Urinary Tract Infection UTI

A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. The main etiologic agent is Escherichia coli. Although urine contains a variety of fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they may cause a UTI.

The most common type of UTI is acute cystitis often referred to as a bladder infection. An infection of the upper urinary tract or kidney is known as pyelonephritis, and is potentially more serious. Although they cause discomfort, urinary tract infections can usually be easily treated with a short course of antibiotics. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine.

• Most common in females because of anatomy of the lower urinary tract: urethra is short and meatus  is close to the anus.
• Peak incidence occurs at 2 to 5 years of age.

Prevention

The following are measures that studies suggest may reduce the incidence of urinary tract infections.

• A prolonged course (six months to a year) of low-dose antibiotics (usually nitrofurantoin or TMP/SMX) is effective in reducing the frequency of UTIs in those with recurrent UTIs.
• Cranberry (juice or capsules) may decrease the incidence of UTI in those with frequent infections. Long term tolerance however is an issue.
• For post-menopausal women intra vaginal application of topical estrogen cream can prevent recurrent cystitis. This however is not as useful as low dose antibiotics.
• Studies have shown that breastfeeding can reduce the risk of UTIs in infants.

A number of measures have not been found to affect UTI frequency including: the use of birth control pills or condoms, voiding after sex, the type of underwear used, personal hygiene methods used after voiding or defecating, and whether one takes a bath or shower.

Therapeutic interventions.

• antibiotics to eliminate infection.
• Identiry and correct structural anomalies if present.
• Bland, high-protein, high carbohydrate diet.
• Prevent recurrence; preserve renal function. 

Principle of growth and development

Children may vary among each othe i their rate of growth and dvelopment. But stil all of them follow certain principles as follow.

• Growth and development is a continuos prcess from conception to adolescence. The rate of growth varie at different ags. During prnatal d infancy period the eate of growth is very rapid. This growth rat gradully declines during early childhood During te middle hilhood the growth rate is slo. the growth rate again becomes rapid durn puberly. Thus infancy and puberty ar two specific periods of rapid growth.
• The development takes place:

a.  In the cephalo-caudal directin.That means development proceeds from head to toe. For example the first step towards walking  is head control then sitting abilility.

b. Fom general to specific: That means general development takes place before special development. For example during skill development the gross motor skills will be developed before fine motor skills.

Developmental Tasks

In the process of physical growth and the development of abilities and skills the children are expected to carry out certain responsibilities or tasks at certain stages of dvelopment. These tasks are called developmental tasks. Havighurst, a psychologist, has defined the developmental task as "the task which arieses at certain periods in the life of an individual, the successful accomplishment of which leads to satisfaction and success with later tasks while the failure leads to dissatisfaction and difficulty with later life."  Some of these developmental tasks arise out of physical maturation e.g. learnng to sit, stand or walk. Wereas other developmental taks arise from social pressure e.g. learning to play , speak, read etc. and some developmental tasks arise out of personal values and desires e.g. preparing for a vocation.

Purposes of developmental tasks

•  Developmental taks serve as guidelines to know what the chiild is expected to do at different ages.
• Developmental tasks enable the parents to motivate children to do what is expected of them.

Developmental taks enable the parents to know what lie ahead and what the child is expected to do in the successive stages.

Stages of growth and development

Although growth and development is a continuous process it varies among children of different ages. Their needs and problems also vary at different ages. Erik Erikson a well known psychologist had divided the period of childhood into 5 stages. he considered that each of these stages is characterised by a crisis situation having favorable and unfavourable components which the child must resolve before progressing to te next stage.

The successful resolution of the crisis situation leads to easy progress to next stage whereas the unsuccessful resolution leads to difficulty in porgressing to next stages.

Stages of childhood and their crisis components as expressed by Erik Erikson.

       S.N.                             Stages of childhood                           Crisis components

1.                             Infancy                                     Trust versus mistrust
2.                             Toddler                                   Autonomy versus shame and doubt
3.                             Preschool                                Intiative versus guilt
4.                             Shool age                                 Industry versus inferiority
5.                            Adolesence                               Identity versus isolation
    with the broadening of the concept of paediatrics to include the child through from the time conception to adolescence, it has become customaary today to divide the period of childhood as follows.

• Intrauterine period.
• Infancy period
• Early childhood
• Middle childhood
• Late childhood

Growth and Development

Growth and develpoment are two improtant characteristics of human begings. The term growth and development generally refers to the process by which the fertilised ovum develops into a mature adult. This maturation occurs through successive changes in both physical structure and functional abilities.

Growth is an essential feature of childhood. Growth refers to physical matureation. In other words, its is the increase in size of the body resulting from increase in the number and size of the cells of body. The increase in body size leads the child to be taller, broader and heavier. These changes in height and breadth (eg. head circumference) can be measured in terms of centimetres or inches and the heaviness or weight in terms of kilogram or pounds. Thus growth is a quantitative change and can be measured easily.

In general the rate of growth is more important than the actual size of the child . so to assess the growth rate, the measurement of height and weight shuld be done at regular intervals.

Development is defined as th functional or physiological maturation that follows physical maturation. In ohter words it is the acquisition of skills and the ability to adopt to environment. It is measured in terms of various behavioural achievemetns or abilities known as milestones. Development is complex qualitative change. Hence it is difficult to measure.

Characteristics of a Child

A child is not a miniature adult but a unique individual wih special needs and qualities. An Adult is a mature being in terms of body structure and functions whereas a child is at a varying stage f rowth and development from birth to adolescence. That means he is an immature inividual in erms of his body structure and functions necessitating a different kind of care. The characteristics of children can be discussed under the follwoing heaidngs.

1. 
   
   body structure
2. 
   
   physiological processess
3. 
   
   intellectual abilites
4. 
   
   emotional responses.

Body structure

In relation to body structure, the proportional size of the body parts is an important feature. For example an infant has a heavier and bigger head in comparison to his body size and weight. It makes handling of infants different from older children and adults. The infants head must  be supported while holding or lifting him. Injury to head can occur more commonly in infants than in the older children.

In neonates the skull bones are joined by membranous spaces called sutures and fontanelle. So any increase in the intracranial pressure in infant causes the suture lines to be widened and fontanelle to be bulged out, thereby increasing the size of the head. But in older children and adults increase in intracranial pressure does not increase the size of the head.

Physiological processes

The difference in the physiological characteristics of childrean at different ages makes it necessary to provide different kinds of care to children at the different ages.

In terms of unit body weight, younger children need more nutritious food than older children because of their rapid growth rate, increased level of body activity and high basal metabolic rate. If young children do not get adequate food, they develop nutritionla deficiencies such as marasums, kwashiorkor, rickets, xerophthalmia etc. much more rapidly that in the older children.

Child care in early civilization

Value of children changed gradually as people started settling in the fertile lands. Some cultures valued physical beauty as an essential characteristics of person. These people cared for children well so that the children would have well formed bodies.

Some cultures valued large families as a blessing of god. Children in these cultures were considered as the gifts of god and so were taken care of well. Some cultures valued cleanliness and food as essential in life. These practices influenced greatly on the health of mother and child.

Historical overview of  child care
The knowledge of historical trend in child care helps to understand the present care in the light of the past and it enables one to determine the fututre direction for better care.
Care of the child at any period is believed to be influenced by the people's way of living, their belief about health and their values for their children.

Child health status

Health is a complex phenomena. According to World Health Organization, health is not merely the absence of disease of infirmity but is a stateof complete physical, mental and social well being. From this definition child health means a state of physical, mental and social harmony of the child which pro,otes his ottimum growth and development. However in estimating the health status of children in a country, the commonly used indicators are the absence commonly used indicators are the absence of disease (ie morbidity ) a death ( mortality)

The IMR can be divided into neonatal mortality rate (NMR) and post neonatal mortality rate ( PNMR). The NMR includes death of children less that 28 days of age and PNMR includes death of children from 28 days until 1 year of age.

Role of the paediatric nurse

Nursing care of children aims at achieving the highest possible health in children and promoting their optimum growth and development. In rder to achieve this aim, the paediatric nurse should play multiple roles as depicted in the following.

Care Provider

As a care provider , the nurese is responsible to care for the sick children in meeting their physical and emotionl needs. The responsibility to administer the prescribed medicines and treatments also falls on her. She is held accountalbe for all her nursing actions. So she must carry out her responsibilites with knowledge and dedication.

To demonstrate her sense of accountablity,she should use nursing process in her care. The use of nursing process enables her:

• to assess each child's need through nistory taking and physical examination.
• to identify the health needs of the child
• to plan and implement nursing ations
• to evaluate the outcome of nursing actions

A child specially the young one, is totally dependent on his parents or care givers to fulfill his basic needs such as food, toileting and clothing. So the parents should be included in the care of their children as far as possible.This enhances their responsibility as parents and help to build their confidence in child care at home.

Health Educator

Health education is oneof the important roles of the nurse. health education of children aims at giving essentail health information to the parents and guardians for the promotion and maintenance of the health of children. health education arouses awareness of the parents regarding child care and influences their child care practive . Some of the important topics of health education are:

• child's nutrition
• immunisation
• prevention of accidents
• personal adn environmental hygiene
• oral rehydration therapy
• child spacing

Introduction to child care

Child is a young human being who has not reache the age of discretion or maturation. This literally childhood is the period from the birth until the achieves full maturation: physically, mentally and socially. the period of childhood ends with the initiation o adulthood period.
The branch of medicine dealing with children is called paediatrics. The term paediatrics is derived from the Greek words "paidos", "iatrike" and "ics". The word "paidos" means a child, iatrike" means treatment and "ics" means science. The paediatrics means the science of child care and treatment of childhood diseases. Since the intrauterine health of child greatly affects his extrauterine health, the intrauterine period of the child is also included in paediatrics. thus, broadly speaking the term paediatrics would mean the study of the child from conception to adolescence.

The specialist doctor who treats children is called paediatrician. The intra uterine health of the child is usually taken care by the obstetrician andmidwife through regular antenatal care.
Paediatric nursing is the branch of nursing that is concerned with the care of children not only during illness but also during health by providng preventive care to them.

The facts about trachoma:

Trachoma (a repeated conjunctivitis infection) is found worldwide. Though eradicated in most developed countries, it remains a significant public health problem in parts of the developing world. It is closely linked to poverty.

The facts about trachoma:

• The World Health Organization estimates that trachoma affects about 84 million people
• 8 million of these are visually impaired
• Trachoma is the second most common cause of blindness after cataract.

Where is it found?

Trachoma is found in hot and dusty parts of the world. It is often endemic in rural areas without basic sanitation, where washing hands and faces is difficult. Trachoma spreads rapidly in crowded households or neighbourhoods.

Children and trachoma

Demographically, active trachoma is most prevalent in children, although the scarring doesn't usually become visible until the early 20s. For those who have suffered since childhood, trichiasis normally sets in during their 40s - or even earlier in the worst-affected areas.

Women and trachoma

Women are much more susceptible to trachoma than men because they spend far more time in contact with children, providing childcare.

Prevention

Although trachoma was eliminated from much of the developed world in the last century, this disease persists in many parts of the developing world particularly in communities without adequate access to water and sanitation. In many of these communities, women are three times more likely than men to be blinded by the disease, due to their roles as caretakers in the family.

Without intervention, trachoma keeps families shackled within a cycle of poverty, as the disease and its long-term effects are passed from one generation to the next.

National governments in collaboration with numerous non-profit organizations implement trachoma control programs using the WHO-recommended SAFE strategy, which includes:

Surgery to correct advanced stages of the disease;

Antibiotics to treat active infection, using Zithromax (azithromycin) donated by Pfizer Inc through the International Trachoma Initiative;

Facial cleanliness to reduce disease transmission;

Environmental change to increase access to clean water and improved sanitation.

Surgery: For individuals with trichiasis, a bilamellar tarsal rotation procedure is warranted to direct the lashes away from the globe. Early intervention is beneficial as the rate of recurrence is higher in more advanced disease.

Antibiotic therapy: WHO Guidelines recommend that a region should receive community-based, mass antibiotic treatment when the prevalence of active trachoma among one to nine year-old children is greater than 10 percent.[8] Subsequent annual treatment should be administered for three years, at which time the prevalence should be reassessed. Annual treatment should continue until the prevalence drops below five percent. At lower prevalences, antibiotic treatment should be family-based.

Antibiotic selection: (single oral dose of 20 mg/kg) or topical tetracycline (one percent eye ointment twice a day for six weeks). Azithromycin is preferred because it is used as a single oral dose. Although it is expensive, it is generally used as part of the international donation program organized by Pfizer through the International Trachoma Initiative. Azithromycin can be used in children from the age of six months and in pregnancy.

Facial cleanliness: Children with grossly visible nasal discharge, ocular discharge, or flies on their faces are at least twice as likely to have active trachoma as children with clean faces. Intensive community-based health education programs to promote face-washing can significantly reduce the prevalence of active trachoma, especially intense trachoma  . If somebody is already infected washing one’s face is strongly encouraged, especially a child, in order to prevent re-infection.
Environmental improvement: Modifications in water use, fly control, latrine use, health education and proximity to domesticated animals have all been proposed to reduce transmission of C. trachomatis. These changes pose numerous challenges for implementation. It seems likely that these environmental changes ultimately impact on the transmission of ocular infection by means of lack of facial cleanliness. Particular attention is required for environmental factors that limit clean faces.

Causes of Trachoma

Causes

Trachoma is caused by Chlamydia trachomatis and it is spread by direct contact with eye, nose, and throat secretions from affected individuals, or contact with fomites (inanimate objects), such as towels and/or washcloths, that have had similar contact with these secretions. Flies can also be a route of mechanical transmission. Untreated, repeated trachoma infections result in entropion—a painful form of permanent blindness when the eyelids turn inward, causing the eyelashes to scratch the cornea. Children are the most susceptible to infection due to their tendency to easily get dirty, but the blinding effects or more severe symptoms are often not felt until adulthood.

Blinding endemic trachoma occurs in areas with poor personal and family hygiene. Many factors are indirectly linked to the presence of trachoma including lack of water, absence of latrines or toilets, poverty in general, flies, close proximity to cattle, crowding and so forth. However, the final common pathway seems to be the presence of dirty faces in children that facilitates the frequent exchange of infected ocular discharge from one child’s face to another. Most transmission of trachoma occurs within the family.

Trachoma

Trachoma (Ancient Greek: "rough eye") is an infectious eye disease, and the leading cause of the world's infectious blindness. Globally, 84 million people suffer from active infection and nearly 8 million people are visually impaired as a result of this disease. Globally this disease results in considerable disability.

Signs and symptoms

The bacterium has an incubation period of 5 to 12 days, after which the affected individual experiences symptoms of conjunctivitis, or irritation similar to "pink eye." Blinding endemic trachoma results from multiple episodes of reinfection that maintains the intense inflammation in the conjunctiva. Without reinfection, the inflammation will gradually subside.

The conjunctival inflammation is called “active trachoma” and usually is seen in children, especially pre school children. It is characterized by white lumps in the undersurface of the upper eye lid (conjunctival follicles or lymphoid germinal centres) and by non-specific inflammation and thickening often associated with papillae. Follicles may also appear at the junction of the cornea and the sclera (limbal follicles). Active trachoma will often be irritating and have a watery discharge. Bacterial secondary infection may occur and cause a purulent discharge.

The later structural changes of trachoma are referred to as “cicatricial trachoma”. These include scarring in the eye lid (tarsal conjunctiva) that leads to distortion of the eye lid with buckling of the lid (tarsus) so the lashes rub on the eye (trichiasis). These lashes will lead to corneal opacities and scarring and then to blindness. Linear scar present in the Sulcus subtarsalis is called Arlt's line(named after Carl Ferdinand von Arlt). In addition, blood vessels and scar tissue can invade the upper cornea (pannus). Resolved limbal follicles may leave small gaps in pannus (Herbert’s Pits).

Further symptoms include:

Eye discharge

Swollen eyelids

Trichiasis (turned-in eyelashes)

Swelling of lymph nodes in front of the ears

Corneal scarring

Further ear, nose and throat complications.

The major complication or the most important one is corneal ulcer occuring due to rubbing by concentrations, or trichiasis with superimposed bacterial infection.

 

Paracetamol comes as:

Paracetamol comes as:

tablets, caplets (torpedo-shaped tablets that may be easier to swallow) or capsules for swallowing a powder or tablet to dissolve in water, or a liquid/syrup forma suppository, for inserting into the rectum (back passage)You can buy paracetamol from pharmacies in packs of 32 tablets. You don't need a prescription.

For safety reasons, you can't buy more than 100 tablets at any one time from a pharmacy. In other shops, such as supermarkets or convenience stores, the packs contain a maximum of 16 tablets. It's crucial that you don't take more paracetamol than the dose recommended on the packet.

Over-the-counter painkillers - ones you buy without a prescription - are only meant to be taken occasionally. If you have to take painkillers for more than three days you should ask your GP or pharmacist about what to take and what else might help. Taking painkillers too often or for too long may make headaches worse.

It's always best to get advice from your GP if you need daily pain relief. Many GPs advise using paracetamol for problems such as painful joints.

Always read the patient information leaflet that comes with your medicine.

Avoiding accidental overdose

Paracetamol comes as tablets, but it is also contained in several other over-the-counter cold and flu remedies, such as powders that you make up into flavoured hot drinks (eg Lemsip). Make sure you count the paracetamol in all the medicines you have taken.

Children and paracetamol

The dose for a child depends on their age and weight and is clearly given on the medicine's container. On a doctor or nurse's advice, you can give paracetamol to young babies after they have had vaccinations, but otherwise it's not recommended for babies under three months old. Syrups containing paracetamol (eg Calpol) can be easier for younger children to take. The children's version of paracetamol syrup contains 120mg of paracetamol per 5ml (teaspoon). Sugar-free versions are available.

Special care

Check with your doctor or pharmacist before taking paracetamol if: you know that your kidneys or liver are not working properly you are a very heavy drinker (both paracetamol and alcohol can harm the liver)you are malnourished

If you're pregnant

As with any drug, it's always wise to discuss your situation with your pharmacist or doctor. However, in general, paracetamol is not known to be harmful in pregnancy.

If you're breastfeeding

Very little paracetamol gets into breast milk so experts say that it's usually safe for nursing mothers to take it.

Side-effects

When taken at the recommended dose, side-effects of paracetamol are rare. Skin rashes, blood disorders and a swollen pancreas have occasionally happened in people taking the drug on a regular basis for a long time.

One advantage of paracetamol over aspirin and similar drugs (eg ibuprofen and diclofenac) is that it won't upset your stomach or cause it to bleed.

A paracetamol overdose is particularly dangerous because the liver damage may not be obvious for four to six days after the drug has been taken. Even if someone who has taken a paracetamol overdose seems fine and doesn't have any symptoms, it's essential that they are taken to hospital urgently. An overdose of paracetamol can be fatal.

Interactions with other medicines

Check with your doctor or pharmacist before you take any other medicines or herbal remedies at the same time as paracetamol.

You may need to adjust your usual dose of anticoagulants (eg warfarin) if you take paracetamol regularly. Check with your anticoagulation clinic. Otherwise there are no serious interactions between paracetamol and other drugs

Paracetamol

Published by Bupa's health information team, March 2007.

This factsheet is for people who would like information about paracetamol and how to use it safely.

Paracetamol (known as acetaminophen in the USA) is a painkiller that lowers a high temperature. Provided that you take the correct dose at the right intervals, paracetamol is relatively safe. An overdose is dangerous.

Why would I take it?How does paracetamol work?How to take paracetamolAvoiding accidental overdoseChildren and paracetamolSpecial careSide-effectsInteractions with other medicinesParacetamol productsFurther informationQuestions and answersSourcesWhy would I take it?

Paracetamol can be taken to relieve a variety of common aches and pains including headache, muscle and joint pain, backache and period pains.

Paracetamol brings down a high temperature caused by a cold or flu. It can be given to children after they have had vaccinations to prevent a high temperature after immunisation. It's often included in cough, cold and flu remedies, which you can buy in pharmacies and shops (see Paracetamol products).

How does paracetamol work?

No one is sure how paracetamol works. It probably acts by blocking the way in which pain signals are processed in the brain. It doesn't have the anti-inflammatory action of NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin. You can't get addicted to paracetamol.

How to take paracetamol

The recommended dose for adults is 500mg to 1000mg - that's usually one or two tablets (depending on tablet size) - every four to six hours with a maximum of 4000mg (usually eight tablets, but make sure you check the size of your tablets) in 24 hours.

However, just twice this dose can be dangerous and you should never exceed the recommended dose. Keep all medicines out of the reach of children.

Paracetamol uses

Adults

The recommended dosage of paracetamol in adults is two 500mg tablets (i.e. 1gm paracetamol) every four to six hours, not exceeding eight tablets (4gms) in any 24 hour period (1). This dosage may be continued for several days. If pain relief is required for a longer period it should be with the supervision of a doctor.

Children

Children's dosages vary with the age of the child and the type of product, therefore the instructions on the pack should always be followed.

In general, children's dosages are based on a single dose of 10mg paracetamol per kilogram bodyweight, which can be repeated 4-6 hourly, not exceeding four doses per 24 hours.

On a doctor's recommendation only, paracetamol may be given to a 2 month old child following immunisation as a single dose of 60mg (i.e. 2.5mL paracetamol liquid (oral suspension) at a strength 120mg per 5 mL).

For children under 3 months, on a doctor's advice only, the dosage is 10mg paracetamol per kilogram body weight (5mg/kg if jaundiced).

For a child 3 months to 1 year of age a dose of between 60mg and 120mg (i.e. 2.5mL to 5mL of paracetamol liquid (oral suspension) at a strength of 120mg/5mL) may be repeated every 4-6 hours to a maximum of 4 doses in 24 hours.

For a child 1 to 5 years of age 120mg to 250mg (i.e. 5mL to 10mL of paracetamol liquid (oral suspension) at a strength of 120mg/5mL) may be repeated every 4-6 hours to a maximum of 4 doses in 24 hours.

For a child 6 to 12 years of age 250mg to 500 mg (i.e. 5mL to 10mL paracetamol liquid (oral suspension) at a strength of 250mg/5mL) may be repeated every 4-6 hours to a maximum of 4 doses in 24 hours.

These dosages have been found to be effective, well tolerated and safe (2) in OTC usage and there are no circumstances in which they should be exceeded. If this dosage is not proving effective, then a pharmacist or doctor should be consulted for further advice.

Prescription Use

In general the recommended dosages shown above should be followed. If, in a hospital setting, a higher dosage is considered desirable it is the responsibility of the prescribing physician. As there is no clear threshold at which toxicity may occur in an individual patient, it has been recommended that where a higher dosage is prescribed for an extended period, liver function should be monitored (2).

References:

1 British National Formulary, Vol. 40; September 2000

2 OICPC Therapeutic Highlights; Progress in Palliative Care (2000); 8 (4); 198-202.

Management of stable COPD

Bronchodilators

Bronchodilators are medicines that relax smooth muscle around the airways, increasing the calibre of the airways and improving air flow. They can reduce the symptoms of shortness of breath, wheeze and exercise limitation, resulting in an improved quality of life for people with COPD. They do not slow down the rate of progression of the underlying disease. Bronchodilators are usually administered with an inhaler or via a nebulizer.

There are two major types of bronchodilator, β2 agonists and anticholinergics. Anticholinergics appear to be superior to β2 agonists in COPD. Anticholinergeics reduce respiratory deaths while β2 agonists have no effect on respiratory deaths. Each type may be either long-acting (with an effect lasting 12 hours or more) or short-acting (with a rapid onset of effect that does not last as long).

 β2 agonists

β2 agonists stimulate β2 receptors on airway smooth muscles, causing them to relax. There are several β2 agonists available. Salbutamol or albuterol (common brand name: Ventolin) and terbutaline are widely used short acting β2 agonists and provide rapid relief of COPD symptoms. Long acting β2 agonists (LABAs) such as salmeterol and formoterol are used as maintenance therapy and lead to improved airflow, exercise capacity, and quality of life.

Anticholinergics

Anticholinergic drugs cause airway smooth muscles to relax by blocking stimulation from cholinergic nerves. Ipratropium is the most widely prescribed short acting anticholinergic drug. Like short-acting β2 agonists, short-acting anticholinergics provide rapid relief of COPD symptoms and a combination of the two is commonly used for a greater bronchodilator effect. Tiotropium is the most commonly prescribed long-acting anticholinergic drug in COPD. It is has more specificity for M3 muscarinic receptors so may have fewer side-effects than other anticholinergic drugs. Regular use is associated with improvements in airflow, exercise capacity, quality of life and possibly a longer life.

Corticosteroids

Corticosteroids act to reduce the inflammation in the airways, in theory reducing lung damage and airway narrowing caused by inflammation. Unlike bronchodilators, they do not act directly on the airway smooth muscle and do not provide immediate relief of symptoms. Some of the more common corticosteroids in use are prednisone, fluticasone, budesonide, mometasone, and beclomethasone. Corticosteroids are used in tablet or inhaled form to treat and prevent acute exacerbations of COPD. Well-inhaled corticosteroids (ICS) have not been shown to be of benefit for people with mild COPD, however, they have been shown to decrease acute exacerbations in those with either moderate or severe COPD. They however have no effect on overall one-year mortality and are associated with increased rates of pneumonia.

Other medication

Theophylline is a bronchodilator and phosphodiesterase inhibitor that in high doses can reduce symptoms for some people who have COPD. More often, side effects such as nausea and stimulation of the heart limit its use. In lower doses, it may slightly reduce the number of COPD exacerbations. The investigative phosphodiesterase-4 antagonists, roflumilast and cilomilast have completed Phase-2 clinical trials. Tumor necrosis factor antagonists such as infliximab suppress the immune system and reduce inflammation. Infliximab has been trialled in COPD but there was no evidence of benefit with the possibility of harm.

Supplemental oxygen

Oxygen can be delivered in different forms: in large containers, in smaller containers with liquid oxygen, or with the use of a oxygen concentrator (shown here) which derives oxygen from room air. The latter two options improve mobility of people requiring long-term oxygen therapy.

Supplemental oxygen can be given to people with COPD who have low oxygen levels in the body. Oxygen is provided from an oxygen cylinder or an oxygen concentrator and delivered to a person through tubing via a nasal cannula or oxygen mask. Supplemental oxygen does not greatly improve shortness of breath but can allow people with COPD and low oxygen levels to do more exercise and household activity. Long-term oxygen therapy for at least 16 hours a day can improve the quality of life and survival for people with COPD and arterial hypoxemia or with complications of hypoxemia such as pulmonary hypertension, cor pulmonale, or secondary erythrocytosis. High concentrations of supplemental oxygen can lead to the accumulation of carbon dioxide and respiratory acidosis for some people with severe COPD; lower oxygen flow rates are generally safer for these individuals.

Pulmonary rehabilitation

Pulmonary rehabilitation is a program of exercise, disease management and counselling coordinated to benefit the individual. Pulmonary rehabilitation has been shown to improve shortness of breath and exercise capacity. It has also been shown to improve the sense of control a patient has over their disease as well as their emotions.

Nutrition

Being either underweight or overweight can affect the symptoms, degree of disability and prognosis of COPD. People with COPD who are underweight can improve their breathing muscle strength by increasing their calorie intake. When combined with regular exercise or a pulmonary rehabilitation programme, this can lead to improvements in COPD symptoms.

Cause of COPD

Smoking

The primary risk factor for COPD is chronic tobacco smoking. In the United States, 80 to 90% of cases of COPD are due to smoking. Exposure to cigarette smoke is measured in pack-years, the average number of packages of cigarettes smoked daily multiplied by the number of years of smoking. The likelihood of developing COPD increases with age and cumulative smoke exposure, and almost all life-long smokers will develop COPD, provided that smoking-related, extrapulmonary diseases (cardiovascular, diabetes, cancer) do not claim their lives beforehand.

Occupational exposures

Intense and prolonged exposure to workplace dusts found in coal mining, gold mining, and the cotton textile industry and chemicals such as cadmium, isocyanates, and fumes from welding have been implicated in the development of airflow obstruction, even in nonsmokers. Workers who smoke and are exposed to these particles and gases are even more likely to develop COPD. Intense silica dust exposure causes silicosis, a restrictive lung disease distinct from COPD; however, less intense silica dust exposures have been linked to a COPD-like condition. The effect of occupational pollutants on the lungs appears to be substantially less important than the effect of cigarette smoking.

Air pollution

Studies in many countries have found that people who live in large cities have a higher rate of COPD compared to people who live in rural areas. Urban air pollution may be a contributing factor for COPD as it is thought to slow the normal growth of the lungs although the long-term research needed to confirm the link has not been done. In many developing countries indoor air pollution from cooking fire smoke (often using biomass fuels such as wood and animal dung) is a common cause of COPD, especially in women.

Genetics

Some factor in addition to heavy smoke exposure is required for a person to develop COPD. This factor is probably a genetic susceptibility. COPD is more common among relatives of COPD patients who smoke than unrelated smokers. The genetic differences that make some peoples' lungs susceptible to the effects of tobacco smoke are mostly unknown. Alpha 1-antitrypsin deficiency is a genetic condition that is responsible for about 2% of cases of COPD. In this condition, the body does not make enough of a protein, alpha 1-antitrypsin. Alpha 1-antitrypsin protects the lungs from damage caused by protease enzymes, such as elastase and trypsin, that can be released as a result of an inflammatory response to tobacco smoke.

Other risk factors

A tendency to sudden airway constriction in response to inhaled irritants, bronchial hyperresponsiveness, is a characteristic of asthma. Many people with COPD also have this tendency. In COPD, the presence of bronchial hyperresponsiveness predicts a worse course of the disease.[17] It is not known if bronchial hyperresponsiveness is a cause or a consequence of COPD. Other risk factors such as repeated lung infection and possibly a diet high in cured meats may be related to the development of COPD.

COPD as an autoimmune disease

Autoimmunity

There is mounting evidence that there may be an autoimmune component to COPD.Many individuals with COPD who have stopped smoking have active inflammation in the lungs.  The disease may continue to get worse for many years after stopping smoking due to this ongoing inflammation. This sustained inflammation is thought to be mediated by autoantibodies and autoreactive T cells

Signs and symptoms of COPD

One of the most common symptoms of COPD is shortness of breath (dyspnea). People with COPD commonly describe this as: "My breathing requires effort," "I feel out of breath," or "I can't get enough air in". People with COPD typically first notice dyspnea during vigorous exercise when the demands on the lungs are greatest. Over the years, dyspnea tends to get gradually worse so that it can occur during milder, everyday activities such as housework. In the advanced stages of COPD, dyspnea can become so bad that it occurs during rest and is constantly present.

Other symptoms of COPD are a persistent cough, sputum or mucus production, wheezing, chest tightness, and tiredness.

People with advanced (very severe) COPD sometimes develop respiratory failure. When this happens, cyanosis, a bluish discoloration of the lips caused by a lack of oxygen in the blood, can occur. An excess of carbon dioxide in the blood can cause headaches, drowsiness or twitching (asterixis). A complication of advanced COPD is cor pulmonale, a strain on the heart due to the extra work required by the heart to pump blood through the affected lungs. Symptoms of cor pulmonale are peripheral edema, seen as swelling of the ankles, and dyspnea.

There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are:

* tachypnea, a rapid breathing rate

* wheezing sounds or crackles in the lungs heard through a stethoscope

* breathing out taking a longer time than breathing in

* enlargement of the chest, particularly the front-to-back distance (hyperinflation)

* active use of muscles in the neck to help with breathing

* breathing through pursed lips

* increased anteroposterior to lateral ratio of the chest (i.e. barrel chest).

What is COPD

Chronic obstructive pulmonary disease (COPD) refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. In contrast to asthma, the limitation of airflow is poorly reversible and usually gets progressively worse over time.

COPD is caused by noxious particles or gas, most commonly from tobacco smoking, which triggers an abnormal inflammatory response in the lung. The inflammatory response in the larger airways is known as chronic bronchitis, which is diagnosed clinically when people regularly cough up sputum. In the alveoli, the inflammatory response causes destruction of the tissues of the lung, a process known as emphysema. The natural course of COPD is characterized by occasional sudden worsenings of symptoms called acute exacerbations, most of which are caused by infections or air pollution.

The diagnosis of COPD requires lung function tests. Important management strategies are smoking cessation, vaccinations, rehabilitation, and drug therapy (often using inhalers). Some patients go on to requiring long-term oxygen therapy or lung transplantation.

Worldwide, COPD ranked as the sixth leading cause of death in 1990. It is projected to be the fourth leading cause of death worldwide by 2030 due to an increase in smoking rates and demographic changes in many countries. [4] COPD is the 4th leading cause of death in the U.S., and the economic burden of COPD in the U.S. in 2007 was $42.6 billion in health care costs and lost productivity.