RESPIRATORY DISORDERS
Cindy B. West, DNP, APRN, CRNA
Assistant Professor
June 24, 2021
https://music.apple.com/us/album/breatheagain/1514698398?i=1514698402
Adapted from previous slides by
Dr. Charlotte Wisnewski, PhD,
MS, RN, CDE, CNE
Copyright 2020 The University of Texas Medical Branch School of Nursing
Objectives
Define
Define terms used in describing the signs and symptoms of
respiratory dysfunction
Relate
Relate the signs and symptoms of common respiratory diseases
(asthma, bronchitis, COPD, pneumonia, emphysema, tuberculosis,
COVID-19) to the pathophysiology of these conditions
Review
Review clinical manifestations of respiratory disorders (asthma,
bronchitis, COPD, pneumonia, emphysema, tuberculosis, COVID-19
Review
Review basic concepts of arterial blood gases
Review
Review agents, nursing interventions used to treat respiratory
alterations
RESPIRATORY DISORDERS
ANATOMY
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TERMINOLOGY TO KNOW
RESPIRATORY SYSTEM
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Hypercapnia
Hypoxia
Hypoxemia
Hypoventilation
Hyperventilation
Lactic Acidosis
Respiratory Center
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TERMINOLOGY TO KNOW
RESPIRATORY SYSTEM
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lung compliance and airway resistance
surfactant
inspiratory reserve
expiratory reserve
vital capacity
residual volume
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RESPIRATORY SYSTEM
FUNCTIONS
• Gas exchange of the airway and lungs (Breathing)
• Consist of structures the provides a ventilator mechanism
• Perfusion of blood through the lungs
• Diffusion of gases between the lungs and blood
• Host defense providing a barrier in and outside of the body
• Inactivates vasoactive substances (ex. Bradykinin)
• Converts Angiotensin I to Angiotensin II
• Creates surfactant with Type II Alveolar cells for efficient lung
inflation
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RESPIRATORY SYSTEM
Respiration
Movement of air (gas) into and
out of the lungs
(NON-DIFFUSION)
Gas Exchange
The exchange of oxygen and
carbon dioxide at the alveolar
level
(DIFFUSION)
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RESPIRATORY SYSTEM
WHAT IS VENTILATION?
• Ventilation is the movement of oxygen, nitrogen, carbon
dioxide and other gases between the atmosphere and the
lungs
• The air moves along a pressure gradient according to the
laws of physics
• The diaphragm is the principle muscle for ventilation with
accessory muscles including sterno-cleido-mastoid, scalene
and intercostals assist in air movement (you would see these
muscles overworked in Respiratory Distress)
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RESPIRATORY SYSTEM
WHAT IS VENTILATION?
• Air movement into the lungs depends on the resistance of the
airways and lung compliance
• The lungs are very elastic under normal situations but
become stiff and noncompliant in conditions such as ARDS
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RESPIRATORY SYSTEM
GASES
• Lobules are the functional units of the lung
• Consist of bronchioles, alveoli and pulmonary capillaries
• This is where GAS EXCHANGE takes place
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RESPIRATORY SYSTEM
GASES
• Two types of Alveolar Cells
1. TYPE I cell (squamous)-provides gas exchange to the Lung
2. TYPE II cell- (progenitor + cuboidal)- produces surfactant
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RESPIRATORY SYSTEM
GASES
• Atmospheric pressure is 760 mm Hg
• This value is assigned a “O” value in relation to respiratory
pressures
• Concentration of oxygen at sea level is 20% so the partial
pressure of oxygen is 20% of 760 (152)
• Measurement of gases dissolved in the blood, PO2- 100 %,
is normal; CO2 has a PCO2 of 35-45
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PLEURAL PRESSURES
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RESPIRATORY SYSTEM
INSPIRATION
• Air moves between the atmosphere and into the lungs
because of pressure differences; physics dictates that air
moves in a gradient from high to low pressure
• Chest expands
• Intrapulmonary pressure decreases
• Intrapleural pressure becomes more negative
• Air enters the lungs
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RESPIRATORY SYSTEM
EXPIRATION
• Elastic components of the chest wall and lung recoil
• Chest cavity size decreases
• Intra-thoracic pressure increases and expiration passively
occurs
• The ease in which air is moved into and out of the lung is
dependent of the resistance of the airway
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RESPIRATORY SYSTEM
PERFUSION
• Movement of blood flow to the gas exchange portion of the
lung
• Perfusion without ventilation results in shunting e.g.
atelectasis (NO GAS EXCHANGE-AKA collapsed lung)
• Ventilation without perfusion is dead air space (air does not
contribute to gas exchange) e.g. pulmonary emboli
• Diseases that interfere with EITHER ventilation or perfusion
result in ventilation-perfusion mismatching, e.g. pulmonary
embolism, COPD, ARDS, ASTHMA, PNEUMONIA
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RESPIRATORY SYSTEM
DIFFUSION
• Movement of gases across the alveolar capillary membrane
• Administration of high concentrations of O2 increases the
difference in partial pressures therefore increases the
diffusion of gas
• Diseases that destroy lung tissue or increases the thickness
of the alveolar-capillary membrane affects diffusion in the
lungs (e.g. Thoracotomy, Pulmonary Edema, Pneumonia)
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RESPIRATORY SYSTEM
OXYGEN TRANSPORT
• Oxygen is transported in chemical combination with
hemoglobin, called oxyhemoglobin (96-98%)
• Oxygen is also transported in the dissolved state (2-4%) and
can diffuse into the tissue cells
• Partial pressure of oxygen depends on dissolved oxygenpO2
• Oxygen saturation depends on amount of oxygen bounded to
hemoglobin
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OXYGEN HEMOGLOBIN CURVE
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RESPIRATORY SYSTEM
HYPOXIA
• Reduction in blood oxygen levels from
a respiratory disease, dysfunction of
the neuro system, and/or alterations in
circulation. This can lead to
ventilation/perfusion mismatching
• As PO2 levels drop, the body switches
to anaerobic metabolism and lactic
acid begins building up in the blood
causing metabolic acidosis
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RESPIRATORY SYSTEM
HYPOXIA
Mild Hypoxemia
Chronic
Hypoxemia
Signs & Symptoms:
> Heart rate, Hypotension
Changes in mental status
Severe Hypoxemia
Hyperventilation
Signs & Symptoms:
Possible cyanosis
Pronounced heart rate and blood
pressure
Restlessness, Impaired Judgment
Compensatory
mechanisms may
include:
Increased ventilation
Increased red blood cell
(RBC) production
Delirium, Stupor, and Coma
Pronounced Cyanosis
Working Together to Work Wonders
RESPIRATORY SYSTEM
HYPOXIA
Heart rate and BP
increase due to
SNS
compensatory
mechanisms.
Treatment:
Treat underlying
cause.
Delivery of
appropriate
amount of oxygen
(consider underlying
disease).
Diagnosis of
hypoxemia?
ABG’s, SvO2 @
tissue level
utilization , &
Pulse oximetry of
O2 sat
Delivery of oxygen
through
appropriate
device, cannula,
mask, or MV
Working Together to Work Wonders
RESPIRATORY SYMTOMS
CYANOSIS
• Cyanosis: Bluish discoloration of the skin resulting
from excessive concentration of deoxygenated
hemoglobin in small vessels. Late sign of
respiratory failure
◦ Central is evident in tongue and lips
◦ Peripheral is in extremities and tip of nose and ears
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RESPIRATORY SYMTOMS
CIRCUMORAL CYANOSIS
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RESPIRATORY SYMTOMS
CYANOSIS OF HANDS
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RESPIRATORY SYMTOMS
CYANOSIS OF FEET
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RESPIRATORY SYMPTOMS
DYPSNEA
• Dyspnea is a SUBJECTIVE sensation of difficulty in breathing
• Occurs in persons with pneumonia, asthma, emphysema, heart disease with
pulmonary congestion, neuromuscular diseases that affect respiratory
muscles such as Myasthenia Gravis
• Seen in untrained persons engaging in physical activity (sedentary lifestyle)
• Treatment of dyspnea depends on the cause
• Causes are unknown, but four mechanisms have been proposed
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stimulation of lung receptors,
CNS transmittal of info to the brain cortex
reduction in ventilatory capacity
stimulation of muscle receptors
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NURSING IMPLICATIONS
RESPIRATORY
SYSTEM
• There are several scales that can be used to measure
dyspnea to evaluate progression; e.g. visual analogue
• Bedrest impairs the expansion of the chest, limits
amount of air, making for a weak, ineffective cough.
Best to have patient sit up for coughing and deep
breathing such as after surgery unless otherwise
contraindicated. The surgical site will need to be
“splinted” with a pillow to prevent herniation.
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NURSING IMPLICATIONS
RESPIRATORY
SYSTEM
• Premature babies don’t have fully formed lungs so
these functions especially surfactant production
may be impaired with severe consequences
• Assess accessory muscles for respiratory difficulty
• Assess and listen to lungs carefully after surgery
• Valsalva maneuver causes strong increase in
intrathoracic pressure, impedes venous return to
right atrium
Working Together to Work Wonders
RESPIRATORY SYMTOMS
COUGH REFLEX
• Coughing is a protective mechanism
• Many conditions interfere with the cough reflex such as when
muscle strength is impaired
• Frequent prolonged coughing such as in bronchitis is
exhausting, painful, and can produce undesirable effects
• Nasogastric tubes interfere with cough reflex by preventing
closure of upper airway structures.
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RESPIRATORY SYSTEM
OBSTRUCTIVE DISEASES
•Asthma
•COPD
•Chronic Bronchitis
•Emphysema
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RESPIRATORY SYSTEM
ASTHMA
• Chronic inflammatory disease of the airways involving recurring symptoms of airflow obstruction and
bronchial hyperresponsiveness
• Exaggerated hypersensitivity response to a variety of stimuli, including allergens, drugs, cold, emotional
distress, cigarette smoke, or exercise
• After the exposure to the inciting factor, inflammatory mediators are released by T- lymphocytes,
activated macrophages, eosinophils, mast cells, and basophils
• Inflammatory mediators then induce bronchoconstriction, increased vascular permeability, and mucus
production
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RESPIRATORY SYSTEM
ASTHMA
• Etiology: both environmental and genetic
• Two types: extrinsic/allergic/atopic and intrinsic/non-allergenic/non-atopic
• Atopic: is initiated by a type I hypersensitivity reaction induced by exposure to the
antigen or allergen and usually begins in childhood/adolescence, attacks can be
initiated by cockroach allergens, animal dander, fungus, molds, dust mites etc.
• Non-Atopic: also called intrinsic; triggers include respiratory infections, exercise,
cold air, drugs, chemicals, hormonal changes, emotional upsets, air-borne
pollutants and GERD; emotional factors produce bronchospasm by way of vagal
pathways acting as a trigger or increasing airway responsiveness; reflux during
sleep can cause asthma.
Working Together to Work Wonders
RESPIRATORY SYSTEM
BRONCHIAL ASTHMA
• Affects 25.7 M in USA (7 months old < 18 years old)
• Accounts for large number of ED visits, lost time in school and
at work
• In 2009, 2.9 Million ED visits
• Occurs in all populations throughout the world
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RESPIRATORY SYSTEM
ASTHMA IN CHILDREN
• Leading cause of chronic illness with 80%
being symptomatic by 6 years of age
• More frequent in black children
• In utero exposure to smoking is also a
concern
• First symptoms may be a cold that
progresses very rapidly and ends in a trip
to the emergency room
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RESPIRATORY SYSTEM
COMMON SYMPTOMS
OF ASTHMA
• Wheezing
• Tightness of chest
• Dyspnea
• Cough
• Increased sputum
production
• Tachycardia
• Tachypnea
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RESPIRATORY SYSTEM
INSTRINSIC
NONATOPIC
ASTHMA
• Triggers in this type of asthma
include respiratory tract
infections, exercise,
hyperventilation, cold air,
exercise, drugs and chemicals,
hormonal changes, airborne
pollutants, GERD
• Respiratory infections stimulate
the production IgE antibodies,
increases airway responsiveness
to other triggers that may last for
weeks.
• Exercise induced asthma is
exacerbated by cold air.
• Inhaled irritants such as smoke
induce broncho-spasm
• The two categories are not useful
clinically since many people have
overlapping symptoms and
etiology.
Working Together to Work Wonders
RESPIRATORY SYSTEM
EXTRINSIC
ATOPIC
ASTHMA
• Initiated by a type I hypersensitivity
reaction induced by exposure to an
extrinsic antigen or allergen, usually
begins in childhood or adolescence
• Secondary to exposure to an allergen
(e.g. dust mites, animal dander, and
cockroach wastes)
• Individuals experience other allergies
also such as hay fever, urticaria, &
eczema
• Attacks are related to a specific allergen
• Two phases of mechanisms of
response:
• Acute-phase response:
• 10-20 minutes
• Release of chemical mediators,
bronchospasm, & edema
• Late-phase response:
• 4-8 hours
• Inflammation and increased airway
responsiveness
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RESPIRATORY SYSTEM
EXTRINSIC ATOPIC ASTHMA
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RESPIRATORY SYSTEM
DIAGNOSIS OF ASTHMA
ASSESSMENT
• History\ Physical Exam
LUNG FUNCTION TESTS
• Spirometry measurements of FVC, FEV, PEF, tidal volume,
inspiratory and expiratory reserve volume
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RESPIRATORY SYSTEM
• Short term-(Rescue Meds for attacks-30 minutes)
• Beta 2 agonists, anti-cholinergics
• Systemic corticosteroids(4 hours) administered by
nebulizer/inhaler
• Long term
• Inhaled corticosteroids, LA bronchodilators,
cromolyn sodium, leukotriene receptor
antagonists, and theophylline
• Never run out of asthma medicines. Call your
pharmacy or doctor’s office at least 48 hours before
you run out to avoid possible emergency airway
scenario
MEDICATIONS
AND TREATMENT
OF ASTHMA
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RESPIRATORY SYSTEM
Two main goals:
(1) prevention &
control of triggers
and effects
(2) medications
MEDICATIONS
AND TREATMENT
OF ASTHMA
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CHRONIC OBSTRUCTIVE PULMONARY
DISEASE-COPD
EMPHYSEMA
BRONCHITIS
COPD is an
umbrella term that
encompasses two
chronic,
progressive
disease
processes that
involve
obstruction of the
airways
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COPD
STATISTICS
• 4th leading cause of death in US
• Most common cause is cigarette smoke
• 2nd is hereditary deficiency in a1—antitrypsin (no cure)
• Other causes are asthma and airway hypersensitivity
• No early symptoms so disease is advanced once diagnosed
• 85-90% have a history of smoking
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COPD
PATHOGENESIS
Inflammation and fibrosis of bronchial wall, hypertrophy of
the submucosal glands and hypersecretion of mucus, and
loss of elastic lung fibers and alveolar tissue
Results in airway obstruction, mismatching of ventilation
and perfusion, decreased area for gas exchange, increased
air trapping, airway collapse, retention of carbon dioxide
Working Together to Work Wonders
COPD
RISK
FACTORS
• Direct inhalation of tobacco smoke
• Second hand exposure to cigarette
smoke
• Genetics
• Occupational exposure to various
dusts/chemicals
• Indoor air pollution involving
biomass fuels used for heating and
cooking in poorly ventilated
dwellings
• Severe respiratory infections
• Maternal smoking during
pregnancy
Working Together to Work Wonders
COPD
SYMPTOMS
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Fatigue
Exercise intolerance
AM productive cough
Shortness of breath
Recurrent respiratory
infections
• Chronic respiratory failure
• Disability in 5th or 6th
decade and then death as
disability progresses and
disease progresses
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COPD
RETRACTIONS
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COPD-Clinical Picture
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COPD
PINK PUFFER
• Predominant emphysema SX
• NO cyanosis, air trapping,
increase in antero-posterior
dimension of chest, causing
barrel chest
• Decreased PaO2 <65 and
increased PCO2>55
BLUE BLOATER
• Chronic Bronchitis
• Cyanosis, fluid retention,
right heart failure
• Hypoxemia can cause
polycythemia
• In actual practice most
have symptoms of both
COPD
OXYGEN THERAPY
• Low flow only (1-2 l/min) to prevent reduction of the
ventilatory drive
• Normal person has a ventilatory drive based on high CO2
levels; the person with COPD has a ventilatory drive based
on low oxygen levels.
Working Together to Work Wonders
EMPHYSEMA
PATHOGENESIS
• Destruction of alveoli by enzymes from neutrophils & macrophages
• Smoking causes alveolar damage 2 ways:
inflammation of the lung tissue
inactivates chemical that protects lung tissue
t
• Leads to multiple actions
loss of alveolar walls
loss of elastic tissue in lung
increases in airway pressure
decreases in airway outflow
air becomes trapped in alveoli
formation of bullae
Working Together to Work Wonders
EMPHYSEMA
• WHAT IS IT?
Destructive change in the alveolar wall without fibrosis
Abnormal enlargement of the distal air sacs
Frequently associated with chronic bronchitis
Develops over a long period of time
• WHAT CAUSES IT?
Smoking
Genetic Predisposition
May follow a bacterial infection
Working Together to Work Wonders
CHRONIC BRONCHITIS
PATHOGENESIS
• Chronic Inflammation & swelling of bronchial mucosa
• Scarring & increased fibrosis of bronchial mucous
membrane
• Increased numbers of bronchial mucous glands & goblet
cells
• Increased bronchial wall thickness
• Obstruction of airflow
Working Together to Work Wonders
CHRONIC BRONCHITIS
WHAT IS IT?
• Airway obstruction caused by inflammation of the major and
small airways
• Hypersecretions of bronchial mucous
• Recurrent cough of more than 3 months
WHAT CAUSES IT?
• Smoking (80-85%) of cases
• Repeated airway infections
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TABACCO SMOKING
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DISORDERS OF THE LUNG
ATELECTASIS
PNEUMOTHORAX
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DISORDERS OF THE LUNG
ANATOMY-PLEURAL CAVITY
Pleura= double-layered
membrane that covers
the lungs.
Pleural space= space
between the two layers.
Partial vacuum allows for
lungs to expand and
prevents collapse.
Working Together to Work Wonders
ATELECTASIS
WHAT IS IT?
• It is “an incomplete expansion of the lung
or portion of a lung.”
WHAT CAUSES IT?
• Airway obstruction
• Compression of lung tissue
• Lack of surfactant
SIGNS & SYMPTOMS
•Tachypnea
•Tachycardia
•Dyspnea
•Cyanosis
•Hypoxemia
•Decreased chest expansion
•Absent breath sounds
•Intercostal retraction
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PNEUMOTHORAX
Definition: Presence of air within the pleural space resulting in
partial or complete collapse of the lung (Pooler, 2009)
Spontaneous Pneumothorax:
- Due to a rupture of a bleb on the
surface of the lung.
- Cause is unknown. Associated with
tall young males and heavy smoking.
Traumatic Pneumothorax:
- Due to injuries (penetrating or
non-penetrating).
Tension Pneumothorax:
- Intrapleural pressure exceeds
atmospheric pressure.
* Life threatening
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TENSION PNEUMOTHORAX
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PNEUMOTHORAX
SIGNS & SYMPTOMS
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Increased respiratory rate
Dyspnea
Decreased (absent) breath sounds on affected side
Increased heart rate
Hypoxemia
Asymmetrical chest expansion
Mediastinal shift (tension pneumothorax)
TREATMENT-Chest tube, Pain control
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MECHANICAL VENTILATION
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CHEST DRAINAGE
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CHEST TUBE
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CHEST TUBE (PLEURAVAC) for DRAINAGE
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RESPIRATORY TRACT INFECTIONS
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Common Cold
Rhinosinusitis
Influenza
Pneumonias
Tuberculosis
Fungal infections
Pollutants- asbestos, coal dust
T
Working Together to Work Wonders
COMMON COLD
• Viral in origin, with children being the
main reservoir, adults have 2-3/ year
and children up to 12/year
• Highly contagious the first 3 days after
symptoms begin
• Secretions are clear and watery,
mucous members are reddened,
swollen, sore throat, hoarseness
• Rest and symptomatic treatment; NO
ANTIBIOTICS
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INFLUENZA (FLU)
• Viral infection that’s highly contagious
• 36,000 deaths per year
• Abrupt onset of fever and chills, malaise, muscle aching, headache,
profuse watery discharge, nonproductive cough and sore throat
• Malaise tends to be the distinguishing feature between common cold,
sinusitis, and influenza
• Treatment: Rest, fluids, ASA except in children for fever, antivirals such
as amantadine which prevent replication of the DNA virus if used in 1st 30
hours
• Prevention is KEY: Influenza vaccination which must be done annually
since the formulation is made according to which viruses are believed to
be causing the outbreak in a given year.
Working Together to Work Wonders
PNEUMONIA
Pneumonia is the inflammation of the lung structures such as the alveoli and bronchioles. Inflammatory reaction in the
alveoli & interstitium of the lung caused by an infectious or non-infectious agent. Most common cause of death from
infectious disease (Porth, 2020)
Microbial agents enter the lung, multiply, and trigger pulmonary inflammation
Alveolar air spaces fill with exudate
Hypoxemia results due to poor oxygenation
Exudate becomes consolidated
Exudate difficult to expectorate
Working Together to Work Wonders
PNEUMONIA
• Type of agent: (typical vs.
atypical)
• Distribution within the
lung (within the lobes or
bronchi)
• Setting: (Community or
hospital acquired)
CATEGORIES
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PNEUMONIA
Community-Acquired Pneumonia (CAP)
• Lung infection with onset in the community or diagnosed
within the first 2 days of hospitalization
• The individual has not lived in a long-term facility within 14
days prior to admission
• The most common culprits implicated in CAP include: S.
pneumoniae, S. aureus, Mycoplasma pneumoniae, &
Chlamydia. Viral causes include the influenza virus
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PNEUMONIA
Hospital-Acquired Pneumonia
• Occurs 48 hours or longer after hospital admission
• Not present upon admission
• Lower respiratory tract infection
• Difficult to treat due to resistance to antibiotics
• Common organisms responsible for pneumonias include:
Pseudomonas aeruginosa, S. aureus & E. coli
Working Together to Work Wonders
PNEUMONIA
TREATMENT
• Selection of the most appropriate antimicrobial- temperature should go to normal within 2-3
days
• The key principles:
• Identify the infecting organism
• Drug sensitivity of the infecting organism
• Host factors to consider (status of host and site of infection)
• Antibiotics
• Levofloxacin
• Piperacillin
• Cefotaxime
• Vancomycin
• Gentamycin
Working Together to Work Wonders
PNEUMONIA
Nursing Implications
• Elderly have higher mortality and less likely to be
symptomatic with a fever
• Watch for signs of rapid mental deterioration especially in
winter months as a sign of pneumonia
• Supplemental oxygen may be needed for more severe
cases.
Working Together to Work Wonders
PNEUMONIA
VACCINES-TWO TYPES
• Prevnar 13® is a pneumococcal conjugate (PCV) vaccine
that protects against 13 types of pneumococcal bacteria
• Pneumovax® 23 is a pneumococcal polysaccharide vaccine
(PPSV) that protects against 23 types of pneumococcal
bacteria www.cdc.gov/vaccines
Working Together to Work Wonders
TUBERCULOSIS (TB)
Number one cause of
death from a single
organism worldwide
(Est 1.5 M in 2014)
Long decline in
deaths until 19501980 when large
increase in cases
occurred as a result of
HIV. (390,000 deaths
in HIV- positive in
2014)
Caused by
mycobacterium
tuberculosis, a rodshaped, aerobic acid
fast bacilli
Can infect any organ
but lungs most
common since the
organisms thrive best
in an oxygen-rich
environment
Working Together to Work Wonders
TUBERCULOSIS
FACTORS
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HIV/AIDS
Foreign immigration
Low income, homeless, malnourished
Residence in crowded urban centers
Incarceration
Ethnic minorities
Old age
Chronic disease- including DM, chronic lung disease, Hodgkin's, CRF,
alcoholism, immunosuppression
• Currently smoking cigarettes
Working Together to Work Wonders
TUBERCULOSIS
• The cell –mediated response takes 3-6 weeks and indicates the person
has been exposed but NOT that they have active TB; On X-ray a GHON
focus can be seen that indicates a cheese like cavernous lesion
containing the bacilli, macrophages and other cells
• This is a Type IV hypersensitivity reaction mediated by T H 1 helper T
cells; individual is infected but not contagious
• TB is walled off and not active possibly for many years until the immune
mechanisms fail. In this latent phase, individual is not contagious.
• Active TB is symptomatic and communicable to others
Working Together to Work Wonders
TUBERCULOSIS
About 5% of exposed people develop active disease
immediately
SX: Insidious and non specific: weight loss, fatigue, night
sweats, fever. Once it spreads to the sputum the person
can pass it on to others
DX: PPD skin test, chest X-ray, and sputum tests
Working Together to Work Wonders
TUBERCULOSIS
TREATMENT
• Multiple drugs are mandatory
• INH (isoniazide), rifampin, pyrazinamide, ethambutol,
and streptomycin for up to six months or more
• Multidrug resistant tuberculosis
• Use special individually fitted mask when caring for
person
Working Together to Work Wonders
LUNG CANCER
STATISTICS
• Leading cause of cancer death for both men and women
• Main risk factor is cigarette smoking (85-90%), 15-20 year delay between
smoking onset and development of cancer
• 221, 200 new cases; 158,040 deaths; 5 year survival rate (17.8%), More
than 50% die within one year of diagnosis American Cancer Society,
2015
• 1954 1st report is published that associates lung cancer and smoking
• 1964 USA Surgeon General issued statement that cigarette smoking was
the cause of lung cancer
Working Together to Work Wonders
LUNG CANCER
Usually, Dx by CT scan of lungs
Bronchoscopy performed for biopsy
Thoracentesis to obtain cells from pleural space for staging
Stage I- no metastasis, surgery;
Stage II & III- Chemo, radiation and surgery may be included
Stage IV- no surgery, palliative measures
Working Together to Work Wonders
LUNG CANCER
PATHOGENESIS
• Chemicals in cigarette smoke/tars bind and mutated DNA causes a stepwise
accumulation of over 20 genetic abnormalities transforming benign cells into malignant
ones. Oncogenes, mutate tumor suppressor genes, and activate signal transduction
molecules are associated with lung cancers.
• Cigarette smoke contains over 250 carcinogens that act as initiators, promoters, and
contaminants.
• Four cell types:
• small cell (previously called oat cell) (most aggressive, fast growing, very malignant)
• adenocarcinoma (most common, most common in women)
• squamous cell carcinoma (almost exclusively found in smokers)
• large cell (tend to metastasize early and to the brain).
Working Together to Work Wonders
LUNG CANCER
SIGNS &
SYMPTOMS
• Usually do not seek medical care until symptoms develop
which is late (believes coughing is related to cigarette
smoking)
• Most common symptom is persistent cough with or without
sputum
• Sputum streaked with blood
• Recurrent bronchitis, dyspnea, chest pain, hoarseness,
obstructive pneumonia, fatigue, weight loss, paraneoplastic
syndromes (production of hormone analogs which cause
inappropriate neuroendocrine secretions)
Working Together to Work Wonders
INTRODUCTION TO BLOOD GASES
Normal Arterial Blood Gases (ABG’s):
pH: 7.35-7.45
(acid-base)
pCO2: 35-45 mmHg
(ventilation)
HCO3: 22-26
(buffer)
pO2: 80-100 mmHg
(oxygenation)
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INTRODUCTION TO BLOOD GASES
Abnormal Arterial Blood Gases (ABG’s): Assistance Chart
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INTRODUCTION TO BLOOD GASES
ACID BASE BALANCE
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INTRODUCTION TO BLOOD GASES
ACID BASE BALANCE
• 2 Types- Respiratory and Metabolic
• Respiratory- decrease in ventilation, causing an
increase in pCO2
• Metabolic- addition or loss of acid/alkali from the
extracellular fluids cause alterations in the HCO3
levels
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INTRODUCTION TO BLOOD GASES
INTERPRETATION
• First determine acidity/alkaline
• What is the PRIMARY alteration? Is it respiratory or
metabolic
• If respiratory, then the metabolic (HCO3) is normal
• If metabolic, then the respiratory component is
normal (pCO2)
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PRACTICE BLOOD GAS
INTERPRET THE RESULTS
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COVID-19
• GLOBAL PANDEMIC 2020
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What is COVID-19 ?
• The virus that made the world stand still
• On February 11, 2020 the World Health Organization
announced that “COVID-19” is the official name for the
disease associated with the current novel coronavirus
outbreak
• Co and Vi are derived from “coronavirus,” D stands for
disease, and 19 is for 2019, the year the first cases were
seen
WHO,2020
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What is COVID-19 ?
• The pathogen causing the disease is termed “Severe Acute
Respiratory Syndrome Coronavirus 2,” abbreviated as SARSCoV-2.
• The date is unknown before the outbreak began in Wuhan,
China, in December 2019.
• To date 62.7 % of Americans has had their 1st vaccination
dose.
WHO,2020
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Signs and Symptoms of COVID-19
• Symptoms may appear 2-14 days after exposure to the virus
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COVID-19 LUNGS
• Older people, with underlying medical problems like high blood pressure,
heart and lung problems, diabetes, cancer and of, African-American
descent are at higher risk of developing serious illness.
• Timeline of infection- onset of virus- 2-3 weeks
• Recovery for a survivor post 2 weeks of onset then improvement
• Course of death- 21 days
• Any one can
catch the
Disease !!!!!
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COVID-19
Theory
• Vasoconstriction in the lungs
• Vasoendotheliitis is an immune response in the blood vessels
that become inflamed
• Hypercoagulopathy- PVT ( clots formed in the Lungs)
resulting in severe
Hypoxia
Respiratory
Distress
Death
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COVID-19
Theory
• Lung Compliance
• Patients with severe symptoms of COVID-19 often go on to
develop acute hypoxemic respiratory failure and pneumonia
and 17 to 29% of these patients develop adult respiratory
distress syndrome (ARDS)
• Currently, clinicians are learning new ways to treat this
disease.
Lippincott,2020
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COVID-19
Theory
• Lung compliance is very important when we are comparing
traditional ARDS to COVID-19 ARDS
• Lungs expand with inspiration and recoil with expiration
• The ability of the lung to expand and recoil is compliance
• Compliance can be divided into two types:
Static compliance
Dynamic compliance
Lippincott,2020
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COVID-19
Theory
1. Static compliance
Compliance of the lungs when the lungs and the muscles of the lungs are at rest;
pressure is the only variable
Think “lungs not moving”
2. Dynamic compliance
Compliance of the lungs during breathing
Think “lungs moving”
Lippincott,2020
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COVID-19 THERAPEUTIC INTERVENTIONS
• Initially, when the virus became widespread the plan of
treatment was to paralyze, intubate and place the patient on
a ventilator for lung rest for 2 weeks
• Ventilator shortage became relevant
• Poor outcomes from this treatment
• Death rates increasing
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COVID-19 THERAPEUTIC INTERVENTIONS
• Data shows the prone positioning with high flow nasal
cannula therapy works best for the COVID-19 patient
• In intubated patients with severe acute respiratory distress
syndrome, early and prolonged (at least 12 hours daily)
prone positioning (PP) improves oxygenation and decreases
mortality
• The main mechanisms of prone position helps recruitment of
lung alveoli in dorsal lung regions, increases lung
compliance, decreases alveolar shunting while improving
tidal volume
ASA,2020
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COVID-19 THERAPEUTIC INTERVENTIONS
WHY?
• Patients left in supine position have reduced pulmonary
function
• Ventral alveoli over-inflation and dorsal alveoli atelectasis
• Compression of alveoli
• V/Q mismatch
• Improves secretion clearance
ASA, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
• Research all over the world continues (non-stop)
• Data continuously collected
• UTMB plays an integral part of COVID-19 research studies
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COVID-19 THERAPEUTIC INTERVENTIONS
MENTAL HEALTH
• The coronavirus disease 2019 (COVID-19) pandemic may be
stressful for people
• Fear and anxiety about a new disease and what could
happen can be overwhelming and cause strong emotions in
adults and children
• Social distancing, can make people feel isolated and lonely
and can increase stress and anxiety
• COVID-19 Mental Health Support Line (PDF) offers COVID19-related mental health support for all Texans.
CDC, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
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COVID-19 THERAPEUTIC INTERVENTIONS
• Personal protective equipment (PPE) to be worn includes:
◦ Either an N95 mask, for which one has been fit-tested, or a powered air-purifying
respirator (PAPR)
◦ A face shield or goggles
◦ A gown
◦ Gloves
• Refer to the CDC guidelines
• https://www.cdc.gov/coronavirus/2019-ncov/index.html
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COVID-19 THERAPEUTIC INTERVENTIONS
HANDWASHING
• Hand hygiene is essential before donning and after doffing
PPE
• Hand hygiene can be performed using alcohol-based hand
rubs or hand washing with soap and water
• Wash hands with soap and water if hands are visibly soiled.
• Use extreme caution when removing and disposing of PPE to
minimize the risk of self-contamination
ASA, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
SOCIAL DISTANCING- 6 FEET
CDC, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
TESTING
• Two kinds of tests are available for COVID-19: viral
tests and antibody tests
• A viral test tells you if you have a current infection
• An antibody test tells you if you had a previous infection
• Suggested quarantine isolation for 14 days if exposed to
contact of virus with or without symptoms
CDC, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
TESTING
• CDC has guidance for who should be tested, but decisions
about testing are made by state and localexternal icon health
departments or healthcare providers
• If you have symptoms of COVID-19 and want to get tested,
call your healthcare provider first
• You can also visit your state or local health department’s
website to look for the latest local information on testing.
CDC, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
TESTING-RESULTS
• If you test positive for COVID-19 by a viral test, know what
protective steps to take if you are sick or caring for someone
• If you test negative for COVID-19 by a viral test, you
probably were not infected at the time your sample was
collected
• However, that does not mean you will not get sick. The test
result only means that you did not have COVID-19 at the time
of testing
CDC, 2020
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COVID-19 THERAPEUTIC INTERVENTIONS
NURSING INTERVENTIONS
• Place patients in an airborne infection isolation room.
• Upon entering the patient’s room, use airborne and contact
precautions, including eye protection.
• Wear PPE, including:
•
•
•
•
Fit-tested N95 mask or a powered air-purifying respirator (PAPR).
Face shield or goggle.
Gown, impervious if possible.
Gloves.
• Perform hand hygiene before donning and after doffing PPE.
CDC, 2020
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COVID-19
• If you test positive or negative for COVID-19, no
matter the type of test, you still should take
preventive measures to protect yourself and others.
MYTHS
• The virus is gone!
• I can’t catch it
• If you test positive or negative for COVID-19, no
matter the type of test, you still should take
preventive measures to protect yourself and others.
• ITS YOUR SOCIAL RESPONSIBILITY AS A
CITIZEN TO DO THE RIGHT THING!
RESPECT!
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COVID-19
MASK UP
HAND
6 FEET
VACCINATIONS
WASHING
SAVE LIVES
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COVID-19 Important Facts
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COVID-19 Important Facts
A close contact is anyone who was withing 6 feet of an infected person for a
minimum of 15 mins
An infected person can spread starting 48 hrs before the person has had any
symptoms or tested positive
You are still considered a close contact if you were wearing a mask around
someone with Covid-19
Direct physical contact ( touched, hugged, kissed, sharing food or drink, sex)
If you think you have been exposed to a person with Covid-19, go home and call
Student Health @409-747-9508 stdwappt@utmb.edu
Get tested, start self-quarantine, isolation
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GET VACCINATED
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Student Health Information
•
•
•
•
•
•
•
UTMB Student Health and Counseling
301 University Blvd.
Galveston, TX 77555-1369
Office: 409-747-9508
Fax: 409-747-9330
Email: stdwappt@utmb.edu
Website: https://www.utmb.edu/studenthealth/home
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NURSING NCLEX QUESTIONS
• What are some examples of Valsalva maneuver?
• Why does the nurse want to avoid? In a patient with a
hemoglobin level of 6.2, the nurse would be most concerned
about:
a. hematomas
b. hypertension
c. hypoxia
d. hypercapnia
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NURSING NCLEX QUESTIONS
• A patient complains of mild nasal congestion for the last few
months. Which of the following questions would not help in
determining the etiology?
a. Do you use any topical sprays or other medications for the
symptoms?
b. Do you have any animals in your home?
c. Can you think of anything that makes your symptoms worse
or better?
d. Can you relate the symptoms to intake of alcohol or
caffeine?
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CASE STUDY
• The nurse observes Mr. Jackson for outward signs of hypoxemia. The
nurse notes that Mr. Jackson's thoracic skin color is dark brown,
consistent with his African-American ethnicity, and that his nail beds are
pink.
• What additional assessment will provide supporting data related to
hypoxemia?
Select all that apply
Color of palms and soles.
Evidence of lower leg swelling.
Presence and location of chest hair.
Multiple thoracic hemangiomas.
Shape of the fingers and fingertips.
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CASE STUDY-Answer
• Cyanosis, a bluish tinge typically signifying tissue hypoxia, is
most evident in the nail beds, lips, and buccal mucosa. In
dark-skinned persons, cyanosis may also be evident in the
palms of the hands and the soles of the feet.
Shape of the fingers and fingertips.
Nail clubbing is associated with chronic hypoxemia. It
develops in stages including fluctuation and softening of the
nail, loss of the normal angle, increased convexity of the nail
fold, thickening of the distal end of the finger, and a shiny
aspect and striation of the nail.
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REFERENCES
American Society of Anesthesiologists. (2020). COVID-19 Information for Healthcare
Professionals. Retrieved from https://www.asahq.org/about-asa/governance-andcommittees/asa-committees/committee-on-occupational-health/coronavirus
American Thoracic Society. (2020). Interpretation of ABG’s. Retrieved from.
https://www.thoracic.org/professionals/clinical-resources/critical-care/clinicaleducation/abgs.php
Brashers, V. L. (2008). Alterations of pulmonary function. In S. E. Huether and K. L. McCance
Understanding Pathophysiology. (4th ed.). St. Louis, MO: Mosby, Inc.
Centers for Disease Control and Prevention. (2020). What is Social Distancing? Retrieved from
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
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REFERENCES
Centers for Disease Control and Prevention. (2020). What is Social Distancing? Retrieved from
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
Dara, P. (2020). Hypoxia in Flight. Retrieved from http://ww2.safepilots.org/hypoxia-in-flight/
Lehne, R. A. (2014). Pharmacology for nursing care. (9th ed.). St. Louis, MO: Saunders
Elsevier.
Pooler, C. (2009). Disorders of ventilation and gas exchange. In C.M. Porth and G. Matfin
Pathophysiology: Concepts of altered health states. (8th ed.). Philadelphia, PA: Wolters
Kluwer Health/Lippincott, Williams, and Wilkins.
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REFERENCES
Porth, C. M. (2020). Respiratory tract infections, neoplasms, and childhood disorders. In C. M.
Porth and G. Matfin Pathophysiology: Concepts of altered health states. (4th ed.).
Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams, and Wilkins.
Sorenson, M, Quinn, L., and Klein, D. (2019). Pathophysiology: Concepts of Human Disease.
NY,NY: Pearson.
Woods, A. (2020). COVID-19 “ Not your Typical ARDS”. Retrieved from
https://www.nursingcenter.com/ncblog/april-2020/covid-19-not-your-typical-ards
World Health Organization. (2020). Q & A on Coronavirus (COVID-19. Retrieved from
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answershub/q-a-detail/q-a-coronaviruses
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