By Q. Derek. Lebanon Valley College. 2018.
Volatile anesthetics protonix 20mg generic, including discount protonix 20mg with mastercard, for example generic protonix 40mg line, halothane, are also given via the pulmonary route. In recent years, the possibility of utilizing the pulmonary route for the systemic delivery of peptides and other molecules which are not absorbed through the gastrointestinal tract has also been explored. Pulmonary drug delivery for both local and systemic effects will be discussed in this chapter. There are a number of schemes for categorizing the different regions of the respiratory tract. With respect to pulmonary drug delivery, division into the following three regions is useful (Figure 10. Every branching of the tracheobronchial tree leads to a new “generation” of airways; for example, the trachea (“generation 0”) bifurcates into two main bronchi (“generation 1”) and then follows sequential branching into lobar bronchi (“generation 2”), segmental bronchi (“generation 3”), intrasegmental bronchi, bronchioles, secondary bronchioles and ultimately the terminal bronchioles (“generation 16”). The terminal bronchioles mark the limit of the tracheobronchial region, beyond which lies the alveolar region (“generations 17 to 23”). Progression from the trachea to the extremities of the tracheobronchial tree is characterized by decreases in both the diameter and length of the tubules with each branching, but the geometrically increasing number of airways results in dramatic increases in surface area. It should be borne in mind, however, that in humans, the left and right lungs are not identical and each contains irregular dichotomous and trichotomous branching patterns. Additionally, while the average path length from trachea to terminal bronchioles is 16 branches, short paths of only 8 to 10 branches may also exist. The alveolar region begins at the respiratory bronchioles, where alveoli begin to appear in the airway walls. Further branching of the respiratory bronchioles is associated with increasing frequency of alveoli appearing until the airway terminates at a respiratory unit, which contains alveolar ducts, atria and about 20 alveoli. The alveoli are packed tightly with adjacent alveoli separated by a common alveolar septum. The diversity of pulmonary epithelia can be illustrated by examining its structure at three principal levels (Figure 10. Some serous cells, brush cells and Clara cells are also present with few Kulchitsky cells. The frequency of goblet and serous cells decreases with progression along the airways while the number of Clara cells increases. The alveolar region This is devoid of mucus and has a much flatter epithelium, which becomes the simple squamous type, 0. Two principal epithelial cell types are present: • Type-I pneumocytes: thin cells offering a very short airways-blood path length for the diffusion of gases and drug molecules. These phagocytic cells scavenge and transport particulate matter to the lymph nodes and the mucociliary escalator (see below). The ciliated cells each have about 200 cilia with numerous interspersed microvilli, of about 1–2 μm in length. They are bathed in an epithelial lining fluid, secreted mainly from the serous cells in the submucosal glands. The tips of the cilia project through the epithelial lining fluid into a layer of mucus secreted from goblet cells. The cilia beat in an organized fashion to propel mucus along the airways to the throat, as discussed below (see Section 10. The mucus largely originates from the vagally innervated submucosal glands, with a smaller contribution from goblet cells. It consists of lipid-rich lipoproteins with the lipid composition dominated by phosphatidylcholine with a high dipalmitoyl content. About 85–90% of isolated surfactant is lipid of which 95% is phosphoglycerols with cholesterol as the main neutral component. Lung surfactant decreases the surface tension and thereby maintains the morphology and function critical for respiration. Thus with each intake of air, the lung receives a high burden of dusts, fumes, pollens, microbes and other contaminants. Efficient defense mechanisms have evolved to minimize the burden of foreign particles entering the airways, and clearing those that succeed in being deposited. All devices employed for drug delivery to the airways of the lung generate an aerosol. Therapeutic aerosols are two-phase colloidal systems in which the drug is contained in a dispersed phase which may be a liquid, solid or combination of the two, depending upon the formulation and method of aerosol generation (see Section 10. Clearly for successful therapy, the drug must be presented to the lung in aerosol droplets or particles that deposit in the appropriate lung region and in sufficient quantity to be effective. Once the aerosol particle or droplet has deposited in the lung, there are a number of further barriers which must be overcome before the drug exerts its pharmacological effect. The respiratory defense mechanisms of mucociliary clearance and phagocytosis by macrophages may act upon undissolved particles. Aerosol particle dissolution may be slow and the drug may then subsequently be subject to enzymatic degradation before it reaches its site of pharmacological action. The factors influencing the deposition and fate of pulmonary delivered drugs will be discussed in this section. Three principal deposition mechanisms operate within the lower respiratory tract (Figure 10. A particle with a large momentum may be unable to follow the changing direction of the inspired air as it passes the bifurcations and as a result will collide with the airway walls as it continues on its original course. The probability of inertial impaction will be dependent upon particle momentum (the product of mass and velocity), thus particles with larger diameters or higher densities and those travelling in airstreams of higher velocity will show greater impaction. Airflow velocities in the main bronchi are estimated to be 100-fold higher than in the terminal bronchioles and 1,000-fold higher than in the A region (Figure 10. It becomes increasingly important for particles that reach airways where the airstream velocity is relatively low, e.
The indications for its use are - a feeble circulation of blood generic protonix 20mg online, pallid cheap 20mg protonix with mastercard, transparent skin order 20mg protonix amex, pale tongue, impairment of the sexual function (irritation without power), irregular and painful menstruation, leucorrhœa. It may be employed in jaundice, dropsy, engorgement of spleen, fullness and oppression of the brain, and some other diseases where there is an obstructed circulation. Glycerine may be used in the prescription to hold the remedy in solution with water. I have employed it with good results in asthma, bronchorrhœa, dilated bronchia, old ulcers, and chronic diseases of the skin, with enfeebled circulation. I have employed it with marked benefit in the treatment of old and indolent ulcers. As we have an abundance of astringent remedies for diarrhœa, it is hardly worth while to import one, so that this may be tried in small dose for other effects. The Guarana of the drug market is the ground seed of the Paullinia Sorbilis, a native of Brazil. It is a stimulant to the cerebro-spinal centers, and its principal use now is to relieve headache. If the face is pallid, the eyes dull, the face expressionless, it may be used with advantage. It may be given in those severe headaches that recur with the menstrual period, the symptoms being as above, with a prospect of relieving the disease of the reproductive function, as well as the headache. It is indicated by vertigo, dizziness, variable appetite, cough, and may prove valuable in the early stages of phthisis. The tincture thus prepared may be occasionally used with advantage in the latter stages of acute, and in chronic rheumatism. It may also be associated with the vegetable alteratives in the treatment of some chronic diseases, where stimulation of the skin is required. Occasionally it will prove useful in functional diseases of the uterine organs, especially in amenorrhœa. An East Indian nut which has been employed in doses of one to ten grains in the treatment of agues, and as a prophylactic against malarial fevers. In doses of from one twenty-fifth of a grain to one grain, it is a remedy in some eruptive diseases, in enlargement of the spleen, hepatic pain, and œdematous swelling; it has also been employed in syphilis. For experiment, a tincture may be made of the bark, beans, or pulp of the seed-pod; the last being regarded as the most active. Herring concluded from his experiments that it might be given with benefit in cases of “cough accompanied or followed by tonsilitis; in erysipelas of the face; in scarlet fever; in so-called hives; in typhoid fever: in remittent or intermittent epidemic fever, with a typhoid character, etc. The ordinary fluid extract may be used as a topical application, as a gargle for the throat, and for the general purposes of an astringent. Where the Witch-Hazel can be readily obtained, I would advise that the leaves be gathered in June or July, and if no apparatus for distilling is at hand, that they be packed in a percolator, and a tincture prepared with a very weak spirit, say 30 per cent. The Hamamelis has a specific action upon the venous system, giving strength to it, and facilitating the passage of venous blood. It may, therefore, be employed with advantage in any case where a part is enfeebled, and there is a sluggish circulation. Thus we use it in cases of catarrh and ozæna; chronic pharyngitis, disease of the tonsils, pillars of the fauces, vellum and uvula, and in chronic laryngitis. The indications for its employment are, thickening of mucous membranes, with enfeebled circulation, and increased secretion, either mucous or muco-purulent. It is especially a valuable remedy in the treatment of hemorrhoids, sometimes effecting a cure in old and very stubborn cases without the use of other remedies. Usually, however, I use the solution of the persulphate of iron as a local application. It is also a very useful remedy in the treatment of diseases of the uterus and vagina. Given, a case with the conditions named, thickening, with relaxation, enfeebled circulation, and increased mucous, or muco-purulent secretion, and its action is very positive. We employ it also in the treatment of various lesions of the lower extremities, both as a local application and an internal remedy, and many times with excellent results. It is an excellent dressing for erysipelas, and for burns, giving that slight stimulation that seems to be required in these cases. I need not name other cases, as the indications for its use first given, will suggest its application. I regard it as one of the most valuable stimulant diaphoretics; very kindly received by the stomach, and quite certain in its action. It is an admirable remedy for amenorrhœa from cold; the safest and most certain we have, I think. It may be given in doses of a teaspoonful every hour or two hours, or two or three times in the evening, with the hot foot bath. Prepare your own tincture in this way: In July, gather a sufficient quantity of the herb, stem it, and at once pack the leaves in a percolator. Let it stand twenty-four hours, and then draw off, putting on water until the tincture measures Oj. It may have other properties, and it would be well to give it a thorough investigation. It has had a reputation as an antidote to the bite of poisonous snakes, and probably possesses some power in this direction. It exerts the general influence of a tonic, and a special tonic action upon the urinary and uterine organs. It is possible that if we can obtain a reliable preparation, it will be found superior to other remedies for these purposes.
Doug realizes that Rosie makes one excuse after another to avoid going to movies cheap 40mg protonix mastercard, even though she enjoys watching them on television cheap 20 mg protonix with mastercard. Gently purchase 40 mg protonix amex, he asks Rosie, “Some things make me a little anxious — heavy traffic or big crowds — what makes you anxious? Several days later, Doug sees a copy of Overcoming Anxiety For Dummies in a bookstore and buys it with Rosie in mind. Doug and Rosie have a productive discussion about her concerns and decide to face them. First, together they devise a staircase of fear, which breaks down the feared situation into small steps. Attending a movie alone and sitting in the middle (95) Attending a movie alone and sitting in the back row by the door (92) Going to the movies with Doug and having him sit in a row behind me (88) Going to the movies with Doug and sitting in the middle (75) Going to the movies and sitting with Doug in the last row by the door (71) Imagining going to the movie and getting stuck in a crowd (70) Going into the theater lobby for a while (69) Buying a ticket by myself (68) Walking up to the ticket window and asking for times of shows (65) Figure 18-1: Walking by the theater while imagining buying a ticket (60) Rosie’s staircase Driving past the theater (48) of fear. Imagining going to the movie (28) 276 Part V: Helping Others with Anxiety Doug plays a role in most of Rosie’s tasks. He reads the script out loud to Rosie while she closes her eyes and tries to picture the experiences. She rates her level of anxiety, and during the first few steps, he stays with her until her anxiety goes down. Not only does he accompany her to the movies, but he also celebrates her successes and encourages her when she starts to falter. It takes attending a number of movies with Doug before she agrees to the final tasks of going by herself. In fact, they begin enjoying their nights at the movies and find that they both love talking about their experiences afterwards over coffee and dessert. Although Rosie balks at going to the theater by herself, her comfort level has increased over the last few months. Rosie and Doug drive to the theater together on her last two items, but he chooses a movie playing on a different screen. Rosie’s fear of the movies had not yet reached the level of severely interfer- ing with her life. Had Rosie not dealt with her fear in this early stage, it would likely have spread from fear of movies to fear of other crowded places. Most people with fears, obsessions, or compulsions need to develop a plan with the help of a therapist. However, the example of Rosie and Doug can serve as an illustration of how a simple plan can be carried out without a therapist. Teaming Up against Anxiety One way you can help your partner overcome anxiety is to collaborate on ways to decrease stress in both your lives. With a little ingenuity, you can explore a variety of solutions that are likely to feel good to you even if you per- sonally don’t suffer from anxiety at all. For example: ✓ Take a stress management class at a local center for adult continuing education. Many of the ideas make life more fun and interesting in addition to reducing stress. It’s a great way to reduce stress, but even if you don’t have much stress, strolling under the sky together is a wonderful time to talk and is great for your health. Chapter 18: When a Family Member or Friend Suffers from Anxiety 277 ✓ Take a yoga, Pilates, or tai chi class together. Again, even if you don’t have anxiety, these classes are terrific for balance, muscle strength, flex- ibility, and overall health. You may choose to attend a church, a synagogue, or a mosque, or scope out a less traditional method of com- muning with a higher power, such as immersing yourselves in nature. Thinking about things bigger than yourselves or the mundane events of the world provides a peaceful perspective. Many people feel that such work enhances the mean- ing and purpose of their lives. And if you don’t have the time for a long vacation, go away for an occasional evening at a local hotel. Getting away from texting, telephones, e-mails, doorbells, and other endless tasks and demands, even for a night, can help rejuvenate both of you. Accepting Anxiety with Love It may seem rather counterintuitive, but accepting your loved one’s battle with anxiety is one of the most useful attitudes that you can take. In other words, whenever you discuss your loved one’s anxiety or engage in any effort to help, you need to appreciate and love all your partner’s strengths and weaknesses. If perfect people even existed, we can only imagine that they would be quite boring. Besides, studies show that people who try to be perfect more often become depressed, anxious, and distressed. You need to accept and embrace both the possibility of productive change as well as the chance that your partner may remain stuck. Accepting your partner is especially important when your efforts to help ✓ Result in an argument ✓ Seem ineffective 278 Part V: Helping Others with Anxiety ✓ Aren’t well-received by your partner ✓ Seem merely to increase your partner’s anxiety even after multiple expo- sure trials What does acceptance do? Acceptance allows you and your loved one to join together and grow closer, because acceptance avoids putting pressure on the one you care about. This message frees your loved one to ✓ Take risks ✓ Make mistakes ✓ Feel vulnerable ✓ Feel loved Change requires risk-taking, vulnerability, and mistakes.
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