NR 507 Week 2 Discussion: Respiratory Disorders and Alterations in Acid/Base Balance, Fluid and Electrolytes - Discussion Part Two 2023

NR 507 Advanced Pathophysiology. NR 507 Week 2 Discussion: Respiratory Disorders and Alterations in Acid/Base Balance, Fluid and Electrolytes - Discussion Part Two 2023. Analyze pathophysiologic mechanisms associated with selected disease states. (PO 1) 2 Differentiate the epidemiology, etiology, developmental considerations, pathogenesis, and clinical and laboratory manifestations of specific disease processes. (PO 1) 3 Examine the way in which homeostatic, adaptive, and compensatory physiological mechanisms can be supported and/or altered through specific therapeutic interventions. (PO 1, 7) 4 Distinguish risk factors associated with selected disease states. (PO 1) 5 Describe outcomes of disruptive or alterations in specific physiologic processes. (PO 1) 6 Distinguish risk factors associated with selected disease states. (PO 1) 7 Explore age-specific and developmental alterations in physiologic and disease states. (PO 1, 4) Discussion Discussion Part Two (graded) Responses Brooke Lobianco 5/11/2016 12:47:33 PM Tammy Patient: Tammy – 33-year-old female Chief Complaint: Presents with a very productive cough of green sputum. She is afebrile but with a “scratchy” throat. History of a “bad cold” 3 weeks ago with associated rhinorrhea. Medical History Medications Allergies Surgical History Social History -N/A -N/A - N/A - N/A - N/A Vitals: N/A 1. Acute Bronchitis The first, and seemingly most likely diagnosis for Tammy would be acute bronchitis. Microorganisms gain access to the lower respiratory tract via inhalation or aspiration (Goroll & Mulley, 2014). Under normal circumstances, organisms are entrapped by mucous- producing cells and ciliated epithelium, which lines the nasal mucosa and oropharynx (Goroll & Mulley, 2014). Immunoglobulin A within the nasal mucosa prevents bacterial adherence, while the cough reflex moves large particles from the lower airway (Goroll & Mulley, 2014). Additionally, ciliated epithelium and mucous in the bronchial tree captures particles too small to be removed by coughing (Goroll & Mulley, 2014). Alveolar fluid contains complement and immunoglobulin, containing pulmonary macrophages that eliminate bacteria (Goroll & Mulley, 2014). Infection occurs when the virulence of an organism overwhelms the host’s defenses, manifesting in productive or non-productive cough, fever, chest discomfort, and fatigue (Goroll & Mulley, 2014). Due to Tammy’s respiratory presentation of a productive cough, she may have acute bronchitis. Diagnosis is vastly achievable by examination and history of current symptoms, as a chest X-ray will not show infiltrates or consolidations in the lungs (Goroll & Mulley, 2014). Being that the top differential diagnosis is acute bronchitis, the patient would be treated conservatively. According to Goroll and Mulley (2014), studies found that antibiotic treatment of this condition with Doxycycline, Bactrim, and Erythromycin showed no clear benefit for treatment. Regardless of the treatment, patients’ coughs began to dissipate after 1 week, with persistent cough potentially lasting for 2 weeks (Goroll & Mulley, 2014). The patient may take an over-the-counter cough suppressant as well as a decongestant and expectorant. 2. Sinusitis Sinusitis is a likely differential diagnosis. Acute sinusitis is the second most common infectious disease seen by general practitioners and is caused by the same viruses that cause the common cold (Worrall, 2011). It is a state of inflammation, which affects the pseudostratified columnar ciliated epithelium, interspersed with goblet cells that cover the surface of the paranasal sinuses and the nasal cavity (Mori et al., 2012). The symptomology of sinusitis rests largely on afflicted individuals' edematous nasal mucosa, and damaged nasal cilia (Feng et al., 2012). Over production of secretions leads to a blockage of ostial drainage of the sinuses, resulting in stagnant infected drainage (Feng et al., 2012). Acute sinusitis is typically based on upper respiratory symptoms and fever, however, with the stagnant and infections sputum in the sinuses leading in post-nasal drip, it may explain Tammy’s cough that worsens at night, and her sputum production. Sick contact history may indicate a viral versus bacterial cause. However, acute sinusitis may not fit the presentation due to the lack of documented paranasal (sinus) tenderness, which is commonly seen in this etiology. Acute sinusitis is characterized by the sudden onset of two or more symptoms, including one of either two key symptoms of nasal blockage/obstruction/congestion or nasal discharge, and facial pain/pressure and reduction or loss of smell for less than 12 weeks (Sng & Wang, 2015). 3. Lung Cancer- Adenocarcinoma Lung cancer, although an unlikely diagnosis, fits the presentation based on Tammy’s persistent productive cough. Research studies suggest that cough is a common symptom in about 23–37% of general cancer patients and 47–86% of lung cancer patients. A longitudinal assessment of 400 patients with non-resectable lung cancer found that >50% reported cough as a key symptom (Molassiotis et al., 2011). Tammy has no documented history of cigarette smoking which is the number one risk factor for lung cancer. Adenocarcinomas typically arise in the peripheral regions of the pulmonary parenchyma and develop in a stepwise fashion through atypical adenomatous hyperplasia (McCance, Huether, Brashers & Tote, 2013). Symptoms of early stage, localized disease are nonspecific and may include clinical manifestations such as coughing, chest pain and excessive sputum production. Adenocarcinoma’s (tumors arising from the glands) of the lung constitutes 35% to 40% of all bronchogenic carcinomas. Adenocarcinoma occurs more frequently in women and non-smokers carcinomas (McCance, Huether, Brashers & Tote, 2013). Exact pathophysiology of these tumors is unclear however a mutation of epidermal growth factor receptor is commonly seen with this type on lung cancer. 4. Pneumonia Pneumonia fits the presentation based on Tammy’s symptoms of productive cough of thick green sputum. Pneumonia is less likely due to the fact that Tammy does not have complaints of pleuritic pain, dyspnea, history of a recent sick contact or hospitalization, or a fever; as well as lack of documentation of inspiratory crackles or tactile fremitus on exam. If Tammy were to have a fever and dyspnea on exertion this would make the pneumonia diagnosis my number one diagnosis, as these symptoms correlate with pneumonia, versus acute bronchitis. Pneumonia is an infection of the lower respiratory tract caused by bacteria, viruses, fungi, protozoa, or parasites (McCance, Huether, Brashers, & Rote, 2013). Pneumonia can be categorized as community- acquired, healthcare-associated, hospital-acquired or ventilator associated. Aspiration of oropharyngeal secretions is the most way pneumonia is acquired (Waybright, Coolidge & Johnson, 2013). The body has multiple mechanisms of defense prior to the pathogen actually reaching the lung. Cough relflex and mucociliary clearance would be the first-line of defense. The next line of defense would be the epithelial cells located in the airway. These cells have the ability to recognize some pathogens directly. Then come the alveolar macrophages, which are present in the lower respiratory tract. The macrophages present infectious antigens activating T cells and B cells. Neutrophils are critical phagocytes that kill microbes (McCance, Huether, Brashers & Tote, 2013). If pneumonia is suspected a posteroanterior and lateral chest x-ray is considered the gold standard for diagnosis (Goroll & Mulley, 2014). 5. Influenza Due to Tammy’s respiratory symptoms, Influenza, be it a less likely diagnosis, should also be considered. With a very similar pathophysiology to the common cold, influenza overlaps the symptoms of rhinovirus in terms of symptom severity (Goroll & Mulley, 2014). Typically surfacing in the winter months (December-March), influenza presents with myalgia, non-productive cough, headache, pharyngitis, and laryngitis (Goroll & Mulley, 2014). Tammy does mention having a cold fairly recently, which could have progressed to influenza. However, influenza is characterized by a nonproductive cough, which is opposite to Tammy’s purulent malodorous sputum. References Goroll, A.H. & Mulley, A.G. (2014). Approach to the patient with acute bronchitis or pneumonia in the ambulatory setting. In A.H. Goroll & A.G. Mulley (Eds.). Primary Care Medicine: Office Evaluation and Management of the Adult Patient ed.) (pp. 435-439). Philadelphia, PA: Wolters Kluwer. (7 Goroll, A.H., & Mulley, A.G. (2014). Management of the common cold. In A. H. Goroll & A.G. Mulley (Eds.), Primary Care Medicine: Office Evaluation and Management of the Adult Patient (7th ed.) (pp. 421-447). Philadelphia, PA: Wolters Kluwer. Feng, C.H., Miller, M.D., & Simon, R.A. (2012). The united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis. American Journal of Rhinology & Allergy, 26(3), 187-190. McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby. Molassiotis, A., Lowe, M., Ellis, J., Wagland, R., Bailey, C., Lloyd-Williams, M., Smith, J. (2011). The experience of cough in patients diagnosed with lung cancer. Supportive Care in Cancer, 19(12), . doi: Sng, W. J., & Wang, D. (2015). Efficacy and side effects of antibiotics in the treatment of acute rhinosinusitis: a systematic review. Rhinology, 53(1), 3-9. doi:10.4193/Rhin13.225 Waybright, R. A., Coolidge, W., & Johnson, T. J. (2013). Treatment of clinical aspiration: A reappraisal. American Journal Of Health-System Pharmacy, 70(15), p. doi:10.2146/ajhp W Worrall, G. (2011). Acute sinusitis. Canadian Family Physician Médecin De Famille Canadien, 57(5), 565-567 th Lorna Durfee 5/11/2016 3:21:40 PM Discussion Part Two Discussion Part Two (graded) Tammy is a 33-year-old who presents for evaluation of a cough. She reports that about three weeks ago she developed a “really bad cold” with rhinorrhea. The cold seemed to go away but then she developed a profound, deep, mucus-producing cough. Now, there is no rhinorrhea or rhinitis—the primary problem is a cough. The development of these coughing fits has become prolonged, very deep, and productive of a lot of green sputum. She hasn’t had any fever but does have a scratchy throat. Tammy has tried over-the-counter cough medicines but has not had much relief and a cough keeps her awake at night and sometimes gets so bad that she gags and dry heaves. Write a differential of at least five (5) possible diagnosis’s and explain how each may be a possible answer to the clinical presentation above. Remember, to list the differential in the order of most likely to less likely. Doctor Brown and Class: DIFFERENTIALS: Differential #1: Acute Viral Bronchitis - File (2016) explains that the presentation of bronchitis is swelling and irritation of the bronchi in the lungs. They are the tubes that are responsible for carrying air to the lungs. Acute bronchitis can occur with a viral infection, such as with a common cold. The symptom of acute bronchitis is a cough that persists and is nagging. This cough can continue for weeks after bronchitis has improved. Accompanying the infection can be a sore throat and congestion (File, 2016). Possibility: Acute bronchitis seems like it would fit the differential. The patient gives a history of a bad cold and runny nose. The cold seemed to go away but then a deep cough persisted along with the mucus that was being brought up. She no longer has the rhinorrhea or rhinitis. She now complains of a cough and bouts of coughing fits that are very prolonged, and she produces a lot of green sputum. She has a sore throat but no fever. She relates that a cough keeps her awake at night, she gags and has dry heaves. With acute bronchitis fever is not mentioned as a symptom. File (2016) explains that the symptoms most commonly associated with bronchitis are, a persistent cough that can last 10 to 20 days. The coughing up of mucus can be clear, yellow or green. Fever is a sign of another condition (File, 2016). Differential #2: Pneumonia - Marrie and File (2015) present an overview of pneumonia as an infection in the lungs. They explain with a focus on community-acquired pneumonia, as it develops in a community and it is one of the common diagnoses, as there are about four million cases each year in the United States. The pathology behind pneumonia encompasses the respiratory tract and its function. As we breathe are comes in through our nose and mouth, and it passes through the trachea and bronchi out to the bronchioles. At the end of the bronchioles are little air sacs known as alveoli. The alveoli have a thin porous wall and tiny blood vessels called capillaries. Every day we are exposed to micro-organisms that come through our mouth and nose. The body is quite capable of preventing these organisms from entering into the lung and infecting them. The immune system helps to defend the lungs. The nose and pharynx have a specialized shape that helps trap the dirt, particles, and microorganisms from entering the patient’s lungs. We have the ability to cough to remove the invaders and the cilia located on the bronchi help to move them out. Pneumonia happens as a result of the immune system is not functioning up to par and exposed to many strong micro-organisms. The body and immune system respond by sending the white blood cells to the alveoli. Alveoli that are infected then become inflamed and are filled with WBC’s, protein and RBCs. These are the changes that lead to signs and symptoms of pneumonia (Marrie and File, 2015). Possibility: Because this patient has had an ongoing infective process and she complains of an ongoing cough this diagnosis may fit because of a cough that produces green or yellow sputum. However, Marrie and File (2015) explain that older people may have fever less often (Marrie and File, 2015). Could be mycoplasma pneumonia, commonly known as “walking pneumonia.” This condition will have to be ruled out. Differential # 3: COPD – The American Thoracic Society states that a diagnosis of COPD is possible if the patient has symptoms of a cough, sputum production, shortness of breath and exposure to cigarettes and environmental pollutants. Chronic Obstructive Pulmonary Disease is a group of lung conditions that make it very difficult to empty air out of the lungs. This condition leads to shortness of breath and feeling tired. A cough and sputum production and shortness of breath that will not go away are key indications for this disease (The American Thoracic Society, 2015). Wise (2016) explains that chronic obstructive pulmonary disease is an inflammatory response to inhaled toxins. Also, an α -Antitrypsin deficiency is not a common cause but may want to be one to consider. The symptoms of a productive cough and shortness of breath occur over time. The α -Antitrypsin deficiency is a congenital lack of primary lung antiprotease which leads to protease-mediated tissue destruction and emphysema in adults. This neutrophil is an elastase inhibitor and protects the lung from the protease-mediated destruction of tissue. It is synthesized by the hepatocytes and monocytes and diffused into lung circulation. It is also produced secondarily by alveolar macrophages and epithelial cells. He explains that smoking, inhaled exposures and genetic factors play a part in the etiology of this disease. As this patient could have underlying COPD, she could have an exacerbation which can be attributed to a URI, acute bacterial bronchitis (Wise, 2016). Differential #4: Sinusitis - Ferguson and Wise (2016) relate that if we look at this patient’s symptoms, we can see that perhaps the sinusitis may be seen with upper respiratory infections or nasal allergies. The authors tell us that inflammation of the sinuses that is present for less than a week or two is a viral infection or viral URI (upper respiratory infection) (Ferguson & Wise, 2011). Possibility: Ferguson and Wise (2016) outline that the common sinusitis symptoms are; congestion in the nasal passages, drainage that is thick and discolored, a decrease in taste and smell and discomfort and facial pressure. They also state that if symptoms are present for more than two weeks without improvement, it may be an acute sinus infection (Ferguson & Wise, 2011). Differential 5: Post Nasal Drip - Silvestri and Weinberger (2014) have an excellent description of what post nasal drip is. They explain that the cause of a chronic cough can be from a postnasal drip, asthma, and acid reflux. These causes are seen most often in a chronic cough. At some time or another, most of us have had post-nasal drip, and we know it is the drip that flows into the back of the throat from the nose. This condition can be very irritating and can be responsible for a cough. Having a runny or stuffed up nose and feeling the liquid in the back of your throat and that need to clear your throat are part of a post nasal drip. There is also another post nasal drip called “silent” which has no symptoms but causes a cough (Silvestri & Weinberger, 2016). Possibility: This patient has had an obvious cold or virus that seemed to go away but then she developed a profound, deep, mucus-producing cough without fever. The coughing fits result in the production of a lot of green sputum. She hasn’t had any fever but does have a scratchy throat. A cough keeps her awake at night and sometimes gets so bad that she gags and dry heaves. Post-nasal drip could be the cause of her complaints. Given the symptoms are worse at night, when she is lying down, post-nasal drip could be the cause. Based on what you have at the top of the differential how would you treat this patient? Treatment of acute viral bronchitis. If this sparks a viral infection of the upper airways from a common cold, the use of antibiotics will not help eliminate the virus. However, the use of antivirals for some forms of viral bronchitis may be considered (File, 2016). Most people after a viral infection who have an upper respiratory infection (common cold) do not need to see a doctor immediately. For the symptom relief, we could suggest consumption of more fluids, use of a non-steroidal anti-inflammatory or aspirin or acetaminophen if not allergic to relieve a headache, sore throat, and humidification (File, 2016). The usual causes of acute bronchitis are from virus infections in the upper respiratory tract including influenza A and B, parainfluenza, and coronavirus (types 1-3). Also, rhinovirus, respiratory syncytial virus, and metapneumovirus. Suppose now, the patient has a fever of 100.4 and complains of foul-smelling mucous and breath. 1 1 File (2016) suggests that as you develop a viral illness, you experience a temperature greater than 100.4, a cough that does not improve after 10 days or lasts longer than 20 days, a cough that by a new fever and discolored mucus production, at this may be developing into pneumonia. When a patient presents later with symptoms like this, then the use of antibiotics would be warranted. This condition may have become a bacterial infection, and it would be prudent to use antibiotics at this point. The use of cough suppressant medications as well as inhaler may also be necessary. There is no evidence that is convincing to implicate these bacterial pathogens in acute bronchitis. However some of the bacterial pathogens could be the pathogens that cause pneumonia and may cause the problem on occasion. They are Streptococcus pneumoniae, Haemophilus influenzae, and Staph Aureus and Moraxella catarrhalis or gram-negative bacilli. Indeed, she complains of producing cups of mucous some days. She has some trouble breathing on moderate exertion, but this is only a minor complaint to her. This condition would make me feel that another pathology is the cause of her issues. Perhaps she could be having signs and symptoms of bronchiectasis or COPD or pneumonia. The undertaking of further examination with perhaps a sputum culture or chest x-ray and perhaps pulmonary function testing. How does this change your differential and why? Bronchiectasis is an enlargement of the bronchi and bronchioles. These airways become enlarged and produce a large amount of mucus. This condition can block or restrict the breathing passages and can happen after severe pneumonia. We have to evaluate for COPD and bronchiectasis and pneumonia (The American Thoracic Society, 2015). Sometimes bronchiectasis and COPD can occur together. The emphasis is being able to determine what disease that patient has by doing pulmonary function tests, sputum samples and perhaps a chest x-ray. When we can further assess, we can determine the disease-causing issue. We can also follow the evidence-based guidelines for treatment so we can treat effectively with recommended therapies (Athanazio, 2012). References Athanazio, R. (2012). Airway disease: similarities and differences between asthma, COPD and bronchiectasis. Clinics, 67(11), . doi:10.6061/clinics/2012(11)19 File, T. M. (2016). Acute bronchitis in adults. In T. W. Post (Ed.), UpToDate. Retrieved from Ferguson, B. J., & Wise, S. K. (2011). American Rhinologic Society: Adult sinusitis. Retrieved from Marrie, T. J., & File, T. M. (2015). Pneumonia in adults. In T. W. Post (Ed.), UpToDate. Retrieved May 11, 2016, from Silvestri, R. C., & Weinberger, S. E. (2016). Chronic cough in adults. In T. W. Post (Ed.), UpToDate. Retrieved from The American Thoracic Society. (2015). American Thoracic Society – Chronic Obstructive Pulmonary Disease: Key points. Retrieved from The American Thoracic Society. (2015). What is Chronic Obstructive Pulmonary Disease. Retrieved from Wise, R. A. (2016). Chronic Obstructive Pulmonary Disease (COPD). In Merck Manual online. Retrieved from Lanre Abawonse reply to Lorna Durfee 5/13/2016 11:55:31 AM RE: Discussion Part Two Your analysis of Tammy’s problem is good. In supporting your diagnosis of acute bronchitis, Hart (2014) noted in their study that a recent meta-analysis of 19 studies found that the mean duration of cough in adults with an acute cough illness was 17.8 days. Purulent sputum is also common in acute bronchitis and is the result of sloughing of the tracheobronchial epithelium and inflammatory cells. However, I don’t think tammy has enough clinical findings that would suggest bronchiectasis. Copstead and Banasik (2013) defined bronchiectasis as dilation of bronchi. It’s said it can be either acquired or congenital, and is classified as both an obstructive and supurative (pus forming) disorder. The diagnosis is based on chronic productive cough which is more than three weeks. The clinical manifestation would suggest bronchiectasis but the duration is not long enough to confirm the diagnosis or the possible diagnosis. Reference Copstead, L. C., & Banasik, J. L. (2013). Pathophysiology (5 th ed.). St. Louis, MO: Mosby. Hart, A. M. (2014). acute bronchitis. Nurse Practitioner, 39(9), 32-40 9p. doi:10.1097/01.NPR.8.99676.2b Sarah Boulware 5/11/2016 4:07:07 PM Part Two Dr. Brown and Class, Respiratory diseases can have very non-specific symptoms, which can make forming a diagnosis difficult. The general symptoms of a respiratory tract infection include: cough (with or without sputum production), hemoptysis, weight loss, breathlessness, night sweats, fever, general lethargy, and malaise (Kaufman, 2011). It appears Tammy was previously suffering from an upper respiratory tract infection, which could have made her more susceptible to a lower respiratory tract infection. Since her previous symptoms resolved her primary problem is a consistent, at times severe, cough accompanied by significant sputum production. 1. Acute Bronchitis Bronchitis is an infection or inflammation of the airways or bronchi. An acute cough is the most common reason patients see their primary care providers and a diagnosis of acute bronchitis is the most common result. Symptoms of bronchitis typically last about three weeks and consist of a cough along with the presence or absence of green sputum. These clinical manifestations are aligned with Tammy’s presenting symptoms and lead to the initial diagnosis of Acute Bronchitis (Albert, 2010). The treatment of bronchitis has been debated. There is a large occurrence of over-prescribing antibiotics for viral infections. Antibiotics do not work on viral infections and 90 percent of cases of acute bronchitis are viral. Because of the risk of antibiotic resistance they should not be routinely used to treat acute bronchitis. Symptom management and monitoring should be initiated and if the symptoms do not reside further evaluation will be needed. Symptom management includes prescription expectorants, antitussives, inhaler medications and alternative therapies. It is important to convey the importance of not prescribing antibiotics for viral infections to Tammy and ensure that she understands they will not eliminate her symptoms and can possibly cause more harm than good (Albert 2010). 2. Bronchiectasis According to Scullion and Holmes (2013), this is a progressive condition that is characterized by thick-walled bronchi and excess sputum production. It is classified as an obstructive lung disease because of the related airflow obstruction and tendency of the bronchi to collapse. The excessive mucus and difficulties with clearance, due to cilia damage, result in frequent bacterial colonization and infections in the respiratory system. The common symptoms of this disease include a cough that produces sputum and recurrent infections. A copious amount of green or yellow sputum that may vary in amount is usually present. Tammy’s primary problem is a cough along with “coughing fits” that produce a lot of green sputum. She has also had an upper respiratory infection recently. These symptoms are concurrent with bronchiectasis. After Tammy’s presentation with the additional symptoms of mild fever, foul smelling mucous and breath, an increased amount of sputum production, and dyspnea on moderate exertion, I would be concerned about an acute exacerbation of bronchiectasis and make this the primary differential diagnosis. Because Tammy is more likely to experience recurrent respiratory infections it is important to monitor for the signs and symptoms that may indicate an infection and exacerbation of bronchiectasis. The signs and symptoms exhibited by Tammy are indicative of an acute exacerbation with accompanying infection. This needs to be treated quickly to prevent progression and further complications such as respiratory failure (Scullion & Holmes, 2013). 3. Pneumonia Pneumonia may occur as a result of a previous respiratory infection. Infections may begin in the upper airway and systemically progress to the lower respiratory tract such as in viral pneumonia, in which organisms that originate in the upper respiratory tract migrate to the terminal bronchioles. Pneumonia usually presents with an onset of fever, chills and a productive cough, and dyspnea. Pneumonia is a possible diagnosis in Tammy because of her previous infection and cough, however she does not have any other typical signs of fever, chills, sweating, headache and vomiting (Driver, 2012). 4. Tuberculosis (TB) It is important to recognize TB as a differential diagnosis to ensure appropriate testing and treatment is provided. There are several non-specific symptoms of TB that are similar to other respiratory disorders. These include cough with or without sputum, hemoptysis, weight loss, breathlessness, night sweats, fever, and general lethargy and malaise. Tammy is exhibiting a cough with sputum production but no other symptoms of TB (Kaufman, 2011). 5. Asthma According to Burns (2012) poorly controlled asthma can result in persistent symptoms that include shortness of breath, chest tightness, cough, and wheeze. Allergic rhinitis can make it worse. Tammy did suffer from rhinitis but that has been resolved. Her only persistent problem is cough with sputum expectoration. Her symptoms could be related to asthma and/or allergic rhinitis but they appear to be more infectious and viral in nature. References Albert, R. (2010). Diagnosis and treatment of acute bronchitis. American Family Physician, 82(11), . Burns, D. (2012). Management of patients with asthma and allergic rhinitis. Nursing Standard, 26(32), 41-46. Driver, C. (2012). Pneumonia part 1: pathology, presentation and prevention. British Journal of Nursing, 21(2), 103-106. Kaufman, G. (2011). Pulmonary tuberculosis: clinical features and patient management. Nursing Standard, 25(47), 48-56. Scullion, J. & Holmes, S. (2013). Diagnosis and management of patients with bronchiectasis. Nursing Standard, 27(49), 49-55