular swelling on one or both sides, pain ranging from mild to severe, tenderness in one or both testicles, nausea, vomiting, fever, and penile discharge. Treatment for viral orchitis is symptomatic and may include taking over-the-counter pain relievers, bed rest, and elevation and application of cold packs to the scrotum. Signs and symptoms may include a tender, swollen, red, or warm scrotum; testicle pain and tenderness (usually on one side); painful urination or an urgent or frequent need to urinate; painful intercourse or ejaculation; chills or fever; a lump on Cryptorchidism Cryptorchidism is not a disease but a failure of the testes to descend from the abdominal cavity, where they develop during fetal life, to the scrotum. Since the testicles typically descend late in fetal development, during the 8th month of gestation, the infant born before this time has a greater chance of having cryptorchidism. In over 50% of people being seen for cryptorchidism, the testes descend by the third month, and by age 1, 80% of all undescended testes have descended into the scrotum. The major sign of cryptorchidism is not being able to feel one or both of the testicles in the scrotum. The affected testicles frequently have a short spermatic artery, poor blood supply, or both. Male Age-Related Diseases In older males, pubic hair thins and grays and the external reproductive genitalia acquire a wrinkled and sagging appearance due to a decrease in elasticity. Risk factors for testicular cancer include cryptorchidism, abnormal testes development, and a family or personal history of testicular cancer. Signs and symptoms may include a lump on a testicle that is painless, testicular enlargement or swelling, and a sensation of heaviness or aching in the lower abdomen or scrotum. Diagnosis may include a medical history, physical examination, ultrasound, serum tumor marker tests (alpha-fetoprotein, lactate dehydrogenase, beta-human chorionic gonadotropin), radical inguinal orchiectomy (surgery to remove a testicle), and biopsy. Treatment may include surgery, radiation therapy, chemotherapy, and stem cell transplant. The 5-year relative survival rate is 95%; if the Prostate Cancer Prostate cancer is a malignant tumor that forms in the tissue of the prostate gland. Prostate cancer is the second leading cause of cancer death in men, behind only lung cancer. Risk factors for prostate cancer include age (most men with prostate cancer are over age 65), a family history of prostate cancer, race (prostate cancer is more common among African American men than among men of other races), certain prostatic changes (prostatic intraepithelial neoplasia), and certain genome changes. Men with prostate cancer may be asymptomatic; signs and symptoms may include not being able to pass urine; having a hard time starting or stopping the urine flow; needing to urinate often, especially at night; weak flow of urine; urine flow that starts and stops; pain or burning during urination; difficulty having an erection; blood in the urine or semen; and frequent pain in the lower back, hips, or upper thighs. Treatment of prostate cancer may include surgery, radiation therapy, and chemotherapy. Other medications may be used to decrease testosterone production by the testes, block uptake of testosterone by tumor cells, or stop production of testosterone by the adrenal glands. The 5-year relative survival rate is 100% for local and regional prostate cancer and 31% for distant prostate cancer. The dilation of penile arteries that leads to engorgement of the erectile tissue of the penis and then erection is under the control of the autonomic nervous system, which is affected by stress, anxiety, and fear. Treatment may include medication to increase blood flow to erectile tissue by relaxing smooth muscle of the penis. Other treatments include surgery, penis pump or implant, therapy, and treatment for underlying conditions. A dental dam is a rubbery material that can be placed over the anus or the vagina before sexual contact. If you use one of these methods, be sure to also use a latex condom or dental dam correctly every time you have sex. Drinking too much and using drugs are linked to sexual risk-taking, such as having sex with more than one partner and not using condoms. If they occur, signs and symptoms include a burning sensation when urinating; a white, yellow, or green discharge from the penis; or painful or swollen testicles. When they occur, signs and symptoms include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Untreated gonorrhea can cause serious and permanent health problems in both women and men. In men, gonorrhea can cause epididymitis, which can lead to infertility if left untreated. Gonorrheal infection in a newborn can cause blindness, joint infection, or a life-threatening blood infection. To prevent this infection, a drop of erythromycin is routinely placed in the eyes of newborn babies. Treatment of gonorrhea as soon as it is detected in pregnant women will reduce the risk of these complications. Many people infected with syphilis do not have signs or symptoms for years and risk complications if they are not treated. Syphilis is transmitted through sexual contact, through direct contact with a syphilis chancre, and during childbirth.

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This causes increased shortness of breath and a loss of elasticity in the alveolar walls that have not been destroyed asthma spacer cheap fluticasone 100 mcg buy. The risk factors for emphysema include smoking asthma symptoms 7 dpo best buy fluticasone, exposure to secondhand smoke asthma definition 411 effective fluticasone 100 mcg, occupational exposure to dust and chemicals asthma cure fluticasone 500 mcg purchase on-line, and genetics (alpha-1-antitrypsin deficiency) asthma lung sounds cheap fluticasone 500 mcg buy line. In emphysema, the alveolar walls break down, adjacent alveoli fuse, and the lungs lose their elasticity and surface area required for normal gaseous exchange. Air cannot be adequately exhaled to allow oxygen to enter, and the lungs become filled with air that is high in carbon dioxide. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Other signs and symptoms may include cyanosis, edema of the feet and ankles, fatigue, headache (especially in the morning), and wheezing. Emphysema patients may develop barrel chest caused by enlargement of the lungs and chest wall and the ineffective use of breathing muscles. As emphysema progresses, many patients experience dyspnea from the slightest activity or even while sedentary. They often exhibit pursed-lip breathing or exhaling through puckered lips, which is a way to make each breath more effective by tending to hold the airways open so that more air can be exhaled. Patients may also have a tendency to lean forward and support themselves with their arms on a surface in front of them or on their knees. This position can help make breathing easier by allowing patients to use accessory breathing muscles. Familial emphysema is inherited and involves a genetic deficiency of alpha-1-antitrypsin, which leaves the lungs susceptible to alveolar destruction. Because the onset of the disease is gradual, many cases are not diagnosed until irreversible damage has occurred. The goals of treatment are to reduce symptoms and to slow progression of the disease. Treatment may also include bronchodilators, inhaled steroids, an alpha-1 protease inhibitor for patients with familial emphysema, supplemental oxygen, and surgery (lung reduction to remove damaged tissue or lung transplant). The most effective way to prevent emphysema is to not smoke, avoid exposure to secondhand smoke, and avoid occupational exposure to dust and chemicals. Chronic bronchitis is defined as having a cough with sputum production that lasts at least 3 months for 2 consecutive years. Over 10 million people in the United States are diagnosed with chronic bronchitis each year. Risk factors for chronic bronchitis include tobacco use, exposure to secondhand tobacco smoke, exposure to irritants on the job, and decreased immunity. Over time, untreated chronic bronchitis leads to scarring, destruction of cilia, and tissue death. Signs and symptoms of chronic bronchitis include mucus-producing cough, wheezing, fatigue, slight fever, chills, and chest discomfort. People exposed to industrial dusts and fumes in the workplace, such as coal miners, grain handlers, and metal molders, are also at high risk of developing the disease. Diagnosis is based on medical history, physical examination, chest x-ray, pulmonary function testing (spirometry), and sputum analysis. The goal of therapy for chronic bronchitis is to relieve symptoms, prevent complications, and slow the progression of the disease. Treatment may include bronchodilator medications, inhaled steroids, antibiotics, oxygen therapy, pulmonary rehabilitation, and surgery (lung reduction surgery to remove damaged lung tissue, lung transplant). Prevention includes never smoking or quitting smoking, wearing a mask over your mouth and nose when using lung irritants (paint, paint remover, or varnish), frequent handwashing to reduce exposure to viruses and bacteria, and getting the seasonal flu vaccine. Chapter Eight Diseases and Disorders of the Respiratory System L 153 Promote Your Health Smoking Cessation the immediate health benefits of quitting smoking are substantial: O Heart rate and blood pressure, which are abnormally high while smoking, begin to return to normal. O Within a few hours, the level of carbon monoxide in the blood begins to decline. O Within several months of quitting, people can expect substantial improvements in lung function. O In addition, people who quit smoking will have an improved sense of smell, and food will taste better. More than 25 million Americans suffer from asthma, including over 8% of adults and over 9% of children. People with asthma have very sensitive airways that react and narrow in response to many different substances, activities, and conditions that, in these persons, cause asthma signs and symptoms to start or worsen. The following are common triggers for asthma: indoor and outdoor allergens, tobacco smoke, chemical irritants, cold air, extreme emotional arousal, certain medications (aspirin and other nonsteroidal anti-inflammatories and beta blockers), and physical exercise. Asthma diagnosis is based on signs and symptoms, medical history, physical examination, pulmonary function tests (spirometry, peak flow, and bronchial provocation), chest x-ray, and allergy testing. Signs and symptoms of asthma include dyspnea, tightness in the chest, coughing, and wheezing. During normal breathing, the bands of muscle that surround the airways are relaxed, and air moves freely. In people with asthma, however, allergycausing substances and other triggers make the bands of muscle surrounding the airways tighten so that air cannot move freely. This causes the asthmatic to feel short of breath, and the air moving through the tightened airways causes a wheezing sound. Fortunately, this airway narrowing is reversible, a feature that distinguishes asthma from other lung diseases such as bronchitis or emphysema. There are two basic types of medications used in asthma treatment: steroids and other antiinflammatory medications and bronchodilators. Anti-inflammatory medications, particularly inhaled steroids, are the most important treatment for most people with asthma. Bronchodilators relax the muscles that can tighten around the airways and help to open them up. Short-acting bronchodilator inhalers are often referred to as rescue inhalers and are used to quickly relieve the signs and symptoms of asthma. Long-acting bronchodilators are used in combination with inhaled steroids when there are ongoing asthma signs and symptoms despite treatment with a daily inhaled steroid. Asthma inhalers are the most common and effective way to deliver asthma drugs to the lungs. A peak flow meter may help determine when an asthma attack is starting, identify asthma triggers, decide if an asthma attack is under control, and help determine when to seek emergency care. However, asthma can be managed by identifying and avoiding asthma triggers, taking medication as prescribed, and obtaining continued monitoring by a physician. The thick, sticky mucus secreted in the lungs causes dyspnea, wheezing, and a persistent cough with thick sputum. The abnormally thick mucosal surface increases susceptibility to recurrent lung infections. Bronchiectasis, or weakened and dilated bronchial tubing, is a common complication or aftermath of cystic fibrosis. Excessive mucus also blocks the ducts of the pancreas, preventing the release of digestive enzymes and resulting in weight loss and malnutrition. Cystic fibrosis gets its name from the fibrous tissue that forms around these cysts. In a sweat test, a sweat-producing chemical is applied to a small area of the skin. Treatment includes chest physical therapy and exercise to loosen mucus so it can be coughed up, nutritional therapy, mucusthinning medications to reduce the stickiness of mucus and loosen it, anti-inflammatory medication to reduce swelling in the airways caused by recurrent infections, and bronchodilators to open the airways by relaxing the muscles around them. Pneumothorax Pneumothorax is a collection of air or gas in the chest or pleural space that causes part or all of a lung to collapse. Normally, the pressure in the lungs is greater than the pressure in the pleural space surrounding the lungs. However, if air enters the pleural space, the pressure there then becomes greater than the pressure in the lungs, causing the lung to collapse partially or completely. Risk factors for pneumothorax include being male, smoking, being tall and underweight, having certain lung diseases, and a history of pneumothorax. Signs and symptoms include a sudden, sharp pain on the same side as the affected lung and dyspnea. The blebs can spontaneously rupture or can rupture due to a change in air pressure. Pneumothorax is diagnosed by physical examination, arterial blood gas analysis, and imaging tests. If a small portion of the lung is collapsed, monitoring the condition may be adequate. If a larger area of the lung is collapsed, a needle or chest tube is inserted into the chest cavity to relieve the pressure on the lung, allowing the lung to reexpand. Prevention includes smoking cessation and seeking medical attention for respiratory problems. Pleurisy or Pleuritis Pleurisy is an inflammation of the pleural membranes that line the chest wall and encase each lung. The main symptom of pleurisy is a sharp chest pain that worsens with breathing in or coughing caused by the inflamed pleura layers rubbing together. As the risk factors just mentioned indicate, pleurisy is often caused by a lung infection. Diagnosis is based on signs and symptoms, physical examination, blood tests for pathogens, and imaging tests. The treatment of pleurisy depends on the cause and may include antibiotics if pleurisy is caused by a bacterial infection as well as over -the-counter or prescription nonsteroidal anti-inflammatory medication for pain relief. Prevention includes seeking medical attention early for lung infections and getting the pneumonia vaccine if recommended. Risk factors for atelectasis include anesthesia, prolonged bed rest with few changes in position, shallow breathing, and underlying lung disease. Atelectasis may be caused by a blockage of the bronchus or bronchioles or by pressure on the lung. Drugs given during surgery make the lungs inflate less fully than usual, so normal secretions collect in the airways. Suctioning the lungs during surgery helps clear away these secretions, but they may continue to build up afterward. Mucus plugs are also common in people with cystic fibrosis and during severe asthma attacks. Treatment may include aerosolized respiratory treatments to open the airway; positioning the body on the unaffected side to allow the affected lung to reexpand; removing obstructions by bronchoscopy; breathing exercises, clap, or percussion on the chest to loosen mucus; tilting the body (postural drainage) so that the head is lower than the chest to drain mucus; and treating a tumor or underlying condition, if present. Prevention includes encouraging movement and deep breathing in anyone who is bedridden for long periods, keeping small objects out of the reach of young children, and maintaining deep breathing after anesthesia. Anticoagulants are the most common treatment; if the condition is life-threatening, clot dissolvers or surgery may be necessary. Prevention includes actions that prevent clot formation in the legs, including avoiding sitting for long periods of time, getting mobile as soon as possible after surgery, wearing elastic compression stockings, and drinking plenty of fluids when traveling to prevent dehydration, which tends to increase blood clot formation. Lung cancer is the leading cause of cancer death among men and women in the United States. The American Cancer Society estimates that in 2013 approximately 228,190 cases of lung cancer will be diagnosed and 159,480 people will die from lung cancer in the United States. Risk factors include smoking, exposure to secondhand smoke, age (over 65), exposure to asbestos or radon, genetics, and a family history of lung cancer. Lung cancer is classified into two basic types depending on the appearance of the lung tissue under a microscope. When signs and symptoms begin, they are usually a result of blocked breathing passages or the spread of the cancer. The blood in the sputum results from erosion of blood vessels by the growing malignancy. Other signs and symptoms include dyspnea and wheezing caused by airway obstruction from compression by tumors and body fluids such as mucus and blood. Anorexia, weight loss, and weakness accompany the disease, caused partly by poor oxygenation of the blood. Smoking causes the great majority of lung cancers; 90% of lung cancers are a result of tobacco use. Tobacco smoke contains over 4,000 chemical compounds, many of which have been shown to be cancer causing, or carcinogenic. Signs and symptoms may include sudden dyspnea, tachypnea, chest pain, and a cough that may produce bloody or blood-streaked sputum. The cough reflex decreases with age, enabling pathogens, irritants, and debris to reach deep into the lungs. Pneumonia is a common cause of death in older adults who suffer from other chronic diseases. On average, one square foot of the respiratory membrane is lost each year after age 30. However, the cancer probably begins earlier in life, and this incidence reflects the relatively late age at diagnosis. Treatment includes surgery, chemotherapy, radiation, and targeted therapy that decreases the growth of tumor cells. Lung cancer can be prevented by not smoking, quitting smoking, avoiding secondhand smoke, testing for radon, and avoiding exposure to carcinogens at work. Age-Related Diseases In older adults, elastic tissue of the lungs deteriorates and reduces lung capacity. Weakening respiratory muscles and arthritis in joints of the rib cage and vertebrae impair respiratory function. This can cause labored breathing in older adults, especially if they have led a sedentary lifestyle.

Urinalysis and Laboratory Tests Renal disease can be detected through analysis of blood for creatinine asthma symptoms worse after quitting smoking fluticasone 100 mcg with amex, uric acid asthma symptoms sneezing order discount fluticasone on-line, and blood urea nitrogen asthmatic bronchitis 18 cheap fluticasone 500 mcg visa. Significant diagnostic information can be obtained by urinalysis asthma 123 facilitator training order 250 mcg fluticasone otc, in which a urine specimen is studied physically asthma 18 month old 100 mcg fluticasone free shipping, chemically, and microscopically. In chronic kidney diseases, the ability of the renal tubules to concentrate urine is absent. For example, albumin in the urine (albuminuria) can indicate inflammation of the urinary tract, particularly of the glomeruli. Urine is centrifuged and examined microscopically for red blood cells, white blood cells, bacteria, crystals, and casts. Casts form within kidney tubules from which the casts take their cylindrical forms. A cystoscopic examination enables visualization of the inside of the bladder and urethra. The cystoscope is a long, lighted instrument resembling a narrow hollow tube inserted through the urethra into the bladder. Acute Diseases and Disorders Acute Kidney Injury Acute kidney injury is the sudden onset of impaired renal function. One is shock, which Chapter Ten Diseases and Disorders of the Urinary System í 203 interrupts blood flow to the kidneys. Second is tubular necrosis, which results in a number of diseases such as systemic lupus erythematosus, sickle cell disease, renal vein thrombosis, acute poststreptococcal glomerulonephritis, or exposure to toxins. Third is obstructed urine flow, a condition arising with kidney stones, an inflamed prostate, or tumors. Significant signs of acute kidney injury include oliguria (low urine output), a sudden drop in urine volume, and rarely a complete cessation of urine production, a condition called anuria. Systemic symptoms arise as the body fails to clear toxins and acid from the blood. Symptoms include nausea, vomiting, diarrhea, and the odor of ammonia on the breath caused by accumulation in the blood of nitrogen-containing compounds. Headache, drowsiness, confusion, neuropathy, seizures, and coma may occur if untreated. At first low blood pressure occurs, then hypertension and heart failure and respiratory edema. Diagnosis includes a history to determine the presence of other diseases or exposure to toxins or medicines that are known to trigger acute kidney injury. Treatment includes a diet low in protein, sodium, and potassium, restricted fluid intake, and dialysis if needed. Acute kidney injury can be prevented by treating the causative diseases and by avoiding known kidney toxins. Urethritis is inflammation of the urethra and cystitis is inflammation of the urinary bladder. Risk factors include being female, having multiple sex partners, and having sexually transmitted infectious diseases. The symptoms of urethritis include a discharge from the urethra, an itching sensation at the opening of the urethra, and a burning sensation during urination. Cystitis is characterized by urinary frequency, a sense of urinary urgency, and dysuria, a painful, burning sensation during urination. Risk factors include being female, kidney stones, having a urinary catheter, or immunodeficiency. Symptoms of pyelonephritis include chills, high fever, sudden back pain that spreads over the abdomen, dysuria, and hematuria. Pyelonephritis is often caused by pyogenic (pus-forming) bacteria, such as Escherichia coli, streptococci, and staphylococci. Prevention relies on prompt treatment of infections in the bladder and lower urinary tract. Bacteria that colonize the urethra usually become dislodged by regular flow of urine. If not cleared from the urethra, bacteria can ascend the urethra and infect the urinary bladder and the kidneys. IgA nephropathy is more common in men, especially those in their late teens to early 30s, although it affects all age groups. Because it takes years to become recognized and cause complications, younger people seldom display symptoms. The most common early symptoms are blood in the urine and later swelling of the hands and feet. No treatment is recommended for mild cases with normal blood pressure and proteinuria, but elevated blood pressure requires hypertension medications. The symptoms include chills and fever, loss of appetite, and a general feeling of weakness. Treatment depends on the cause and usually involves anti-inflammatory drugs and immune suppressants. Here we discuss these inflammatory conditions, which may be considered autoimmune diseases because the immune system causes kidney inflammation and injury. Diagnosis of lupus nephritis begins with a patient history, physical exam, and evaluation of symptoms. Lab tests include urinalysis, blood tests, ultrasound, and might include kidney biopsy to determine the type of kidney injury. Prevention is not possible, but risk can be reduced by adequate treatment of systemic lupus erythematosus. The stones, called urinary calculi or uroliths, occur in 9% of adults in the United States. Men are four times more likely than women to produce renal calculi, with the first episodes occurring between ages 20 and 40. Urinary calculi may cause no symptoms, even when passed through the urinary tract, unless they are larger than a quarter inch in diameter, in which case they become lodged in the ureter. The lodged stones cause intense pain that radiates from the kidney to the groin area. In addition to intense pain, other signs and symptoms include hematuria, nausea, vomiting, and diarrhea. Kidney stones may cause urinary tract infections by blocking urine flow and permitting bacterial growth in the urinary tract. The presence of bladder stones causes urinary tract infections because they frequently obstruct the flow of urine. Urinary calculi may be treated with medication that partially dissolves the stone, permitting it to be passed in the urine. Lithotripsy, the crushing of kidney stones, is particularly effective for the 20% of kidney stones that do not pass on their own. In this technique, the partially submerged patient is subjected to the sonic waves that shatter the hard stones into sand-sized particles that can be eliminated with the urine. Recovery is rapid, but there may be some bruising, and the patient might require a hospital stay. To prevent recurrence, fluid intake should be increased to keep the urine dilute, and dietary calcium and protein should be reduced. Acoustic shock waves generated by the shock-wave generator travel through soft tissue to shatter the renal stone into fragments, which are then eliminated in the urine. Chapter Ten Diseases and Disorders of the Urinary System í 207 Promote Your Health Stay Hydrated A simple way to promote urinary system health is to stay hydrated. Good hydration also reduces the risk for the developing kidney and bladder stones. The best drink in most circumstances is plain water because it adds no salt, sugar, calories, or caffeine to the diet. Chronic Diseases and Disorders Renal Failure Renal failure is the progressive loss of kidney function over time. Risk factors include diabetes, glomerulonephritis, or other chronic kidney diseases. Ischemia, hemorrhage, shock, toxins, and large kidney stones or tumors may cause renal failure. In renal failure the kidneys are unable to clear the blood of urea and creatinine, which are nitrogen-containing waste products of protein metabolism. These metabolic products are toxic if they accumulate in the blood, a condition known as uremia. Treatment depends on the underlying cause of renal failure but usually includes renal dialysis. Chronic Kidney Disease Chronic kidney disease is life-threatening and has a much poorer prognosis than acute kidney injury. The risk factors for chronic kidney disease include chronic glomerulonephritis, hypertension, and diabetic nephropathy, kidney disease resulting from diabetes mellitus. Here we discuss diseases associated with the development of chronic kidney disease. Diabetic Nephropathy Today diabetic nephropathy is recognized as the most common cause of chronic kidney disease and end-stage renal disease in the United States. The best way to reduce the risk for diabetic nephropathy is to manage diabetes mellitus from the first day it is diagnosed. The kidney damage of diabetic nephropathy is cumulative and irreversible, so it is much better to prevent this disease than to deal with its consequences. Diabetics are at risk for nephropathy if blood glucose and hypertension remain uncontrolled. Symptoms develop slowly over 5­10 years and include fatigue, headache, itching, frothy urine, frequent hiccups, and edema, particularly in the legs. Hypertensive Kidney Disease Hypertensive kidney disease is caused by kidney injury. Also called renovascular hypertension, hypertensive kidney disease is found in about 1 in 10 people with systemic hypertension. Hypertensive kidney disease is caused by atherosclerosis of renal arteries and their small branches within the kidneys. The decreased blood to kidneys causes them to release renin, which converts the plasma protein angiotensin into angiotensin I. Signs and symptoms include typical features of systemic hypertension, such as headache, heart palpitations and tachycardia (rapid heart rate), light-headedness, and anxiety. Sustained hypertension elevates the risk for heart failure, myocardial infarction, and stroke. Because surgery might be able to help, the kidneys are examined to determine which kidney is affected and where the problems lie. Ultrasound and renal arteriography permit visualization of blood flow and obstruction. The blood in the renal veins can be tested for elevated renin to determine which kidney is affected. Symptoms can be managed with antihypertension medication and diuretics and by controlling sodium intake. Renal hypertension may not be easily prevented, but the risk can be lowered by regular exercise, a low-fat diet, not smoking, and by treating hypertension, all of which help prevent atherosclerosis. Nephrotic syndrome results from glomerular injury that occurs in the course of other kidney diseases. High lipid levels can lead to premature atherosclerosis and associated complications. Treatment of Chronic Kidney Disease Chronic kidney disease is treated with antihypertensives, diuretics, and kidney dialysis. Controlling weight, blood lipids, sodium intake, sugar levels, and engaging in regular exercise may help control progression of renal disease. Renal dialysis is commonly used to treat renal failure before considering kidney transplant. For hemodialysis, a patient typically must visit a clinic or hospital for dialysis treatment and stay for 3­6 hours during the process. However, residential dialysis units allow patients more convenient and private treatment. Small portable dialysis units have further reduced cost and have increased availability for many patients. The fluid draws toxic materials out of capillaries surrounding the body cavity, and after a suitable amount of time, the peritoneal fluid is removed, along with its dissolved toxins. A bag may be attached externally to collect the fluid, permitting the patient to remain mobile and providing more freedom and flexibility during treatment. Dialysis may be required for years but may not be sufficient in advanced chronic kidney disease. Kidney function can decline to a point that dialysis is no longer an effective treatment option. One transplanted kidney can replace the function of two nonfunctional kidneys, but the procedure is not for everyone. The candidate must be healthy enough to endure the risks of surgery, a long recovery, and a lifetime of antirejection drugs. Available tissue-matched kidneys are uncommon, and long wait lists have developed, resulting in waiting a year or more before a potential donor kidney is identified. Chronic Kidney Disease Chronic kidney disease is life-threatening and potentially preventable. Notice that these behaviors reduce the risk for atherosclerosis and heart disease. Prevention is not possible, but risk can be reduced by treating stones or tumors that obstruct urine flow.

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