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By T. Zapotek. The Ohio State University. 2018.

A close inspection of the bottles revealed that the only ingredient was the drug itself generic betnovate 20 gm on-line, identical to those obtained by prescription at the local pharmacy generic 20gm betnovate otc. I understand that you might be skeptical about considering the use of aquarium antibiotics for humans in a collapse betnovate 20 gm line. Yet, a number of them seem to come in dosages that correspond to pediatric or adult human dosages. However, at the time of this writing, there are few instructions that tell you how much to put in a ½ gallon fishbowl as opposed to a 200 gallon aquarium. The aquatic or avian drug had to be identical to that found in bottles of the corresponding human medicine. Logically, then, it makes sense to believe that they are manufactured in the same way that human antibiotics are. Further, it is my opinion that they are probably from the same batches; some go to human pharmacies and some go to veterinary pharmacies. Many cat, dog, and livestock antibiotics contain additives that might even cause ill effects on a human being. They come in lots of 30 to100 tablets for less than the same prescription medication at the local pharmacy. If you so desired, it appears that you could get as much as you need to stockpile for a collapse. These quantities would be close to impossible to obtain even from the most sympathetic physician. Of course, anyone could be allergic to one or another of these antibiotics, but it would be a very rare individual who would be allergic to all of them. There is a 10% chance for cross-reactivity between Penicillin drugs and Keflex (if you are allergic to penicillin, you could also be allergic to Keflex). Any of the antibiotics below should not cause a reaction in a patient allergic to Penicillin-family drugs: Doxycycline Metronidazole Tetracycline Ciprofloxacin Clindamycin Sulfa Drugs This one additional fact: I have personally used some (not all) of these antibiotics on my own person without any ill effects. Whenever I have used them, they have been undistinguishable from human antibiotics in their effects. Finding Out More Antibiotics are used at specific doses for specific illnesses; the exact dosage of each and every medication in existence is beyond the scope of this handbook. It’s important, however, to have as much information as possible on medications that you plan to store, so consider purchasing a hard copy of the latest Physician’s Desk Reference. This book comes out yearly and has just about every bit of information that exists on a particular drug. The Desk Reference has versions that list medications that require prescriptions as well as those that do not. Under each medicine, you will find the “indications”, which are the medical conditions that the drug is used for. Also listed will be the dosages, risks, side effects, and even how the medicine works in the body. It’s okay to get last year’s book; the information doesn’t change a great deal from one year to the next. Antibiotic Overuse It’s important to understand that you will not want to indiscriminately use antibiotics for every minor ailment that comes along. In a collapse, the medic is also a quartermaster of sorts; you will want to wisely dispense that limited and, yes, precious supply of life- saving drugs. You must walk a fine line between observant patient management (doing nothing) and aggressive management (doing everything). Liberal use of antibiotics is a poor strategy for a few reasons: Overuse can foster the spread of resistant bacteria, as you’ll remember from the salmonella outbreak in turkeys in 2011. Millions of pounds of turkey meat were discarded after 100 people were sent to the hospital with severe diarrheal disease. Potential allergic reactions may occur that could lead to anaphylactic shock (see the section on this topic earlier in this book). In other words, symptoms could be temporarily improved that would have helped you know what disease your patient has. You can see that judicious use of antibiotics, under your close supervision, is necessary to fully utilize their benefits. Discourage your group members from using these drugs without first consulting you. Other Medicines For medications that treat non- infectious illness, such as cholesterol or blood pressure drugs, you will also need a prescription. These medications are not available in aquarium supply houses, so how can you work to stockpile them? You may consider asking your physician to prescribe a higher dose than the amount you usually take. If your medicine is a 20 milligram dosage, for example, you might ask your doctor to prescribe the 40 mg dosage. You would then cut the medication in half; take your normal dosage and store the other half of the pill. It’s very important to assure your physician that you will continue to follow their medical advice and not take more medicine than is appropriate for your condition. Others have managed to obtain needed prescriptions by indicating that they are traveling for long periods of time out of the country or telling their physician some other falsehood. I can’t recommend this method, because I believe that dishonesty breaks the bond of trust between doctor and patient. Describe your concerns about not having needed medications in a disaster situation. You don’t have to describe the disaster as a complete societal collapse; any catastrophe could leave you without access to your doctor for an extended period.

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Have your patient drink at least 8 glasses of water per day to produce a large amount of urine order betnovate 20gm with visa. Stronger pain medications buy betnovate 20 gm low cost, if you can get them buy betnovate 20gm with visa, may be necessary for severe cases. Some of the larger stones will be chronic issues, as the high technology and surgical options used to remove these will not be available in a collapse scenario. Medications specific to the type of stone may be helpful: Allopurinol (prescription medicine for uric acid stones and gout). Sodium bicarbonate or sodium citrate (which increases the alkalinity of the urine). A good home remedy to relieve discomfort and aid passage of the stone is lemon juice, olive oil, and apple cider vinegar. With the first twinge of pain, drink a mixture of 2 ounces of lemon juice and 2 ounces of olive oil. After 1 hour, drink a mixture of 1 tablespoon of raw apple cider vinegar with 2 ounces of lemon juice in a large glass of water. Other natural substances that may help are: Horsetail tea (a natural diuretic) Pomegranate juice Dandelion root tea Celery tea Basil tea Gall Bladder Stones The gall bladder is a sac-like organ that is attached to the liver; it stores the bile that the liver secretes. Gallstones are firm deposits that form inside the gallbladder and could block the passage of bile. This blockage can cause a great deal of pain and inflammation (known as “cholecystitis”). Cholesterol stones: The grand majority, these are not related to the actual cholesterol levels in the bloodstream. Bilirubin stones: These occur in those people who have illnesses that destroy their red blood cells. The by-products of this destruction releases a substance called “bilirubin” into the bile and forms a stone. Additional risk factors include diabetes, liver cirrhosis (discussed in the section on hepatitis), and low blood counts (“anemia”). If a large stone causes a blockage, however, you may experience what is called “biliary colic”. Symptoms of biliary colic include: Cramping right upper abdomen pain (constant, spreading to the back). If the gallbladder is tender, the patient should complain of significant pain at the site. Unfortunately, the main treatment for gallstones is to surgically remove the gall bladder (you can live without it and stay healthy). As surgical suites are unlikely to be available in a collapse situation, you might consider some alternative remedies. These are mostly preventative measures: Apple cider vinegar (mixed with apple juice) Chanca Piedra, (Phyllanthus niruri), a plant that is native to the Amazon; translated, the name means “Break Stones”. Peppermint Turmeric Alfalfa Ginger root Dandelion root Artichoke leaves Beet, Carrot, Grape, Lemon juices Sadly, it is very difficult to eliminate most of the risk factors for gall bladder disease. If you’re forty, female, and have children, there is not much you can do about it. Dietary changes to decrease intake of high- cholesterol foods may help you decrease weight and the risk of gallstones. Seborrheic Dermatitis In austere circumstances, a caregiver may consider a skin rash to be of no consequence. Symptoms associated with it, however, may cause sleep loss or irritation that make affect a group member’s work efficiency. Therefore, it makes common sense to treat any condition that decreases the quality of life of a loved one. Most types of dermatitis usually present with swollen, reddened and/or itchy skin. Continuous scratching traumatizes the irritated area and may lead to cellulitis once the skin is broken. Some of the more common types of skin inflammation are: Contact dermatitis: Caused by allergens and chemical irritants. Seborrheic dermatitis: A commonly seen condition that affects the face and scalp (common cause of dandruff). Atopic Dermatitis or Eczema: A chronic itchy rash that can be found in various areas at once and tends to be intermittent in nature. Neuro-dermatitis: A chronic itchy skin condition localized to certain areas of the skin (as seen in a herpes virus infection known as “Shingles”). Stasis dermatitis: An inflamed area caused by fluid under the skin, commonly seen on the lower legs of older individuals. Indeed, some cannot be conclusively diagnosed without sending a sample of skin to a laboratory. Whatever the cause, effective treatment of symptoms will be important in a grid-down situation. Limiting trauma from repeated scratching will prevent secondary, deeper infections from developing. Moisturizing dry skin may be one way to help decrease frequency of outbreaks of dermatitis. You can prevent this by: Using mild soaps: Deodorant soaps are to be avoided in patient with significant dermatitis. Bathe less: Sure enough, limiting the frequency and duration of baths may decrease symptoms.

A 25-year-old Hispanic male PhD candidate recently traveled to rural Mexico for 1 month to gain further information for his dissertation regarding socioeconomics generic betnovate 20gm line. However best betnovate 20gm, over the 2 to 3 weeks since coming home order betnovate 20gm overnight delivery, he has continued to have occa- sional loose stools plus vague abdominal discomfort and bloating. In August you saw a debilitated 80-year-old female who required nursing home placement. She had had no immunizations for many years except for a pneumococcal vaccine 3 years ago when discharged from the hospital after a stay for pneumonia. An asymptomatic 50-year-old man who has smoked one pack of cig- arettes per day for 30 years comes to you for a general checkup and wants “the works” for cancer screening. Based on American Cancer Society guidelines for early detection of breast cancer, this patient at standard risk should be advised to a. On presentation for yearly exam, a healthy, non–sexually active post- menopausal 60-year-old female gives a history of having had normal yearly mammograms and normal yearly Pap smears over the past 10 years, but never an endometrial tissue sample or any screening test for ovarian cancer. You have been asked to perform a preoperative consultation on a 65-year-old male who will be undergoing transurethral resection of the prostate for urinary retention. Of the following findings, which you detect by history, physical, and lab, which is of most concern in predicting a car- diac complication in this patient undergoing noncardiac surgery? A 78-year-old female comes to your office with symptoms of insom- nia nearly every day, fatigue, weight loss of over 5% of body weight over the past month, loss of interest in most activities, and diminished ability to concentrate. Although further testing may be necessary, based on this his- tory the most likely diagnosis is a. A 20-year-old college basketball player is brought to the university urgent care clinic after developing chest pain and palpitations during prac- tice, but no dyspnea or tachypnea. There is no unusual family history of cardiac diseases, and social history is negative for alcohol or drug use. For each numbered item, select the one lettered option with which it is most closely associated. Items 433–435 The initial choice of an antihypertensive agent may depend on concomitant factors. For each of the conditions below, indicate the medication choice that would give the best additional benefit after blood pressure control. For each of the conditions below, indicate the medication choice that needs to be avoided above all others. A 92-year-old woman with type 2 diabetes mellitus has developed cellulitis and gangrene of her left foot. She requires a lifesaving amputation, but refuses to give consent for the surgery. She has been ambulatory in her nursing home but states that she would be so dependent after surgery that life would not be worth living for her. A 20-year-old complains of diarrhea, burning of the throat, and diffi- culty swallowing over 2 months. Bullae and erythema develop around the bite, and some skin necrosis becomes apparent. The patient has necrotizing fasciitis secondary to streptococcal infection 238 Medicine 443. A 70-year-old male with unresectable carcinoma of the lung metasta- tic to liver and bone has developed progressive weight loss, anorexia, and shortness of breath. The patient has executed a valid living will that pro- hibits the use of feeding tube in the setting of terminal illness. Place a feeding tube until such time as the matter can be discussed with the patient 444. After being stung by a yellow jacket, a 14-year-old develops the sud- den onset of hoarseness and shortness of breath. A 40-year-old male is found to have a uric acid level of 9 mg/dL on routine screening of blood chemistry. The patient has no evidence on history or physical exam of underlying chronic or malignant disease. Asymptomatic hyperuricemia is associated with an increased risk of gouty arthritis, but benefits of prophylaxis do not outweigh risks in this patient c. The presence or absence of lymphoproliferative disease does not affect the deci- sion to use prophylaxis in hyperuricemia d. Lowering serum uric acid will provide a direct cardiovascular benefit to the patient in lowering coronary artery disease risk General Medicine and Prevention 239 Items 446–451 For each patient, select the best course of action. Most patients will require a second visit to confirm the diagnosis of essential hypertension. Annual evalua- tion (assuming all is normal) is recommended for blood pressure check, eye exam, lipid profile, and urine microalbumin level; evaluation every 6 to 12 months is recommended for foot exam. Hemoglobin A1c (or similar test) should be obtained every 6 months if stable, or quarterly if treatment changes or the patient is not achieving goals. Despite their decades-long use in the treatment of coronary artery disease, such as for angina, nitrates are not indicated for secondary prevention of infarction. Less than 130 is rec- ommended if free of coronary heart disease and with two or more risk fac- tors. In this example, although the patient is healthy, he has two risk factors by virtue of being male age 45 years or older, plus family history of early coronary heart disease. The cardiovascular system may benefit from aspirin via anti- platelet effects and folic acid/pyridoxine via lowering high homocysteine levels; after initial enthusiasm for vitamin E, more recent studies have not shown consistent cardiovascular benefit. The diagnostic criteria for panic attack are a discrete period of intense fear or discomfort, in which four or more of the following symptoms develop abruptly and reach a peak within 10 min: palpitations, pounding heart, or accelerated heart rate; sweat- ing; trembling or shaking; sensations of shortness of breath or smothering; feeling of choking; chest pain or discomfort; nausea or abdominal distress; 242 Medicine feeling dizzy, unsteady, lightheaded, or faint; derealization or depersonaliza- tion; fear of losing control or going crazy; fear of dying; paresthesias; chills or hot flushes. This may be transitory and may best be heard in expiration with patient upright or leaning forward.

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Geography Giardiasis Occurs worldwide but most common in the tropics and subtropics quality betnovate 20gm. Definition Infection of the gastrointestinal tract by Giardia lamblia a flagellate protozoa order 20 gm betnovate with amex. Aetiology The condition is caused by Entamoeba histolytica 20 gm betnovate visa,trans- Aetiology mission occurs through food and drink contamination Giardia is found worldwide especially in the tropics and or by anal sexual activity. Pathophysiology The amoeba can exist as two forms; a cyst and a tropho- Pathophysiology zoite, only the cysts survive outside the body. Following The organism is excreted in the faeces of infected pa- ingestion the trophozoites emerge in the small intestine tients as cysts. These are ingested, usually in contami- and then pass to the colon where they may invade the nated drinking water. Clinical features r Patients may have a gradual onset of mild intermittent Patients may be asymptomatic carriers or may present diarrhoea and abdominal discomfort. Subsequently 1–2 weeks after ingestion of cysts with diarrhoea, nausea, bloody diarrhoea with mucus and systemic upset may anorexia, abdominal discomfort and distension. A may be steatorrhoea, and if the condition is prolonged fulminating colitis with a low-grade fever and dehy- there may be weight loss. Complications r Aspirates from the duodenum or jejunal biopsy can r Severe haemorrhage may result from erosion into a be used for identification. A 3-day course of metronidazole or a single oral dose of r Progression of fulminant colitis to toxic dilatation tinidazole are highly effective treatments for giardiasis. Prevention is by improved sanitation and precautions r Chronic infection causes fibrosis and stricture forma- with drinking water. Management Management Metronidazole is the drug of choice, large liver abscesses r Ciprofloxacin, chloramphenicol and amoxycillin have require ultrasound guided percutaneous drainage. Enteric fever (typhoid and r Avaccine is available which gives some protection for paratyphoid) up to 3 years. Definition Typhoid (Salmonella typhi) and paratyphoid (Salmon- Botulism ella paratyphi A, B or C)produce a clinically identical disease. Definition Botulism is a serious food poisoning caused by the Gram Aetiology/pathophysiology positive bacillus Clostridium botulinum. Organisms pass The bacteria are soil borne, spores are heat resistant to via the ileum and the lymphatic system to the systemic 100˚C. Some secrete salmonella for over a 1 Food borne botulism in which toxin in the food is year and measurement of Vi agglutinin is used to detect ingested. Clinical features 3 Wound botulism in which the organism is implanted 1 The condition typically runs a course of around 1 into a wound. There is gradual onset of a viral like illness with headache Pathophysiology and fever worsening over 3–4 days. There is initially Toxins are transported via the blood stream to the pe- constipation. Botulinum toxin acts to block 2 Week 2 the patient appears toxic with dehydration, neurotransmission. Patients develop an erythematous maculopapular-blanching Clinical features rash with splenomegaly. The illness starts with nausea and vomiting 12–72 hours 3 During week 3 complications include pneumonia, afteringestingtheorganism. Neurologicalfeaturesresult haemolytic anaemia, meningitis, peripheral neuropa- from neuromuscular blockade: blurred vision, squint thy, acute cholecystitis, osteomyelitis, intestinal perfo- due to lateral rectus muscle weakness, the pupil is fixed ration and haemorrhage. Laryngeal 4 Over the subsequent week there is a gradual return to and pharyngeal paralysis heralds the onset of a gener- normal health. Chapter 4: Gastrointestinal infections 153 Investigations The toxin is demonstrable in the faeces. Intravenous antitoxin and guanidine hydrochlo- ride to reverse neuromuscular blockade has been used. The serovar 0:1 is the major pathogenic strain and Clinical features is divided into two biotypes; classical and the more Theincubationperiodisbetweenafewhoursand1week. Phage typing can be used to but in severe cases there may be watery diarrhoea with examine epidemics to try and see if the observed condi- mucous, termed rice water stool. Serotyping of Biotype: growth on Bacteria somatic O media, and enzyme antigens production Classical Serovar 0:1 Vibrio cholera El Tor Non 0:1 Figure 4. Caseating granulomas and fibrosis may volaemia may be made using clinical indices such as the result in stricture formation and obstructions. Clinical features r In significant volume depletion intravenous saline The presentation depends on the site of infection and should be administered. Patients may present with put should be documented hourly and reviewed with diarrhoea, abdominal pain, alteration of bowel habit, care. Gastric outflow obstruction may result in choice using a solution containing sodium, potas- vomiting and a succussion splash on examination. Clinically gastroin- glucose to facilitate absorption, rice-based polymers testinal tuberculosis may be difficult to distinguish from have been used in place of glucose with some evi- Crohn’s disease. Investigations r Tetracycline or ciprofloxacin can be used to shorten Abdominal ultrasound may demonstrate mesenteric duration and reduce severity of illness. Management Aetiology/pathophysiology Treatment with a combination of rifampicin, isoniazid, Infections are most common in the immunosuppressed pyrazinamideandethambutolifresistanceislikely. Sources of gastroin- apy should continue for 1 year in gut infections and testinal tuberculous infections: 2years in peritonitis. Intestinal tuberculosis occurs at any point of turbulence, Disorders of the abdominal wall e. Glucose, anhydrous 75 Potassium 20 Incidence Citrate 10 85% occur in males, with a lifetime risk of 1 in 4 males, Total Osmolarity 245 but less than 1 in 20 females.

Further information in: Unproven Uses: In folk medicine discount betnovate 20 gm with amex, English Lavender is used Hansel R proven betnovate 20gm, Keller K quality betnovate 20 gm, Rimpler H, Schneider G (Hrsg. Phytopharmaka und Preparation: An infusion is prepared by adding 5 to 10 ml of pflanzliche Homoopathika, Fischer-Verlag, Stuttgart, Jena, New drug per cup of hot water (150 ml), draw for 10 minutes, and York 1995. Daily Dosage: A tea prepared as indicated above can be administered 1 cup three times daily. Medicinal Parts: The medicinal parts are the dried leaves, Buchbauer G, Jirovet L, Jager W, Dietrich H, Plank C, the dried herb and the fresh plant. Karamat E, (1991) Aromatherapy: Evidence for Sedative Effects of the Essential Oil of Lavender after Inhalation. Z Naturforsch Flower and Fruit: The globular or shortly cylindrical spikes 46c: 1067-1072. The scarious calyx is Approved by Commission E: deeply divided into 4 parts and has a cylindrical tube and a • Common cold margin with 4 ovate tips. There are 4 long stamens with • Cough/bronchitis yellowish-white filaments and anthers and 1 superior ovary. The seeds • Inflammation of the mouth and pharynx are oblong, 2 mm long and blackish. All the Unproven Uses: In folk medicine, the pressed juice of leaves are in basal rosettes and are lanceolate or linear- English Plantain is used internally for conditions of the lanceolate, deeply 3 to 5 ribbed, entire-margined or short- respiratory tract, cystitis, enuresis, liver disease, stomach dentate. Habitat: The plant is widespread in the cool temperate Externally the plant is used for wounds, furuncles, conjuncti- regions of the world. Flavonoids: including among other chief components apige- nine-6,8-diglucoside, luteolin-7-glucuronide Tea—1 cup of freshly made tea to be drunk several times a day. Hydroxycoumarins: aesculetin Davini E, The quantitative isolation and antimicrobial activity of aglycone of aucubin. Saponins (traces) Elich J, Die antibakterielle Aktivitat einiger einheimischer Silicic acid Plantago-Arten. The aucubigenin (hydrol- lanceolata and inhibitory effects on arachidonic acid-induced ised acubin) and an antimicrobial saponin are believed to be mouse ear edema. In addition, accelera- tion of blood clotting has been demonstrated and a possible Wunderer H, Zentral und peripher wirksame Antitussiva: eine epithelization effect has been mentioned. The spore, usually deposited by a visiting insect, Handbuch der Pharmazeutischen Praxis, 5. When the ovary has been completely destroyed, the myceli- Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde. Horizontal walls are formed and fat vacuoles *f£ Nachdruck, Georg Olms Verlag Hildesheim 1979. The hyphae of the skin layer store purple pigment 3 weeks after the infection a long, curved, black Schulz R, Hansel R, Rationale Phytotherapie, Springer Verlag sclerotium develops. The sclerotium usually falls to the ground before harvest and Teuscher E, Biogene Arzneimittel, 5. Production: Ergot consists of the sclerotium of Claviceps purpurea, a parasitic fungus harvested after it has grown on Ephedra sinica cultivated rye. It is The drug contains ergoline alkaloids of which only ergomet- black, hard and much larger than the grains of rye. However, therapeutic use cannot be recom- through inducement of vomiting and gastric lavage with mended because of the risks involved. The therapy for ^| Unproven Uses: Although the risk involved is too high to poisonings consists of treating angiospasms with Nitrolingu- recommend therapeutic use, ergot and ergot preparations al-spray and vascular massage, sedatives for spasm (di- were previously used in gynecology and obstetrics. Uses azepam or chloral hydrate), administration of blocking included hemorrhages, climacteric hemorrhages, menorrha- agents, electrolyte substitution and treating possible cases of gia and metrorrhagia, before and after miscarriage, for acidosis with sodium bicarbonate infusions. Intubation and removal of the placenta and shortening of the afterbirth oxygen respiration may also be necessary. The powdered especially in the presence of peripheral blood flow disorders form should not be stored. Deutsche Apotheker Ztg 134 (1994), 1887 severe coronary insufficiency, kidney damage, pregnancy, £- nursing, infectious diseases, sepsis, hypertonia and severe Anon. Among side effects that may occur are queasiness, vomiting, feeling of weakness in the legs, muscle pain, Crespi-Perellino N et al. Chronic poisonings appear as: Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Nachdruck, Georg Olms Verlag Hildesheim 1979. Ergotismus gangrenosus: characterized by painful arterial Marshall M, Wiistenberg P, Klinik und Therapie der blood flow disorders of the extremities with dry gangrene, chronischen venosen Insuffizienz. Roth L, Daunderer M, Kormann K: Giftpflanzen, Pflanzengifte, Flower and Fruit: The plant bears small terminal cymes on 4. Leaves, Stem and Root: The plant is 15 to 60 cm high, Seiffer B, Therapie der Akromegalie. Teuscher E, Lindequist U, Biogene Gifte - Biologie, Chemie, Characteristics: The root is spicy. Eryngo herb is the dried leaves and blossoms of pflanzliche Homoopathika, Fischer-Verlag, Stuttgart, Jena, New York 1995. The herb is said to be a mild diuretic and an expectorant; Madaus G, Lehrbuch der Biologischen Arzneimittel. Unproven Uses: The root is used in the treatment of bladder and kidney stones, renal colic, kidney and urinary tract inflammation, urinary retention and edema.

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It should requires treatment of lung infection and assessment of be noted betnovate 20gm without a prescription, however cheap betnovate 20 gm with mastercard, that because routine hospital micro- coagulation and vitamin K status buy discount betnovate 20 gm line. For massive hemopty- biologic cultures are performed under conditions that sis, bronchial artery embolization should be performed. J Clin (3 x normal), but this treatment has not been shown to Invest 109:317, 2002 influence the course of hepatic disease. This dose-response relation- chronic cough and phlegm; and small airways disease, a con- ship between reduced pulmonary function and cigarette dition in which small bronchioles are narrowed. This finding suggests that additional environmental By 1964, the Advisory Committee to the Surgeon General or genetic factors (or both) contribute to the impact of of the United States had concluded that cigarette smoking smoking on the development of airflow obstruction. Several specific occupational exposures, to the lower dose of inhaled tobacco by-products during including coal mining, gold mining, and cotton textile cigar and pipe smoking. This suggests that asthma, chronic bronchitis, than the effect of cigarette smoking. The clinical laboratory test used most fre- chronic airflow obstruction remains unproven. Among PiZ nonsmokers, impressive variability has been Exposure of children to maternal smoking results in sig- noted in the development of airflow obstruction. In utero tobacco smoke genetic and environmental factors likely contribute to exposure also contributes to significant reductions in post- this variability. Although rare individ- nonuniform distribution of ventilation, and ventilation- uals may demonstrate precipitous declines in pulmonary perfusion mismatching also occur. Individuals appear to track in their quartile of Airflow limitation, also known as airflow obstruction, is pulmonary function based on environmental and genetic typically determined by spirometry, which involves forced factors that put them on different tracks. Maximal inspiratory tion can be modified by changing environmental expo- flow can be relatively well preserved in the presence of a sures (i. Genetic factors likely contribute to flow and the resistance of the airways limiting flow. The decrease in flow coincident with decreased lung volume is readily apparent Persistent reduction in forced expiratory flow rates is the on the expiratory limb of a flow-volume curve. In more advanced disease, the entire curve has Normal decreased expiratory flow compared with normal. Second, because the muscle fibers of the flat- University of Groningen, 1991, with permission. This Cigarette smoking often results in mucous gland enlarge- follows from Laplace’s law, p = 2t/r. These changes are pro- thoracic cage is distended beyond its normal resting vol- portional to cough and mucus production that define ume, during tidal breathing, the inspiratory muscles must chronic bronchitis, but these abnormalities are not related do work to overcome the resistance of the thoracic cage to airflow limitation. Goblet cells not only increase in to further inflation instead of gaining the normal assis- number but also in extent through the bronchial tree. These abnormalities may cause luminal narrowing by Nonuniform ventilation and ventilation-perfusion mis- excess mucus, edema, and cellular infiltration. Nitrogen washout while breathing Fibrosis in the wall may cause airway narrowing directly 100% oxygen is delayed because of regions that are poorly or, as in asthma, predispose to hyperreactivity. Respira- ventilated, and the profile of the nitrogen washout curve tory bronchiolitis with mononuclear inflammatory cells is consistent with multiple parenchymal compartments collecting in distal airway tissues may cause proteolytic having different washout rates because of regional differ- destruction of elastic fibers in the respiratory bronchioles ences in compliance and airway resistance. Ventilation/ and alveolar ducts where the fibers are concentrated as perfusion mismatching accounts for essentially all of the rings around alveolar entrances. Whereas changes in large airways cause cough and spu- Lung Parenchyma tum, changes in small airways and alveoli are responsible for physiologic alterations. Their walls become perfo- 183 rated and later obliterated with coalescence of small dis- tinct airspaces into abnormal and much larger airspaces. Cigarette smoke Macrophages accumulate in respiratory bronchioles of essentially all young smokers. Bronchoalveolar lavage fluid from such individuals contains roughly five times as many macrophages as lavage from nonsmokers. In smok- ers’ lavage fluid, macrophages comprise >95% of the total cell count, and neutrophils, nearly absent in nonsmokers’ lavage, account for 1–2% of the cells. Serine Cysteine proteinases proteinases Centriacinar emphysema, the type most frequently associated with cigarette smoking, is characterized by enlarged air- Neutrophil Macrophage spaces found (initially) in association with respiratory bronchioles. Centriacinar emphysema is most prominent Proteinase inhibitors in the upper lobes and superior segments of lower lobes and is often quite focal. Upon long-term exposure to panacinar emphysema are interesting and may ultimately cigarette smoke, inflammatory cells are recruited to the lung; be shown to have different mechanisms of pathogenesis. Pathologic findings that can contribute to small airway obstruction are described The Elastase:Antielastase Hypothesis above, but their relative importance is unknown. Fibrosis surrounding the small airways appears to be a significant Elastin, the principal component of elastic fibers, is a contributor. Mechanisms leading to collagen accumula- highly stable component of the extracellular matrix that tion around the airways in the face of increased collagenase is critical to the integrity of both the small airways and activity remain an enigma. In addition to Matrix Proteolysis restoring cellularity after injury, it appears difficult for an adult to completely restore an appropriate extracellular Macrophages patrol the lower airspace under normal matrix, particularly functional elastic fibers. A notably neutrophil elastase, work together by degrading careful history, however, usually reveals the presence of the inhibitor of the other, leading to lung destruction. The develop- Proteolytic cleavage products of elastin also serve as a ment of exertional dyspnea, often described as increased macrophage chemokine, fueling this destructive positive effort to breathe, heaviness, air hunger, or gasping, can be feedback loop. It is best elicited by a careful history focused on Concomitant cigarette smoke-induced loss of cilia in typical physical activities and how the patient’s ability to the airway epithelium predisposes to bacterial infection perform them has changed. Conversely, response remains, suggesting that mechanisms of cigarette activities that allow the patient to brace the arms and smoke-induced inflammation that initiate the disease use accessory muscles of respiration are better tolerated.