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Khaled N. Almusrea, MBBS, FRCSC

• Chairman, Spine Surgery Department
• Subspecialty Consultant Neurosurgeon, Spine Surgeon
• Department of Spine, Department of Neurosurgery
• Neurosciences Center
• King Fahd Medical City
• Riyadh, Saudi Arabia

This chapter focuses on equipment that can be used easily in the feld and equipment that would be found in the laboratory setting anxiety 6 months order aripiprazolum toronto. There will depression glass defined cheap aripiprazolum master card, of course depression with psychotic features order online aripiprazolum, be some overlap between the crime scene and laboratory equipment depression severe joint pain buy 10 mg aripiprazolum with mastercard. Light sources are indispensable to a crime scene responder and a variety of them are useful. Currently, there are many types of forensic light of light used (Masters, 1995, pp 133?142). In more recent years, several forensic light sources Fingerprint powder applicators come in many shapes, have been designed to use light-emitting diodes instead of sizes, and fber components. An investigator selects face; soft brushes reduce the risk of damaging the fragile certain wavelengths of light through the use of a flter or a print (Fisher, 1993, pp 101?104). This ability to select various wavehis early design, many variations have been manufaclengths can be a beneft not found in most lasers. When the rod is not retracted, Forensic light sources are used by shining the light over the head of the applicator is magnetized. Contaminants in, and constituents of, a latent print To use the magnetic applicator, it is lowered into the magwill sometimes cause an inherent luminescence when netic powder. These adhere to the constituents of the latent print and make the are small pieces of backing material with a same-size piece print visible. They allow an examiner to place ends of the suspended powder, not the applicator itself, to the adhesive tape on an impression and then press it the surface being processed. Rubber/gel lifters come in Excess powder can be removed by frst retracting the precut elastic sheets. They have a low-tack adhesive gelatin magnetic rod and releasing the unused powder from the layer on the backing material, which is covered with clear applicator back into the powder jar (or appropriate disposal acetate. The low-tack adhesive and fexibility of the backing container, if the powder has become contaminated) and material make these lifters desirable for lifting prints off then passing the applicator over the area again to allow any curved and delicate surfaces such as light bulbs, doorexcess powder to re-adhere to the magnet. The card is usually preprinted with areas for information about the lift When the surface of an item is rough or textured, a casting (date, case number, location, who made the lift, etc. Casting material can also be useful to preserve and record fngerprint impressions in 11. Aside from the standard clear and frosted terial is available in a variety of compounds. A color that will contrast with the to it, allowing for lifts to be more easily taken from curved print powder should be selected (Morris, 2005). Tapes that are thicker than the clear and frosted tapes were developed to conform better to textured sur11. Adhesive tape from a roll may be torn or cut to any length and then Any type of camera that has accessories for close-up affxed to the developed print. Care should be exercised to work can be used in fngerprint and palmprint photography remove a suitable length of tape in one continuous motion (Moenssens, 1971, p 151). However, a camera system with to avoid lines that are created by intermittent stops during a lens for macrophotography works best. These, in combination, form a system that can use the roll as a secure handle for the tape. The press or view camera using 4 x 5 sheet flm After an item has been processed with powder, the edge was the most commonly used camera until it was replaced of the lifting device. The newer high-resolution the surface adjacent to the latent print and the device is digital single-lens refex cameras are also suitable for fngercarefully smoothed over the print. The tape is then peeled print photography (Dalrymple, Shaw, and Woods, 2002, pp off and placed on a backing card of contrasting color to 750?761; Crispino, Touron, and Elkader, 2001, pp 479?495). Warning labels (for biohazard and chemically can be easily obtained at the scene, but often they are processed evidence) overlooked. If the time is taken to obtain the elimination prints, comparisons can be made and lab personnel are 7. Rulers (metal machine ruler and small plastic rulers; a laser ruler may be helpful as well) 12. Scales to indicate dimensions in photographs (nonadhesive and adhesive for placing on walls, if necessary) Sometimes evidence needs to be collected for processing at the laboratory. Packaging containers (to preserve the evidence in the evidence include: condition it is found and to prevent contamination) 1. As these molecules what does not, he or she can modify his or her personal collect, they begin to form clusters, often becoming viskit as needed. The second requirement referred to as superglue fuming, was introduced into the is proper ventilation. Theys, Turgis, and Lepareux frst reported in 1968 heat source, such as a coffee cup warmer. This heat causes that the selective condensation of metals under vacuum the glue to vaporize, thereby developing the latent print settles on the sebum (fat) flms, revealing latent prints. The chamber should also deposited onto the latent print, making it visible (Lee and include a system to separate and suspend the specimens Gaensslen, 2001, p 140). This chamber vaporizes fumes from cyano(1993, p 111), Not all lasers are suitable for fngerprint acrylate under vacuum conditions without the white work. The color or wavelength of the output, as well as the buildup of residue that might typically occur when fuming light intensity or power output, is important. In addition, unlike with ordinary the concept for the laser was frst noted in 1957 by containers, there is no need to spread out items to be Gordon Gould, a Columbia University graduate student processed when they are placed in the chamber; everything (Taylor, 2000, pp 10?11). The use of a complex patent dispute and legal battle regarding this this chamber also makes overfuming less likely, avoiding remarkable invention (Taylor, 2000, p 284). Dalrymple, Duff, and Menzel (1977, pp 106?115) introduced the use of the laser to fngerprint examiners around the 11. This article described how A vacuum metal deposition chamber, used for developing natural components in some latent fngerprints luminesce latent prints, is typically a steel cylindrical chamber with under laser illumination. The chamber is attached to a system There are various types of lasers, but they all basically work of valves and vacuum pumps that work to reduce the the same way. To understand how they work, one must pressure to a level where the evaporation of metals may understand the basics of atoms. Within the cloud, electrons exist at various energy levels (levels of excitation), depending on Relative humidity from dry and wet bulb the amount of energy to which the atom is exposed by thermometer readings heat, light, or electricity. When the atom gets excited by a specifc quantity (quantum) of energy, the electrons are t t 2. When electrons drop 68 83 78 74 70 66 back into the ground state energy level, the atom releases energy in the form of a particle of light (photon). As the photons bounce back and forth between 71 83 80 76 72 68 the two mirrors, they stimulate other atoms to release 72 83 80 76 72 68 65 more photons of the same wavelength. This allows a portion of the coherent radiation (a laser beam) to 74 84 80 76 72 69 65 be emitted (Menzel, 1980, pp 1?21). A very basic 80 85 82 78 75 71 68 65 way to determine humidity is simply to have one wet bulb 81 85 82 78 75 71 68 65 thermometer and one dry bulb thermometer inside the chamber. The wet bulb thermometer has a piece of muslin 82 85 82 78 75 72 69 65 tightly wrapped about its bulb. This cloth is dampened with 83 85 82 78 75 72 69 65 distilled water; as the water evaporates, the thermometer 84 86 82 79 76 72 69 66 cools. The dry bulb thermometer measures 85 86 82 79 76 72 69 66 the surrounding air temperature in the chamber. Table 11?1 86 86 83 79 76 73 70 67 provides an easy way to determine relative humidity based on the readings of the wet and dry bulb thermometer 87 86 83 79 76 73 70 67 measurements (Olsen, 1978, pp 197?199). Experience and 88 86 83 80 77 73 70 67 65 research have determined that the best prints obtained 89 86 83 80 77 73 71 68 65 from treatment with ninhydrin are those that have been exposed to relative humidity of 65?80% (Kent, 1998; Nielson, 90 86 83 80 77 74 71 68 65 1987, p 372). Digital thermo-hygrometers are also available to monitor the processing of humidity and temperature. The top horizonIn the absence of a humidity chamber, some technicians tal row is the difference between the dry bulb reading and will use a common household iron to provide a warm and the wet bulb reading (t t). Find the cell at the intersection moist environment to accelerate the development of ninhyof the dry bulb reading and the difference of the bulb readdrin prints. For example, if the dry reading is 85 and the wet bulb success, excessive moisture could damage the prints reading is 81, the difference is 4. The employed a fxed focus and were placed directly over the use of 4 x 5 sheet flm to record fngerprints at a life-size print to be photographed. These cameras were equipped scale on the negative is still common in some agencies.

To be accepted as signifcant fndings depression symptoms in child buy aripiprazolum 10mg low cost, Documentation of a difcult airway and its management Mantel?Haenszel odds ratios must agree with combined Registration with an emergency notifcation service test results whenever both types of data are assessed depression test in hindi generic aripiprazolum 15mg fast delivery. In the For the literature review anxiety facts best 15mg aripiprazolum, potentially relevant clinical studabsence of Mantel?Haenszel odds ratios mood disorder 29696 order aripiprazolum line, fndings from both ies were identifed via electronic and manual searches of the the Fisher and weighted Stoufer combined tests must agree literature. The updated electronic search covered an 11-yr with each other to be acceptable as signifcant. The manual search covered New meta-analytic fndings were obtained for the followa 16-yr period from 1997 through 2012. Over 400 citations ing evidence linkages: (1) preoxygenation for 3-5 min versus that addressed topics related to the evidence linkages were 4 deep breaths, (2) videolaryngoscope versus direct laryngosidentifed. Tese articles were reviewed and combined with copy, and (3) supplemental oxygen after extubation (table 4). Of these, 253 contained data pertaining specifcally to established by interrater reliability testing. Tree-rater chance-corrected agreement vallines, organized by section, is available as Supplemental Digiues were: (1) study design, Sav = 0. Tese valnal Guidelines reported literature pertaining to seven clinical ues represent moderate to high levels of agreement. For the interventions that contained enough studies with well-defned updated Guidelines, the same two methodologists involved experimental designs and statistical information to conduct in the original Guidelines conducted the literature review. New literature pertaining to two clinical interventions contained enough studies with well-defned B. Tese interventions were: (1) preoxygenation: (1) survey opinion from consultants who were selected based 3?5min of breathing oxygen versus four maximal breaths, on their knowledge or expertise in difcult airway manageand (2) postextubation supplemental oxygen: delivery by ment, (2) survey opinions solicited from active members of mask, blow-by, or nasal cannulae versus room air. Practice Guidelines received from active American Society of Anesthesiologists strategy =64% and follow-up care = 72%. The percent of responding consultants expecting percent indicated that new equipment, supplies, or trainno change associated with each linkage were as follows: ing would not be needed to implement the Guidelines, (1) airway history = 84%, (2) airway physical examinaand 100% indicated that implementation of the Guidetion =88%, (3) preparation of patient and equipment = lines would not require changes in practice that would 80%, and (4) difcult airway strategy = 80%, extubation afect costs. Components of the Preoperative Airway Physical Examination Airway Examination Component Nonreassuring Findings Length of upper incisors Relatively long Relationship of maxillary and mandibular incisors Prominent overbite (maxillary incisors anterior to mandibuduring normal jaw closure lar incisors) Relationship of maxillary and mandibular incisors Patient cannot bring mandibular incisors anterior to (in front during voluntary protrusion of mandible of) maxillary incisors Interincisor distance Less than 3 cm Visibility of uvula Not visible when tongue is protruded with patient in sitting position. The decision to examine some or all of the airway components shown on this table is dependent on the clinical context and judgment of the practitioner. The table is not intended as a mandatory or exhaustive list of the components of an airway examination. The order of presentation in this table follows the line of sight that occurs during conventional oral laryngoscopy. Techniques for Diffcult Airway Management Unit for Diffcult Airway Management Techniques for Diffcult Techniques for Diffcult Rigid laryngoscope blades of alternate design and Intubation Ventilation size from those routinely used; this may include a rigid fberoptic laryngoscope. Blind intubation (oral or nasal) Invasive airway access Tracheal tubes of assorted sizes. Examples include (but are not Intubating stylet or Oral and nasopharynlimited to) semirigid stylets, ventilating tube-changer, tube-changer geal airways light wands, and forceps designed to manipulate the Supraglottic airway as an Rigid ventilating distal portion of the tracheal tube. Light wand Equipment suitable for emergency invasive airway Videolaryngoscope access. The order of presentation is alphabetithe items listed in this table represent suggestions. The contents cal and does not imply preference for a given technique or of the portable storage unit should be customized to meet the sequence of use. Consultant Survey Responses Percent Responding to Each Item Strongly Strongly N Agree Agree Equivocal Disagree Disagree 1. The likelihood and clinical impact of the following basic management problems should be assessed: Diffculty with patient cooperation or consent 66 60. The following airway devices should be options for emergency noninvasive airway ventilation: Rigid bronchoscope 66 13. Transtracheal jet ventilation should be considered an 66 example of: (check one) Invasive airway ventilation 95. The preformulated extubation strategy should include consideration of: the relative merits of awake extubation vs. The likelihood and clinical impact of the following basic management problems should be assessed: Diffculty with patient cooperation or consent 302 49. The relative merits and feasibility of the following basic management choices should be considered: Awake intubation vs. The following airway devices should be options for emergency noninvasive airway ventilation: Rigid bronchoscope 302 6. Transtracheal jet ventilation should be considered an example 302 of: (check one) Invasive airway ventilation 95. The strategy for intubation of the diffcult airway should include consideration of the relative clinical merits and feasibility of four basic management choices: Awake intubation vs. The strategy for intubation of the diffcult airway should include the identifcation of a primary or preferred approach to: Awake intubation. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B: Prediction of diffcult mask ventilation. Anesthesiology 1992; 77:67?73 Charuzi I: Increased body mass index per se is not a predic7. Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann mediastinal masses in children. J Pediatr Surg 1985; 20:816?22 A, Schmidt J: Incidence and predictors of diffcult laryngos8. Miyabe M, Dohi S, Homma E: Tracheal intubation in an infant Scand 1992; 36:109?11 with Treacher-Collins syndrome?pulling out the tongue by a 36. Nagamine Y, Kurahashi K: the use of three-dimensional 1995; 7:93?6 computed tomography images for anticipated diffcult intu37. Ramamani M, Ponnaiah M, Bhaskar S, Rai E: An uncommon Preoxygenation in the morbidly obese: A comparison of two cause of unanticipated diffcult airway. Anesthesiology 1985; Treacher Collins and Pierre Robin syndromes: A report of 62:827?9 three cases. Can J Anaesth 1994; 41(5 Pt 1):372?83 niques: Comparison of three minutes and four breaths. Six years experience in a teachA comparison of anesthetic techniques for awake intubaing maternity unit. Anaesthesia 1993; cal spine, retropharyngeal cold abscess and progressive air48:910?3 way obstruction. Anesth Analg 2007; Anaesthesiol Scand 2009; 53:964?7 104:1610?1; discussion 1611 56. Anaesth Intensive Care 1982; Soft palate perforation during orotracheal intubation facili10:151?3 tated by the GlideScope videolaryngoscope. Krafft P, Fitzgerald R, Pernerstorfer T, Kapral S, Weinstabl C: awake tracheal intubation. Anaesthesia 2007; 62:746?7 A new device for blind oral intubation in routine and diffcult 61. Eur J Anaesthesiol 1994; 11:207?12 intubating laryngeal mask airway to facilitate awake orotra80. J Bullard laryngoscope for patients with a simulated diffcult Clin Anesth 1999; 11:346?8 airway. Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y: Pentaxtion over a plastic tube changer. Fetterman D, Dubovoy A, Reay M: Unforeseen esophageal Macintosh laryngoscope for tracheal intubation in patients misplacement of airway exchange catheter leading to gastric with restricted neck movements: A randomized comparative perforation. Jungbauer A, Schumann M, Brunkhorst V, Borgers A, Groeben airway management after carotid endarterectomy: Utility and H: Expected diffcult tracheal intubation: A prospective comlimitations of the Laryngeal Mask Airway. J Clin Anesth 2007; parison of direct laryngoscopy and video laryngoscopy in 19:218?21 200 patients. Korean J Anesthesiol 2010; after a prolonged suspension laryngoscopy to preserve a 59:314?8 vocal cord fat graft. Br J Anaesth 2008; 101:723?30 J, Rosenberg H: the laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated diffcult tracheal 68. Asai T, Fujise K, Uchida M: Use of the laryngeal mask in a child with manual in-line stabilization: Direct laryngoscopy verwith tracheal stenosis. Nagai K, Sakuramoto C, Goto F: Unilateral hypoglossal nerve predicted diffcult airway: A comparison of conventional paralysis following the use of the laryngeal mask airway.

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Biopsy of suspected sarcoma depression chat order aripiprazolum 10mg free shipping, or resection of a complex bone or complex soft tissue tumour(s) is not eligible for payment as R226 when rendered in conjunction with another procedure(s) by the same surgeon when the biopsy or tumour resection is not the major procedure depression ups and downs generic 20mg aripiprazolum mastercard. R226 is eligible for payment for complex tumour resection by amputation only when the tumour resected is malignant anxiety high blood pressure buy cheap aripiprazolum 15 mg on-line. If the nature anxiety kian lawley buy aripiprazolum 10 mg with amex, complexity and/or length of the procedure require(s) two oncological orthopaedic surgeons to render components of the same procedure simultaneously or sequentially, R226A is eligible for payment to each surgeon. Claims submission instructions: Submit R226A claims for a second surgeon using the manual review indicator and accompanied by operative report. Time calculation commences when the surgeon begins the procedure and ends when the surgeon leaves the operating room. The subsequent application of plaster casts may be claimed according to the following Schedule. A wrist procedure listed in the Hand and Wrist section of the Schedule performed arthroscopically is eligible for payment in addition to R682 if that procedure is not described as a component of R682 or described by an E-add-on code to R682. Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R682 when the service described by the E-code is a generally accepted component of a procedure described in Note #1. Services listed under Skin Flaps and Grafts are not eligible for payment with R549 or R551. R551, E832 and E831 include the palmar and digital components of the Dupuytrens procedure, when rendered. E497 is payable in addition to R322 and R345 if a pedicled vascularized bone graft is used in addition to , or in place of a non-vascularized bone graft. F019 and Z279 rendered in conjunction with R322 and R345 are not eligible for payment. An elbow procedure listed in the Elbow section of the Schedule performed arthroscopically is eligible for payment in addition to R683 if that procedure is not described as a component of R683 or described by an E-add-on code to R683. Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R683 when the service described by the E-code is a generally accepted component of a procedure described in Note #1. A shoulder procedure listed in the Shoulder section of the Schedule performed arthroscopically is eligible for payment in addition to R684 if that procedure is not described as a component of R684 or described by an E-add-on code to R684. Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R684 when the service described by the E-code is a generally accepted component of a procedure described in Note #1. Midface fractures Application of craniofacial suspension wires and external fixation devices (not to be billed in addition to maxillary repair). Z239, Z240, R652 or D062 are not eligible for payment in addition to F138 or F139. A knee procedure listed in the Knee section of the Schedule performed arthroscopically is eligible for payment in addition to R687 if that procedure is not described as a component of R687 or described by an E-add-on code to R687. Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R687 when the service described by the E-code is a generally accepted component of a procedure described in Note #1. R687 is an uninsured service for arthroscopic lavage of the knee alone (without debridement) for osteoarthritis. Arthroscopic lavage of the knee alone (without debridement) is not recommended for any stage of osteoarthritis. E489 and/or E494 are not eligible for payment in addition to E496 for debridement of attachment site. R695, R696, and R697 include any neurovascular exploration and/or protection and tenolysis, when rendered. An ankle procedure listed in the Foot and Ankle section of the Schedule performed arthroscopically is eligible for payment in addition to R688 if that procedure is not described as a component of R688 or described by an E-add-on code to R688. Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R688 when the service described by the E-code is a generally accepted component of a procedure described in Note #1. Services listed under "Skin Flaps and Grafts" are not eligible for payment with R549 or R576. R576 and E831 include the plantar and digital components of the Dupuytrens procedure, when rendered. F063, F065) may be eligible for payment when rendered in addition to D026 or D028. Identification of the anatomy of the paranasal sinuses distorted by previous surgery, trauma, abnormalities of development or benign or malignant tumours; or 2. A pathological lesion abuts the base of the skull, orbit, optic nerve or carotid artery. When bronchoscopy, flexible or rigid, is rendered in conjunction with laryngoscopy or oesophagoscopy, only the bronchoscopy is eligible for payment. Bronchoscopy rendered by the same surgeon immediately following thoracic surgery under the same anaesthetic is not eligible for payment. Bronchoscopy (including intraoperative bronchoscopy) rendered the same day as a major lung resection is not eligible for payment if a bronchoscopy has been rendered by the same physician to the same patient in the 3-week period preceding the major lung resection. Z360 is eligible for payment only for life-threatening emergency situations where the patient is not intubated. Life Threatening Critical Care and Other Critical Care services are not payable in addition to Z360 to the same physician for the same patient, same day. Z325 is eligible for payment only for life-threatening emergency situations where the patient is not intubated. Percutaneous tracheostomy, cricothyroidotomy or other emergency airway punctures do not constitute Z325. Z361 and Z362 are not payable for adjustment of a previously inserted indwelling pleural catheter. Unless otherwise stated, excision or repair procedures for arteries and veins include endartectomy, thrombectomy and/or bypass graft. Excision or repair procedures for arteries and veins include harvest of graft tissue, except where harvest of graft tissue is explicitly excluded from the procedure. Where harvest of graft tissue is included as a specific element of the procedure, the harvest is an insured service payable at nil. The basic anaesthetic fee of 28 units or more for major cardiovascular surgery includes such procedures as insertion of C. Re-operation involving open heart procedures with pump # E670 following previous thoracotomy. R701 or R702 are eligible for payment only for paracorporeal devices inserted for less than 14 days. Despite payment rule #1, R701 is also eligible for payment in addition to R703 or R704 when a right ventricular assist device is inserted to support a left ventricular assist device, regardless of the duration of insertion of the right ventricular assist device. R703 is eligible for payment only for paracorporeal devices inserted for 14 or more days. R705 is only eligible for payment for removal of paracorporeal or implantable ventricular assist devices inserted for 14 or more days. Z744 (decannulation of circulatory assist device) is eligible for payment for removal of paracorporeal or implantable ventricular assist devices inserted for less than 14 days. Only one of Z744 or R705 is eligible for payment per patient per day for removal of ventricular assist devices. Extracorporeal membrane oxygenator procedures do not constitute R701, R702, R703 or R704. If a ventricular assist device is replaced, both the appropriate removal and insertion fee codes are eligible for payment. For the anaesthesiologist, when off-pump coronary artery bypass grafting is rendered, submit claim using E645C with 40 basic units plus time units, instead of R742C or R743C. For the surgical assistant, when off-pump coronary artery bypass grafting is rendered, submit claim using E645B with 24 basic units plus time units, instead of R742B or R743B. Where a single segment of vein is used for more than 2 anastomoses, the second and subsequent anastomoses are to be claimed at 50% of the E654 fee. Percutaneous transluminal catheter assisted closure for Secundum arterial septal defect Z465 device closure of a single defect. R784, R785) includes repair to the profunda femoris artery as far as the first major branch. If the repair extends beyond the first major branch of the profunda femoris artery, R815 may be claimed in addition. If the repair extends beyond the second major branch of the profunda femoris artery, R856 instead of R815 may be claimed in addition. For procedures involving the application of a complete aortic cross clamp, the anaesthetic basic fee will depend on: a. These services include insertion of all catheters including access catheters, interpretation of any images which may be taken at the time of the procedures.

If your condition is more severe mood disorder free test discount 15mg aripiprazolum visa, activities such as getting dressed anxiety yoga poses purchase aripiprazolum with amex, taking a bath or even combing your hair could make you breathless depression symptoms worse in morning generic 20mg aripiprazolum amex. It is important not to feel ashamed and to talk about your concerns with your doctor depression test in pregnancy aripiprazolum 20mg low price, nurse or physiotherapist. As well as taking regular treatment, you can also reduce your shortness of breath by training and strengthening your muscles so they work better. This means they will lose strength and weaken, making physical activities become more dif? As a consequence, you will need to breathe even more, which will make even simple activities hard. If you maintain physical activity, your lungs and muscles will keep working as well as they can do, and your health will deteriorate much less rapidly. Your breathing dressing or undressing should return to normal after a few minutes of rest. If you take deep breaths through the nose and release air through pursed lips, your airways will be open longer, which will help you regain a normal breathing rate. Depending on how severe your symptoms are and how you prefer to exercise, keeping active ranges from basic activities around the home to structured exercise sessions. Image adapted the Ohio State University Medical Center You can try to build different activities into your daily routine in order to maintain your level of? Stretching routines at home to strengthen your muscles If you want to improve your? Pulmonary rehabilitation involves organised exercises and education about your lungs and keeping healthy, as part of a group. Talk to your doctor, nurse or physiotherapist about the type of exercise that is right for you and the programmes available in your area. Breathlessness can feel distressing, but increases in heart rate and breathing are normal during exercise, and are not dangerous. If you are more short of breath than people of your own age during exercise, you should consult a doctor and ask for advice. They could recommend a training heart rate for you, which will give you the number of pulse beats per minute which you should be aiming for when exercising. There are often simple solutions which can make physical activities more comfortable for you. Doctors provide oxygen to people based on the level of oxygen in your blood, not on how breathless you feel. You could be very short of breath, but the levels of oxygen in your blood are suf? If the oxygen in your blood stream is below a critical level, then you may be prescribed oxygen. You should also see a doctor if your breathing suddenly becomes worse during exercise, or it doesn?t recover soon after you stop exercising. Abd El-Kader Associate Professor of Physical Therapy Chronic Obstructive Pulmonary Disease Definition Chronic obstructive pulmonary disease is a general term that refers to a number of chronic pulmonary conditions characterized by narrowing and obstruction of airways, 4 increased retention of pulmonary secretions and structural deterioration of alveoli. Characteristics of patients with obstructive lung disease 1Patients exhibit persistent resistance of airflow, which causes prolonged and often forced expiration. General clinical problems 1Frequent episodes of shortness of breath dyspnea on exertion. Presentation: Significant overlaps exist in signs and symptoms among the three major diseases of airflow obstruction: asthma, chronic bronchitis and emphysema. The large overlap has been long noted and well illustrated in Venn diagram fashion (Fig. Classification of Severity 6 For educational reasons, a simple classification of disease severity into four stages is recommended (Table 1). Pathophysiology Pathological changes in the lungs lead to corresponding physiological changes characteristic of the disease, including mucus hypersecretion, Ciliary dysfunction, Expiratory airflow limitation, pulmonary hyperinflation, gas exchange abnormalities, pulmonary hypertension, and corpulmonale. The hyperinflation of the lung flattens the diaphragm, shortens the inspiratory muscles and places them at a mechanical disadvantage. In addition to the reduced efficiency of the 7 inspiratory muscles, large amount of pressure work are required to overcome the high airway resistance. In addition, loss of protein and lean body mass leads to skeletal muscle and diaphragmatic weakness. It is an effective technique to reduce both the symptoms of breathlessness and the work of breathing. The techniques most commonly taught are diaphragmatic breathing and pursed lips breathing or a combination of both. In addition, it is often used in combination with pursed lips breathing and relaxation techniques. In addition, prolonged expiration leads to decrease air trapping and residual volume. In addition, breathing control can be performed via diaphragmatic and pursed lips breathing exercise, which encourage deep breathing and control the dyspnea. Cthe oximetry biofeedback augmented pursed lips breathing training: patients can use pulse oximetry as a biofeedback guide to teach them to increase their oxygen saturation during performance of pursed lips breathing which relieves dyspnea and improves gas exchange, which result in improvement of oxygen saturation. As an alternative, the huff consists of a slow inspiration to total ling capacity, followed by huffs with the glottis open and may be effective. The multiple huffs are thought to minimize collapse of small airways, bronchospasm and fatigue. BChest physiotherapy: Postural drainage, percussion and chest wall vibration are clinically effective. Flexibility/stretching considered as a part of the warm up before aerobic training and as part of the cool down after aerobic training. B) Aerobic Exercises: 10 1Mode: Should incorporate Lange muscle groups that can be continuous and rhythmic in nature. Since these diseases are often closely related and often seen in conjunction with each other, the underlying goals and principles of treatment are similar. Chronic bronchitis is an inflammation of the bronchi that causes an irritating and productive cough that lasts up to 3 months and recurs over at least 2 consecutive years. The pathologic changes that occur in chronic bronchitis are: 1) An increase in the number of mucus-producing goblet cells in the lining of the bronchial tree 2) A decrease in the number and action of the ciliated epithelial cells, which mobilize secretions. Emphysema is a chronic inflammation, thickening, and destruction of the respiratory bronchioles and alveoli. These airways become scarred, distorted, and kinked, and the alveoli lose their elastic recoil, then weaken and rupture. Over a period of years, severe chronic bronchitis and emphysema often lead to congestive heart failure and death. Although not as common, emphysema can also be a primary disease that can occur in nonsmokers. The pathologic changes that occur in emphysema are: 1) An over inflation of the lungs and formation of pockets of air known as bullae. An abnormal breathing pattern with the most difficulty experienced during expiration which results in: 1) Use of accessory musculature. Deep and effective cough of secretions, (this is an important goal postural drainage to areas if emphysema is associated with where secretions are chronic bronchitis or if there is an identified acute respiratory infection). Note: Drainage positions may need to be modified if the patient is dyspneic in the head-down position. Promote for relaxation muscles of inspiration to decrease relaxed head up position in reliance on upper chest breathing and bed; trunk, arms, and head decrease tenseness associated with are well supported dyspnea. Breathing exercises and ventilation Relaxed diaphragmatic breathing 13 Emphasize relaxed expiration; decrease the with minimal upper chest rate of respiration and the use of accessory movement. Carry over controlled breathing to Pursed lip breathing (careful to functional activities. Have the patient assume a relaxed position, so the upper chest is relaxed and the lower chest is as mobile as possible. Have the patient breathe out as rapidly as possible without forcing expiration (Note: Initially, the rate of respiration will be rapid and shallow. It is related to hypersensitivity of the trachea and bronchi and causes difficulties with respiration are cause of bronchospasm and increased mucus production. Asthmatic attacks involve severe shortness of breath when the patient comes in contact with a specific allergen.