Respiratory System: Oxygen Delivery System

The primary function of the respiratory system is to supply the blood with oxygen in order for the blood to deliver oxygen to all parts of the body. The respiratory system does this through breathing. When we breathe, we inhale oxygen and exhale carbon dioxide. This exchange of gases is the respiratory system\\\'s means of getting oxygen to the blood.

Respiration is achieved through the mouth, nose, trachea, lungs, and diaphragm. Oxygen enters the respiratory system through the mouth and the nose. The oxygen then passes through the larynx (where speech sounds are produced) and the trachea which is a tube that enters the chest cavity. In the chest cavity, the trachea splits into two smaller tubes called the bronchi. Each bronchus then divides again forming the bronchial tubes. The bronchial tubes lead directly into the lungs where they divide into many smaller tubes which connect to tiny sacs called alveoli. The average adult\\\'s lungs contain about 600 million of these spongy, air-filled sacs that are surrounded by capillaries. The inhaled oxygen passes into the alveoli and then diffuses through the capillaries into the arterial blood. Meanwhile, the waste-rich blood from the veins releases its carbon dioxide into the alveoli. The carbon dioxide follows the same path out of the lungs when you exhale.

The diaphragm\\\'s job is to help pump the carbon dioxide out of the lungs and pull the oxygen into the lungs. The diaphragm is a sheet of muscles that lies across the bottom of the chest cavity. As the diaphragm contracts and relaxes, breathing takes place. When the diaphragm contracts, oxygen is pulled into the lungs. When the diaphragm relaxes, carbon dioxide is pumped out of the lungs.

        H1N1 Influenza (Swine Flu)

Conducted by: Dr. Rajeev Singh, B.Sc., B.H.M.S. (Gold Medalist); Jail Road; Rae Bareli    

Introduction: Swine influenza is a highly contagious respiratory disease in pigs caused by one of several swine influenza A viruses. In addition, influenza C viruses may also cause illness in swine. Current strategies to control swine influenza virus (SIV) in animals typically include one of several commercially available bivalent swine influenza virus vaccines.

Transmission of swine influenza viruses to humans is uncommon. However, the swine influenza virus can be transmitted to humans via contact with infected pigs or environments contaminated with swine influenza viruses. Once a human becomes infected, he or she can then spread the virus to other humans, presumably in the same way as seasonal influenza is spread (i.e., via coughing or sneezing).

In humans, the severity of swine influenza can vary from mild to severe. From 2005 until January 2009, 12 human cases of swine flu were reported in the United States. None were fatal. In 1988, however, a previously healthy 32-year-old pregnant woman in Wisconsin died of pneumonia as a complication of swine influenza.

A recent investigation sought to determine the link between GBS and the 1976 swine flu vaccine, since subsequent influenza vaccines did not have this strong association. Nachamkin et al (2008) found that inoculation of the 1976 swine flu vaccine, as well as the 1991-1992 and 2004-2005 influenza vaccines, into mice prompted production of antibodies to antiganglioside (anti-GM1), which are associated with the development of GBS. They proposed that further research regarding influenza vaccine components is warranted to determine how these components elicit antiganglioside effects.

                                                                                    
"A new strain of influenza A virus (novel influenza A H1N1) that originated in swine has rapidly spread from the initial outbreak in Mexico and the southern United States to Canada and many countries in Europe and Asia, like India"

"Consequently, the World Health Organization raised the level of alert for an influenza pandemic to 5 on Apr. 29, 2009. Because many infected people are young, the care of pregnant and lactating women is a concern."

The US Centers for Disease Control and Prevention states that H1N1 is susceptible to the neuraminidase-inhibitor antiviral medications oseltamivir and zanamivir, which target the early phase of influenza infection, but that this influenza strain is resistant to amantadine, rimantadine, and other adamantanes.

Government and public health officials are monitoring this situation worldwide to assess the threat from H1N1 influenza and to provide guidance to health care professionals and the public. Because the situation is changing rapidly, it is important to check regularly for changes in recommendations as new information becomes available. Online resources for daily guidance include the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO).

Morbidity and Mortality:

H1N1 influenza (swine flu) tends to cause high morbidity but low mortality rates (1%-4%).

WHO Pandemic Levels-

Here is a quick look at the WHO's pandemic alert phases:

• Phase 1: A virus in animals has caused no known infections in humans.
• Phase 2: An animal flu virus has caused infection in humans.
• Phase 3: Sporadic cases or small clusters of disease occur in humans. Human-to-human transmission, if any, is insufficient to cause community-level outbreaks.
• Phase 4: The risk for a pandemic is greatly increased but not certain. The disease-causing virus is able to cause community-level outbreaks.
• Phase 5: Still not a pandemic, but spread of disease between humans is occurring in more than one country of one WHO region.
• Phase 6: This is the pandemic level. Community-level outbreaks are in at least one additional country in a different WHO region from phase 5. A global pandemic is under way.

Note that all of those phases are about how the virus is (or isn't) spreading -- they're not about the severity of the disease.

How should Swine flu be diagnosed?

Preferred specimens: If swine flu is suspected, clinicians should obtain a respiratory specimen for analysis. In an ideal situation, the best method is via nasal pharyngeal aspirate or nasal wash aspirate into viral culture media; however, some experts are recommending the use of Dacron nasal swabs to decrease aerosolization of the virus. If these specimens cannot be collected, a combined nasal swab with an oropharyngeal swab is also acceptable and will be feasible in most settings.

Recommended tests: The CDC currently recommends "real-time RT-PCR for influenza A, B, H1, H3 conducted at a State Health Department Laboratory. Currently, swine influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR. If reactivity of real-time RT-PCR for influenza A is strong (e.g., Ct ≤ 30) it is more suggestive of a novel influenza A virus."

Symptoms:

Manifestations of H1N1 influenza (swine flu) are similar to those of seasonal influenza. Patients present with symptoms of acute respiratory illness, including at least 2 of the following:   

v  Fever

v  Rhinorrhoea

v  Cough

v  Sore throat

v  Body aches

v  Headache

v  Chills and fatigue

v  Diarrhoea and vomiting (possible).

Persons with these symptoms should call their health care provider promptly. The treatment should ideally be initiated with 48 hours from the onset of symptoms. The duration of illness is typically 4-6 days. The infectious period for a confirmed case is defined as 1 day prior to the onset of symptoms to 7 days after onset.

In children, signs of severe disease include apnoea, tachypnoea, dyspnoea, cyanosis, dehydration, altered mental status, and extreme irritability.

Viral Strain and Testing: Outbreaks of H1N1 influenza (swine flu) are common in pigs year-round. Historically, when humans have become infected, it is a result of close contact with infected pigs (but not consumption of pork). However, the current virus is a novel influenza A (H1N1) virus not previously identified in humans, and it appears to be spread by human-to-human transmission. The WHO has raised its pandemic alert level for H1N1 influenza to phase 6, which means that community-level outbreaks are in at least one additional country in a different WHO region from phase 5. A global pandemic is under way.

Clinicians should consider the possibility of H1N1 influenza virus infections in patients who present with febrile respiratory illness. The CDC criteria for suspected H1N1 influenza are as follows-

• Onset of acute febrile respiratory illness within 7 days of close contact with a person who has a confirmed case of H1N1 influenza A virus infection, or
• Onset of acute febrile respiratory illness within 7 days of travel to a community (within the United States or internationally) where one or more H1N1 influenza A cases have been confirmed, or
• Acute febrile respiratory illness in a person who resides in a community where at least one H1N1 influenza case has been confirmed.

If H1N1 flu is suspected, the clinician should obtain a respiratory swab for H1N1 influenza testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact his or her state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.

H1N1 Influenza Treatment:

Treatment of swine flu in modern medicine (allopathic) is largely supportive and consists of bed rest, increased fluid consumption, cough suppressants, and antipyretics and analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs) for fever and myalgias. Severe cases may require intravenous hydration and other supportive measures. Antiviral agents may also be considered for treatment or prophylaxis.

But in homoeopathy there is very treatment for swine flu. The mortality rate of people treated with traditional medicine and drugs was 30 percent, while for those treated by homeopathic physicians had mortality rate of 1.05 percent. Of the fifteen hundred cases reported at the Homeopathic Medical Society of the District of Columbia there were only fifteen deaths. Recoveries in the National Homeopathic Hospital were 100%. It can easily be cured. The commonest drugs which have given excellent results are-

Antipyrene: Itching, burning in swollen nose, violent, incessant sneezing; stoppage of nose, though discharge is watery and profuse; eyes deeply suffused, lachrymation,  itching and burning in eyes and ears, tinnitus in ears.

Arsenic alb: Nose discharges thin watery fluid, which excoriates the upper lips and nasal passages feel stuffed all the time; dull, throbbing, frontal headache, sneezing without relief, ulcer and scabs form in nose; irritation in one spot in the nose as from tickling of a feather, causing sneezing, catarrhal dyspnoea.  

Dulcamara: Nostril entirely filled up, preventing breathing, constant sneezing, profuse discharge from nose and eyes in closed room; at the seaside.

Euphorbium: Sneezing, cough, chilliness and heat alternating; inflamed eyelids glued together at night; dryness of the mouth and throat; oppression of chest; dry, deep hollow, hoarse cough, with irritation of larynx; general prostration with desire to sit or lie down; < from draught of air or dust.

Gelsemium: At very start of the disease; summer colds with violent sneezing in the morning; edges of nostrils red and sore; pharyngeal inflammation with pain on swallowing, shooting up into ear; deafness; hands and feet cold in afternoon, fever till morning.

Naphthalinum: Fullness, pressure, stuffed up and aching feeling in frontal sinus and forehead, with itching in mouth, nose, ears and eyes; severe paroxysms of sneezing, profuse coryza, and lachrymation, irritating the anterior nares, causing redness, heat, swelling and soreness of nose; stuffed up, raw feeling in frontal sinus; asthmatic labored respiration, desire to have doors and windows open; bloated, full feeling with tenderness in epigastric region, stuffed up feeling in chest, more marked towards left and under sternum, must loosen  clothing; used also as a prophylactic.

Psorinum: Boring, stinging in right nostril, followed by excessive sneezing, burning, followed by thin nasal discharge, which relieves; nose sensitive when inhaling air; psoric constitution is the cause of swine flu.

Silphium lanc: Scraping-tickling irritation of fauces and throat, nausea, faint feeling, sense of soreness in epigastrium; constant hawking and scraping to throw off thin viscid mucus; constant sneezing followed by discharge of limpid acrid mucus from the nose, with constriction and pressure in supraorbital region; rough cough with expectoration of yellow mucus.   

Sticta pulm: Feeling of fullness and heavy pressure at root of nose; tingling in right side of nose; loss of smell; coryza; dull, heavy pressure in forehead and root of nose; severe dry hacking cough, caused by tickling in trachea, below larynx,    

Patients should be encouraged to stay home if they become ill, to avoid close contact with people who are sick, to wash their hands often, and to avoid touching their eyes, nose, and mouth.

Home isolation:

• Patients who develop flulike illness (ie, fever with either cough or sore throat) should be strongly encouraged to self-isolate in their home for 7 days after the onset of illness or at least 24 hours after symptoms have resolved, whichever is longer.
• To seek medical care, patient should contact their health care providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician's office, or hospital.
• Patients who have difficulty breathing or shortness of breath or who are believed to be severely ill should seek immediate medical attention.
• If the patient must go into the community (eg, to seek medical care), he or she should wear a face mask to reduce the risk of spreading the virus in the community when coughing, sneezing, talking, or breathing. If a face mask is unavailable, ill persons who need to go into the community should use tissues to cover their mouth and nose while coughing.
• While in home isolation, patients and other household members should be given infection control instructions, including frequent hand washing with soap and water. Use alcohol-based hand gels (containing at least 60% alcohol) when soap and water are not available and hands are not visibly dirty. Patients with H1N1 influenza should wear a face mask when within 6 feet of others at home.

Household contacts who are not ill-

• Remain home at the earliest sign of illness.
• Minimize contact in the community to the extent possible.
• Designate a single household family member as caregiver for the patient to minimize interactions with asymptomatic persons.

School dismissal and childcare facility closure

• Strong consideration should be given to close schools upon a confirmed case of H1N1 flu or a suspected case epidemiologically linked to a confirmed case.
• Decisions regarding broader school dismissal within these communities should be left to local authorities, taking into account the extent of influenza like illness within the community.
• Cancelation of all school or childcare related gatherings should also be announced.
• Encourage parents and students to avoid congregating outside of the school if school is cancelled.
• Duration of schools and childcare facilities closings should be evaluated on an ongoing basis depending on epidemiological findings.
• Consultation with local or state health departments is essential for guidance concerning when to reopen schools. If no additional confirmed or suspected cases are identified among students (or school-based personnel) for a period of 7 days, schools may consider reopening.
• Schools and childcare facilities in unaffected areas should begin preparation for possible school closure.

Social distancing-

• Large gatherings linked to settings or institutions with laboratory-confirmed cases should be cancelled (e.g., sporting events or concerts linked to a school with cases); other large gatherings in the community may not need to be cancelled at this time.
• Additional social distancing measures are currently not recommended.
• Persons with underlying medical conditions who are at high risk for complications of influenza should consider avoiding large gatherings.

Preventive measures for health care personnel:

Recommended measures for care of patients with suspected or confirmed H1N1 influenza include the following:

• Place patients in a single-patient room with the door kept closed. An airborne-infection isolation room with negative-pressure air handling can be used, if available. Air can be exhausted directly outside or can be recirculated after filtration by a high efficiency particulate air (HEPA) filter.
• Suctioning, bronchoscopy, or intubation should be performed in a procedure room with negative-pressure air handling.
• Patients should wear a surgical mask when outside their room.
• Encourage patients to wash their hands frequently and to follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons.
• Routine cleaning and disinfection strategies used during influenza seasons can be applied.
• Standard, droplet, and contact precautions should be used for all patient care activities and maintained for 7 days after illness onset or until symptoms have resolved.
• Health care personnel should wash their hands with soap and water or use hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions.
• Personnel providing care to or collecting clinical specimens from patients should wear disposable non sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure.
• As per previous recommendations regarding mask and respirator use during influenza pandemics, personnel engaged in aerosol-generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy) and/or resuscitation involving emergency intubation or cardiac pulmonary resuscitation should wear a fit-tested disposable N95 respirator.
• Pending clarification of transmission patterns for the 2009 H1N1 influenza A (swine flu) virus, personnel providing direct patient care for suspected or confirmed cases should wear a fit-tested disposable N95 respirator when entering the patient's room.

H1N1 influenza in pregnancy

As of May 10, 2009, a total of 20 cases of novel influenza A (H1N1) virus (swine flu) infection had been reported among pregnant women in the United States, including 15 confirmed cases and 5 probable cases. Among the 13 women from 7 states for whom data are available, the median age was 26 years (range, 15-39 y); 3 women were hospitalized, one of whom died.

Pregnant women with confirmed, probable, or suspected novel influenza A (H1N1) virus infection should receive homoeopathic treatment for 5 days as per the complete individualization. The commonest homoeopathic prophylactic drugs are Gelsemium 1M 3doses at 10 minutes gap then one dose for 2 days followed by Antipyrene 200 O.D. 2-4 drops, ½ hr after Arsenic alb 30 T.D.S 2-4 drops ( sometimes R 88 is also being used for prophylaxis). Oseltamivir is the preferred treatment in modern medicine for pregnant women, and the drug regimen should be initiated within 48 hours of symptom onset, if possible. Pregnant women who are in close contact with a person with confirmed, probable, or suspected novel influenza A (H1N1) infection should receive a 10-day course of homoeopathic prophylaxis like Gelsemium, Antipyrene, Arsenic alb etc or in modern medicine she should take chemoprophylaxis with zanamivir or oseltamivir.

·         Prophylaxis with homoeopathic drugs or some antiviral agents should also be considered in the following individuals (pre-exposure or post-exposure):

• Close household contacts of a confirmed or suspected case who are at high risk for complications (e.g., chronic medical conditions, persons >65 y or <5 y, pregnant women)
• School children at high risk for complications who have been in close contact with a confirmed or suspected case
• Travellers to Mexico who are at high risk for complications (e.g., chronic medical conditions, persons >65 y or <5 y, pregnant women)
• Health care providers or public health workers who were not using appropriate personal protective equipment during close contact with a confirmed or suspected case
• Pre-exposure prophylaxis can be considered in the following persons:
  • Any health care provider who is at high risk for complications (e.g., persons with chronic medical conditions, adults >65 y, pregnant women)
  • Individuals not considered to be at high risk but who are nonetheless travelling to Mexico, first responders, or border workers who are working in areas with confirmed cases

Especially during the third trimester, pregnant women are thought to be at high risk for complications from influenza, including mortality, although data are limited regarding the current novel H1N1 influenza A strain.

N.B.: For pregnant women and others at high risk for complications, the Centres for Disease Control and Prevention currently recommends use of either oseltamivir or zanamivir for treatment and chemoprophylaxis against novel H1N1 influenza or she should go for homoeopathic prophylaxis as described before. Treatment should be started within 48 hours of the first influenza-related symptoms. But both of these drugs are thought to be compatible with breast-feeding, and continuing breast-feeding when the mother is taking either medication is not likely to cause significant drug exposure in the infant. In fact, continuing breast-feeding is recommended even if the mother is being treated with oseltamivir and zanamivir because of the anti-infective benefits of human milk for infants. Therefore homoeopathic drugs are more effective and safe.

Oseltamivir appears to be extensively metabolized by the placenta, but transplacental transfer of the metabolite is incomplete, with minimal accumulation on the foetal side. Postmarketing surveillance showed that of 61 pregnant women exposed to oseltamivir at unknown gestational time, 10 underwent abortion, including 6 therapeutic terminations, and 1 case each of trisomy 21 and anencephaly.