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RESPIRATORY AIRWAY DISORDERS DISORDERS OF THE UPPER AIRWAY EPISTAXIS: (also called nosebleed) 1. The pathophysiology is congestion of the nasal membranes, leading to capillary rupture. This condition is frequently caused by injury. This condition happens more in men than in women. 2. Can be either a primary or a secondary disorder. EPISTAXIS, cont. PRIMARY: 1. hereditary hemorrhagic telangiectasia 2. sclerotic vessels SECONDARY: 1. nasal tumor 2. nasal fracture 3. trauma 4. cocaine use 5. hypertension 6. inhaled steroids CLINICAL MANIFESTATIONS The presence of bright red blood from one or both nostrils With severe bleeding, an adult can lose as much as one liter of blood per hour. This is rare. NOSEBLEED ASSESSMENT SUBJECTIVE: 1. Interview the pt. 2. Ask questions relevant to the duration and severity of the bleeding. 3. Ask the precipitating factors. ASSESSMENT, cont. OBJECTIVE: 1. Assess the bleeding; is it from one nostril or from both. 2. The nurse must determine if the bleeding is from the anterior or the posterior portion of the nasal passageway. 3. The nurse checks the vital signs: BP,P,R and T. She also checks for signs of hypovolemic shock. DIAGNOSTIC TESTS 1. Draw H + H, PT, INR, PTT. These lab. tests determine the amount of blood loss, and identify clotting abnormalities. 2. A rhinoscopy may be performed to locate the bleeding site. This procedure involves the insertion of a lighted speculum into the nasal cavity. RHINOSCOPY RHINOSCOPY Multiple foreign bodies; sprigs from an evergreen tree. MEDICAL MANAGEMENT 1. Nasal packing (cotton) that is saturated with 1:1000 epinephrine for vasoconstriction. 2. Cautery can be either electrical (the bleeding vessel is burned), or chemical in which a silver nitrate stick is applied to the site of bleeding. 3. Posterior packing may be needed. The use of balloon tamponade may be needed. 3. cont: Balloon tamponade is accomplished by inserting a Foley catheter (or something similar) into the nose and inflating the balloon after it is placed posteriorly. Then traction is applied to the catheter to compress the area. 4. Antibiotics may be prescribed to minimize the risk of infection. Sengstaken-Blakemore tube NURSING INTERVENTIONS 1. Keep the pt. quiet. 2. Place in a sitting position, leaning forward, or, reclining with the head and shoulders elevated. 3. Apply direct pressure for 10-15 minutes. 4. Apply ice compresses to the nose; have the pt. suck on ice. NURSING INTERVENTIONS, cont. 5. Monitor for s/s of bleeding. 6. Apply a gauze pad into the nostril; gently apply pressure if bleeding continues. NURSING DIAGNOSES 1. Ineffective tissue perfusion, cerebral and/or cardiopulmonary, related to blood loss 2. Risk for aspiration, related to bleeding PATIENT AND FAMILY TEACHING 1. Do not pick, scratch or irritate the nose. 2. Do not blow the nose vigorously. 3. Avoid dryness of the nose, 4. Do not insert any foreign objects in the nose. 5. Encourage the use of nasal or saline lubricants. 6. May use a vaporizer. 7. THE PROGNOSIS IS GOOD WITH TREATMENT. VAPORIZERS Deviated septum and nasal polyps Etiology/pathophysiology: 1. Deviated septum is either congenital or from trauma. 2. The septum deviates from the midline, causing obstruction (usually partial) of the nasal passageway. 3. Polyps are tissue growths on the nasal tissues. These are usually caused by allergies or sinus inflammation. NASAL POLYPS CLINICAL MANIFESTATIONS 1. Stertorous respirations: These sound like snores. The breathing can be dyspneic, cause an effort, have postnasal drip, be strenuous. NASAL POLYPS ASSESSMENMT SUBJECTIVE: 1. Ask if there were any previous injuries or infections. 2. Check for allergies and sinus congestion. OBJECTIVE: 1. Identify the condition and its location. 2. Monitor the rate and rhythm, and character of respirations. DIAGNSOTIC TESTS 1. Visual exam. 2. Sinus radiographic tests. SINUS CT SCAN MEDICAL MANAGEMENT 1. Surgical correction. A nasoseptoplasty may need to be done to reconstruct, align, or straighten the nasal septum. (for a deviated septum). 2. Nasal polypectomy. 3. Medications include: a. Corticosteroids to decrease or make polyps disappear. b. Antihistamines for allergies, and to decrease congestion. c. Antibiotics may be used to prevent infection. d. Analgesics for pain (often for a HA). NURSING INTERVENTIONS 1. Maintain a patent airway. 2. Prevent infection. 3. Monitor for bleeding and pain. DIAGNOSES: 1. Ineffective airway clearance, related to nasal exudate 2. 2. Risk for injury, related trauma to bleeding with vigorous nose blowing PATIENT AND FAMILY TEACHING 1. Avoid vigorous nose blowing, coughing, or holding your breath while bearing down. (for at least 2 days post-op) 2. Notify PCP if bleeding or infection occurs. 3. Use nasal sprays and drops sparingly. 4. Facial edema and ecchymosis may appear. NASAL SPRAYS HAY FEVER Also called antigen-antibody allergic rhinitis and allergic conjunctivitis. These conditions occur in the nasal membranes, nasopharynx, and conjunctiva form inhaled or contact allergens. HAY FEVER HAY FEVER Etiology/pathophysiology 1. Occur as the result of an antigen-antibody reaction. 2. Ciliary action slows, mucous increases, leukocytes infiltrate. 3. Capillaries dilate, become more permeable, tissue edema then results. ALLERGENS COMMON ALLERGENS: 1. weed pollens 2. trees, grass 3. molds, mites 4. fungi, animal dander CLINICAL MANIFESTATIONS 1. Photophobia, edema, blurring of vision, pruritis, excessive tearing. 2. Inability to breathe through the nose, excessive nasal secretions. 3. Otitis media may occur if the eustachian tubes are occluded. NASAL CONGESTION ASSESSMENT 1. 2. 3. 4. 5. 6. 7. 8. Severe sneezing Congestion Pruritis Lacrimation (watery eyes) Cough Nosebleed Headache Nasal drip HAY FEVER, cont. If the s/s are not treated, the chronic sufferers can develop secondary infections. DIAGNOSTIC TESTS Physical exam, visualization of the eyes, ears nose. A search for the allergens. This is done by skin testing or by a serum radioallergosorbent test (RAST) SKIN TESTING FOR ALLERGENS MEDICAL MANAGEMENT 1. Relieve the s/s. 2. Prevent infection. 3. Alleviate other complaints (fatigue, severe HA, malaise). 4. Antihistamines. 5. Decongestants. 6. Alomide is recommended for allergic conjunctivitis. MEDICAL MANAGEMENT, cont. 7. Topical or nasal corticosteroids. 8. Analgesics. 9. Hot packs over the facial sinuses. (for HA relief) PATIENT AND FAMILY TEACHING Teach the pt. to avoid the allergens that cause this condition. Teach the pt. to self-manage through symptom control. Teach about the meds. OBSTRUCTIVE APNEA OBSTRUCTIVE SLEEP APNEA ETIOLOGY AND PATHOPHYSIOLOGY 1. Complete or partial upper airway obstruction during sleep, causing apnea and hypopnea. 2. Apnea: the cessation of spontaneous respirations 3. Hypopnea: abnormally shallow and slow respirations. 4. The tongue and the soft palate fall backward, and partially or completely obstruct the pharynx. 5. This may last 15-90 sec. 6. During this time, the pt. experiences hypoxemia (decreased PaO2) and hypercapnia (increased PaCO2). 7. These changes stimulate the pt. to awaken and take a breath. 8. Apnea and arousal cycles occur as many times as 200-400 times during a 6-8 hour sleep period. CLINICAL MANIFESTETIONS 1. 2. 3. 4. 5. 6. 7. 8. Frequent awakening at night. Insomnia. Excessive daytime sleepiness. Witnessed apneic episodes. Loud snoring. Morning headaches. personality changes, irritability. Systemic HTN, stroke, cardiac dysrhythmias. Symptoms of sleep apnea 9. Chronic sleep loss can lead to inability to concentrate, impaired memory, failure to accomplish tasks, and interpersonal difficulties. 10. Driving accidents are more common. 11. It is more difficult to maintain employment and a family life. 12. The male may experience impotence. 13. Severe depression is not uncommon. Sleep apnea symptoms RISK FACTORS 1. 2. 3. 4. 5. 6. Male gender. Older age. Obesity. Nasal allergies, polyps, septal deviation. Receding chin. Phayngeal structural abnormalities. Appropriate referral should be made if these problems or risk factors are identified. DIAGNOSTIC TESTS This dx. Is made during sleep with the use of polysomnography. The pt.’s chest , abdominal movement, oral airflow, nasal airflow. SpO2, ocular movement, and heart rate and rhythm are monitored and time in each sleep stage is determined. A dx. of sleep apnea requires documentation of multiple episodes of apnea or hypopnea. POLYSOMNOGRAPHY MEDICAL MANAGEMENT 1. Avoid sedatives. 2. Avoid alcoholic beverages 3-4 hours before sleep. 3. Enter a weight loss program if needed. 4. Symptoms resolve in half of the pts with sleep apnea who use an oral appliance during sleep to prevent airflow obstruction. 5. Support groups can be helpful. nCPAP 6. Nasal continuous positive pressure (nCPAP) can be used for pts. who have severe sx. The blower maintains positive pressure from 5-15 cm. of H2O in the airway during both inspiration and expiration to prevent airway collapse. 7. BiPAP is also used for those pts. who cannot exhale against a high pressure. nCPAP devices BiPAP face mask with the machine Other treatments If the previously mentioned measures fail, then surgery is the next step. The 2 most common procedures are: 1. uvulopalatoplasty, pharyngoplasty. 2. genioglossal advancement and hyoid myotomy. #1 Involves the excision of the uvula, tonsillar pillars, and posterior soft palate. This removes the obstructing tissue. (called a UPPP) UPPP (removal of the uvula, tonsillar pillars, and the posterior soft palate) The # 2 surgery involves advancing the attachment of the muscular part of tae tongue on the mandible. (called GAHM) When GAHM is done, UPPP is also done. A still newer procedure is laser-assisted uvulopalatpplasty. This is used to treat sleep apnea. MANDIBLE ADVANCEMENT UPPER AIRWAY OBSTRUCTION Etiology/Pathophysiology 1. Precipitated by a recent respiratory event, such as trauma to the airway or to the surrounding tissues. 2. Common items that obstruct are: dentures aspiration of vomitus or secretions the tongue ( the most common in an unconscious person) UNCONSCIOUS PERSON CLINICAL MANIFESTATIONS 1. Stertorous respirations. (snoring) 2. Altered respiratory rate and character. 3. Apneic periods. ASSESSMENT SUBJECTIVE: Very limited because the pt. has a difficult time with breathing, and therefore, also with speaking. OBJECTIVE: 1. Assess for signs of hypoxia (disorientation, fatigue, anxiety, etc.) 2 . Cyanosis of the skin, esp. the lips and nail beds. 3. Snoring, wheezing, or stridorous respirations. 4. With increased hypoxia, the result is bradycardia and shallow, slow respirations. CYANOSIS, BRADYCARDIA DIAGNOSTIC TESTS This is a medical emergency. No diagnostic tests are needed. Prompt assessment is of utmost importance!!!!!! MEDICAL MANAGEMENT 1. Emergency tracheostomy. 2. An artificial airway may need to be inserted to maintain patency. TRACHEOSTOMY NURSING INTERVENTIONS 1. Open the airway and restore patency. 2. The Heimlich maneuver may be needed to remove a foreign body. 3. Reposition the head and neck by using the head-tilt/chin/lift technique. NURSING DIAGNOSES 1. Ineffective airway clearance, related to obstruction in airway. 2. Risk for aspiration, related to partial airway obstruction. 1. You walk in the pt.’s room, find him with the universal choking sign. What do you do? 1. Can you talk? Are you choking? 2. If he shakes his head, indicating “no”, then perform the Heimlich maneuver 1. 2. 3. 4. 5. 6. 7. 8. You walk into your pt.’s room to perform the morning assessment. You observe vomitus all over his face and chest. He is somnolent. What do you do? Monitor his respiratory rate, rhythm, and effort. Turn him onto his side. Suction out the secretions from his mouth. Wash all the vomitus from his face, chest. Check his V.S. ,including pulse oximetry. Apply O2 by nasal cannula. Auscultate the lungs. Ask the pt. if he is still feeling nauseated. Administer med., if indicated. Elevate the head of the bed and turn onto his side. Assess the pt. as to why he experienced the nausea, and consequent vomiting. PATIENT AND FAMILY TEACHING 1. Teach PREVENTION!!!!!! 2. Teach the Heimlich maneuver. 3. Teach the reasons for all treatments and procedures. 4. Maybe a CPR class should be recommended. Disorders of the Upper Airway Cancer of the larynx – Etiology/pathophysiology Squamous cell carcinoma (is increasing in frequency, and also increasing among women) Heavy smoking and alcohol use (cigarettes, cigars, pipes, chewing tobacco, smokeless tobacco) Chronic laryngitis Vocal abuse Family history CANCER OF THE LARYNX Cancer of the larynx limited to the vocal cords is very slow-growing. There is a decreased supply of lymph tissue and fluid there. Elsewhere in the larynx, there is an abundance of lymph tissue, so cancer in these areas spreads rapidly. CLINICAL MANIFESTATIONS 1. Progressive or persistent hoarseness. If hoarseness persists for longer then 2 weeks, medical treatment should be sought. The following symptoms may indicate metastases to other areas. (#2-#6) 2. Pain in the larynx, radiating to the ear. 3. Difficulty swallowing. 4. A feeling of a lump in the throat. 5. Enlarged cervical lymph glands. 6. Hemoptysis. ASSESSMENT SUBJECTIVE: Assess the onset and duration of sx. OBJECTIVE: Exam the sputum for blood (usually this is blood from the respiratory tract). DIAGNOSTIC TESTS 1. Visual exam with direct laryngoscopy. 2. CT scan or MRI may be performed to detect local and regional spread. 3. Take a health hx. 4. A biopsy and a microscopic study of the lesion will be definitive. LARYNGOSCOPY MEDICAL MANAGEMENT 1. Treatment is determined by the extent of the tumor. 2. Radiation or surgery is often performed. 3. If the tumor is limited to the cord without limitation of cord movement, then radiation therapy is the best treatment. 4. Surgery is used when extension of the tumor becomes affixed to one of the cords, or extends upward or downward from the larynx. 5. Total or partial laryngectomy. 6. Radical neck dissection. This is done to remove the cervical lymph nodes and the entire larynx. These pts. Have a high risk of metastases to the neck. LARYNGECTOMY NURSING INTERVENTIONS 1. Proper suctioning techniques. 2. Assess skin integrity around the tracheal opening. Be alert for s/s of infection. 3. Monitor I + O. Assist with tube feedings. (usually temporary) 4. Daily weights. Assess hydration status. 5. Perform a thorough psychosocial assessment. 6. Order a speech consult. 7. Encourage communication through writing, gestures, facial expressions. 8. Invite a member from a support group to come and visit the pt. Or recommend that the pt. join a support group. (Lost Chord Club, New Voice Club) NURSING DIAGNOSES 1. Impaired airway clearance, related to secretions or obstruction 2. Impaired communication (verbal), related to removal of larynx 1. Provide the pt. with implements for communication (paper, pencil, Magic Slate, electronic voice device, 2. Keep the call light at hand at all times. 3. Ask the pt. questions that only require a “yes” or “no” answer. 4. Order a speech consult. 5. Refer to local support groups. RESPIRATORY INFECTIONS 1. ACUTE RHINITIS (or coryza, also known as the common cold) ETIOLOGY and PATHOPHYSIOLOGY An inflammatory condition of the mucous membranes of the nose and sinuses. Caused by one or more viruses. It may become complicated by a bacterial infection. Sinus congestion causes an increase in sinus drainage, post-nasal drip, throat irritation, HA, and earache. CLINICAL MANIFESTATIONS 1. Increased amount of thin, serous nasal exudate. 2. Productive cough. 3. Sore throat and fever. 4. If uncomplicated, it subsides in a week. ASSESSMENT SUBJECTIVE: 1. The pt.’s complaints of sore throat, dyspnea, and congestion. OBJECTIVE: 1. Note the color and consistency of the nasal discharge. 2. Visually exam the throat. Observe redness, edema, local irritation. Diagnostic Tests Throat and sputum cultures. MEDICAL MANAGEMENT 1. Accurate dx and prevention of complications. 2. No specific tx. For the common cold. 3. ASA and/or Tylenol may be used for analgesia or reduction of fever. 4. Cough suppressant for a dry, nonproductive cough. 5. An expectorant for a productive cough. 6. An antibiotic for a bacterial infection. NURSING INTERVENTIONS 1. Promote comfort. 2. Encourage fluids. 3. Apply warm, moist packs to sinuses. PATIENT AND FAMILY TEACHING 1. Teach proper hand washing and disposal of disposal of tissues that were used for nasal discharge. 2. Limit exposure to others during the first 48 hours. 3. Check body temp. every 4 hours. NURSING DIAGNOSIS Health-seeking behaviors: illness prevention, related to preventing exacerbation or spread of infection. 1. Health maintenance behaviors. (proper hand washing, disposal of used Kleenexes, etc. 2. Adequate fluids and nutrition. ACUTE FOLLICULAR TONSILLITIS ETIOLOGY and PATHOPHYSIOLOGY 1.This can be an acute inflammation of the tonsils. 2. It is the result of an air- or food borne bacterial infection. (often Streptococcus) 3. It can be viral also, but this is less the case. 4. If it is caused by Group A B-hemolytic Streptococci, sequelae can occur. These can be: rheumatic fever, carditis and nephritis. It is most common in children. CLINICAL MANIFESTATIONS 1. Sore throat, fever, chills, malaise. 2. Enlarge, tender, cervical lymph nodes. 3. General muscle aching. 4. Lab. Test reveals an increased WBC count. MUSCLE ACHE, ENLARGED CERVICAL NODE ASSESSMENT SUBJECTIVE: 1. Monitor the severity of the sore throat 2, Ask if the pain is referred to the ears. 3. Is a HA or joint pain present? JOINT PAIN OBJECTIVE DATA: 1. Visual exam that shows throat secretions and enlarge, reddened tonsils. DIAGNOSTIC TESTS 1. Throat culture 2. CBC to check the WBC count. MEDICAL MANAGEMENT 1. Early antibiotic meds. Specific to the bacteria. 2. A tonsillectomy and adenoidectomy (T+A) is performed. (usually done in people who have recurrent attacks). 3. Meds. used for tonsillitis are: antipyretics, analgesics, and antibiotics. 4. Warm, saline mouth gargles. NURSING INTERVENTIONS 1. Thorough oral care that will promote comfort and reduce/prevent infection. 2. If the pt. if a post-op. pt., observe for frequent swallowing. (this may indicate excessive bleeding). 3. Post-op care: IV fluids until the nausea subsides, then the pt. may begin drinking ice cold fluids slowly. 4. Advance the diet to soft liquids, then to a regular diet. 5. Apply an ice collar to the neck for comfort and vasoconstriction. 6. Check V.S. 7. Provide physical and emotional comfort. NURSING DIAGNOSES 1. Pain, related to inflammation/irritation of 1. Assess the degree of pain and the need for the pharynx. analgesics. 2. Offer warm, saline gargles, ice chips, and/or ice collar. 3. Document. 2. Risk for deficient fluid volume, related to inability to maintain usual oral intake because of painful swallowing. WHAT ARE THE NURSING INTERVENTIONS? INTERVENTIONS: 1. Assess hydration status. (skin turgor, mucous membranes, urine output). 2. Encourage ice chips, popsicles, and more oral intake of cold fluids. Avoid citrus fluids because these may irritate the throat. (ice cream, sherbet, puddings, yogurt, etc) 3. Risk for aspiration, related to postoperative bleeding. WHAT ARE THE NURSING INTERVENTIONS? NURSING INTERVENTIONS 1. Maintain patent airway; keep the pt. lying on his side as much as possible to prevent aspiration. (if there is vomitus, check the color. Dark brown may indicate swallowed blood.) 2. Observe for frequent swallowing. This may indicate bleeding. Check the back of the throat with a flashlight for blood trickling down. VOMITING PATIENT AND FAMILY TEACHING 1. The pt. must complete the entire course of the prescribed antibiotic. 2. For the T+A pt. , instruct on the dietary precautions. 3. Teach the post-op pt. to avoid clearing his throat, vigorous coughing, sneezing, or nose blowing after surgery for 1-2 weeks. These actions may cause bleeding. 4. Know how to notify the PCP if there are any complications. 5. Avoid ASA or other blood-thinning meds. Respiratory Infections Laryngitis – Etiology/pathophysiology – Inflammation of the larynx due to virus or bacteria May cause severe respiratory distress in children under 5 years old Clinical manifestations/assessment Hoarseness Voice loss Scratchy and irritated throat Persistent cough Respiratory Infections Laryngitis (continued) – Medical management/nursing interventions Viral—no specific treatment Bacterial—antibiotics Analgesics Antipyretics Antitussives Warm or cool mist vaporizer Limit use of voice Respiratory Infections Pharyngitis – Etiology/pathophysiology Inflammation of the pharynx Chronic or acute Frequently accompanies the common cold Viral, most common Bacterial Respiratory Infections Pharyngitis (continued) – Clinical manifestations/assessment – Dry cough Tender tonsils Enlarged cervical lymph glands Red, sore throat Fever Medical management/nursing interventions Antibiotics; analgesics; antipyretics Warm or cool mist vaporizer Respiratory Infections Sinusitis – Etiology/pathophysiology – Inflammation of the sinuses Usually begins with an upper respiratory infection; viral or bacterial Clinical manifestations/assessment Constant, severe headache Pain and tenderness in involved sinus region Purulent exudate Malaise Fever Respiratory Infections Sinusitis (continued) – Medical management/nursing interventions Antibiotics Analgesics Antihistamines Vasoconstrictor nasal spray (Afrin) Warm mist vaporizer Warm, moist packs Nasal windows Disorders of the Lower Airway Acute bronchitis – Etiology/pathophysiology – Inflammation of the trachea and bronchial tree Usually secondary to upper respiratory infection Exposure to inhaled irritants Clinical manifestations/assessment Productive cough; wheezes Dyspnea; chest pain Low-grade fever Malaise; headache Disorders of the Lower Airway Acute bronchitis (continued) – Medical management/nursing interventions Cough suppressants Antitussives Antipyretics Bronchodilators Antibiotics Vaporizer Encourage fluids Disorders of the Lower Airway Legionnaires’ disease – Etiology/pathophysiology Legionella pneumophila Thrives in water reservoirs Causes life-threatening pneumonia Leads to respiratory failure, renal failure, bacteremic shock, and ultimately death Disorders of the Lower Airway Legionnaires’ disease (continued) – Clinical manifestations/assessment Elevated temperature Headache Nonproductive cough Difficult and rapid respirations Crackles or wheezes Tachycardia Signs of shock Hematuria Disorders of the Lower Airway Legionnaires’ disease (continued) – Medical management/nursing interventions Oxygen Mechanical ventilation, if necessary IV therapy Antibiotics Antipyretics Vasopressors Disorders of the Lower Airway Anthrax – Etiology/pathophysiology – Clinical manifestations/assessment – Bacillus anthracis Spread by direct contact with bacteria or spores Three types: cutaneous, GI, inhalational Cold or flu-like symptoms Hemorrhage, tissue necrosis, and lymphedema Medical management Antibiotics SEVERE ACUTE RESPIRATORY SYNDROME (SARS) This is a serious acute respiratory infection caused by a coronavirus. It’s spread by close contact with people, via droplets of air. It may also be spread by touching objects that are contaminated with the virus. CLINICAL MANIFESTATIONS Fever > 104 degrees (38 degrees C). HA, feeling of discomfort all over, muscle aches. After 2-7 days, some people may develop a cough, SOB, or hypoxia. About 20% of pts. with SARS require intubation and mechanical ventilation. SARS DIAGNOSTIC TESTS Chest x-ray: It may be normal in the early stage. In some pts., the chest x-ray may later reveal interstitial infiltrates that progress to patchy appearances. A SARS dx. can later be made from detection of serum antibodies or positive tissue cultures. LUNG INFILTRATES LUNG INFILTRATES LAB. AND DIAGNOSTIC TESTS, cont. Blood specimen for lab. tests. Nasopharyngeal swab, oropharyngeal swab, and nasopharyngeal aspirate will be obtained. Bronchoalveolar lavage may be used to obtain secretions from the lower respiratory tract. Reverse transcription polymerase chain reaction tests may be done on serum, stool, and nasal secretions. NASOPHARYNGEAL SWAB Initially, the pt.’s WBC count will be normal or low. In about 50% of cases, the platelet count will be 50,000-150,000/mm.3. Early in the respiratory phase, the creatine phosphokinase levels (CPK) may be as high as 3000 units/L. (normal 5-200 units/L) More criteria that can be used to dx. SARS include travel within the last 10 days of sx. onset to an area with current community transmission of SARS. (China, Hong Kong, Taiwan, Toronto, etc.) Close contact within 10 days of sx. onset with a person suspected of having SARS. MEDICAL MANAGEMENT The disease is serious so treatment needs to be started ASAP. The treatment is based on the signs and sx., and before the cause is confirmed. People who are suspected of having SARS should be placed in respiratory isolation, including use of an appropriate disposable particulate respirator mask. PARTICULATE RESPIRATOR MASK There is no definitive treatment, but antiviral agents (ribavirin), antibiotics, and corticosteroids may be used.