Category: Respiratory Disorders

Introduction

Respiratory compromise due to pneumothorax could occur due to various causes. Two types of pneumothorax were described: spontaneous and traumatic (Porter, 2008). The former was characteristic of young men who were otherwise healthy. Six times more young men had a primary spontaneous pneumothorax. Older men usually had the secondary variety associated with chronic respiratory illnesses like bronchitis and emphysema. The commonest was chronic obstructive pulmonary disease (Lobato et al, 2007). There could also be some other underlying disease or a problem with the mechanism of ventilation. Causative factors that had been identified included mostly respiratory illnesses. Bronchial asthma could limit the airflow leading to pneumothorax. A similar mechanism was attributed to bullous emphysema too. It could be induced by positive pressure ventilation. Infections affecting the lung-like staphylococcal pneumonia and tuberculosis could produce pneumothorax. Cystic fibrosis and Marfans syndrome also could have been associated with pneumothorax (Porter, 2008). Traumatic pneumothorax following a chest injury has a high mortality rate. This variety is being discussed in this paper.

A 19-year-old male presented to the emergency department with extreme shortness of breath and chest pain. Having been involved in a motorbike accident, he sustained bruising to his left chest. Complaining of pain in that area and difficulty in breathing, he was pale, perspiring and generally unwell with a blood pressure of 90/50 and a heart rate of 120 beats a minute in sinus tachycardia. Chest X-ray showed a left flail chest as well as a large pneumothorax in the left lung. An intercostal catheter was inserted in the emergency department. When transferred into the intensive care unit, he became confused and disoriented with a respiratory rate of 44 breaths a minute. His condition deteriorated rapidly. Following immediate intervention and management, he was intubated and placed on mechanical ventilation.

Clinical presentation of pneumothorax and flail chest

The history and physical examination corroborated by radiological investigations provided the grounds for a diagnosis of pneumothorax (Rankine et al, 2000). The clinical presentation varied according to the causes. The comorbidities that the patient already suffered from also influenced the clinical features (Lobato et al, 2007). Typically there was a sudden onset of symptoms with severe chest pain, the difficulty of breathing which progressed and accompanying cough (Porter, 2008). Physical examination revealed lesser respiratory excursion on the involved left side. Percussion exhibited an exaggerated resonance. Lesser breath sounds were found through auscultation and their absence over the apex of the lung was significant (Porter, 2008). Pleuritic chest pain though a feature of traumatic pneumothorax became usually masked by other, perhaps greater, injuries. A blowing or sucking wound would be found on the chest. The accompanying flail chest occurred due to multiple rib fractures. The respiratory functions were severely affected in such an eventuality.

The flail portion moved in and out in correspondence with inspiration and expiration (Lobato et al, 2007). Flail chest had a high mortality rate and was accompanied by long-term pain with disability (Marasco et al, 2009). Some patients developed a paradoxical movement of the chest wall compromising respiration severely. This condition required internal pneumatic splinting. Mechanical ventilation was continued for long periods. The outcomes could include intermittent chronic pain preventing the patient from returning to work. The movement of the chest wall was restricted and subsequent deformity was expected. Tension pneumothorax was accompanied by extreme hypotension causing the patient to be semi-conscious. Physical examination showed prominent neck veins. The trachea has deviated. Percussion showed hyper resonance on the left side. Clinical features of other underlying co-morbidities needed to be watched for. Subcutaneous emphysema was another possible development.

The 19 years old patient who arrived after a motorbike accident had the typical features of chest pain in the area of hit and shortness of breath. The pallor, perspiration, the general feeling of being unwell, the hypotension and the sinus tachycardia could be attributed to a developing tension pneumothorax. With the history of the accident, the possibilities of internal bleeding also needed to be excluded. Lung markings were not detected in the Chest X-ray. This confirmed the diagnosis of a left-sided, large pneumothorax and a flail chest on the same side.

Clinical diagnosis: This boy had tension pneumothorax with flail chest and multiple fractures of the ribs following a blunt trauma for which he was subjected to intercostal catheterization, endotracheal intubation and intermittent positive pressure ventilation.

The physiological relationship between the pneumothorax, flail chest and his deteriorating respiratory condition  including the key issues of oxygenation at a cellular level.

The pleural space between the parietal pleura (against the chest wall) and the visceral pleura (lining the lung) normally contained fluid. The elastic property of the lung and chest wall caused the lung to move inwards and the chest wall to move outwards causing a negative subatmospheric pressure in the space (Rankine et al, 2000). This negative pressure sucked the air from the atmosphere if the pleural space was interrupted. Air had entered the boys pleural cavity and the lung had recoiled and collapsed. Air could enter the pleural space in a variety of ways depending on the cause of the pneumothorax. In trauma, the causes were chest wall damage and rib fractures (Rankine et al, 2000).

Had the hole in the pleura been small, it would have closed by itself and the re-expansion of the lung would have occurred. However, with a large opening, the hole started acting like a valve. During inspiration, the air had entered but had failed to escape during expiration causing trapping of air. The pneumothorax enlarged progressively and the collapsed lung remained so. The enlarging pneumothorax pushed the heart to one side also displacing the great vessels. This was leading to tension pneumothorax. The flail chest added to the severe pain. It was also moving with the movement of the chest. There could have been a paradoxical movement of the flail chest. This tension pneumothorax was an emergency. The boy respiratory distress was not relieved by the intercostal catheter. The tension pneumothorax was progressing and more had to be done to save the patient.

The blood gas analysis had indicated a reduction of PaO₂ to critical levels. The next step would be the rise in PaCO_2. Simple needle aspiration could relieve only small spontaneous pneumothoraces. Complications seen were local emphysema, vasovagal reactions, catheter kinking, dislodgement and empyema (Yazkan and Han). Due to his deteriorating condition, the boy was admitted to the ICU where his disorientation, confusion and tachypnoea became worse. The intercostal catheter was usually placed by the axillary method. The posteroapical or anterior approach also was common (Yazkan and Han, 2010). Trauma to the chest and viscera of the abdomen, wrong placement of the tube, empyema, bronchopleural fistula were seen rarely as complications. Other possible complications included perforation of the internal mammary artery, pulmonary edema and lung infarction (Kelly, A.M., 2007). The intercostal catheter placed in the emergency room was insufficient to correct his pneumothorax. Pleural catheters of small-bore also could be used. Pulmonary edema occurring with the re-expansion was a potentially fatal complication. The cost and hospital were the same for both the intercostal catheter and the pleural catheter (Liu, 2003).

Possible complications of his presenting condition, the most likely mode of mechanical ventilation that will be used to manage his condition and critical analysis of the mode of ventilation in relation to this presentation.

Tension pneumothorax could cause collapse due to hemodynamic compromise (Greenberg, 2005). If treatment was not offered, death could follow. Persistent pneumothorax could result. Laceration of the lung was another possible complication. Intercostal nerves or vessels could be injured. Empyema could result from the trauma or inaccurate placement of the intercostal catheter (Greenberg, 2005).

The boy was immediately intubated and mechanically ventilated. This was the usual treatment administered in the US. Internal stabilization was possible by endotracheal intubation. Patients who had flail chests were provided critical care (Gunduz, 2005). More than 40 years had passed when mechanical ventilation ruled the roost (Rodriguez, 1990). Mechanical ventilation if prolonged produced complications like lung injury. Pneumonia occurring as a hospital-acquired infection would be another complication that could end fatally (Cross, 1981). Major atelectasis also could occur. Epidural analgesia and sufficient oxygenation had been indicated by Trinkle et al (1975). Recently non-invasive positive pressure ventilation had been proposed. The boy in this case could have had CPAP (continuous positive airway pressure) through a mask because he had trauma to the chest wall and was hypoxic in addition (Boundain 2002). However, he was most likely given intermittent positive pressure ventilation as he was intubated endotracheally. Endotracheal intubation further improved oxygenation and pulmonary function.

A pulmonary function could be affected by the pain from the rib fractures. Effective pain management was critical for this patient. It permitted proper inspiration. The secretions also could be removed easily. The two techniques of epidural analgesia and the patient-controlled analgesia did not have differences in the outcomes like duration of hospital stay or intensive care or pulmonary complications. Organ failure had also not been reported (Wu, CL, 1999). Within the first two hours of admission, the Thoracic Traumatic Severity Score (25 point score) could have been used for determining the extent of injuries but this case had been excluded as he was very much compromised in his respiratory functions (Pape, 2000). Pneumonia, sepsis and septic shock, which were complications, influenced the mortality rates.

CPAP did not improve the PO₂ as did the IPPV. Gunduz et al suggested CPAP as the first step in the management of flail chest caused by blunt trauma (2005). However later their effects had been considered similar. Patients with CPAP produced lesser oxygenation. The pain was supposed to be the cause of this. Analgesia was considered very significant in the management of the flail chest.

Discussion and critical analysis of the nursing and interdisciplinary assessment and diagnosis for this patients presentation.

Trauma could be due to a blunt instrument or surface or a penetrating injury. Differences between the two were clear. In a blunt injury, the large energy transfer to the body caused drastic complications. In the thoracic region, rupture of the alveoli and bronchial tears were injuries occurring to the respiratory system (Lobato et al, 2007). Laceration of the oesophagus was another injury possible. There was no indication whether this esophagus injury was ruled out in this case.

The bruise on the chest could be attributed to a blunt injury. It was also not known whether a high velocity or low-velocity injury had occurred. The type of injury could have indicated the extent of injuries to look out for. The fracture of multiple ribs or the flail chest could have caused injuries to the soft tissue, the pleura, bone and blood vessels. No mention was made of soft tissue injuries. Penetrating trauma could be due to injuries caused at low or high velocity. The low-velocity ones could cause injuries that were anatomically affected. The high-velocity ones could cause distant injuries due to the sudden shock (Lobato et al, 2007). There was a probability of this boy going into shock as he was hypotensive with tachycardia, perspiring and becoming disoriented. The chest wall was not affected in the closed variety of traumatic pneumothorax. The pneumothorax if an open variety could communicate with the atmosphere. Open pneumothorax could be expected in this case as the pneumothorax was large and progressing. Tension pneumothorax was an emergency situation where immediate measures for relieving the tension had to be taken. In hemothorax, blood and air would have been found in the pleural space (Lobato et al, 2007).

Thoracic ultra-sound had been recommended for the detection of pneumothorax over the chest X-ray in the AP position as it was more sensitive. The absence of pleural sliding and comet-tailed artefacts (B lines) and the presence of the lung were the findings characteristic of pneumothorax (Wilkerson and Stone, 2010). B lines were found in alveolar edema and in some normal subjects too. The movement of the lung at the border of the pneumothorax clinched the diagnosis (Linchtenstein, 2000). Imaging using a transthoracic B-mode was done. The transducer of high or low frequency was placed at the anterior and lateral chest wall (Wilkerson and Stone, 2010). The sliding movement of the two layers of pleura against each other in respiration was indicative of a normal lung. The artifacts were hyperechoic lines that began in the pleura and were limited at the outer extent, moving with respiration. The normal pattern showed physiologic A line artifacts.

Studies had indicated that Chest X-ray in the AP supine position was only 36 to 48 % sensitive (Rowan et al, 2002; Neff et al, 2000). Recently the CT scan had been identified as being the superior technique of imaging for pneumothorax. It had also been indicated that patients with pneumothorax which was not seen in the Chest X-ray but seen with the CT scan, were amenable to positive pressure ventilation while other patients felt a progression of their illness (Barrios et al, 2008). Occasionally patients needed to be air-lifted for further management. Then tube thoracostomy would be helpful in controlling the respiratory distress temporarily.

Critical analysis of current treatment modalities

The usual treatment of flail chest was to do internal pneumatic splinting. This was followed by mechanical ventilation which could be continued for long periods of time (Marasco, 2009). The pain would accompany the recovery period. An active management strategy had been suggested to overcome the prolonged and painful recovery for the flail chest. Different prostheses like metallic plates, Kirschner wires and pins had been used unsuccessfully. Marascos study investigated the safety of absorbable prostheses in fixing the broken ribs (2009). Surgery was efficiently planned by scrutinizing the CT scans. It involved reducing the fractures and keeping the bones in place. The plates were approximated to and fixed in position to the outer surface of the reduced fractures (Marasco, 2009). The paradoxical movement of the flail portion was thus controlled. Time healed the fractures and the method was considered effective. All thirteen patients had the treatment and left the hospital after being weaned from the ventilator support. Tanaka et al discussed the costs in their study (2002). Only one study used conservative management by strapping the flail segment with Elastoplast (Granetzny et al, 2005). One group of researchers classified the patients into two: those who had contusion formed one group and those without, another group (Voggenreiter et al, 1998).

They found that the presence of contusion complicated the management. All the patients benefited from surgery but those who had the contusion benefited less. Mayberry (2003) also used absorbable prostheses for the flail chest. They were used for pain in the chest due to rib fractures and deficiencies in the chest wall addition. Marascos prostheses were degraded by mere hydrolysis in vivo. In the body, they were metabolized into carbon dioxide and water (2009). The prostheses remained strong by 40% even after 3 months when the fractures were healed. By three years, they were totally absorbed without producing any toxicity. The advantage of these over metallic plates was that there was no associated slowing of bone healing (Viljanen, 2001). Cost-saving was associated with this method as the necessity of removing the prostheses did not arise. The complications associated with metallic plates and screws like migration, palpability or thermal sensibility were not associated with the absorbable prostheses (Marasco, 2009). Stress shielding was a disadvantage of metallic plates as the plates took over the weight-bearing functions and relieved the limb or part of the body from taking loads. Sufficient stimulus for bone growth was thereby not obtained. The absorbable plates also allowed the patient to have MRI imaging. Good results had been indicated by other researchers recently (Viljanen, 2001; Bell, 2006).

Conclusion

Flail chest and pneumothorax are severe complications in blunt traumatic injury. The management strategies are still controversial researchers have different opinions. Analgesic techniques are being adopted. Ventilation should not be invasive. Fluid therapy may be used sparingly as necessary. Surgical intervention may be done as indicated. The optimal management is with prostheses after surgery. The latest material used for rib fracture management is absorbable material that remains in the body without removal. Metallic plates and nails may have to be removed. Absorbable material is not removed and is metabolized in the body without causing toxicity even after 3 years. Further research needs to be done to discover newer methods of management to reduce morbidity and mortality.

References:

Barros, C., Tran, T., Malinoski, D. et al (2008). Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation. Am. Surgery Vol.74:958-961.

Bell, R.B., Kindsfater, C.S. (2006). The use of biodegradable plates and screws to stabilize facial fractures. J.Oral Macillofac. Surg. Vol. 64:31-39.

Boundain, S., Blumenthal, S., Cooper, B et al (2002) (British Thoracic Society Standards of Core Committee) Non-invasive ventilation in acute respiratory failure. Thorax Vol. 57:192-211.

Cross, A.S. and Roupe, B. (1981). Role of respiratory assistance in endemic nosocomial pneumonia. Am. J. Med. Vol. 70:681-685.

Granetzny, A., El-Aal, M.A., Emam, E., Shalaby, A., Boseila, A. (2005). Surgical versus conservative treatment of flail chest: Evaluation of the pulmonary status. Interact. Cardiovascular. Thoracic Surg. Vol.4:583-587.

Greenberg, M. I. (2005) Greenbergs Atlas of emergency medicine, Lippincoot, Williams and Wilkins Medical, Philadelphia PA.

Gunduz, M., Unlugenc, H. Ozalevli, M., Inanoglu, K. and Akman, H. (2005). A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure (IPPV) in patients with flail chest. Emerg Med J. Vol. 22: 325-329.

Kelly, A.M. (2007) Review of management of primary spontaneous pneumothorax: Is the best evidence clearer 15 years on? Emergency Medicine Australasia Vol. 19: 303-308.

Lichtenstein, D. Meziere, G., Biderman, P. and Gepner, A. (2000). The Lung Point: an ultrasound sign specific to pneumothorax. Int.Care Med. Vol. 26: 1434-1440.

Liu, C., Hang, L., Chan, W. et al (2003). Pigtail tube drainage in the treatment of spontaneous pneumothorax. Am.J.of Emerg Med Vol. 21: 214-244.

Lobato, E.B., Gravenstein, N. and Kirby, R.R. (2007). Complications in anaethesiology. Wolter-Kluwer/ Lippincott Williams and Wilkins. USA.

Marasco, S., Cooper, J., Pick, A. and Kossman, T. (2009). Pilot study of operative fixation of fractured ribs in patients with flail chest.

Mayberry, J.C., Terhes, J.T.,Ellis, T.J. et al. (2003). Absorbable plates for rib fracture repair: preliminary experience. J. Trauma Vol. 55:835-839.

Neff, M.A., Monk, J.S., Peters, K. and Nikjilesh, A. (2000). Detection of occult pneumothoraces on abdominal computed tomographic scans in trauma patients. Journal of Trauma, Vol. 49: 281-285.

Pape, H.C., Remmes, D., Rice, J. ( 2000)Appraisal of early evaluation of blunt chest trauma: Development of a standardized scoring system for initial clinical decision making. J. TraumaVol.49: 496-504.

Porter, S. (2008). Tidys physiotherapy 14^th Ed. Elsevier Health Sciences. Elsevier Ltd. Printed in China.

Rankine, J.J., Thomas, A.N. and Fluechter, D. (2000). Diagnosis of pneumothorax in critically ill adults Postgrad. Med. J. Vol. 76: 399-404.

Rodriguez, A. Injuries of chest wall, the lung and the pleura. In Turney S.Z., Rodriguez A., Cowley, R.A. (Eds) in Management of cardiothoracic trauma, edn Baltimore: Williams and Wilkins: 155-177.

Rowan, K.R., Kirkpatrick, A.W., Liu, D., Forkehim, K.E., Mayo, J.R. and Nicolau, S. (2002). Traumatic pneumothorax detection with thoracic US: correlation with chest radiograpahy and CT- initial experience Radiology 2002 Vol. 225: 210-214.

Tanaka, H., Yukioka, T., Yamaguti, Y. et al. (2002). Surgical stabilization of internal pneumatic stabilization: A prospective randomized study of management of severe flail chest patients. Journal of Trauma. Vol. 52: 727-732.

Trinkle, J.K., Richardson, J.D., Frenz, J.L. et al. (1975) Management of flail chest without mechanical ventilation. Ann. Thoracic Surg. Vol. 19:355-363.

Viljanen, J., Pihlajamaki, H. , Kinnunen, J. et al. (2001). Comparison of Poly-L-Lactide and metallic intramedullary rods in the fixation of femoral shaft oseteotomies: an experimental study in rabbits. J.Orthop Sci. Vol. 6:160-166.

Voggenreiter, G., Neudeck, F., Aufmkolk, M. et al. (1998). Operative chest wall stabilization in flail chest- outcomes of patients with or without pulmonary contusion. J. of Am. Coll. Of Surg. Vol. 187:130-138.

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Abstract

Toxicants are poisonous substances that are produced artificially and introduced to the environment as a result of human activities. These toxicants have serious implications on human health. For instance, they have been found to affect vital organs of the body and lead to death in some cases.

PCBs (Polychlorinated Biphenyls) are among the most dangerous persistent organic toxicants in the environment that have been known to adversely affect the health of humans, animals, and the environment. This article focuses on the effects of PCBs on the respiratory system, the immune system, and the liver.

A toxicant is a xenobiotic substance that produces hazardous effects on the body or the environment. Toxicants are introduced into the environment through as a result of human activities. Most of these toxicants mostly circulate through the body and accumulate in specific target organs, which they eventually affect adversely.

However, others can damage any cell or tissue that they come into contact with. There are numerous toxicants in the environment, including heavy metals, non-metals, radioactive pollutants, and persistent organic pollutants (Kacew & Lee, 2013).

Polychlorinated Biphenyls (PCB) toxicants are classified under persistent organic pollutants. They are artificial organic chemicals with a slow breakdown, thus they remain for long in the body system or the environment. A variety of health effects can occur in particular body organs and systems when the human body system is exposed to PCBs.

PCBs can lead to immunotoxicity, either in the form of hypersensitivity like in allergy, as well as autoimmune, immunodeficiency, and uncontrolled growth. Studies have found out that PCBs impair the immune system function. They bind to receptors that are responsible for immune system function control, resulting in disturbances in lymphocytes and T cells.

A study conducted on Dutch children found a remarkable reduction in the immune system function associated with PCBs’ exposure (Weisglas-Kuperus et al., 2000). Studies in the rhesus monkey revealed that exposure to PCBs can bring about reduction of the thymus, slowed immune response, and reduced Epstein –Barr Virus resistance, as well as other infections (Kacew & Lee, 2013).

PCBs also affect the liver adversely. This was recognized as early as the 1930s. PCBs have been associated with the production of abnormal enzymes of the liver and suspected non-alcoholic fatty liver disease (NAFLD) (Shi et al., 2012).

They induce microsomal enzymes, particularly EROD (this is the marker for CYP1A1) and urinidine diphosphate glucuronyl transferase (UDPGT), which in turn lead to hepatogenic porphyria, as well as high endogenous steroid degradation in the liver. Induction of CYP1A1 has been said to promote cancer and hyperplasia sensitivity, as well as necrosis and fatty infiltration (Kacew & Lee, 2013).

Exposure to PCBs also poses adverse effects on the respiratory system. The enzymes uridine diphosphate glucuronyltransferases (UDPGTs) produced in the liver as a result of PCB exposure can also be induced in the lungs, among other body organs. This has the same effect with the effect in the liver; that is, cancer (Kacew & Lee, 2013).

Structural damage can occur in the lungs if exposed to PCB toxicants for long, leading to chronic diseases like pulmonary fibrosis, emphysema, besides cancer. Chronic exposure to PCBs via inhalation has been found to lead to symptoms in the respiratory tract, like cough and chest tightness. Exposure to PCBs also increases the vulnerability to asthma, as well as other infectious respiratory diseases (Carpenter, Ma & Lessner, 2008).

References

Carpenter, D. O., Ma, J., & Lessner, L. (2008). Asthma and infectious respiratory disease in relation to residence near hazardous waste sites. Ann N Y Acad Sci. 1140, 201-208. doi: 10.1196/annals.1454.000.

Kacew, S., & Lee, B. M. (2013). Lu’s basic toxicology: Fundamentals, target organs, and risk assessment (6th ed.). New York, NY: Informa Healthcare.

Shi, X. et al. (2012). Metabolomic analysis of the effects of polychlorinated biphenyls in non-alcoholic fatty liver disease. Journal of Proteome Research, 11(7), 3805-3815. doi: 10.1021/pr300297z.

Weisglas-Kuperus, N., Patandin, S., Berbers, G. A., Sas, T. C., Mulder, P. G., Sauer, P. J., & Hooijkaas, H. (2000). Immunologic effects of background exposure to polychlorinated biphenyls and dioxins in Dutch preschool children. Environmental Health Perspectives, 108(12): 1203-1207.

Introduction

Respiratory therapy is an important part of healthcare that requires the therapist to have a broad range of skills and knowledge. In nursing, respiratory care requires high skills both in cardiology and pulmonology, and extensive knowledge about the diseases infecting the respiratory tract. Due to their responsibilities in maintaining airway management and intensive care, respiratory therapists are often in charge of managing life support and the related staff.

Respiratory care is an area in medicine that requires extensive specialized training both through formal and informal mechanisms. As a result, there are many courses and educational materials available to the medical and nursing students. Evaluating their effectiveness can be a hard job for a tutor or the therapist himself if he is practicing self-learning.

For this reason, it is important to be able to evaluate the materials studied objectively for both strengths and weaknesses, and how to advance the practice of respiratory care.

Respiratory Care Study Material

The first learning material in question is the Leadership Institute (n.d.). It provides information in numerous fields, including courses for respiratory therapists, created by experts in the field of respiratory care education, research, and management, for the purpose of increasing the students’ depth of knowledge. The courses are designed to be completed at one’s pace and in a format that is most comfortable for the user.

The second set of course materials is the Obstructive Pulmonary Disease (COPD) Educator Course. The course studies the COPD, which is a lung disease with symptoms of long-term poor airflow, breathlessness, and cough with mucus. As more and more people become afflicted by the disease, it has become more important for medical staff to be able to discuss this issue with the patients, educate them about it, and create the motivation for them to overcome it.

The final certification reviewed is the Advanced Cardiovascular Life Support course. Its purpose is to practice the essential skills for the urgent treatment of cardiac arrests, strokes, and other similar life-threatening dangers. The course focuses on the teamwork and its importance in timely dealing with the affected patients. The course provides additional guidelines for respiratory care specialists and supplies them with knowledge on behavior in challenging cardiovascular and respiratory emergencies.

The few flaws that can be attributed to these certifications are of their web-based nature, which implies a lack of hands-on practices for the staff, and that can impede their effectiveness in the early stages of actual work. Another issue is their relatively high price, which can also create a barrier for some of the students. However, both of these issues are offset by the high quality of materials in the courses.

The advantages of the studied certifications

All three courses provide vital information for the development and preparation of respiratory care specialists. They all address issues that a therapist will encounter at some point in his career.

The Leadership Institute provides the students with access to vast abundances of course materials related to their specialization. The respiratory care course gives the students information in Education, Management, and Research, allowing future therapists to study them in any combination. For example, it allows the students to not only learn methods of respiratory therapy, but also receive advice on how to deal with a client, organize a medical team, improve one’s leadership skills, develop and conduct research studies, and more. The other two courses provide equally important skills for treating Chronic Obstructive Pulmonary Disease, and more urgent heart and lungs related emergencies.

Conclusion

Ultimately, this is a very useful set of courses, which vastly advances the practice of respiratory care, while simultaneously providing education in other related and relevant skills, both medical and social.

Reference

Leadership Institute. (n.d.). Web.

Introduction

According to statistics 260 million vehicles were registered in the USA in 2014 (Number of vehicles registered in the United States from 1990 to 2014, n.d.). This enormous amount proves the existence of the great demand and poses a threat to peoples security. The fact is that any vehicle could be considered dangerous for people. The same statistics evidence that thousands of people die from motor vehicle car accidents (MVA) annually (Number of vehicles registered in the United States from 1990 to 2014, n.d.).

Additionally, a number of individuals suffer from serious injuries and other complications that deteriorate the quality of their lives. Besides, the existence of the given problem conditions the rapid evolution of the spheres and tools that are aimed at the provision of help and assistance for those who suffered from the road traffic accident and became injured. The health care sector could be considered one of these fields that provided numerous tools and practices to guarantee an individuals existence and improve his/her quality of life.

Background

As stated above, road traffic accidents could be considered one of the main causes of death in the modern age (Murty & Ram, 2012). Yet, the character of traumas peculiar to this sort of patients predetermined the appearance of certain practices needed to help people and protect their lives. Besides, at the moment phrenic nerve paralysis, diaphragmatic injuries, and thoracic cage injuries could be considered the main characteristics of an individual who experienced a motor vehicle accident (Murty & Ram, 2012).

For this reason, the modern health care sector provides numerous approaches to the treatment of these very traumas. Furthermore, there are many researchers and investigations that revolve around the given issue and provide their own approaches and solutions to the given problem. The significance of these traumas and efficiency of some approaches are proven by the increased success rates peculiar to medical establishments that are specialized on the provision of the needed care for patients.

Phrenic nerve paralysis

Description

Nevertheless, the great percentage of road tolls suffer from serious problems with respiration. In the majority of cases, the accident of this sort is characterized by a strong stroke in the thoracic region which might result in phrenic nerve paralysis, diaphragmatic and thoracic cage injuries (Murty & Ram, 2012). These problems could also cause a great threat to the patients health and be one of the main causes of death. That is why there are numerous approaches to the way these very patients should be treated. However, provision of the respiratory care is one of the main tasks that arise from the nature of trauma and the patents basic needs. In other words, there is the great necessity of the breathing management to guarantee a patients survival. However, the care should consider the character and complexity of trauma.

Literature Review

If to speak about the above-mentioned problems, phrenic nerve paralysis could be considered rather common. The crash and strong stroke might result in the palsy of this very nerve and condition the appearance of numerous respiratory problems. For this reason, it is crucial to assure that a patient will be able to breathe and initiate the procedure of treatment. The complexity of the trauma and issue comes from the great significance of the given nerve and its impact on the whole respiratory system. There are numerous approaches to the treatment as its results determine the terms of the patients recovery and his/her further living. That is why it is crucial to investigate the main existing approaches to obtain the clear image.

Yet, the modern medical science provides several approaches to this problem. Tsakiridis et al. state that phrenic nerve paresis is one of the main traumas appearing after serious crashes (2012). For this very reason, it is vital to apply the modern and efficient surgical treatment that could help a patient recover and improve the quality of life.

The authors state that there are several techniques and approaches that are employed for diaphragmatic plication which are thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery (Tsakiridis et al., 2012). These practices are needed to provide respiratory care for this sort of patients and help them to recover. However, the researchers also state that the efficiency of these approaches could be impacted by the general state of the patient’s health.

Furthermore, Liu et al. (2015) underline the great threat of phrenic nerve paralysis and the necessity of the efficient treatment. They tend to consider phrenic nerve transfer the main dynamic treatment that could be used to avoid problems with respiration (Liu et al., 2015). In numerous cases, the character of the injury from which a patient suffers, introduces the great necessity of the above-mentioned transfer as it could hardly be restored by means of the modern medicine. That is why this approach could be used in the most complicated situations when there is no perspectives and possibilities for other treatment. The great potential risk of surgery is compensated by the expected positive outcomes.

Goff, Spencer, and Jaizzo (2016) also suggest several approaches to treatment. They are sure that phrenic nerve injury can be a significant complication of any road traffic accident (Goff et al., 2016). Considering their frequency, the creation of the efficient approach to treatment could be considered an important task of the modern healthcare sector. Additionally, it is vital to obtain the clear image of the harm done to this very nerve. Researchers highlight the importance of MRI and creation of the computer model to analyze its current state and prescribe the procedures needed to guarantee a patients recovery. Yet, it is extremely vital to assure that all patients will be able to breathe independently and recover from the injury.

Nevertheless, the idea of nerve transport is supported by Al-Qattan and El-Sayed in their paper. They are sure that the provision of the respiratory care for patients should be followed by the phrenic nerve transplantation as only this measure could guarantee patients complete recovery. The authors state the fact that the “phrenic nerve in healthy adults does not result in any clinically significant problems” (Qattan & El-Sayed, 2014, para. 4) and could not condition some troubles with aspiration.

For this reason, “entire phrenic nerve is commonly sacrificed and used for nerve transfer” (Qattan & El-Sayed, 2014, para. 5) in complicated cases. To solve various problems with aspiration among victims of MVA this very measure could be recommended. It might help to mitigate the negative aftermath of this very accident and improve the quality of the patents life greatly.

Finally, speaking about the problems with the phrenic nerve that appear after the traffic accident, one should consider the fact that a number of researchers also tend to accept the idea that the successful provision of respiratory care depends on the state of this very nerve. The patient might experience serious problems with breathing and have the need for intubation, lung ventilation, and some extra medical equipment. It is crucial to guarantee the timely and efficient usage of the needed devices. Besides, there is the possibility to implant a nerve stimulator that will control its functioning and guarantee the patients recovery. The electrode placed next to the phrenic nerve will help a patient to breathe and result in the significant improvement of his/her current state.

Diaphragmatic injuries

Description

Besides, diaphragmatic injuries might also accompany the above-mentioned symptoms and pose a great threat to the patients life. The given kind of trauma might introduce significant deterioration of the respiration process and result in an individuals death. For this reason, numerous investigators and therapists admit the great role this very injury might play in the process of delivery of respiratory care. One should give great attention to the problem because of its extreme importance. Diaphragmatic injuries could result in the decrease of respirations and even death. Under these conditions, a specialist should be able to consider its problems and create the most appropriate care pattern. There are several important methods suggested by scientists in numerous researches.

Literature Review

Yet, Sersar, Albohiri, and Abdelmohty (2016) are sure that any penetrating chest trauma might condition the appearance of diaphragmatic injuries and problems with respiration. Additionally, the problem is complicated by the existence of other factors that might impact the functioning of a diaphragm and predetermine the respiratory standstill. For this reason, a specialist should mind all factors that impact this very aspect and guarantee the provision of the respiratory care to assure that a patient will be able to survive and recover.

The fact is that there is the great need for some additional devices and equipment that could help a team of specialists. Furthermore, there could also be the necessity to use surgery to promote the patients recovery. The identification of the most problematic areas is crucial for patients who experience problems with respiration.

Diaphragmatic injuries also might be considered the problem that appears in the majority of accidents. Panda et al. (2014) assume that blunt and or penetrating traumas pose a great threat to patients security and should be treated in accordance with a certain procedure needed to guarantee the patients fast recovery. They are sure that the diaphragmatic injuries have been found in a number of individuals who experienced severe clashes. At the same time, respiratory problems could be observed when working with these traumas. For this reason, the analysis of vitals and provision of the efficient and high-quality health care is crucial to help individuals who suffer from this very problem.

Thiam et al. emphasize the fact that thoracoabdominal blunts or traumas might result in the appearance of the above-mentioned injuries. However, there is a certain problem related to diagnosing as it is often delayed (Thiam et al., 2016). The usage of various devices could not serve as the guarantee of the correct identification of the problem. Yet, the surgical management remains one of the most efficient treatments used in these cases. The researchers are also sure, that to mitigate the negative impact of the incident and help a patient it is vital to act immediately and identify the main reasons that result in the problems with respiration (Thiam et al., 2016).

Only under these conditions, the gradual and efficient recovery process could be initiated. Additionally, there is the great need for the usage of the appropriate approaches to guarantee the coherent analysis of the situations and reasons that caused the injury.

Nevertheless, management of the patients who suffer from the traumatic injury of the diaphragm could be complex as there is a great need for the unusual approaches and extra resources. Hwang, Kim and Byun (2011) state that there is a certain set of factors that might affect the incidence of complications and mortality in patients with the given problem. The great threat of this sort of trauma is also proven by numerous companion problems that appear when treating a patient of this sort. Hwang et al. (2011) are sure that to restore the respiration it is crucial to use operative treatment and accomplish the diaphragm’s restoration and help patients to recover. Yet, these surgeries could also be dangerous because of its great complexity.

At the same time, Bas et al. (2015) state that the reparation of traumatic diaphragmatic injuries and breathing management could be performed by means of synthetic mesh. It could be used to repair the injuries of the diaphragm and guarantee the patients survival.

They also tend to consider surgical intervention to be the only possible way to help a patient. However, there are still several crucial points that appear while providing respiratory care to a patient. A patient might die because of the unexpected complications that occur when trying to guarantee the diaphragm recovery. For this reason, the main task of any modern healthcare specialist is to assure that a patient perceives the needed care and could endure the treatment and surgery. There could be the need for some special equipment and medical devices.

Thoracic cage injury

Description

Besides, thoracic cage injury is another common problem that occurs among patients who experienced motor-vehicle accident. A high impact and the great energy of a car results in the appearance of numerous traumas. Considering the character of these very accidents, one could accept the fact that chest is one of the parts of the body that are subjected to a great threat. Statistics show that 80% of victims suffer from thoracic cage injury that could result in significant problems with respiration. For this reason, there the great need for the provision of the efficient respiratory care.

Literature review

Cogitating around the given issue, Bailey et al. (2012) state that the complexity of these traumas might be considered the main issue related to the given sphere. Thoracic cage injury is taken as potentially life-threatening as it covers such important organs as the heart, lungs, liver, etc. In this regards, efficient treatment is one of the key aspects needed to guarantee success. Yet, the authors tend to consider the provision of the respiratory care the most important concern. Moreover, there is the need for some extra actions aimed the patients state improvement.

Yet, Chaudhary, Roselli, Steinmetz, and Mroz (2012) proclaim that problems with respiration are one of the main factors that should be given greatest attention while trying to save patients lives and improving their current state The character of trauma might imply the significant deterioration of the patient’s health. The fact is that the traumatic chest injury could be considered a major cause of mortality and morbidity in patients. Moreover, the proximity of aorta, heart, and lungs increases the risk of severe complications and introduces the necessity of some extra measures.

Dongel, Coskun, Ozbay, Bayram and Atli (2013) also adhere to the above-mentioned idea. They are sure that only in terms of the efficient breathing management and immediate interventions some visible results could be achieved. For this reason, patients with thorax traumas caused by motor vehicle accidents should be given great attention. It is crucial to provide the precise and comprehensive analysis of all factors the impact his/her health and assure that he/she will be able to obtain oxygen as needed. Besides, it could be considered the complicated task in case ribs or some internal parts of the body are damaged.

Reviewing the literature devoted to this very topic, Chotai and Abdelgawad (2014) highlight the fact that thorax traumas might appear because of various reasons. However, a stroke in the chest is one of the most frequent cases that result in the appearance of complex problems. For this reason, almost any motor vehicle accident results in a serious injury that might prevent a patient from breathing. Under these conditions, the breath management is essential to guarantee his/her survival and assure that there will be the opportunity to continue recovery and help a patient to.recuperate.

As stated above, the efficient usage of the needed equipment is the key to the complete recovery. The artificial lung should be used to provide the needed oxygen and support a patient. Furthermore, the alarm system should also be introduced to warn specialists and inform them about the appearance of some emergency. All workers of the intensive care unit should be able to work with the given equipment and ready to respond to the slightest oscillations in the patients vitals. At the same time, there is the great need for the usage of some extra approaches in case there is a tendency towards the worsening of the current situation.

Finally, the modern health science tends to accept complications that appear after MVA as a great threat to the patients health (Blyth, 2014). For this reason, it provides numerous possibilities for their investigation and precise analysis. The usage of MRI and other scanning devices might provide the clear image of the current situation and help therapists to introduce the needed treatment. Moreover, there is the tendency towards the appearance of the new methods to work with these very traumas to mitigate the negative impact of the above-mentioned accidents and guarantee the patients recovery (Ustaalioglu 2015).

Conclusion

In conclusion, phrenic nerve paralysis, diaphragmatic injuries and thoracic cage injury could be considered the most dangerous concerns peculiar to patients who experienced road traffic accidents and needed recovery badly. That is why the modern science provides a number of approaches aimed at the provision of the most efficient treatments and procedures. However, there are still various perspectives that exist on the way how this sort of traumas should be cured to guarantee the patients survival.

In these regards, breathing management and provision of respiratory care for victims of traffic accidents is an important task that predetermines the success of the whole recovery process. The investigation of the credible sources proves the idea that thoracic injuries are extremely dangerous for patients and should be treated immediately.

References

Bailey, J., Heiden, T., Burlew, C., Sibbel, S., Jordan, J., Moore, E.,…Stahel, P. (2012). Thoracic hyperextension injury with complete “bony disruption” of the thoracic cage: Case report of a potentially life-threatening injury. World Journal of Emergency Surgery, 7,14. Web.

Bas, G., Ozkan, V., Alimoglu, O., Eryilmaz, R., Sahin, M., Okan, I.,…Cevikbas, U. (2015). The role of n-butyl-2-cyanoacrylate in the repair of traumatic diaphragmatic injuries. International Journal of Clinical and Experimental Medicine, 8(4), 5876-5882. Web.

Blyth. A. (2014). Thoracic Trauma. BMJ, 348. Web.

Chaudhary, S., Roselli, E., Steinmetz, M., & Mroz, T. (2012). Thoracic Aortic Dissection and Mycotic Pseudoaneurysm in the Setting of an Unstable Upper Thoracic Type B2 Fracture. Global Spine Journal, 2(3), 175-182. Web.

Chotai, P., & Abdelgawad, A. (2014). Tug-of-War Injuries: A Case Report and Review of the Literature. Case Reports in orthopedics, n.pag. Web.

Dongel, I., Coskun, A., Ozbay, S., Bayram, M., & Atli, B. (2013). Management of thoracic trauma in emergency service: Analysis of 1139 cases. Pakistan Journal of Medical Sciences, 29(1), 58-63. Web.

Goff, R., Spencer, J., & Jaizzo, P. (2016). MRI Reconstructions of Human Phrenic Nerve Anatomy and Computational Modeling of Cryoballoon Ablative Therapy. Annals of Biomedical Engineering, 44, 1097-1106. Web.

Hwang, S., Kim, H., & Byun, J. (2011). Management of Patients with Traumatic Rupture of the Diaphragm. The Korean Journal of Thoracic and cardiovascular surgery, 44(5), 348-354. Web.

Liu, Y., Xu, X., Zou, Y., Li, S., Zhang, B., & Wang, Y. (2015). Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics. Neural Regeneration Research, 10(2), 328-333. Web.

Murty, V., & Ram, K. (2012). Phrenic nerve palsy: A rare cause of respiratory distress in newborn. Journal of pediatric neurosciences, 7(3), 225-227. Web.

Number of vehicles registered in the United States from 1990 to 2014. (n.d.). Web.

Panda, A., Kumar, A., Gamanagatti, S., Patil, A., Kumar, S., & Gupta, A. (2014). Traumatic diaphragmatic injury: a review of CT signs and the difference between blunt and penetrating injury. Diagnostic and Interventional Radiology, 20(2), 121-128. Web.

Qattan, M., & El-Sayed, A. (2014). The Use of the Phrenic Nerve Communicating Branch to the Fifth Cervical Root for Nerve Transfer to the Suprascapular Nerve in Infants with Obstetric Brachial Plexus Palsy. BioMed Research international, 348. Web.

Sersar, S., Albouhiri, K., & Abdelmothy, H. (2016). Impacted thoracic foreign bodies after penetrating chest trauma. Asian Cardiovascular and Thoracic Annals, n. pag. Web.

Thiam. O., Konate, I., Gueye, M., Omar, T., Seck, M., Cisse, M.,…Toure, C. (2016). Traumatic diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects. Springerplus, 5(1), 1614. Web.

Tsakiridis, K., Visouli, A., Zarogoulidis, P., Machairiotis, N., Christofis, C., Stylianaki, A.,…Zarogoulidis, K. (2012). Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis. Journal of Thoracic Disease, 4(1), 56-68. Web.

Ustaalioglu, R., Yildirim, M., Cosgun, H., Dogusoy, I., Imamoglu, O., Yasaroglu, M.,…Okay, T. (2015). Thoracic Traumas: A Single-Center Experience. Turkish Thoraric Journal, 16(2), 59-63. Web.

Respiratory disorders can have a variety of symptoms that do not differ significantly from each other. For example, one of the alterations that characterize pulmonary conditions is a cough (Hammer & McPhee, 2014). A cough can be a sign of many issues with one’s breathing functions, including acute and chronic disorders. In the second presented case, the boy’s cough is harsh, deep, and hoarse, while other symptoms are barely noticeable. This description along with the fact that the boy did not receive proper vaccinations suggests that the patient has acute laryngotracheobronchitis (croup). Croup is a disorder that affects children (especially boys) and is distinguished by a “barking” cough developed as a result of an infection of the trachea.

Scenario Analysis

The patient in the scenario shows multiple signs of having croup. First of all, the central respiratory alteration, in this case, is a cough. The boy’s cough is described as having a “barking sound,” and it also produces mucus and leads to the child vomiting occasionally. Another symptom is light fever, and no additional problems are visible or examined in the case. The analysis of these symptoms suggests that the child has croup – an acute disorder that is usually acquired through a virus such as a parainfluenza (Huether & McCance, 2017). Another argument supporting this diagnosis is the fact that the patent may not have the necessary vaccinations – the primary way to prevent the development of croup in children (Huether & McCance, 2017).

Pathophysiology

The pathophysiology of cough in croup is initiated by a virus. The infection causes the activation of the white blood cells and their infiltration of the subglottic region which also results in a mild fever. In a response to the virus, edema develops in the subglottis, leading to the accumulation of mucus and the obstruction of airways. The inflammation spreads from the larynx to bronchi, reducing the airflow and increasing the patient’s efforts to breathe. Although it is not described, the patient is likely to develop stridor, an easily identifiable breath sound in the larynx (Huether & McCance, 2017). Following the production of mucus and the decrease in airflow, the child develops a cough.

Patient Factors

Age and gender are factors that are strongly associated with the development of croup. First of all, croup is one of the most common pediatric respiratory disorders (Mandal, Kabra, & Lodha, 2015). This disease is prevalent in children from 6 months to 5 years old, although some patients may develop the infection later than that (Huether & McCance, 2017). Moreover, the condition affects young boys more often than girls, and the difference in genders is rather significant (Mandal et al., 2015; Modaresi et al., 2018). Thus, while croup can develop in older children, its regular occurrence in adults is not recorded. The factor of age directly impacts the probability of a person acquiring the condition. The variation between male and female patients with croup differs from one article to another, but the prevalence of young boys is noted in all studies (Mandal et al., 2015; Modaresi et al., 2018).

Conclusion

The discussed case study shows how a particular type of cough can serve as the primary source for the patient’s diagnosis. The young patient in the scenario has croup – an infectious condition that affects children and is characterized by a “barking” cough. This cough is a result of subglottic edema and mucus formation. The patient’s age and gender were influential in his developing the condition. Croup is a pediatric disorder that is prevalent in young boys.

References

Hammer, G. G., & McPhee, S. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.) New York, NY: McGraw-Hill Education.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.

Mandal, A., Kabra, S. K., & Lodha, R. (2015). Upper airway obstruction in children. The Indian Journal of Pediatrics, 82(8), 737-744.

Modaresi, M., Pourvali, A., Azizi, G., Taher, R. R., Alinia, T., & Reisi, M. (2018). Association of childhood croup and increased incidence of airway hyperreactivity in adulthood. Journal of Education and Health Promotion, 7, 97.

Respiratory System: Description

The human respiratory system (RS) is known as the system of organs that allows obtaining oxygen from the air, delivering it to the necessary organs, and exhale carbon dioxide (CO2). The RS consists of the lungs, which maintain the continuous flow of oxygen and remove gaseous products from the human body (Kon & Rai, 2016). The RS also contains the airways, which are categorized into lower and upper ones, and which serve the purpose of pumping air, whereas the oxygen that it contains is delivered to specific organs with the help of red blood cells (Kon & Rai, 2016).

Despite the clockwork mechanism of the system, the RS is rather fragile since its performance can be disrupted once airways are blocked. The resulting experience of problems breathing and even possible suffocation may cause severe consequences from oxygen deprivation to death (Kon & Rai, 2016). Therefore, the case under analysis, which involves seemingly minor concerns, particularly, cough, needs in-depth analysis.

Physiology: Structure and Function

The upper respiratory tract consists of the nasal cavity, nostrils, pharynx, epiglottis, and larynx (Boore, Cook, & Shepherd, 2016). The lower respiratory tract, in turn, is composed of the trachea, esophagus, pulmonary vessels, intercostal muscles, left and right lungs, heart, bronchioles, the pleural membrane, alveoli, and the diaphragm (Boore et al., 2016). During the process of breathing, oxygen (O2) is converted into CO2. The latter, in turn, is transformed into HCO3 when transported from tissue cells to the lungs (Ward, ‎Ward, ‎& Leach, 2015). The process of HCO3 creation occurs as CO2 emitted from the lungs is combined with H2O to produce carbonic acid (H2CO3). The latter decomposes into HCO3 and H+ ions. The specified process is known as peripheral control, which is opposed to the central control.

Relevant Health History Questions

The current information concerning the health status of the patient does not allow making clear assumptions and diagnosing the problem. Therefore, a detailed assessment of the patient’s health history will be required. It is currently known that the patient is eight years old and that he has had a cough for five days. However, the root causes of the specified symptoms may vary from a minor respiratory inflammation caused by an infection to the early stage of asthma development. Therefore, further steps will have to be taken to determine the cause of the patient’s current condition. To define the factors that may have caused the cough, one may need to ask the patient or his mother the following questions:

1. Does the child have any known allergies?
2. Has the child been diagnosed with respiratory diseases such as asthma?
3. Has the child been exposed to cold recently?
4. When did the cough start?
5. What was the child doing when the cough started?
6. How can you describe the cough?

Objective Data and Expected Findings

Apart from relying on the evidence provided by the patient, a therapist will also have to perform several tests to locate the actual cause of the cough. For this purpose, the characteristics of a cough must be defined. For example, it will be necessary to check whether the cough is dry or productive. Also, a chest X-ray will allow determining whether the problem is caused by lung obstruction. Pulmonary function tests (PFTs) can be useful in case the problem turns out to be chronic (Sharafkhaneh, Yohannes, Hanania, & Kunik, 2017). Bronchial challenge testing and sinus imaging will have to be deployed if other methods of determining the problem prove to be futile. It is expected that the results of the patient assessment will point to a respiratory inflammation possibly caused by an infection.

Physical Assessment of Examination Techniques

As stressed above, a physician may need to run several tests to determine the factors that may have caused the issue. However, apart from the specified strategies, one will also need to use specific examination techniques. For example, the vital signs of the patient must be assessed. Also, a physician will have to revise all of the patient’s systems to ensure that the cause of the cough has been determined correctly and that no other factors affect its development. The specified step will have to be followed by the examination of the patient’s head, eyes, ears, nose, and throat. Also, a therapist will need to examine the patient’s neck and cardiovascular system to locate possible factors that may cause the cough.

Finally, chest examination as the most important step in the specified assessment process will be performed. The therapist will inspect and palpate the patient’s chest to locate the reasons for the cough to take place. The doctor will also have to evaluate the percussion of the lung fields along with the possible auscultation of the lungs. The specified checks will allow identifying the presence of wheezing, chest vibrations, and other characteristics of pulmonary obstruction that will allow defining the problem.

Physical Assessment Skills

To conduct the assessment, the therapist will have to use basic skills associated with the management of respiratory issues. Specifically, active observation will have to be used to identify the presence of a problem and explore its nature. Also, a therapist will require the ability to calculate the respiratory rate of the patient, examine his nasal cavity, and locate the presence of breathing problems such as wheezes and forced exhalation.

The specified skills can be used to accommodate the needs of infants by taking the fact that their airways are smaller into consideration. To manage the needs of pregnant women, one will have to assess abdominal muscle thickness as well. Finally, to address the health concerns of geriatric patients, one will need to consider the issues of comorbidity and frailty. Thus, a comprehensive assessment will be conducted.

Disease That Can Affect the Respiratory System

As stressed above, there is a range of diseases and disorders that may have caused the cough that is currently observed in the patient. Among the most common causes of the cough, one should mention asthma, common cold, and chronic obstructive pulmonary disease (COPD). The latter represents a combination of health issues that cause breathing issues (Boore et al., 2016). Therefore, the RS may have been affected by a vast variety of factors, and further tests will help to locate the actual cause of the cough.

Expected Abnormal Findings

The tests are most likely to return the results that will signify the presence of an infection, a common cold, or an allergic reaction that the patient must have suffered recently. The exposure to allergens may have triggered the fast development of the disease and, thus led to an unceasing cough. However, other causes of the problem may also be discovered in the course of the assessment since the current information is far too scarce to state the problem with certainty.

Summary

The case of a cough that was analyzed above lacks the data that could help define the presence of a particular issue straightaway. Thus, a therapist must perform further assessments to locate the cause of the issue and suggest the medications and treatment techniques that will help the patient. It is believed that the patient may have developed a common cold, asthma, or another respiratory issue that may have caused the problem to emerge. In any scenario, a detailed assessment of the patient’s health history and profound analysis of test results are required.

References

Boore, J., Cook, N., & Shepherd, A. (2016). Essentials of anatomy and physiology for nursing practice. Thousand Oaks, CA: SAGE.

Kon, C., & Rai, M. (2016). The microbiology of respiratory system infections. New York, NY: Academic Press.

Sharafkhaneh, A., Yohannes, A. M., Hanania, N. A., & Kunik, M. E. (2017). Depression and anxiety in patients with chronic respiratory diseases. New York, NY: Springer.

Ward, ‎J. P. T., Ward, J., ‎& Leach, R. M. (2015). The respiratory system at a glance (4th ed.). New York, NY: John Wiley & Sons.

Acute respiratory distress syndrome

The authors review and summarize eight articles on Acute Respiratory Distress Syndrome (ARDS) to compare their clinical relevance. The variability and incidence of ARDS were perceived to differ across clinical settings across the world. These variances are mainly attributed to factors such as alterations in diagnosis, risk factors, the bias in clinical trials, and the inability to properly recognize the condition. The authors’ analysis further showed that efforts to prevent the condition were futile, with medicines such as aspirins and statins failing to assist in randomized trials. On issues of treatment, glucocorticoids were identified as a viable model in the management of ARDS. Therefore, Confalonieri, Salton, and Fabiano (2017) note the inadequacies involving the clinical practice of the condition. The authors are affiliated with the pulmonary department of the University Hospital of Cattinara, hence, are knowledgeable about issues affecting the respiratory system. They present a variety of information from several sources, comparing the definition, diagnosis, and treatment of ARDS. This article provides the basis for arguments that call for increased efforts to enable better diagnosis and recognition of the condition in patients.

The role of red blood cells and cell-free hemoglobin in the pathogenesis of ARDS

Janz and Ware (2015) analyze the pathophysiology of ARDS with the underlying complications such as lung inflammation and pulmonary edema that increase morbidity and mortality in patients. Red blood cell (RBC) membranes become damaged due to sepsis in patients leading to lower transmission of oxygen to organs which causes their failure. Additionally, a study found that cell-free hemoglobin (CFH) played a critical role in ARDS in human beings. It showed that patients had higher levels of CFH, which led to instances of higher pulmonary artery pressures and pulmonary vascular resistance (Janz & Ware, 2015). The use of haptoglobin as a treatment regimen improved renal function in patients with ARDS, while acetaminophen can reduce oxidative injury. Cell-free hemoglobin in RBC, thus, shows signs of being a pathologic mediator of ARDS in human beings. Both authors work in departments of medicine and have the requisite expertise in matters concerning ARDS. Consequently, this article widens the perspective on the causes and effects of the condition to enable the development of appropriate therapies to directly target the affected regions of the chest cavity.

Formal guidelines: Management of acute respiratory distress syndrome

The authors note that the study conducted by LUNG SAFE showed the lack of recognition of ARDS in patients by approximately 40% of cases diagnosed by clinicians. Existing guidelines at the time were more than 20 years old, thus required an update due to evolving technology and knowledge in the field. The methodology used by the authors included the use of an expert working group specifically selected to research the guidelines (Papazian et al., 2019). Their reviews included a rating guided by a Grade of Recommendation Assessment, Development, and Evaluation (GRADE) procedure. Consequently, procedures showing a high level of proof were graded higher and strongly recommended for use while lower ones received lower ratings. The authors work in the various medical field ranging from emergency departments to intensive care units hence have witnessed first-hand cases of patients. The guidelines provided in this article enable better management of ARDS by primary care clinicians to avoid critical cases based on wrong diagnosis and treatment procedures.

Analysis

The article by Papazian et al. (2019) offers the most informative data due to its extensive coverage of the various recommendations and guidelines for managing ARDS in patients. The article provides the rating of each recommendation based on the analysis completed by a group of experts, thus, can help clinicians offer assistance through evidence-based practices that increase survivability. In cases where data is insufficient to give any professional opinions, the authors explicitly state the facts available and fail to make any recommendation. This shows their concentration on evaluating data based on its impact on the patients and the medical field. Therefore, the article is based on objective data not only to inform the masses but also to enhance service delivery for patients in health institutions. The article mainly targets individuals in the medical field, including clinicians and physicians, that directly deal with ARDS patients. Being informative in nature, it adds value by imparting knowledge previously unavailable in the field.

Furthermore, the length of the article also shows its attention to detail, with each guideline specifically discussed, culminating with a recommendation on its usage in the treatment and management of ARDS. The rationale for the selection requires complete agreement by a majority of the experts used in the study for a recommendation to achieve a high score. As a result, the GRADE methodology used implies the extensive use of scientific analysis to come up with the conclusions by the reviewing of secondary data previously used and available on ARDS. Additionally, the massive pool of authors highlights the vast knowledge base used to compile and review the information used in the article. Being experts in their fields, the analysis used provides viable, evidence-based information. Therefore, the article can be identified as a reliable source of medical data on ARDS that can be relied upon due to its accuracy.

References

Confalonieri, M., Salton, F., & Fabiano, F. (2017). Acute respiratory distress syndrome. European Respiratory Review, 26(144), 160116. Web.

Janz, D. R., & Ware, L. B. (2015). The role of red blood cells and cell-free hemoglobin in the pathogenesis of ARDS. Journal of Intensive Care, 3, 20. Web.

Papazian, L., Aubron, C., Brochard, L., Chiche, J.‑D., Combes, A., Dreyfuss, D.,… Faure, H. (2019). Formal guidelines: Management of acute respiratory distress syndrome. Annals of Intensive Care, 9(1), 69. Web.

Acute respiratory failure (ARF) refers to a condition where there is severe annihilation of gas transfer at the alveolar, and this condition becomes characterized by hypercapnia (>50 mmHg) and hypoxia (<50 mmHg) in a patient who had healthy lungs formerly (Weinberger, 2008). The typical value for pulse oximeter saturation (SpO2) is 94- 98%, while arterial partial pressure of oxygen (PaO2) is 9.3-13.3 or kPa (80-100 mmHg). Further, pH is 7.35- 7.45 and arterial carbon dioxide (PaCO2) is 4.7 and kPa (35-45 mmHg) (McCurdy, 2012). Common conditions triggered by failure of ventilation include acidosis and hypercapnia.

ARF does not have a standardized definition in critical care. However, the most prevalent criteria for clinical and epidemiologic examinations include diagnosis of Acute Lung Injury (ALI) as well as Acute Respiratory Distress Syndrome (ARDS). Other criteria include some level of oxygen malfunction, employment of variable intervals of ventilator support and the respiratory factor of the Sequential Organ Failure Assessment (SOFA) score (Weinberger, 2008). ALI is the early stage of ARDS. Other ailments related with ARF include pneumonia, acute exacerbation of COPD and status asthmaticus.

ARF occurs once the fibrotic and exudative regions of the lung overlap. Subsequent to the first acute endothelial and epithelial injury, deposition of fibrin, alveolar oedema and haemorrhage occur in the lung together with disseminate interstitial inflammatory cell infiltrate (Weinberger, 2008). While hyaline membranes line the alveolar spaces, increasingly, alveolar consolidation happens.

In ARDS, the compliance of the lung obtains first reduction through alveolar oedema and disintegration, and second, by pulmonary fibrosis. While a low compliance is not commonly incorporated as a diagnostic measure of ARDS, it is an even feature of the ailment and necessitates accurate assessment to optimize support through mechanical ventilation (McCurdy, 2012). The following equations demonstrate calculations for respiratory compliance and lung compliance, respectively.

In the equation, Poes and Paw represent the pressures obtained in a 2- s inspiratory suspension at the esophagus and airway respectively. Besides, total PEEP is the summation of both intrinsic and applied positive end-expiratory pressure. VT represents tidal volume. Thus, aspects that must be incorporated into the evaluation of respiratory compliance, in patients with ARDS include assessment of auto-PEEP and intra-thoracic pressure together with measurement of plateau pressure at different lung volumes (Weinberger, 2008).

Management and Treatment

ARF can be managed through invasive, noninvasive and respiratory rescue therapy techniques. Invasive mechanical ventilation enhances gas circulation and protects the airway in severely ill patients. Initially, positive pressure ventilators, which pressured gas into endotracheal tubes, obtained common use in treating patients with acute respiratory failure. Ventilators became further refined to allow patients to prompt breaths so that they harmonized with the breathing patterns of individual patients, for comfort and efficiency. The last 15 years have experienced development of enhanced ventilators, which provides enhanced delivery of air to patients. Besides, development of methods to wean patients from invasive ventilation more safely and swiftly have helped eliminate avoidable complications and reduced expenses in intensive care units. Further, use of noninvasive ventilation has enhanced results.

Noninvasive ventilation is a significant evolution in the treatment of ARF. Noninvasive ventilation lessens injuries in the airway and the threat of pneumonia, which arises because bacteria may move into the lungs via the endotracheal tube (Bolton & Bleetman, 2008). However, noninvasive ventilation should only be used for patients with heart failure of chronic obstructive pulmonary disease. Heart failure causes inadequate pumping of blood, making fluid go back to the lungs and impede circulation of oxygenation. Usually, noninvasive ventilation has the potential of maintaining the client pending removal of the excess fluid.

Some respiratory rescue therapies include prone positioning and high frequency oscillatory ventilation. Prone positioning can enhance oxygenation in patients with ARF. Some techniques of prone positioning include enhancement of ventilation, perfusion circulation and recruitment of atelectasis. Prone positioning alleviates hydrostatic pressure of superimposing lung parenchyma and the constrictive effect of the heart on lungs.

Equally, high frequency oscillatory ventilation enhances gas exchange through an elevated mean airway pressure and reduced tidal volume compared to normal minute volume, thus allowing lung protective ventilation.

ARF treatment involves pharmacological adjuvant therapies, which include neuromuscular blocking agents and corticosteroid treatment. Managing high levels of intracerebral pressure, reducing oxygen consumption, allowing invasive MV, and treating muscle spasms are some of the roles of neuromuscular blocking agents (Bream-Rouwenhorst, Beltz, Ross, &Moores, 2008). This application is relevant when other methods fail.

On the other hand, corticosteroids obtain use in several physiological mechanisms. Insufficiency of corticosteroid can result in severe illness although critical illness can as well trigger relative insufficiency (Bream-Rouwenhorst et al., 2008). Corticosteroids obtain most use in conditions that cause ARFs such as severe asthma and acute chronic obstructive pulmonary diseases, due to their anti-inflammatory effect.

Prolonged use of corticosteroids causes risks associated with an increased vulnerability to infection. Similarly, extended use of NMBAs can cause severe polyneuropathy, weakness and myopathy in mechanically ventilated patients and those with septic illness. Prolonged use of both corticosteroids and NMBAs causes the risk of muscle weakness.

New treatments of ARFT include use of surfactants, extracorporeal techniques of gas exchange and new mechanical ventilation. Lung surfactants can be used for replacement therapy in treatment of ALI, especially when the alleged cause is aspiration pneumonia (Weinberger, 2008). However, this method is still under investigation.

There are also new ways of mechanical ventilation. The traditional way of ventilating ALI patients’ provides hefty tidal volumes, reduces the fraction of inspired oxygen and maintains standard amounts of arterial oxygen as well as carbon dioxide. Considerable changes to this custom have obtained consideration based on the traumatic impacts of mechanical ventilation on lungs.

Lastly, extracorporeal techniques of gas exchange are new to clinical practice. The idea underlying the utilization of this technique in patients with ARF is to offer an interim alternative for transpulmonary respiration as the damaged lungs recuperate.

Planning for Care

Care for ARF can be obtained from home or hospital. Chronic alveolar hypoventilation can be enhanced by long-term mechanical ventilation in the course of impulsive breathing. Long-term mechanical ventilation reduces hospitalization need, enhances quality of life, besides survival (Bream-Rouwenhorst et al., 2008.

At the same time, acute and severe respiratory failure requires medical intervention. Levels of oxygen require swift normalization through providing additional oxygen. Patients experiencing high levels of carbon dioxide l require breathing support. Such patients obtain pressurized gas from gadgets that augment pressure when prompted by a timer or the patient’s breathing efforts. This gas may be supplied through invasive ventilation, whereby a plastic tube gets slotted into the trachea, or through noninvasive ventilation, whereby a mask gets fastened over the mouth and nose. Certain patients may require noninvasive ventilation just at nighttime. Noninvasive ventilation allows an enhanced quality of sleep because the patient’s fatigue becomes alleviated. Hence, the plan to take care of a patient from home or hospital should be based on the needs of the patient. If a patient’s situation calls for hospitalization, that is what should follow.

Assessment and Evaluation

Most patients with ARF end up in the Intensive Care Unit (ICU). Since ICU may have an impact on quality of life, an assessment on long-term quality of life (QOL) is vital. The Euro-QOL-5D (EQ-5D) and the Short Form 36-item questionnaire (SF-36) can be used to access QOL for patients with ARF (Fitzgerald, 2010). SF-36 evaluates 8 aspects including physical pain, task limitations because of physical difficulties, social functioning, bodily functioning, task restrictions owing to emotional issues, mental wellbeing, health views as well as fatigue. Conversely, EQ-5D evaluated 5 aspects including self-care, mobility, normal activities, depression, physical pain and vision.

Prevention and Interventions

Common principles of clinical practice are essential for the deterrence of ALI. Some of these principles include quick fixation of fissures, sufficient volume recovery of hypovolaemic states, timely drainage of abscesses, grafting of burnt marks and proper use of antibiotics.

Education should be offered to clients who seem to be at risk of acquiring ailments related to ARF. For instance, clients who are smokers should be enlightened on the dangers of smoking. Patients who exhibit symptoms of ARF should be taught how to manage the disease. Patients also require education upon receiving treatment and medications, in order to know how to manage the disease.

References

Bolton, R. & Bleetman, A.(2008). Non-invasive ventilation and continuous positive pressure ventilation in emergency departments: Where are we now? Emergency Medical Journal, 25(4), 190-1944.

Bream-Rouwenhorst, H.R., Beltz, E.A., Ross, M.B., Moores, K.G.(2008). Recent developments in the management of acute respiratory distress syndrome in adults. American Journal of Health System Pharmacy, 65 (1), 29-36.

Fitzgerald, R.C. (2010). Pre-invasive disease pathogenesis and clinical management. New York, NY: Springer.

McCurdy, B. (2012). Noninvasive positive pressure ventilation for acute respiratory failure patients with chronic obstructive pulmonary disease (COPD): An evidence-based analysis. Ontario Health Technology Assessment Series, 12 (8), 1–102.

Weinberger, S. (2008). Principles of pulmonary medicine. London, England: Sage.

Respiratory alterations are ranked as the leading cause of respiratory illnesses in infants and children. Depending on the organs affected, these respiratory disorders can be classified either as upper respiratory disorders or lower respiratory disorders (Huether & McCance, 2012). The former affects organs that include the nose, the ear, the larynx, and the pharynx while the former affects the bronchi, the trachea and the lungs. It is incumbent for advanced practice nurses (APNs) to draw a distinction between severe and moderate respiratory illnesses and offer a proper diagnosis and prescription to patients that seek their professional help. APNs can only execute this mandate after they have a clear understanding of the pathophysiology of different respiratory disorders.

Infants are prone of contacting respiratory disorders. This is because of their immature immune system, underdeveloped supporting cartilages and smaller airways. These expose infants to respiratory illnesses. Their small airways can get obstructed when mucus accumulates in the system. Additionally, their immature immune system can also not withstand some mild attacks that a well developed or mature respiratory system can withstand. In scenario 1, Ms Teel’s baby is brought to the APN and the mother fears that the infant might be suffering from RSV. This is the correct diagnosis because of the chronic nature of the cough. Viral infections do not respond to medication. Again, infants whose immune system was affected by a previous infection are susceptible to such chronic attacks. This is because of the weakened immune system.

Pathophysiology of RSV

The chronic cough exhibited by the infant shows that there is a likelihood that the infant’s lungs might not have developed properly. The infant’s lung might be lacking in surfactant, a material that is responsible for structural support and prevents collapse of the air spaces during the normal course of breathing (McPhee & Hammer, 2012). In a properly functioning lung, the surfactant packed with lamellar bodies which extrude into the air space and folds to form a lining of the air space. This lining helps in reducing the surface tension exerted on the air space by the fluid that lines the cavity of the air sac (Shanley, Wheeler, & Wong, 2007). Approximately two-thirds of the recoil forces that occur inside the air space can be attributed to surface tension.

The reduced surface tension caused by the surfactant prevents the total collapse of the air spaces during exhalation and also causes the air spaces to re-open with a lower amount of force. This shows the important role played by surfactants in ensuring that the air spaces functions as they should (Iannuzzi, Rybicki, &Teirstein, 2007). A lung with insufficient amount of surfactant can be seen microscopically showing expanded area with collapsed air spaces. This results into a reduced gas exchange capacity of the lungs. Positive pressure ventilation and administration of therapeutic oxygen can help remedy the situation.

The Effect of Age and Gender on RSV

RSV is very common in infants. Children under the age of one year are the most affected by this virus. Almost all children get infected with this virus but only a selected few develop a severe respiratory alteration from the viral infection (Frequently Asked Questions, 2008). The virus is can also be found in school going children. Most infants get infected with the virus when their siblings carry the virus home from school. Meaning that the older children contact the virus from their peers in school and bring it home from where they unknowingly infect their younger siblings. Gender does not impact RSV in any significant way. The virus infects both boys and girls in same frequency.

References

Frequently Asked Questions. (2008, October 17). Centers for Disease Control and Prevention. Web.

Huether, S. E., &McCance, K. L. (2012). Understanding pathophysiology (Laureate custom ed.). St. Louis, MO: Mosby.

Iannuzzi, M. C., Rybicki, B. A., &Teirstein, A. S. (2007). Sarcoidosis. The New England Journal of Medicine, 357(21), 2153–2165.

McPhee, S. J., & Hammer, G. D. (2012). Pathophysiology of disease: An introduction to clinical medicine (Laureate Education, Inc., custom ed.). New York, NY: McGraw-Hill Medical.

Shanley, T. P., Wheeler, D. S., & Wong, H. R. (2007). Pediatric critical care medicine: Basic science and clinical evidence. London: Springer.

Stein, Paul.Pulmonary Embolism (2^nd ed.). Oxford: Blackwell Publishing, 2007. Print. Web.

According to Stein (3), morbidity of the population and age are the two main factors that enhance the development of pulmonary embolism.

Hough, Alexandra. Physiotherapy in Respiratory Care: An Evidence-Based Approach to respiratory and Cardiac Management (3^rd ed.). London: Chapman & Hall, 2001.Print. Web.

The clotting of blood around the region of pulmonary vasculature is the main cause pulmonary embolism (Hough 116). It may be caused by various factors. However, this type of blood clot is common among individuals who do not carry out a lot of physical exercises to enhance blood flow.

Zadik Yehuda, Becker Tal and Levin Liran. Intra-oral and peri-oral piercing. J Isr Dent Assoc 24 (2007): 29–34. Print. Web.

Ludwig’s angina affects the floor of the mouth. In most cases, the infection affects the connective tissue inside the lower regions of the mouth. It is also known as angina ludovici. The infection is mainly diagnosed among adults. The airways may be obstructed if the infection is left untreated for a long time.

Goldhaber, Samuel & Ruth Morrison. Pulmonary Embolism and Deep Vein Thrombosis. Circulation. 2002, 106, 1436-1438. Print. Web.

Pulmonary embolism results from the movement of blood clots in the veins to the heart. The blood containing clots is then pumped into the pulmonary arteries. This article will offer information on the risk factors, diagnosis, warning signals, preventive measures, and treatment of pulmonary embolism.

Galiè, Nazzareno; Hoeper, Marius M.; Humbert, Marc; Torbicki, Adam; Vachiery, Jean-Luc; Barbera, Joan Albert; Beghetti, Maurice; Corris, Paul; Gaine, Sean; Gibbs, J. Simon; Sanchez, Miguel Angel Gomez; Jondeau, Guillaume; Klepetko, Walter; Opitz, Christian; Peacock, Andrew; Rubin, Lewis; Zellweger, Michael & Simonneau, Gerald. Guidelines for the diagnosis and treatm ent of pulmonary hypertension. Eur Heart J (2009) 30 (20), 2493-2537. Web.

This article offers information on necromantic peptides, prognosis, thrombosis, heart diseases, and embolism. It will provide a deep understanding of the risk factors associated with pulmonary embolism.

Deep vein thrombosis (DVT) affects certain veins in the human body through random clotting of blood. It is known to cause severe pain on the affected patient since the veins tend to swell and consequently hinder the smooth flow of blood. The worst affected area of the body is usually the legs. Although most infections of this nature have open symptoms, DVTs do not demonstrate signs and symptoms at all. However, sitting down for a long time may cause DVTs.

Van Neste, Els G., Verbruggen, Ward & Leysen, Mark. Deep venous thrombosis and pulmonary embolism in psychiatric settings. The European Journal of Psychiatry, 2009. Web.

This is a research paper on how the right ventricular dysfunctional status can help in predicting the expected results on stable clinical patients who have been affected with pulmonary embolism. Grifoni et al (2819) is quite categorical that this type of infection can be treated although delay in treatment may lead to further complications.

Bordow, Richard, Ries Andrew and Timothy Morris. Manual of Clinical Problems in Pulmonary Medicine (6^th Ed.). New York, NY: Lippincott Williams & Wilkins, 2005. Print.

The book has adequate information on the diagnosis and treatment of wide range of pulmonary disorders. For instance, medication heparin is usually made of sodium injection. It is often considered to be having a sterilizing effect. The solution is made up of heparin sodium. The main contents of this solution are intestinal mucosa porcine. It is mixed with water before the medication can be offered to the patient. The sample liquid medicine injections are stored in small containers with various denominations ranging from 1000 to 25000 ml units.

Works Cited

Bordow, Richard, Ries Andrew and Timothy Morris. Manual of Clinical Problems in Pulmonary Medicine (6th Ed.). New York, NY: Lippincott Williams & Wilkins, 2005. Print.

Hough, Alexandra. Physiotherapy in Respiratory Care: An Evidence-Based Approach to respiratory and Cardiac Management (3rd. ed.). London: Chapman & Hall, 2001.Print.

Goldhaber, Samuel and Ruth Morrison. Pulmonary Embolism and Deep Vein Thrombosis. Circulation 106 (2002): 1436-1438. Print.

Galiè, Nazzareno; Hoeper, Marius M.; Humbert, Marc; Torbicki, Adam; Vachiery, Jean-Luc; Barbera, Joan Albert; Beghetti, Maurice; Corris, Paul; Gaine, Sean; Gibbs, J. Simon; Sanchez, Miguel Angel Gomez; Jondeau, Guillaume; Klepetko, Walter; Opitz, Christian; Peacock, Andrew; Rubin, Lewis; Zellweger, Michael & Simonneau, Gerald. Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J (2009) 30 (20), 2493-2537. Web.

Stein, Paul. Pulmonary Embolism (2nd ed.). Oxford: Blackwell Publishing, 2007. Print.

Van Neste, Els G., Verbruggen, Ward & Leysen, Mark. Deep venous thrombosis and pulmonary embolism in psychiatric settings. The European Journal of Psychiatry, 2009. Web.

Zadik Yehuda, Becker Tal and Levin Liran. Intra-oral and peri-oral piercing. J Isr Dent Assoc 24 (2007): 29–34. Print.