Respiratory Difficulty in a 40 year old male –

Our present case study is based on the learning outcomes obtained from handling a case of a 40 year old man who was admitted to emergency unit following breathing complications. The real reasons for his complications were not immediately known at the time of admission however several reasons have been proposed. COPD, Congenital heart disease, asthmatic history if any, bronchial diseases and pneumonia or related illnesses were given as probable causes of his condition.

However a prolonged investigation and history of past record yielded that the patient was suffering from COPD (chronic obstructive pulmonary disease) and his breathing problem was a direct effect of his pulmonary dysfunction and alpha 1 anti-trypsin deficiency syndrome. Considering the management and treatment conditions of the patient, certain treatment and learning outcomes have been identified. In this essay we discuss how these learning objectives could be achieved.

In this paper we would examine the case of severe broncho-spasms and breathing difficulties in a 40 year old male patient who was admitted to the Emergency Unit of a hospital following calls to 999, emergency ambulance division. When the patient was brought to the hospital and subsequently admitted to emergency unit, he was unable to breathe, required oxygen mask and was also unable to talk properly, with mainly incoherent rumbling speech. The patient’s relatives were in tremendous emotional pressure and psychological crises. We would begin our paper with an analysis of the patient’s condition through several studies cited and then discuss the treatment objectives as well as learning outcomes and how this could be achieved using reflective practice, collaborative working and application of knowledge and skills. Some discussion on learning outcomes as training objectives in the medical profession and counseling of patients’ relatives to overcome any psychological shock is also present in the analysis.

Cases and Evidence of Breathing Difficulty

Breathing problems and asthmatic conditions have been reported in cases and studies worldwide. According to a report by the National Statistics Department, the prevalence of treated asthma increased in both sexes and all age groups except for children under 5 years. The percentage of patients being treated with the combined use of bronchodilators with regular preventive treatment has also increased, suggesting improved adherence to British Thoracic Society guidelines (National Statistics, 2003).

Citing a case of severe broncho-spasm in a patient, Dominguez (2002) described the patient as having severe difficulties in breathing, speaking and denied any past medical history of breathlessness. The pre-hospital providers and clinicians according to the author were challenged with determining the differential diagnosis for broncho-spasm and hypoxemia. The focus was on the diagnosis and whether the patient was experiencing an acute asthmatic attack or an anaphylactic reaction. A thorough assessment and patient history taking was emphasized in this case as all wheezing symptoms could not be considered as asthma. It had to be determined whether the patient was suffering from bronchitis and broncho-spasms, anaphylaxis, asthma, pneumonia, COPD or a severe congestive heart failure (CHF). As Dominguez points out anaphylatic and asthmatic patients have difficulty moving air but do not have problems with oxygenation and many respiratory conditions are capable of causing wheezing. Even in case of CHF, when left ventricular function decreases, there can be increased pulmonary pressure when serum begins to leak out of pulmonary vessels and into interstitial space leading to increases in interstitial pressure. This causes the narrowing of bronchioles and air traveling through the narrowed bronchioles can also cause the wheezing sound and fluid can also leak out of pulmonary capillaries to occupy much space of the alveolar sacs and when the interstitial pressure rises and bronchioles continue to narrow down, initially a wheezing sound is given out and in this condition, oxygen is not exchanged adequately into the blood with the patient becoming hypoxemic. With an accurate patient history and proper assessment, the cause o the broncho-spasm is identified and the questions identified by Dominguez are as follows does the patient have a history of asthma? Does the patient have any rash, hives or swelling? Is the patient elderly, and does he/she show pedal edema, JVD, hypoxemia and/or distended neck veins? Answers to these questions would determine whether the patient is suffering from asthma, anaphylaxis, or CHF. However the use of bronchodilators in patients suffering from CHF has been controversial and if a CHF patient has broncho-spasm and wheezes then a beta 2 selective treatment along with nitrates and diuretics is usually recommended. Within CHF, lack of oxygenation rather than air movement is the primary problem and hypoxemia worsens cardiac function. Dominguez points out that both broncho-constriction and filling up of alveolar sacs impair oxygenation of RBCs and also that of vital organs. Pre-hospital management issues of CHF relate to restoring oxygenation and many agencies use oxygen nitrates, ACE inhibitors and CPAP. The improvement of patient outcomes approach taken by Dominguez accordingly rests on understanding the pathophysiology of respiratory emergencies and their differential diagnosis. Diagnosis of the actual cause of the respiratory problem has been identified as the primary clinical and patient outcome of health care approach related to respiratory emergencies. However we will mention other possible learning outcomes suggesting the very specific ones that we will be concerned with.

In another relevant study Mukhopadhay and Lim (2005) examined the diagnostic and clinical outcomes of consecutive adult inpatients who were admitted to a university hospital and referred to respiratory physicians for breathlessness. All adults referred for breathlessness were enrolled on record for the study and evaluations were done on clinical features and on the utility of routine investigations such as blood tests and radiology. 105 patients were chosen from surgical and cardiology departments of the hospital of whom 49 were men and 56 women and with average age of 66 years. Postoperative acute pulmonary embolism was diagnosed in four patients, chest radiographs helped to make diagnosis in 66 % of patients and computed tomography pulmonary angiogram of thorax was performed in 31 of 34 patients investigated for acute pulmonary embolism. Postoperative patients were tested more for PE than non postoperative patients.

The authors concluded from their survey and study of patients with breathing problems that in hospitalized patients referred for breathlessness, respiratory infections were the most common diagnosis and chest radiograph the most useful method for initial investigation of breathlessness. Computed tomography pulmonary angiogram was also identified as preferred method of investigation for acute PE and it was also found that postoperative cases of breathlessness being most apparent, clinicians are more inclined to investigate for PE in postoperative patients. Falk et al (2005) pointed out from a study on athletes that exercise induced broncho-constriction may involve oxidative stress. They suggest that strenuous exercise promotes free radical production leading to pathophysiological changes associated with asthma and broncho-constriction, mucous secretion and micro vascular leakage. Lycopene is shown to have high anti-oxidative activity. The objective of the study was to evaluate the effects of lycopene supplementation on airway hyperactivity and inflammation in young athletes who complained of a breathing difficulty related to excessive physical exercise or exertion. For their methodology, 19 young athletes with exercise related difficulty in breathing visited the exercise laboratory thrice. During their first visit, the athletes underwent a baseline evaluation of exercise induced broncho-constriction. For each of the two subsequent visits, participants ingested 30 mg of lycopene which is a natural antioxidant or a placebo and between each visit a two week gap period was given. During each visit lung functions were evaluated after a brief exercise program. The results indicated that there was no difference in the mean or SD measures in forced expiratory volume after exercise during lycopene treatment compared with placebo treatment. Also there was no division between responders and non responders. The authors concluded that a daily lycopene dose for a week does not seem to affect lung function after exercise and may not provide any protective effect against clinical difficulty in breathing in young athletes.

There can be several causes of breathing difficulty and Heinz and Dunne (2004) discuss a typical case study of a 7 year old boy who had a respiratory collapse and with proper management of the condition could reach a stage of successful resuscitation. Heinz and Dunne argue that airway obstruction is a recognized complication in children with mediastinal masses and respiratory difficulties in breathing and associated respiratory noises. They suggest that general anesthesia in these patients can lead to complete obstruction of airway and lungs with fatal consequences and successful management in the emergency department necessitates rapid recognition of the underlying problem with regard to breathing difficulty symptoms and highlight the need for rapid and appropriate intervention.

Ledez and Zbitnew (2005) discuss one important reason of breathlessness considering an infant with congenital heart disease. The authors claim that infants with cyanotic congenital heart disease are at risk for cerebral arterial gas embolism (CAGE) from iv infusion lines and concerns about the hazards and difficulties of caring for such patients inside a hyperbaric chamber may deter referral. Ledez and Zbitnew report a complex case in which a small fourth month old infant weighing 6.19 kg was managed successfully using a modified hyperbaric oxygen treatment (HBOT) schedule. The clinical features of the baby showed a seizure on the double outlet right ventricle that became unstable after iv drug infusion. The patient was sedated, intubated and ventilated with commencement of dobutamine. A computerized tomography or CT scan which was performed ten hours later demonstrated intracranial air bubbles and about ten hours later the patient was referred for HBOT which commenced soon afterwards in multiplace chamber. HBOT was modified using abbreviated schedule at reduced pressure and two 90 minute HBOT sessions were administered within 24 hour at 38 feet of sea water pressure and during the treatment the infant was ventilated using a ventilator. A subsequent CT scan demonstrated absence of air and following extubation, the child appeared neurologically intact except for some weakness in the left arm. The authors concluded that hyperbaric oxygen may be utilized to treat cerebral arterial gas embolism in small infants and breathing problems with right to left shunt that should be commence immediately.

In a study on 429 young children admitted to a hospital in Bangladesh, with bronchiolitis Kabir et al (2003) identified 348 children as well for putative risk factors, clinical profile, management and outcomes. Both the cases with bronchiolitis and without it were examined for respiratory syncytial virus (RSV) antibody status. The diagnosis of bronchiolitis was first made on the basis of the first initial attack of wheezing in previously healthy children below the age of two years. So, detailed case histories were taken with possible risk factors, management plans and follow up on the ward with outcomes at discharge were all documented through structured questionnaires. Chest x-ray was also done in each case to find out the radiological changes and blood of 266 patients and 30 controls were studied using RSV IgM and IgG antibody with the help of test ELISA. 66% were male and 33% were female children with median age of 3 months and 82.7% of these children were below 6 months of age. 88% of these babies were born through normal vaginal delivery with exclusive or predominant breast feeding given to 72% of the cases. The babies home location was rural in 55% of cases with majority 74% of them coming from poor families. The clinical features and symptoms of bronchiolitis were cough, respiratory distress, fast breathing, spasms and feeding difficulty. Fever was seen in one third of the cases although complaints of fever were from 90% of cases. Wheezes and crackles in lungs were seen in 96% of cases. Liver was affected in 83% and spleen in 42% of cases. The radiological features marked here were increased translucency, interstitial markings, hyperinflation and streaky densities. The main modalities of treatment were antibiotics with ampicillin in most cases, oxygen therapy, nebulised salbutamol, intravenous fluid with median duration of hospital stay for 4 days. After treatment and management of the conditions, 96% of the children were discharged with improvement with 2% mortality. However outside Dhaka, bronchiolitis was not detected. Cefratiaxone and parenteral steroids were the main tools of therapy used in these cases. From this study it is obvious that respiratory distress and breathing difficulty can be intricately associated with bronchial problems and several other diseases as there can be management procedures and treatment outcomes equally varied involving the right balance of management and care approaches with medical treatment alternatives

Considering our case identified with chronic obstructive pulmonary disease research on COPD reveal several factors responsible for the disease and the effective methods of treatment. The possible links between psychological status and respiratory sensations have been found in several recent studies and Chetta et al (2005) discuss the physical disturbances associated with psychologically stressful events. It is generally accepted by clinicians now that some stressful events affecting emotions can lead to exacerbations of asthmatic tendencies and breathlessness. The authors conclude that in patients with chronic respiratory diseases, the evaluation of breathlessness perception, psychological disturbances and recording of all stressful events should be considered relevant as the physical and functional assessment of respiration (Chetta et al, 2005, p. 214)

In certain cases, severe pulmonary hypertension is believed to occur in patients with chronic obstructive pulmonary disease and in a study on identifying patients with pulmonary hypertension and chronic obstructive pulmonary disease, Chaouat et al (2005) did a retrospective study on 27 COPD patients with severe pulmonary hypertension among 998 patients who underwent right heart catheterization between 1990 and 2002 as part of chronic respiratory failure workup. Of the 27 patients, 16 had another disease which was capable of causing pulmonary hypertension. However 11 patients had chronic obstructive pulmonary disease as the only cause of pulmonary hypertension. Cardiopulmonary abnormalities in these patients caused mild to moderate airway obstruction, severe hypoxemia, hypocapnia and with severe exertional dyspnea, survival chances being lower than patients without COPD. The authors conclude that severe pulmonary hypertension is uncommon in COPD patients but when it is seen in such patients a secondary cause may be sought. When COPD is the sole condition accompanying pulmonary hypertension, pulmonary vascular diseases are usually diagnosed.

For care and treatment of COPD conditions, several options are used to restore normal breathing. Bradley and O’neill (2005) suggest the use of ambulatory oxygen for COPD. They define ambulatory oxygen as the use of supplemental oxygen during exercise and activities of daily living. Ambulatory oxygen therapy is used for patients on long term oxygen therapy during exercise and this has been suggested by evidence obtained from single assessment studies and longer term studies. Longer term studies assess the impact of ambulatory oxygen therapy that is used at home during the daily activities whereas single assessment studies compare performance during an exercise test using oxygen with performance during exercise test using placebo air. The authors studied the efficacy of ambulatory oxygen in patients with COPD using single assessment studies. For their purposes only randomized controlled trials were included which compared oxygen and placebo when administered to people with COPD who underwent an exercise test and 27 studies randomized 469 participants who met the inclusion criteria of the review. The authors suggested that administration of oxygen improved outcomes relating to exercise capacity and conditions of breathlessness. The authors concluded that their review provided some evidence from single assessment studies that ambulatory oxygen improves exercise performance in people with moderate to severe COPD, although small sample size limitations have not been overlooked. The need to replicate the findings on to larger samples and wider trails has been considered. For ambulatory oxygen assessment, maximal or endurance tests can be used in assessment of ambulatory oxygen although endurance tests are more related to daily life activities. In the assessment of ambulatory oxygen, the authors recommend the need to understand the level of benefit provided to people with COPD. Apart from providing ambulatory oxygen therapy, the importance of body care such as daily routine on bathing and washing of patients with COPD has been emphasized by Lomborg and Kirkevold (2005).

In a unique and influential study done as early as 1946, Carr and Essex carried out experimental studies on dogs anaesthetized with pentobarbital sodium to determine effects of long period of pressure breathing both exclusively and when combined with acute hemorrhage or trauma of hind limbs. They obtained the following important results as discussed: Continuous positive pressure respiration and five of nine animals survived three hours of continuous positive pressure respiration and other four developed fatal apnea Continuous positive pressure respiration had variable effects on the femoral arterial pressure and on the heart rate and it slowed and deepened respiration, decreased diameter of heart and dilated tracheo-bronchial tree.

Three of eight animals survived two hours of continuous positive pressure respiration after a hemorrhage although circulatory failures developed for others. a group of five animals withstood three hours of intermittent positive pressure respiration Intermittent positive pressure respiration produced considerable fluctuation of the femoral arterial pressure with a decrease of the mean pressure, elevating jugular venous pressure, the pulmonary venous pressure, renal venous pressure, and pulmonary arterial pressure. It slowed and deepened respiration rate but had no consistent effect on the heart rate.

Some animals were unable to withstand even a small hemorrhage during intermittent positive pressure respiration. It was demonstrated that the pressure breathing was a definite factor in hastening the death of certain animals Trauma to the hind limbs during intermittent positive pressure respiration proved fatal to all four animals Although the experiments were carried out on animals, certain results could be extrapolated to humans and in this way, the results are important as they suggest that positive pressure respiration had important and definite effects on the circulatory and respiratory systems although the study also suggest that pressure breathing hastened the death of certain animals. The importance of methods of respiration, the relationship of the circulatory and respiratory systems and the fatality of cases with respiratory problems have been highlighted effectively in this study and is thus very important in the analysis of management of breathing problems.

In the diagnoses and management of breathing problems, certain sleep related disorders have been found to be common contributing factors for causing essential hypertension but are usually neglected, under diagnosed or left untreated. Silverberg et al (1997) suggest that there is now strong evidence from animal studies, from epidemiological studies as well as from retrospective and prospective intervention studies that obstructive sleep apnea or OSA can cause permanent hypertension not only during sleep but also during normal waking hours. Even without OSA, some snoring has been reported and the authors state that epidemiological, clinical, biochemical, hematological and physiological abnormalities seen in essential hypertension could be accompanied by sleep related breathing disorders or SRBD. The study point out that many cases of resistant hypertension are due to SRBD and recent studies show that SRBD are common in EH and a vast majority of patients with sleep related breathing disorders are not usually considered by physicians who tend to treat hypertension as isolated physical ailments even when patients have very clear symptoms of constructive sleep apnea. The under diagnoses of OSA may be due to lack of physician’s knowledge about the condition and the authors point out that this lack of knowledge is prevalent among family physicians, among hypertension specialists, and researchers in the field. OSA is a common ailment, easily diagnosed and is a treatable condition associated not only with disturbed sleep but also with conditions such as hypertension and a wide range of cardiovascular problems, loud snoring and excessive daytime sleepiness causing traffic accidents, decreased sexual functioning and memory deficits, difficulty in concentration and changes in mood. The authors conclude with the suggestion for further research on sleep apnea and other sleep related disorders and more attention on hypertension that is currently given to the condition.

Unetani et al (2003) discussed the case of a 34 year old male who weighed 110 kg and had severe obstructive sleep apnea syndrome (OSAS) and was taken to hospital urgently for heart and respiratory failure. In this case as well a close relation between heart and respiratory systems functions are also seen. The body mass index of the patient was 39 showing that he was considerably obese. He was also supposed to have tonsillectomy under general anesthesia and the BiPAP or the bi-level positive airway pressure which was applied for respiratory assist. However the patient was on diet to prepare for surgery and preoperative examination revealed that his tongue and tonsils were hypertrophic. There were some difficulties expected in maintaining upper airway open during the perioperative period. Anesthesia was induced with intubation which was performed by preserving spontaneous breathing. After the operation he was taken to an intensive care unit and mechanically ventilated for 6 days. His pharyngeal edema aggravated his respiratory condition when extubated after surgery. He was successfully extubated and BiPAP was applied. The authors suggested that in case of obese patients with sleep apnea, the patients should be cared for intensively during perioperative period. Being Overweight, having heart problems and respiratory failures are all interrelated and this interrelation plays an important role in respiratory management.

Hopkins et al (2004) suggest in their study that Acute Respiratory Distress Syndrome is characterized by lung injury and hypoxemia with a high mortality rate and is associated with morbidity in cognitive and emotional aspects of life with decreased quality of life. Emphasizing on the importance of quality of life, the authors attempted to find the relationships between quality of life, cognitive and emotional functions with ARDS survivors after a year of post hospital discharge. In this study 66 ARDS survivors were administered a battery of neuropsychological tests with measures of emotional function an quality of life after a year of hospital discharge. Following through one year of post hospital discharge, 45% of ARDS patients had cognitive failures and 29% had mild to moderate symptoms of depression an anxiety. Depression, anxiety, and length of care at the intensive care unit have been found to be significantly associated and correlated with a decreased quality of life. However surprisingly the authors emphasize that cognitive impairments did not correlate with decreased quality of life and illness, severity and emotional function are all associated with decreased quality of life following one year after ARDS. However Acute respiratory distress syndrome is characterized cognitive and emotional morbidity and decreased quality of life.

In our case study of the 40 year old male, several reasons for respiratory failure and breathing difficulty can be identified and these are associated with several diseases and conditions and involve several physiological functions and systems of the body. Symptoms are also involved with decreased quality of life, depression, anxiety along with associated problems of illness, heart failure and cognitive impairments. The patient’s COPD condition along with alpha 1 anti-trypsin deficiency can be supported with evidence from many studies. As early as 1975, Rasche et al measured proteolytic activities, total protein concentrations, alpha 1 anti-trypsin, alpha 1 anti chymo trypsin and free and bound proteinase inhibitors along with total proteinase inhibition against trypsin and chymotrypsin and found free proteinase inhibitors together with the proteolytic activities. According to this study, the free to bound inhibitor rate was approximately 1:1 alpha 1 anti trypsin and alpha1antichymotrypsin which were measured in sputum in low concentrations. The authors pointed out that a particular patient with alpha 1 anti trypsin deficiency had no alpha 1 anti-trypsin but high concentrations of total proteinase inhibitors in free and bound states in bronchial mucous. Rasche et al suggested in the paper that in the alveolar part of the lung, the humoral proteinase inhibitors were effective whereas in the bronchial part of the lung, specific mucosal inhibitors had a greater role. The proteinase inhibition of mucosa specific inhibitors in bronchial mucous has been found to be responsible for the pathogenesis of emphysema or severe chronic obstructive bronchitis.

The learning outcomes for treatment of such a patient are given here and considering the case we would also discuss treatment outcomes using treatment, care and management methods to develop a management plan for the patient.

Breathing problems can be triggered due to several factors including illness, pneumonia, bronchitis, chronic pulmonary obstructive disease and respiratory tract infections, or due to heart disease, and postoperative complications of surgery.

Rogers et al (2000) discusses a different aspect of clinical experience analyzing the learning objectives of medical professionals by applying analytic, evaluative and psychomotor skills of critical care medicine. The authors aimed through their study to determine whether fourth year medical students can learn basic evaluative, analytic and psychomotor skills that are needed to initially manage a critically ill patient. For the experimental design, student learning was evaluated using performance examination, the objective structured clinical examination (OSCE). Before their elective, students were randomly assigned to one of two clinical scenarios and after the elective, students completed the other scenario using crossover design. The entire experiment was done in five surgical intensive care units in a tertiary care university teaching hospital and involved 40 fourth year medical students enrolled in critical care medicine elective. For the interventions, all the students were asked to evaluate a live simulated critically ill patient , requested physiological data from a nurse , ordered laboratory tests and received data in real time and intervened as found appropriate.

Student performance of specific behavioral objectives was evaluated at five points and the learning outcomes in their case were that they were expected to a) assess airway, breathing, and circulation in appropriate sequence; b) prepare a manikin for intubation, obtain an acceptable airway on the manikin, demonstrate bag-mouth ventilation, and perform acceptable laryngoscopy and intubation; c) provide appropriate mechanical ventilator settings; d) manage hypotension; and e) request and interpret pulmonary artery data and initiate appropriate therapy. The objective structured clinical examinations or OSCEs were videotaped and reviewed by two faculty members and a checklist of key behaviors was used to evaluate performance. The primary outcome was the difference in examination scores before and after rotation. The authors concluded from the results of their study that fourth year medical students without a critical care medical elective do not possess the basic cognitive and psychomotor skills which are necessary to manage critically ill patients. After a month of CCM elective training however, students thinking and application skills required to manage critically ill patients improved markedly, as demonstrated by OSCE using a live simulated patient and also a manikin.

In another study on analyzing learning objectives, Modell et al (2004) examined how directing students in a laboratory setting helped them to repair a faulty mental model in respiratory physiology. In their study, a written protocol directed students to predict what would happen to frequency and depth of breathing during exercise on a bicycle ergometer run the experiment and compare results to their predictions. In a predictor with verification group, students followed the same written protocol and were required to show the instructor their predictions before running the experiment. In a third group, students reported their predictions verbally to an instructor immediately before exercise and reviewed results with the instructor immediately following exercise through the instructor intervention group. Similar results were found for predictor with verification and predictor without verification protocols. The authors suggest that their result point out to multiple factors impacting learning in student laboratory with a major factor being a mismatch between students' approaches to learning and intended learning outcomes of the experience. Students own approach to learning is thus an important factor that shape whether learning objectives would be met.

Botsis et al (2004) studied the usefulness of developing a computer simulation system for the human respiratory system in order to educate nursing students as a training program. The approach was based on existing mathematical models and the computer simulation system was also done on a mathematical basis constructed with specific functions. Appropriate software packages were used according to demands of the process and the system was called ReSim or Respiratory Simulation consisting of two parts dealing with pulmonary volumes and representing mechanical behavior of lungs the target group evaluated this ReSim system and the outcomes of the evaluation process being positive helped the authors to realize why and whether the system characteristics needed further improvement. Botsis et al concluded that the extended use of such systems supports the educational process and offers new potential for learning. Mechanical devices, and artificial simulation systems of the human body are used for training program in medical and nursing courses and using these methods can actually improve the effectiveness o a training program as seen from the study here. Models and simulated systems are aids in learning and help to reach learning outcomes easily and effectively.

Tables and Charts – Data related to Asthma, Chronic Respiratory Diseases and CHD

Statistics on Asthma Deaths provided below by Asthma .org

Asthma:

• On average, 1,500 people die from asthma each year in the UK. This equates to four people per day, or one person every six hours.

• About a third of deaths (34%) caused by asthma occur in people under the age of 65.

• An estimated 75% of admissions for asthma are avoidable and as many as 90% of the deaths (1,500) from asthma are preventable.

• There are 18,000 first or new episodes of asthma presented each week to GPs in the UK.

• A primary care organisation of 100,000 people is likely to experience on average 2–3 deaths from asthma per year.

• Respiratory disease now kills more people than coronary heart disease – that's one in four people in the UK.

The WHO priorities and objectives of treating Chronic respiratory diseases are as follows:

__ Development and evaluation of reproducible and inexpensive methodologies to monitor COPD suitable for use in developing countries;

__ Identifying and addressing barriers to drug and essential device accessibility, developing approaches to improve accessibility to essential drugs in low income countries, designing and implementing a study of CRD drug and device availability and pricing in low and middle income countries;

__ Identifying gaps in existing guidelines, using methodologies for guideline development that are evidence-based and take into account public health considerations like cost-effectiveness and feasibility specially in developing countries, using the newly developed guidelines as the rational basis for inclusion of drugs into the Essential Drug List;

__ Strengthening research on primary and secondary prevention interventions of CRD;

__ Identifying research priorities, which should include in addition to prevention strategies, therapeutic regimens, alternative drug delivery systems, traditional medicine and alternative therapeutic approaches;

__ Establishment and promotion of partnerships with professional, scientific, and educational institutions to promote and implement the initiative. The WHO also gives the following facts related to Chronic Respiratory disease: Source: WHO, 2003 report

Treatment Outcomes for Respiratory Diseases: Source: WHO strategy, 2005

Programme objectives

• Better surveillance to map the magnitude of Chronic Respiratory Diseases and analyze their determinants with particular reference to poor and disadvantaged populations, and to monitor future trends.

• Primary prevention to reduce the level of exposure of individuals and populations to common risk factors, particularly tobacco, poor nutrition, frequent lower respiratory infections during childhood, and environmental air pollution (indoor , outdoor, and occupational).

• Secondary and tertiary prevention to strengthen health care for people with Chronic Respiratory Diseases by identifying cost-effective interventions, upgrading standards and accessibility of care at different levels of the health care system.

Learning Outcomes:

The treatment and care of emergency conditions such as breathing difficulty or severe asthma can involve several learning outcomes in healthcare such as:

A better understanding on the causes of breathing difficulty, also examining the pre-disposing or precipitating factors for breathing problems

Critically examining the nature and incidence, and prevalence of breathing difficulties or asthmaticconditions

appraisal of methods for diagnosing breathing problems

Assessing the principal effects of asthma on a patient, including physiological effects on the respiratory tract, analyzing the critical issues while assessing a patient with breathing problems Teaching skills are required by the asthmatics to manage their own conditions and should be emphasized

The management of asthmatic patients with knowledge, skill and understanding, delineating common management steps to be taken during emergency situations discussion of psychological issues related to patient care

Identifying precautionary steps that may prevent asthmatic emergencies from occurring in patients and informing patients on what they should do during emergency

Be able to provide the pathophysiology, signs and symptoms, and prevention and emergency procedures for the difficult breathing conditions

Justifying methods for diagnoses of asthma and breathing difficulties in patients of different ages or suffering from different ailments. Asthma or breathing problems related to many ailments and underlying physical problems

How medical practitioners and carers can be prepared in the event of an emergency of this sort participating in learning through experience as 'experiential practical learning' and exploring the implications for practice

Developing reflective practice through learning experiences, objectives and individual case study A proper appraisal of the role of health workers and carers considering the impact on health outcomes

Utilizing recent research, national and local guidelines as bases for the skilled practice and learning outcome

Extending knowledge on etiology, pathology, and medical investigations for treatment An evaluation of one's own role as a nurse or healthcare worker within the multi-professional and multilevel healthcare team

Understanding the social impact of breathing problems and asthmatic conditions such as restrictions and social stigma and adequate measures to dispel certain social myths related to breathing problems

However the specific learning outcomes we are concerned here with are:

1 identifying areas of own practice which require further reflection and development

2. being conversant with academic and professional debates and the received literature and informed on the systematic approaches as it pertains to professional practice

3. Synthesizing personal insight theory practice and skills issues into a coherent whole.

4. Demonstrating the integration of theoretical and personal understanding in assessment diagnosis treatment and accountability within the professional practice.

5. Evaluating one's effectiveness as a provider of care incorporating assessment diagnosis, treatment, discharge and referral approaches.

6. Demonstrating appreciation of ethical issues and dilemmas in the assessment diagnosis and treatment discharge and referral cycle for emergency practitioners.

Achieving the above mentioned learning outcomes seem to be the primary motive of management in care and treatment of the 40 year old patient. The patient was admitted to the emergency unit and given oxygenation which was not completely effective. However proper medication and treatment conditions were identified and his breathing was restored to normal levels. After restoration of his breathing conditions to normalcy, the treatment objectives were focused on care and rehabilitation programs and awareness initiatives to help the patient avoid future emergency breathlessness conditions. The patient was identified to have the autosomal genetic condition of alpha 1 anti trypsin deficiency that surfaced after being exposed to long term smoking resulting in chronic obstructive pulmonary disease.

The first step is the accurate assessment of breathlessness and breathing difficulty conditions. As also identified by Booker (2004) the effective assessment of acute breathlessness in patients involves an understanding of the physiology and the mechanism of breathing. As Booker emphasizes, breathing is the fundamental life process that usually occurs without conscious thought and for the healthy person breathing is a normal process and taken for granted. Breathing involves the coordinated action of inspiratory and expiratory muscles, the unimpeded passage of air from the atmosphere through the upper to lower respiratory tract, the exchange of oxygen and carbon dioxide across the alveolar membrane. Stating that breathlessness can be associated with a variety of disorders Booker also defines breathlessness as 'an abnormal awareness or difficulty with breathing' following Bourke and Brewis, 1998 . Breathlessness can be acute or chronic. Acute breathlessness occurs for a short time frame ad may be quite severe and can present or highlight symptoms of a life threatening underlying disease. Chronic breathlessness develops over several months or years and is commonly found in smokers or bronchitis patients. As in our particular case, individuals with alpha-1-antitrypsin deficiency have a 20-fold increased risk of developing COPD or emphysema and 80-90% of alpha 1 anti trypsin deficient individuals eventually develop this condition in their lifetime and develop fatal symptoms of respiratory diseases by the age of 40.

Breathlessness can be due to several underlying diseases or abnormal physical conditions ranging from sleep apnea and sleep disorders (Naughton, 2005), chronic dyspnea (Karnani et al, 2005), due to asthma (Silverman et al 2005), SARS (Chan et al 2005), and influenza viruses (Joseph, 2005) to pneumonia (Sinaniotis et al, 2005); cigarette or tobacco smoking (Ebihara et al 2005), environmental and occupation related (Zhang et al 2005), and congestive heart failure (Caroci, et al 2005). The several causes and different associated illnesses of breathlessness makes it difficult for a proper diagnoses by nurses and physicians and history taking of patient and a study of associated symptoms have to be considered important. If the patient has a history of asthma, the breathlessness is due to asthma, other wise if the patient has a heart disease , breathlessness may be due to congestive heart failure or congenital heart diseases and a dysfunctional circulatory system in general. In our case the patient has a history of heart disease and was suffering from COPD and his breathing difficulty is found to be related to his chronic obstructive pulmonary diseased condition and alpha 1 anti trypsin deficiency. He is also a smoker, making his condition even more difficult. Excessive smoking has caused an increased in his breathing problems and deteriorated his conditions and his current breathing problems have been precipitated by excessive smoking.

The learning and treatment outcomes in this are intricately related and learning is primarily dependent on assessment and treatment of the patient. In this case the primary means of assessment was checking the patient physiological symptoms along with history taking and finding out the cause of his breathlessness. The reason for breathlessness was COPD condition which caused severe pressure on his chest and gave him considerable discomfort. The immediate concern upon his admission was treating his breathing problems and restoring normal levels and rhythms of breathing. This was followed by diagnosis of his underlying problems of asthma, heart problems if any and illness such as pneumonias, viral infections or smoking history. This was quickly followed by identification of the real causes and treatment methods adapted for the causes. The long term management plans for treatment and care of the patients included several programs. Collaborative working between nurses and other medical professionals allowed for a proper assessment of the person’s condition using chest imaging, ECG reports, respiratory and pulse rhythm analysis as well as blood pressure, breathing rate and other measures which were constantly used to examine and monitor the patient. The alpha 1 anti-trypsin deficiency, an autosomal recessive condition in the patient has been identified. This I specifically a genetic condition with manifestations due to environmental pollutants such as cigarette smoke. Thus this patient is a strong example of a genetic problem that makes an individual predisposed towards adverse cigarette smoke effects. Reflective practice of what has been learnt from handling and attending to this particular case is important here and within the reflective practice for this particular case study, certain learning outcomes were achieved:

1. The proper diagnosis of the condition and identifying the underlying cause of the breathing problem

2. The physiological conditions and breathing mechanism – knowing the physiology of the respiratory system which seems to be very important as a learning outcome

3. the reactions to specific medication and patient improvement and response to certain medication

4. the relation between smoking, chest infection, heart disease, pulmonary disease and breathing difficulty were established and understood

5. integrating professional experience with personal understanding of the case involved using the case study to have better insight on respiratory distress and acute breathing problem.

6. psychological help, advice and counseling sessions were being provided to relatives and friends of the patient

7. finally a reflective appraisal of the care method, treatment outcomes and diagnoses and referrals was helpful in identifying where the treatment went wrong if at all and how it could have been improved.

 8. the ethical issues were also noted.

The diagnosis of this condition revealed that the patient suffered from chronic obstructive pulmonary disease, a severe respiratory disease and has a habit of excessive smoking that has precipitated his condition.

The physiological mechanism of breathing was identified and was found to put considerable stress on his ventricles and chest and diaphragm in general

It was pointed out to the patient that smoking habits should be completely stopped and he was given oxygen a mask along with test such as ECG and breathing rate monitoring regularly He was identified to have alpha 1 anti-trypsin deficiency syndrome

Essential drugs were provided and the need for collaborative working between different department of hospital working staff was also recognized

Patient feedback form was given to get patient appraisal of the treatment provided to him, an evaluation of services and if there were flaws in the management, how it could be improved Reflective practice method was used to understand and study the patient’s condition to learn more fro this particular case. The result of the case suggested that COPD and smoking combined can be a deadly combination and can lead to a chronic breathlessness condition with frequent episodes of acute and severe breathing difficulty as has been found in the patient. This suggests that the potential dangers of smoking especially when combined COPD conditions

The ethical issues definitely involved using artificial respiration and such methods as well certain medications which may have had certain minor side effects. The ethical issues concerned with smoking could be emphasized as a learning outcome as COPD conditions have been found to be especially affecting smokers with alpha 1 anti trypsin deficiency rather than non smokers without the deficiency. The dangers of smoking as a practice and habit were especially noted in counseling and training sessions for relatives of patients and for nurses as well as in awareness sessions given to the patients. Patient consent to treatment methods and medications is an important ethical dimension that was considered.

The case study has been especially effective for reflective practice, collaborative working and feedback on management issues within health care settings. In keeping with WHO objectives and NHS plans individual case studies could be successfully used as examples of moving further with health care implementation plans for respiratory diseases. From a review of the evidence of respiratory diseases we found that there can be several reasons for breathing difficulty and also there are equally varied methods of treatments. However for our purposes we have specified the treatment and management approach suggesting continuous monitoring of circulatory and respiratory systems functioning and medication along with evaluation of services, patient feedback, reflective practice, collaborative working and an unbiased appraisal of healthcare systems in accordance with NHS and WHO objectives as essential for a health management plan.

Conclusion

In this case study of a 40 year old male who was admitted to a hospital emergency unit following calls to 999, has hi family by his side and all his family members were considerably distressed when he was admitted to the hospital unit. He was given special care with immediate concerns and focus being on relieving him of his respiratory distress and restoring his normal respiratory levels. Although there was a general obstruction in his lungs, his symptoms and tests suggested that respiratory problems were due to his chronic obstructive pulmonary disease and alpha 1 anti trypsin deficiency syndrome which gave considerable pressure to his chest and caused discomfort. Apart form this sudden acute attack of respiratory distress, the patient also showed some chronic symptoms of weakened respiratory system and this was supported by record take from his family members that he was a regular smoker and has been diagnosed with alpha 1 anti trypsin deficiency at the same time. Alpha 1 anti trypsin deficiency is a common autosomal recessive disorder and although symptoms may not be obvious early in life, the deficiency surfaces when individuals are exposed to cigarette smoke. No tumors were found and so the treatment was oriented toward restoring and correcting the patient’s respiratory disorder. While doing so, several management and treatment outcomes were identified which involved restoring proper respiration, exercise schedules and diet and therapeutic programs including advice on cutting down smoking and dealing with emergency conditions such as acute breathing difficulty. The patient’s relatives and friends who accompanied him to the emergency unit were also in considerable shock and counseling and advice sessions were scheduled for them. In this context the importance of reflective practice and collaborative working were also highlighted along with the need for patient feedback and frequent evaluation of health services in keeping with NHS and general health care plans.

References

Aoe K, Hiraki A, Murakami T, Maeda T, Umemori Y, Katayama H, Eda R, Takeyama H. Sudden onset of interstitial lung disease induced by gefitinib in a lung cancer patient with multiple drug allergy. Anticancer Res. 2005 Jan-Feb;25(1B):415-8.

Agnihotram VR. Reviewing respiratory disease burden in rural India: household environment matters. Rural Remote Health. 2005 Jan-Mar;5(1):357. Epub 2005 Feb 28.

Beebe DW, Wells CT, Jeffries J, Chini B, Kalra M, Amin R. Neuropsychological effects of pediatric obstructive sleep apnea. J Int Neuropsychol Soc. 2004 Nov;10(7):962-75.

Bradley J, O'neill B. Short term ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004356.

Booker R. The effective assessment of acute breathlessness in a patient. Nurs Times. 2004 Jun 15-21;100(24):61-3, 65, 67.

Booker R. Causes and management of chronic breathlessness in adults. Nurs Times. 2004 Sep 21-27;100(38):46-7, 49-50.

Botsis T, Halkiotis SC, Kourlaba G. Computer simulation of the human respiratory system for educational purposes. Comput Inform Nurs. 2004 May-Jun;22(3):162-70.

Chaouat A, Bugnet AS, Kadaoui N, Schott R, Enache I, Ducolone A, Ehrhart M, Kessler R, Weitzenblum E. Severe Pulmonary Hypertension and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2005 Apr 14;

Cantani A, Micera M. Epidemiology of passive smoke: a prospective study in 589 children. Eur Rev Med Pharmacol Sci. 2005 Jan-Feb;9(1):23-30.

Certain effects of positive pressure respiration on the circulatory and respiratory systems American Heart Journal, Volume 31, Issue 1, January 1946, Pages 53-73

David T. Carr and Hiram E. Essex Caroci Ade S, Lareau SC. Descriptors of dyspnea by patients with chronic obstructive pulmonary disease versus congestive heart failure. Heart Lung. 2004 Mar-Apr;33(2):102-10.

Casaburi R, Kukafka D, Cooper CB, Witek TJ Jr, Kesten S. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD. Chest. 2005 Mar;127(3):809-17.

Chan WM, Liu DT, Chan PK, Chong KK, Yuen KS, Chiu TY, Tam BS, Ng JS, Lam DS. Precautions in ophthalmic practice in a hospital with a major acute SARS outbreak: an experience from Hong Kong. Eye. 2005 Apr 29; [Epub ahead of print] Chetta A, Foresi A, Marangio E, Olivieri D. Psychological implications of respiratory health and disease. Respiration. 2005 Mar-Apr;72(2):210-5.

Chirakalwasan N, Dallal MM. Pulmonary sarcoidosis presenting with acute respiratory failure. South Med J. 2005 Mar;98(3):382-4.

Dee SA, Deen J, Jacobson L, Rossow KD, Mahlum C, Pijoan C. Laboratory model to evaluate the role of aerosols in the transport of porcine reproductive and respiratory syndrome virus. Vet Rec. 2005 Apr 16;156(16):501-4.

Dominguez OJ Jr. Breathless. Emerg Med Serv. 2002 Apr;31(4):87.

Ebihara S, Ebihara T, Okazaki T, Sasaki H. Cigarette smoking, cough reflex, and respiratory tract infection. Arch Intern Med. 2005 Apr 11;165(7):814.

Ersu R, Arman AR, Save D, Karadag B, Karakoc F, Berkem M, Dagli E. Prevalence of snoring and symptoms of sleep-disordered breathing in primary school children in istanbul. Chest. 2004 Jul;126(1):19-24.

Falk B, Gorev R, Zigel L, Ben-Amotz A, Neuman I. Effect of lycopene supplementation on lung function after exercise in young athletes who complain of exercise-induced bronchoconstriction symptoms. Ann Allergy Asthma Immunol. 2005 Apr;94(4):480-5.

Feltes TF, Groothuis JR. Acute and long-term effects of infection by the respiratory syncytial virus in children with congenital cardiac malformations. Cardiol Young. 2005 Jun;15(3):266-73.

Florida-James G, Donaldson K, Stone V. Athens 2004: the pollution climate and athletic performance. J Sports Sci. 2004 Oct;22(10):967-80; discussion 980.

Garten S, Falkner RV. Continual smoking of mentholated cigarettes may mask the early warning symptoms of respiratory disease. Prev Med. 2003 Oct;37(4):291-6. Review.

Goncalves MA, Paiva T, Ramos E, Guilleminault C. Obstructive sleep apnea syndrome, sleepiness, and quality of life. Chest. 2004 Jun;125(6):2091-6.

Groeneveld AB. Vascular pharmacology of acute lung injury and acute respiratory distress syndrome. Vascul Pharmacol. 2002 Nov;39(4-5):247-56. Review.

Hameed MK. An unusual foreign body in nasopharynx. J Coll Physicians Surg Pak. 2005 Mar;15(3):178-9.

Heinz P, Dunne J. Wheeze and mediastinal mass: a challenging patient. Emerg Med Australas. 2004 Jun;16(3):241-3.

Heinen-Kammerer T, Holtmannspotter C, Schnabel S, Motzkat K, Kiencke P, Rychlik R. [Effectiveness of echinacin in therapy of chronic recurrent respiratory disease.] Gesundheitswesen. 2005 Apr;67(4):296-301.

Heinzer MM, Bish C, Detwiler R. Acute dyspnea as perceived by patients with chronic obstructive pulmonary disease. Clin Nurs Res. 2003 Feb;12(1):85-101.

Hodgev VA, Kostianev SS, Torosian AA, Yanev IB, Mandoulova PB. Long-term changes in dyspnea, lung function, and exercise capacity in COPD patients. Folia Med (Plovdiv). 2004;46(3):12-7.

Hopkins RO, Weaver LK, Chan KJ, Orme JF Jr. Quality of life, emotional, and cognitive function following acute respiratory distress syndrome. J Int Neuropsychol Soc. 2004 Nov;10(7):1005-17.

Hours S, Lejaille M, Pozzi D, Falaize L, Zerah-Lancner F, Raphael JC, Lofaso F. Perceived inspiratory difficulty in neuromuscular patients with primary muscle disorders. Neuromuscul Disord. 2004 May;14(5):289-96.

Jansen HJ, Haerkens-Arends H, Vervoort G. A patient with dyspnoea, subfebrile temperature and electrocardiographic abnormalities. Neth J Med. 2005 Mar;63(3):111, 118.

Joseph T, Subbarao K. Human infections with avian influenza viruses. Md Med. 2005 Winter;6(1):30-2.

Kabir ML, Haq N, Hoque M, Ahmed F, Amin R, Hossain A, Khatoon S, Akhter S, Shilpi T, Haq R, Anisuzzaman S, Khan MH, Ahamed S, Khashru A. Evaluation of hospitalized infants and young children with bronchiolitis - a multi centre study. Mymensingh Med J. 2003 Jul;12(2):128-33.

Karnani NG, Reisfield GM, Wilson GR. Evaluation of chronic dyspnea. Am Fam Physician. 2005 Apr 15;71(8):1529-37.

Keenan SP, Powers CE, McCormack DG. Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial. Respir Care. 2005 May;50(5):610-6.

Keatinge WR, Donaldson GC. Changes in mortalities and hospital admissions associated with holidays and respiratory illness: implications for medical services. J Eval Clin Pract. 2005 Jun;11(3):275-81.

Kendall KA, Louie S. Severe obstructive airway disorders and diseases: vocal fold dysfunction. Clin Rev Allergy Immunol. 2003 Dec;25(3):221-31. Review.

Ledez KM, Zbitnew G. Hyperbaric treatment of cerebral air embolism in an infant with cyanotic congenital heart disease: [Le traitement hyperbare d'une embolie gazeuse cerebrale chez un enfant atteint de cardiopathie cyanogene congenitale]. Can J Anaesth. 2005 Apr;52(4):403-408.

Lindberg A, Jonsson AC, Ronmark E, Lundgren R, Larsson LG, Lundback B. Ten-Year Cumulative Incidence of COPD and Risk Factors for Incident Disease in a SymptomaticCohort. Chest. 2005 May;127(5):1544-52.

Lomborg K, Kirkevold M. Curtailing: handling the complexity of body care in people hospitalized with severe COPD. Scand J Caring Sci. 2005 Jun;19(2):148-56.

Lindell RM, Hartman TE. Chest imaging in iatrogenic respiratory disease. Radiol Clin North Am. 2005 May;43(3):601-10.

Lupatkin H. Influenza Vaccine in the Elderly and Chronic Obstructive Pulmonary Disease. Curr Infect Dis Rep. 2005 May;7(3):200-203.

Laugesen M, Fowles J. Scope for regulation of cigarette smoke toxicity according to brand differences in published toxicant emissions. N Z Med J. 2005 Apr 15;118(1213):U1401.

Liu CY, Huang LJ, Lai CH, Chen HP, Chen TL, Fung CP, Liu CY. Clinical characteristics, management and prognostic factors in patients with probable severe acute respiratory syndrome (SARS) in a SARS center in Taiwan. J Chin Med Assoc. 2005 Mar;68(3):110-7.

Lomborg K, Bjorn A, Dahl R, Kirkevold M. Body care experienced by people hospitalized with severe respiratory disease. J Adv Nurs. 2005 May;50(3):262-71.

Linan Cortes S, Cobos Barroso N. [Infant asthma] Rev Enferm. 2004 Nov;27(11):20-6.

McConnell TR, Mandak JS, Sykes JS, Fesniak H, Dasgupta H. Exercise training for heart failure patients improves respiratory muscle endurance, exercise tolerance, breathlessness, and quality of life. J Cardiopulm Rehabil. 2003 Jan-Feb;23(1):10-6.

Modell HI, Michael JA, Adamson T, Horwitz B. Enhancing active learning in the student laboratory. Adv Physiol Educ. 2004 Dec;28(1-4):107-11.

Martinez MW, Rodysill KJ, Morgenthaler TI. Use of ambulatory overnight oximetry to investigate sleep apnea in a general internal medicine practice. Mayo Clin Proc. 2005 Apr;80(4):455-62.

Mukhopadhyay A, Lim TK. A prospective audit of referrals for breathlessness in patients hospitalised for other reasons. Singapore Med J. 2005 Jan;46(1):21-4.

Naughton MT. The link between obstructive sleep apnea and heart failure: underappreciated opportunity for treatment. Curr Cardiol Rep. 2005 May;7(3):211-5.

Nicholson PJ, Cullinan P, Taylor AJ, Burge PS, Boyle C. Evidence based guidelines for the prevention, identification, and management of occupational asthma. Occup Environ Med. 2005 May;62(5):290-9.

Nield M, Hoo GS, Roper J, Santiago S, Dracup K. Usefulness of the human activity profile, a functional performance measure, in people with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2005 Mar-Apr;25(2):115-21.

Oksenberg A, Silverberg DS. The effect of body posture on sleep-related breathing disorders: facts and therapeutic implications. Sleep Med Rev. 1998 Aug;2(3):139-62.

Parish JM. Identifying patients with sleep apnea. Mayo Clin Proc. 2005 Apr;80(4):453-4. Piepoli MF. Exercise training in heart failure. Curr Cardiol Rep. 2005 May;7(3):216-22.

Prigmore S. Assessment and nursing care of the patient with dyspnoea. Nurs Times. 2005 Apr 5-11;101(14):50-3.

Pugazhenthi M. Sarcoidosis presenting as acute respiratory failure. South Med J. 2005 Mar;98(3):265.

Rasche B, Hochstrasser K, Marcic I, Ulmer WT. Mucous membrane specific protease inhibitors in bronchial mucus in severe chronic obstructive bronchitis and in alpha 1-antitrypsin deficiency syndrome Respiration. 1975;32(5):340-54.

Rogers PL, Jacob H, Thomas EA, Harwell M, Willenkin RL, Pinsky MR. Medical students can learn the basic application, analytic, evaluative, and psychomotor skills of critical care medicine. Crit Care Med. 2000 Feb;28(2):550-4.

Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, Im K, Donahoe M, Pinsky MR. Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002 Apr;30(4):746-52.

Routledge T, Jenkins D. Images in clinical medicine. An unusual case of pulmonary embolism. N Engl J Med. 2005 Apr 14;352(15):1578.

Seah ST, Low JA, Chan YH. Symptoms and care of dying elderly patients in an acute hospital. Singapore Med J. 2005 May;46(5):210-4.

Sinaniotis CA, Sinaniotis AC. Community-acquired pneumonia in children. Curr Opin Pulm Med. 2005 May;11(3):218-25.

Silverman R, Richmond NJ, Kusick M, Matallana L, Winokur J. Out-of-Hospital Administration of Albuterol for Asthma by Basic Life Support Providers. Acad Emerg Med. 2005 May;12(5):396-403.

Silverberg DS, Oksenberg A, Iaina A. Sleep related breathing disorders are common contributing factors to the production of essential hypertension but are neglected, underdiagnosed, and undertreated. Am J Hypertens. 1997 Dec;10(12 Pt 1):1319-25. Review.

Szabo A, Cserhati E. Bronchial asthma and the short-term quality of life: follow-up study of childhood bronchial asthma in Hungary. Pediatr Allergy Immunol. 2004 Dec;15(6):539-44.

Thomas MW, Gebara BM. Difficulty breathing. Late onset vitamin K deficiency bleeding. Clin Pediatr (Phila). 2004 Jun;43(5):499-502.

Thomas N, Alder E, Leese GP. Barriers to physical activity in patients with diabetes. Postgrad Med J. 2004 May;80(943):287-91.

Unetani H, Hidaka S, Tanaka H, Kawamoto M, Yuge O. Perioperative management of a morbidly obese patient with sleep apnea syndrome] Masui. 2003 Jun;52(6):646-9.

van den Berg AA, Chitty DA, Jones RD, Sohel MS, Shahen A. Intravenous or inhaled induction of anesthesia in adults? An audit of preoperative patient preferences. Anesth Analg. 2005 May;100(5):1422-4.

Wilhelm FH, Roth WT, Sackner MA. The lifeShirt. An advanced system for ambulatory measurement of respiratory and cardiac function. Behav Modif. 2003 Oct;27(5):671-91. Review.

Zhang Y, Chen J, Chen Y, Dong J, Wei Q, Lou J. Environmental mycological study and allergic respiratory disease among tobacco processing workers. J Occup Health. 2005 Mar;47(2):181-7.

Websites:

www.who.org www.asthma.org www.nhs.uk http://www.hse.gov.uk/.