Breath

1. Breath Lecture for 1st year students

2. Active act Pasive act

7. how to measure breathing rate

11. 14 - 20 Person is after rest, sitting/lying in a quiet possition

12. 14 – 18 optimal

13. Abnormal breath • tachypnea - frequent breathing (more than 20 per minute at rest) • bradypnea - rare breathing (less than 12 per minute at rest) • apnea - no breath for a minute

14. test

25. How do you measure your breathing rate? • Answer: • You will need a stopwatch or a watch that can act like a stopwatch.  • 1.Choose a person to help you with this experiment. 2.Tell the person to count the times he or she inhale air say that you will say 'GO' when he or she have to start.  • 3.Say 'GO' at the same time you start the stopwatch. 4.Say 'STOP' after 1 minute or 60 secinds.  • This will be the breathing rate.You should normally get from12 to 20 breaths per minute. • 5.Record your findings

26. How to Measure and Record Respiratory Rate

27. which measure heart rate, breathing rate and skin temperature among other things. The measurements provide feedback about the person's stress level. electrical sensors,

30. Heart Rate alone is not the answer Heart Rate is noisy when activity is high. Heart Rate is shallow so accuracy moves a large amount between zones. Heart is effected by anxiety and stress. Heart Rate is effected by chemicals such as caffeine. Combine Measures for Valuable Information

31. Physical Examination Body mass index (BMI): 25.2 kg/m2 Blood pressure (BP): 145/92 mm Hg Lungs: normal breath sounds Heart: regular rhythm, no murmurs or gallop No jugulovenous distention Abdomen: normal for age Head, eyes, ears, nose, throat (HEENT): normal for age No peripheral edema Case 1: A 53-Year-Old Man With Bronchitis

32. Case 1: A 53-Year-Old Man With BronchitisPresentation • comes to your office for a follow-up evaluation after visiting the emergency department 2 weeks ago for an episode of bronchitis. • This was his third trip to the emergency department for bronchitis in a year. When asked to describe his respiratory symptoms, he reports noticing shortness of breath with activity. • Over the past year, it has become increasingly difficult to climb stairs at his construction site, where he works as a foreman. Robert has mild hypertension, which has been well controlled with an angiotensin-converting enzyme inhibitor (ACEI) since his diagnosis 3 years ago. Robert switched ACEIs 3 months ago because of a change in insurance coverage and is happy with the switch. • His job required him to have an electrocardiogram (ECG) 3 months ago, and findings were normal. A colonoscopy performed 1 year ago was also normal.

33. Decision Point 1 (more than 1 option is possible)What other information would you like regarding the patient’s respiratory status?  A. Allergies  B. Smoking status  C. More information about his ACEI as a potential source of cough  D. History of asthma as a child

34. Selection Rationale A. OPTIONAL. Robert’s occupational exposure to building materials and outdoor allergens may lead you to suspect allergies as a source of his cough.4 However, it is unlikely that allergies have contributed to his recent episodes of bronchitis or his new-onset shortness of breath. B. RECOMMENDED. When conducting a history in patients with respiratory symptoms, clinicians should evaluate a patient’s current smoking status and smoking history, including cumulative smoking exposure. Smoking exposure can be assessed by calculating the number of smoking pack-years, which helps clinicians to account for differences in smoking duration and intensity.5  Higher levels of cumulative smoking exposure are associated with more dramatic declines in lung function.6        C. NOT RECOMMENDED. Dry, persistent cough is a well-described class effect of ACEI therapy that occurs in 5% to 35% of patients who have been treated with these agents.7 Thus, it is possible that Robert’s cough is related to a recent switch in ACEI therapy. However, ACE inhibition would not explain his episodes of bronchitis or his new-onset dyspnea.D. OPTIONAL. In patients with respiratory symptoms, a thorough medical history should include any history of asthma, allergy, or respiratory infections in childhood.8 This information is not diagnostic, but medical history could be useful for distinguishing COPD from asthma.

35. Presentation(cont’d) • Robert is a former smoker with a 35–pack-year history. • He quit smoking approximately 6 months ago and has not relapsed. • Before he stopped smoking, Robert had a productive cough most mornings, with more sputum on some days than others. • He says his coughing has improved since he quit smoking, but he still coughs a few mornings each week.

37. Decision Point 2Further information on which of the following would help you evaluate Robert’s respiratory status? •  A. Seasonal allergies •  B. Respiratory disease (eg, asthma or COPD) •  C. Cardiovascular disease (eg, heart failure or coronary artery disease) •  D. Obesity and deconditioning

39. Selection Rationale • A. NOT LIKELY. In a patient with chronic cough, physical signs of allergic rhinoconjunctivitis—pale and swollen turbinates, prominent nasal crease, nasal polyps, or allergic shiners—should trigger a suspicion of allergies.9However, Robert’s HEENT evaluation was normal. In addition, seasonal allergies are not typically associated with dyspnea on exertion.10 • B. LIKELY. Robert’s chronic and progressive symptoms of cough and dyspnea suggest the potential for respiratory disease, such as asthma or COPD. COPD should be considered in any patient who has symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk factors for the disease.8 COPD should also be considered in patients with at least a 20–pack-year smoking history.11       C. NOT LIKELY. Robert had normal ECG findings 3 months ago and has no physical signs that suggest the presence of underlying cardiovascular disease. He appears to be doing well on his ACEI. Continued monitoring of his hypertension is appropriate. • D. NOT LIKELY. Although Robert is slightly overweight with a BMI of 25.2 kg/m2, his body weight has been stable for the past 5 years. Therefore, his weight does not account for his recent changes in respiratory symptoms. He has remained relatively active on his job, yet he is experiencing an increase in shortness of breath with the same level of activity.

40. Presentation(cont’d) • After considering Robert’s clinical presentation, you decide to pursue a diagnosis of asthma or COPD. Asthma and COPD may present with overlapping symptoms,  so it is important to understand the differences between these diseases. With additional workup, you may be able to identify recurrent symptoms or other disease features that can help differentiate between asthma and COPD. 

43. Case Conclusion • Robert is diagnosed—on the basis of his history, physical examination, and spirometry results—with moderate (stage II) COPD. He should begin evidence-based therapy according to the GOLD guidelines, which provide treatment recommendations according to COPD stage.3 •  The Advisory Committee on Immunization Practices of the US Centers for Disease Control and Prevention (CDC) recommends that all people with COPD receive annual influenza vaccinations.19 In addition to prescribed pharmacotherapy for COPD, Robert should now receive an influenza shot every year (plus a novel H1N1 influenza vaccination in 2010) and a pneumococcal polysaccharide vaccine if he has not already received this. •  Once he has started therapy, Robert should return after 4 weeks to ensure that he understands his diagnosis and is taking his medication as prescribed, that the medications are improving his symptoms, and that he is using proper inhaler technique. •  Robert should be monitored for continued smoking abstinence, history of exacerbations, and changes in comorbid conditions at each future follow-up visit.3 If he develops a second exacerbation within this year, the addition of inhaled corticosteroids may be appropriate.

44. Sleep Apnea Test...

45. Sleep apnea, the disorder marked by abnormal pauses in breathing during sleep, is already known to boost the risk of stroke. Now, a new study links sleep apnea to so-called silent strokes, in which there is tissue death in the brain without symptoms. Sleep Apnea May Be Tied to ‘Silent’ Strokes

46. What are the symptoms? • excessive daytime sleepiness • frequent episodes of obstructed breathing during sleep. (The patient may be unaware of this symptom - usually the bed partner is extremely aware of this).

47. How serious is sleep apnea? • It is a potentially life-threatening condition that requires immediate medical attention. The risks of undiagnosed obstructive sleep apnea include heart attacks, strokes, impotence, irregular heartbeat, high blood pressure and heart disease. In addition, obstructive sleep apnea causes daytime sleepiness that can result in accidents, lost productivity and interpersonal relationship problems.  The severity of the symptoms may be mild, moderate or severe.

48. is based on the conjoint evaluation of clinical symptoms (e.g. excessive daytime sleepiness and fatigue) and of the results of a formal sleep study (polysomnography, or reduced channels home based test). The diagnosis of sleep apnea

49. Polysomnogram is the result of a multi-parametric test called polysomnography also known as sleep study. The word polysomnogram is derived from Greek polus, which means many/much and Latin somnus, which means sleep.