CHEST AND LOWER RESPIRATORY TRACT

DISORDERS

RESPIRATORY INFECTION: ACUTE

TRACHEOBRONCHITIS
• inflammation of the mucous membrane of the trachea
and the bronchial tree
• most common in children particularly Male
• common cause: Viruses
o parainfluenza virus
• one of the major factors in the prevention: Adequate
treatment of upper respiratory tract infection

Pathophysiology
• Px with viral infections have decreased resistance and
can develop secondary bacterial infection
• The inflamed mucosa of the bronchi produces
mucopurulent sputum in response to infection caused
by:
 Streptococcus pneumoniae
 Haemophilus influenzae
 Mycoplasma pneumoniae
 Aspergillus (fungal infection)
• Inhalation of physical and chemical irritants, gases, or
other contaminants cause Tracheobronchial irritation
• Ventilator- associated tracheobronchitis (subcategory)
–may lead to VAP
Medical management
• Antibiotic treatment (after Sputum GS/CS result)
• Antihistamines are not prescribed (it can cause drying
and make more secretions difficult to expectorate)
• Increase Fluid Intake as indicated
• It may lead to pneumonia and respiratory obstruction
if with severe secretions:
• Suctioning and bronchoscopy
maybe needed to remove
secretions
• Endotracheal intubation is rarely performed if it leads
to respiratory failure (due to co-existing disease)
• Mostly symptomatic treatment:
• Cool vapor therapy, steam inhalations,
moist heat (relieve tracheal irritation)
• Analgesics for pain and soreness

Nursing management
• Encourage bronchial hygiene
• Increased OFI
Clinical manifestation • Coughing to remove secretions
• Dry, irritating cough, • Assist patient to sit up frequently (to cough
• Scanty amount of mucoid sputum effectively, prevent retention of sputum)
• Sternal soreness from coughing • Take full course of antibiotics as prescribed
• Fever and chills • Advised patient to rest, avoid overexertion for fatigue
• Night sweats
• Headache Pneumonia
• General malaise • Inflammation of the lung parenchyma
• Short of breath • Caused by various microorganisms:
• Noisy inspiration (stridor) and expiration (wheezes) • Bacteria
• Purulent sputum (pus-filled) • Mycobacteria
• Blood streaked secretions (severe tracheobronchitis) • Fungi
• Virus
• Pneumonitis – general term that describes
inflammatory process in the lung tissue
• Pneumonia single largest infectious cause of death in
children worldwide (2019)
 • Most common cause of hospital admission in the US
(WHO-2019)
• 8th cause of death in the US (CDC)
• In the Philippines, 3rd leading cause of death across
ages and the most common cause of death in children
Classification
 Four types of Pneumonia
1. Community-Acquired Pneumonia (CAP)
2. Health Care-Associated Pneumonia
(HCAP)
3. Hospital-Acquired Pneumonia (HAP)
4. Ventilator-Associated Pneumonia (VAP)
1.Community-Acquired Pneumonia
 occurs either in community setting or withing the first
48 hours after hospitalization
• Streptococcus pneumoniae
most common cause of CAP in
people younger than 60 years
without co-morbidity and 60
years older with co-morbid
• H. influenzae common in adult
with COPD, diabetes,
alcoholism
• M. pneumoniae mycoplasma
pneumonia
• Viruses common cause of
pneumonia in infants and
children
• Cytomegalovirus common
cause for immunocompromised
2. Health Care Associated Pneumonia
 common causative pathogens are often
MDR bacteria
 Difficult to identify
 Hospitalization for ≥ 2 days in an acute
care facility within 90 days of infection
 Residence in a nursing home or long-term
care facility
 antibiotic therapy, chemotherapy or
wound care within 30 days of current
infection
 hemodialysis treatment at a hospital or
clinic
3. Hospital-Acquired Pneumonia
 pneumonia occurring ≥ 48 hours after
hospital admission that did not appear to be
incubating at the time of admission
 Factors that could predispose:
 impaired host defense
(acute/chronic illness)
 variety of co-morbid conditions
 Supine positioning
 aspiration
 coma
 malnutrition
 Prolonged Hospitalization
 Metabolic disorders
 respiratory therapy devices
Factors that could predispose:
 intervention related factors:
therapeutic agents leading to
central nervous system,
inappropriate antibiotic use, use
of nasogastric use etc.)
 immunocompromised patient
 most common organism
responsible for HAP:
• Enterobacter species
- E. coli
• Klebsiella species-
Pseudomonas
• MRSA- Proteus
• S. pneumoniae
4.Ventilator-Associated Pneumonia
 subtype of HAP
 develops ≥48 hours after endotracheal
tube intubation and with mechanical
ventilator support
 is a complication to patients who requires
mechvent
 Bacteriologic agents:
 if VAP occurs within 96 hours
of using the ventilator it may be
due to antibiotic-sensitive
bacteria
 if VAP occurs 96 hours after
ventilatory support it may be
due to MDR bacteria
OPPORTUNISTIC PNEUMONIA
 Seen in clients with very poor immune
systems: malnutrition, HIV/AIDS,
transplant clients receiving steroids, cancer
clients.
 Opportunistic pneumonias are caused by
Pneumocystis jiroveci (PCP),
Mycobacterium Tuberculosis)
cytomegalovirus, and fungi.
ASPIRATION PNEUMONIA
 consequences resulting from the entry of
substance into lower airway
 occurs most common in patients with
decreased levels of consciousness or
impaired gag reflex and coughing reflex
 stroke, under general anesthesia, seizures
and other serious illness
Pathophysiology
• Pneumonia affects both ventilation and diffusion
• An inflammatory reaction can occur in the alveoli,
producing an exudate that interferes with the diffusion
of oxygen and carbon dioxide.
• White blood cells, mostly neutrophils, also migrate
into the alveoli and fill the normally air-filled spaces.
• Areas of the lung are not adequately ventilated
because of secretions and mucosal edema that cause
partial occlusion of the bronchi or alveoli, with a
resultant decrease in alveolar oxygen tension
• Pneumonia affects both ventilation and diffusion
• An inflammatory reaction can occur in the alveoli,
producing an exudate that interferes with the diffusion
of oxygen and carbon dioxide.
• White blood cells, mostly neutrophils, also migrate
into the alveoli and fill the normally air-filled spaces.
• Areas of the lung are not adequately ventilated
because of secretions and mucosal edema that cause
partial occlusion of the bronchi or alveoli, with a
resultant decrease in alveolar oxygen tension
• Bronchospasm may occur with reactive airway
disease
• Because of hypoventilation, a ventilation-perfusion
(V/Q) mismatch occurs in the affected area of the lung
• Venous blood entering the pulmonary circulation
passes through the under ventilated area and travels to
the left side of the circulation poorly oxygenated
• The mixing of oxygenated and unoxygenated
eventually results in arterial hypoxemia
• Lobar Pneumonia – substantial portion of one or
Clinical Manifestations
more lobes involved
• Fever and chills
• Bronchopneumonia – used to describe pneumonia
• Pleuritic chest pain
that is distributed in patchy fashion, having originated
• Tachypnea
in one or more localized areas within bronchi and
• Shortness of breath
surrounding lung parenchyma
• Use of accessory muscles in respiration
• URTI (nasal congestion, sore throat)
• myalgia
• Headache
• Mucoid or mucopurulent sputum
• Central cyanosis (severe)
• Orthopnea
• Poor appetite
• Crackles
• Increased tactile fremitus
• Egophony
• Whispered pectoriloquy

Assessment and Diagnostic Findings

• History taking (recent respiratory tract infection)
• Physical Examination
• Chest-Xray
• Blood Culture
• Sputum Examination
• Invasive procedure: nasotracheal or orotracheal
suctioning or bronchoscopy

Prevention
• Pneumococcal vaccination
 reduces incidence
 Hospitalizations for cardiac conditions
 deaths are reduced in older adult
Two types:
1. PCV13 (Pneumococcal conjugate vaccine)-
recommended for all adults 65 years old above; 19
years old above with weaken immune system (HIV,
leukemia, CKD)
 2. PPSV23 (Polysaccharide vaccine) – for adult 65
years above and 19 to 64 years old who smokes and
have asthma
!!!! Note: 2 vaccines should not be co-administered
Medical Management
A. PHARMACOLOGIC THERAPY
• Appropriate antibiotics determined by result of C/S
• In suspected HAP – treatment is on broad-spectrum
antibiotics IV therapy
 Monotherapy (for no known drug resistant)
 ceftriaxone, ampicillin/sulbactam, levofloxacin,
ertapenem
 Combination Therapy (with known drug resistance)
 3-way drug combination (antipseudomonal
cephalosporins, carbapenem, piperacillin/tazobactam
+ antipseudomonal fluoroquinolones or
aminoglycoside + linezolid or vancomycin
B. Other Therapeutic Regimens
• Supportive care particularly if viral cause
• Hydration is necessary due to insensible fluid loss
• Antipyretics for fever and headache
• Antitussive medications for cough
• Warm, moist inhalations for bronchial irritation
• Antihistamines reduced sneezing and rhinorrhea
• Nasal decongestants to improve sleep
• Bed rest
• Oxygen therapy if with hypoxemia
• More aggressive O2 administration (endotracheal
intubation and mechanical ventilation)
Complications
• Shock and Respiratory Failure
• hypotension, septic shock and respiratory
failure
• patients who have received no specific
treatment or inadequate or delayed
treatment.
• the infecting organism is resistant to
therapy, when a comorbid disease
complicates the pneumonia, or when the
patient is immunocompromised.
• Pleural Effusion
• accumulation of pleural fluid in the pleural
space; detected on a chest x-ray
• a thoracentesis may be performed to
remove the fluid, which is sent to the
laboratory for analysis
• A chest tube may be inserted to treat
pleural infection by establishing proper
drainage of the empyema.
• Sterilization of the empyema cavity
requires 4 to 6 weeks of antibiotics, and
sometimes surgical management is
required.
Nursing Intervention
• Administer oxygen as prescribed.
• Monitor respiratory status.
• Monitor for labored respirations, cyanosis, and cold
and clammy skin.
• Encourage coughing and deep breathing
• Place the client in a semi-Fowler’s position to
facilitate breathing and lung expansion.
• Change the client’s position frequently and ambulate
as tolerated to mobilize secretions.
• Provide CPT.
• Perform nasotracheal suctioning if the client is unable
to clear secretions.
• Monitor pulse oximetry
• Monitor and record color, consistency, and amount of
sputum.
• Provide a high-calorie, high-protein diet with small
frequent meals.
• Encourage fluids, up to 3 L/day, to thin secretions
unless contraindicated.
• Provide a balance of rest and activity, increasing
activity gradually
• Administer antibiotics as prescribed.
• Administer bronchodilators, cough suppressants,
mucolytic agents, and expectorants as prescribed.
• Prevent the spread of infection by hand washing and
the proper disposal of secretions.
• Teach client about the importance of rest, proper
nutrition, and adequate fluid intake
• Educate patient regarding medications and the use of
inhalants as prescribe
• Notify the HCP if chills, fever, dyspnea, hemoptysis,
or increased fatigue occurs
• To receive a pneumococcal vaccine as recommended
by the Health Care Provider
PULMONARY TUBERCULOSIS
• Highly communicable disease
• Mode of transmission: airborne transmission /
droplet inhalation
• Caused by Mycobacterium tuberculosis (aerobic
bacterium)
• It primarily affects the pulmonary system
(upper lobe)
• Can also affect areas of the body (brain,
intestine, peritoneum, kidney, joints, liver
etc)
• Insidious onset (gradual)
• Goal of treatment: to prevent transmission, control
symptoms, and prevent progression of the disease.
• Mycobacterium tuberculosis characteristics:
• Rod-Shaped Bacilli
• Aerobic
• Waxy Cell Wall (acid-fast)
• Hardy Wall (resist in weak disinfectants,
can survive on dry surfaces)
• Latent TB Infection
• TB bacteria can live in the body without
making you sick
• The body is able to fight the bacteria to
stop them from growing
• Active TB Infection
• It becomes active if the immune system
can’t stop from growing
• When TB bacteria are active (multiplying
in the body) it is called TB disease

Risk factors
• Close contact with someone who has active TB
• Immunocompromised status
• Substance Abuse
• Any person without adequate health care (homeless,
impoverished, minorities)
• Pre-existing medical conditions (DM, CKD,
malnourishment)
• Recent to travel with countries high prevalence of TB
• Institutionalization (long-term care facilities,
psychiatric institutions, prisons)
• Living in overcrowded, substandard housing
• Healthcare worker (performs procedures sputum
collection, suctioning, coughing, intubation etc)
Pathophysiology
• when a susceptible person inhales mycobacterium
and becomes infected; TB begins
• bacteria are transmitted through the airways to the
alveoli, where they are deposited and begin to
multiply
• The body’s immune system initiates inflammatory
responses:
• Phagocytes (neutrophils and macrophages)
engulfs bacteria
• Encapsulated by phagosome and enzyme
lysosome that can break biochemical
molecules
• However, in TB once inside the macrophage, they
produce a protein that inhibits this fusion, that allows
mycobacterium to survive and proliferates creating
localized infection
• This reaction results in the accumulation of exudate
in the alveoli, causing Bronchopneumonia
• Initial infection occurs 2 t0 10 weeks after exposure
• Patient Develop Primary Tuberculosis
• Which means they develop signs soon after
being exposed to TB
• On this stage, patient is
ASYMPTOMATIC or mild-flu like illness
• 3 weeks after exposure – Cell- Mediated Immunity
• Immune cells surround the site of
infection, creating GRANULOMA (wall
off bacteria, prevent from spreading)
• The tissue inside dies as a result, a process
referred to CASEOUS NECROSIS
• The area is known as GHON FOCUS
• The tissue that encapsulated by the granuloma
undergoes fibrosis and calcification that produces scar
tissue
• The calcification of Ghon is called Ranke complex
• In some cases, although a scar is leftover, the
mycobacteria is killed off by the immune system
• In other cases, even though they were walled off, they
remain viable, still alive but they’re just still dormant
• If the person’s immune system is
compromised like AIDS or aging, the
GHON FOCUS is reactivated and can
spread in upper lobes of the lungs
• Since previously exposed, the immune
system’s memory T-cells quickly release
cytokines to control the new outbreak
• forms more areas of caseous necrosis that
cavitates that allow bacteria to disseminate
• In the lungs causing
Bronchopneumonia
• In the vascular system –
systemic Miliary TB
Assessment
• Low grade fever
• Cough (>14 days or 1 month)
• Night sweats
• Fatigue
• Weight loss and Anorexia
• Production of mucoid and mucopurulent sputum
which is occasionally streaked with blood
Diagnostic Test
• PPD skin test (exposure)
• QuantiFERON TB GOLD (blood analysis, rapid
testing within 24 hour) could not detect active TB
• Chest Xray (screening tool)
• Sputum culture smear for Acid fast bacilli (AFB) for
3 takes at least early in the morning specimen- done
to confirm
Medical Management
• Pulmonary TB is treated primarily with anti-TB
agents for 6 to 12 months.
• A prolonged treatment duration is necessary to ensure
eradication of the organisms and to prevent relapse.
1. Long term treatment with antimicrobial
drugs
2. Follow-up AFB smear, cultures and chest
x-rays
3. Follow up care addressing needs and
concerns of patient and close contacts, and
involving community health care workers
and social workers
 • For newly diagnosed TB cases, have two phases of
treatment: Initial and Continuation Phase
1. Initial Phase
• Multiple-medication regimen
(RIPE)
• Taken once daily and orally
• It is done for 8 weeks/ 2 months
2. Continuation Phase
• Includes INH (isoniazid) and
Rifampicin
• It lasts for 4 to 7 months
• 4-months period mostly used
• 7-month is recommended for
cavitary PTB whose sputum
culture is POSITVE after
initial 2 months treatment
NOTE:
a. after 2-3 weeks of continuous
medication therapy patients
are considered non-infectious
b. The total number of doses
taken, not simply the duration:
more accurately determines the
course has been completed
• In latent infection, SINGLE drug for long
period: ISONIAZID
• It is also used as prophylaxis (daily dose 6-
12 months)
1. Household member of
patients with active
disease
2. Px with HIV infection-
PPD test reaction of 5mm
or more induration
3. Px with fibrotic lesions
(old TB) with PPD
reaction of 5mm or more
4. Px with PPD results show
recent exposure
5. Px with high risk
comorbid conditions with
PPD result of 10mm
induration
Nursing Intervention
1.Promoting Airway Clearance
• Increase fluid intake promotes systemic
hydration and serves as an effective
expectorant
• Instruct of correct positioning to facilitate
airway drainage (postural drainage)
2. Promoting Adherence to Treatment Regimen
• Educate patient that taking medication is
the most effective means to prevent
transmission
• Educate the patient to take medications
empty stomach or at least 1 hour before
meal
• If taking with Isoniazid, avoid food with
tyramine (tuna, aged cheese, red wine, soy
sauce, yeast extracts) – prevent
hypotension, flushing, headache,
palpitations, diaphoresis,
lightheadedness
• Avoid alcohol, potential for hepatotoxicity
• Rifampicin should not be taken with other
drugs making it less effective (beta-
blockers, oral anti-coagulants, digoxin, oral
hypoglycemic agents)
• Liver enzymes (AST, ALT), serum
creatinine, BUN
• instructs the patient about the risk of drug
resistance if the medication regimen is not
strictly and continuously followed
3. Promoting Activity and Adequate Nutrition
• nurse plans a progressive activity schedule
that focuses on increasing activity
tolerance and muscle strength
• A nutritional plan that allows for small,
frequent meals may be required
4. Preventing Transmission of Tuberculosis Infection
• important hygiene measures
• TB is a disease that must be reported
• placed under airborne isolation precautions
in a negative pressure room; to maintain
negative pressure, the door of the room
must be tightly closed
• Wear mask
• Instruct the client to cover the mouth and
nose when coughing or sneezing and to put
used tissues into plastic bags.
• Instruct the client and family about
thorough hand washing.
Influenza
• It commonly referred to as the flu, a viral infection
of the respiratory tract.
• Many different flu viruses have been identified, and
new strains appear each year.
• < 5 years old and Elderly > 65 are at risk, immune
compromised, with lung or heart disease
• Influenza is easily transmitted via small and large
particle droplets, or it may be transmitted by physical
contact with a person or object that harbors the virus.
• The incubation period from time of exposure to
onset of symptoms 1 to 3 days. Symptoms may last to
a week
Types of Influenza
There are four types of influenza viruses: A, B, C and D.
1. Human influenza A and B viruses cause seasonal
epidemics of disease (known as the flu season)
• Influenza A viruses are the only influenza
viruses known to cause flu pandemics
2. Influenza type C infections generally cause mild
illness and are not thought to cause human flu
epidemics.
3. Influenza D viruses primarily affect cattle and are
not known to infect or cause illness in people
 • Avian influenza, more commonly known as bird flu,
Signs and symptoms: has been identified in Asia, Canada, and the
1. Fever and chills Netherlands, and is a growing concern.
2. Headache • Humans can contract it from contact with infected
3. Fatigue birds (often poultry) or their secretions or excrement
4. Anorexia (waste matter/ discharged)
5. Sore throat
6. Cough (2 weeks) Transmission
7. Rhinorrhea • from human to human is rare, but is also a potential
8. Body aches concern
9. N/V and diarrhea (influenza B)
Etiology
Complication • Type A strain of the Influenza virus
Pneumonia • Incubation period – 2 to 8 days and possibly as long as
• caused by the same virus as the flu or by a secondary 17 days.
bacterial infection.
• Occur most commonly in persons >65 years of age, Symptoms
those with underlying cardiopulmonary disease, those • Symptomps of bird flu are similar to influenza
with immunosuppression, and women who are in the symptoms, but complications can be more severe and
second or third trimester of pregnancy deadly.
• Conventional vaccines are not effective in preventing
Diagnostic Tests bird flu.
• Typically, it is diagnosed with the Client’s History,
Physical Assessment and presence of influenza Management
outbreak • Oseltamivir (Tamiflu) may be useful in treatment,
• Viral Culture or nasal Swabbing can be done: along with supportive measures
• Detect presence of influenza in secretions • Acetaminophen for pain and fever
• RT-PCR and Rapid Molecular Assay – • Cough and Decongestant medication
can detect VIRAL RNA (more accurate, • Oxygen therapy
highly sensitive and specific) • Hydration
• Rapid Influenza Diagnostic Test (RIDT) • Hand hygiene
– can detect viral antigen, less sensitive • Cough etiquette
and less specific but faster result more • Quarantine or isolation
commonly used • Personal protective equipment
• Cultures may also be done to rule out bacterial
infection. Swine Flu A (H1N1) OR (H3N2) influenza
• H1N1 Swine flu is a subtype of influenza A virus
MEDICAL MANAGEMENT • a common infection in pigs worldwide, and that is
• Treatment involves supportive care to reduce why it is also known as swine flu.
symptoms • Communicable disease that leads to respiratory
• Rest and Hydration disease that can potentially infect the respiratory tract
• Acetaminophen is given for fever, headache and of pigs.
myalgia • Sometimes, people who are closely associated with
• Antibiotics are used only if a secondary bacterial pigs or in the proximity of pigs have developed swine
infection is present flu
• Antiviral drugs (Zanamivir, Oseltamivir, • H1N1 swine flu is an acute disease that infects the
Peramivir) may be helpful for high risk patients if upper respiratory tract and can cause inflammation of
given within 48 hours of exposure. These drugs may the upper respiratory passages, trachea, and possibly
reduce the severity and duration of symptoms the lower respiratory tract
• Effective way to prevent Influenza is through
Vaccination

NURSING INTERVENTION
• Encourage rest and provide comfort measures Incubation Period
• Encourage fluids to prevent pulmonary complications • ranges from 1 to 4 days, with the average around 2
(unless contraindicated). days in most individuals, but some individuals, it may
• Monitor lung sounds and vital signs be as long as 7 days.
• Provide supportive therapy such as antipyretics or • contagious period for adults starts about 1 day before
antitussives as indicated. symptoms develop and lasts around 5 to 7 days after
• Administer antiviral medications as prescribed for the the person develops symptoms.
current strain of influenza
• Encouraged hand hygiene Symptoms
• Avoid direct contact • (similar to regular flu)
• High fever
Avian influenza A (h5n1) • Coryza
• Affects bird, human cases have been reported in some • Myalgia
countries. • Headaches
• Sore throat
 • Cough • Wearing PPE
• Rhinorrhea
• Gastrointestinal irritation • COVID 19 was first identified in
December 8, 2019 – Wuhan, China
Prevention • The first reported case was
• Prevention of transmission of swine flu from swine- December 31, 2019
to-humans, and prevention of human-to-human spread • On February 12, 2020
WHO announced that the novel disease will be called
Management CORONAVIRUS Disease 19 or COVID 19
 Isolation or quarantine
 Antiviral medications • COVID-KAYA
 Rest stores data from all covid confirmed cases; it provides data for
 Hydration the government to provide evidenced based decisions and actions
 Hand hygiene • In the Philippines, the first suspected case was
 Cough Etiquette investigated
January 22, 2020
 Personal protective equipment
• First confirmed case identified by the RT-PCR
January 30, 2022
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
• Two First cases in the Philippines
• a viral respiratory illness caused by SARS-associated
Patient 1: 39 years old female from Wuhan, China
coronavirus
Patient 2: 44- male from Wuhan, China (died on day 15)
• It was first reported in Asia in 2003
It was considered First death outside CHINA
• SARS develops in people who have either close
• In the Philippines, the first suspected case was
contact with a person who has been diagnosed with
investigated
the disease or a history of travel or residence in an
January 22, 2020
area with known cases.
• First confirmed case identified by the RT-PCR
• The SARS-associated coronavirus is transmitted via
January 30, 2022
respiratory droplets when an infected person coughs
• Two First cases in the Philippines
or sneezes; the droplets may be deposited on the
Patient 1: 39 years old female from Wuhan, China
mucous membranes (mouth, nose, eyes) of a nearby
Patient 2: 44- male from Wuhan, China (died on day 15)
person.
It was considered First death outside CHINA
• The virus may also be spread when a person touches a
surface or an object contaminated by the droplets and
then touches his or her mucous membranes.
• The virus may be transmitted in other ways, including
sewage and water, but these methods of transmission
are unclear at this time
• The incubation periods
• 2 to 7 days and about 95% of patients
develop symptoms within 10 days

Risk Factors
• Direct contact with infected people
• Health workers
• Travelers to region where SARS are prevalent

Assessment

• Fever(> 38 degree Celsius)

• Coughing
• Dyspnea
• Myalgia
• Lethargy
• Gastrointestinal symptoms
• Sore throat

Management
• Use of negative pressure isolation room
(quarantine)
• Use of personal protective equipment
• Proper Hand Hygiene
• Environmental Cleaning and disinfection
• Antiviral Medications
• Hydration
• Oxygen Therapy