1

CLINICAL GUIDELINES ON

MANAGEMENT OF CHEST DISEASES

IN 5 YEARS & OLDER PATIENTS

FOR

PRIMARY HEALTH CARE PHYSICIANS

2008

2

Introduction Practical Approach to Lung health (PAL) is an initiative aiming at managing respiratory patients in primary health care (PHC) settings while expanding TB detection and quality TB services. PAL focuses on the most prevalent respiratory diseases at first level health facilities such as pneumonia, acute bronchitis and other acute respiratory infections, tuberculosis, and chronic respiratory conditions including asthma and chronic obstructive pulmonary disease (COPD). In the global population aged 5 years and older, almost one fifth of total deaths are caused by respiratory diseases. The main causes of respiratory deaths in developing countries are pneumonia, tuberculosis and COPD. The prevalence of asthma has been increasing substantially everywhere in the world during the last few decades, in parallel with the increasing demographic trend of urbanization. PAL looks for an integrated case management of respiratory patients in PHC on the basis of two main approaches: standardization of diagnosis and treatment of respiratory conditions, and coordination among health staff of different levels. Primary health care staff needs to be prepared to assess patients presenting with respiratory symptoms, whom some of them will have TB but most of them will have other respiratory conditions. Criteria of referral of respiratory patients or treatment at home need to be standardized and unified. PHC staff needs to be guided on health education activities and on recording and reporting of data. PAL strategy implementation will help strengthen the coordination between TB control and the PHC system and improve the process of detecting and diagnosing tuberculosis cases. PAL strategy implementation will help to strengthening the health services delivery and the management of the PHC system through developing and implementing sound technical guidelines on diagnosis and treatment of common respiratory conditions. The implementation of the PAL strategy is expected to convey benefits to health staff working at first level health facilities and first referral hospitals. These benefits include increase their competence in the management of respiratory diseases and strengthening the connections between workers at the first level health facilities and professionals at first referral level.

This guideline is directed to the family physicians working in PHCs in governorates where family medicine is implemented. During orientation and training session the chest physicians in the referral district chest centers and referral chest hospitals will join these training sessions to organize and coordinate the referral and counter referral system between them.

General Director for Chest Diseases Executive Director of NTP Egypt Dr. Essam Elmoghazy

3

List of abbreviations arranged alphabetically

CBC Complete blood count

COPD Chronic obstructive pulmonary disease

FEV1 Forced expiratory volume in first second

FVC Forced vital capacity

GERD Gastro-esophageal reflux disease

IM Intramuscular

IV Intravenous

NSAID Non-steroidal anti-inflammatory drugs

PAL Practical approach to lung health

PEF Peak expiratory flow

PHC Primary health care

SR Slow release or sustained release

TB Tuberculosis

4

Acknowledgements

Special thanks go to Prof. Adel Khattab, the minister consultant for chest diseases and the chief of chest department, Ain Shams University, who reviewed this document. The NTP is grateful to those who, one way or the other, have contributed to this Guide, but are not mentioned here by name.

5

How to use this guide

Dear colleague at the primary health care unit, this guide is developed to help you managing patients with respiratory symptoms 5 years and older, attending the primary health care settings. It also helps you to make use of the chest clinics in you governorate and collaborate with your colleagues, chest physicians, if you need their help.

First, on page 7, you will find a table that will remind you with the cardinal

respiratory symptoms and the points you should check during generally and locally examining your patient.

On page 8, you will find an algorithm summarizing the whole guidelines. As

stated in this algorithm, you have first to determine whether your patient is visiting the health care unit asking for routine follow up of a chronic condition e.g. COPD or Bronchial asthma. Or he is visiting the unit because he is now suffering of an acute distressing problem.

If the patient is visiting the unit because of an acute condition, you have first to

exclude symptoms and signs of severity. For this, you will find a table on page 9 that enumerates severe symptoms and signs that necessitate urgent refer to a hospital. On page 10, you will find a diagram that helps you to prepare the patient for urgent or non-urgent refer.

If the patient is coming for an acute problem but his condition dose not

necessitate urgent refer, check whether your patient is wheezy or not and for how long he is suffering of the problem. The algorithm on page 8 again will help you to determine the way you go through to deal with every probable condition. For each probability in this algorithm, you will find its details in the corresponding part through out the guidelines.

On pages 23 and 24, you will find the diagnostic criteria of both COPD and

Bronchial asthma. This will help you keeping in mind the signs and symptoms of both conditions and how to proceed with the diagnosis.

If you need to investigate your patient e.g. to do chest x-ray, sputum analysis for

acid fast bacilli or for any other test, to do spirometry to confirm or stage a case of COPD or Bronchial asthma, use the usual referral form in your health care. For those units in which family medicine system is not implemented yet, use the referral for at the end of this guideline.

A patient might be referred mostly in one of three conditions, first to handle a

serious condition that needs diagnostic and treatment interventions that are not available in you unit, secondly to investigate the patient to reach a final diagnosis and finally to adjust or modify the management plan of a chronic patients e.g. bronchial asthma or COPD who presented with exacerbations or even those who improved that need adjustment of treatment plan

On pages 26 & 27, you will find a list of some recommended antibiotics and their

dosage for use in pneumonia, COPD or any other condition before referral.

6

For units in which family medicine has been implemented, register the patient in

the outpatient register and add the word (PAL) in the column of remarks just to facilitate counting the cases you diagnosed using this guideline. When the patient is diagnosed as a case of COPD, Bronchial asthma or TB, register the patient in the chronic cases register. For those units where family medicine has not implanted yet, use an ordinary notebook to enlist patients you encountered and diagnosed using this guideline.

On pages 28 to 34, you will find health educational material for patients with

COPD, Bronchial asthma and their families. It is very important to read these pages carefully in order to effectively counsel the patients with theses conditions.

At the end, you will find a list of chest facilities' addresses in all governorates.

7

ASK EVERY PATIENT ABOUT THESE SYMPTOMS: 1. Cough - For how long have you been coughing? - If more than 2 weeks History of weight loss? or history of TB or contact with TB patient? - If yes, ask about history of present or previous TB treatment? - is it at night or early morning mainly.

- is it productive, and if KNOWN COPD, ALSO ASK TO DETECT ACUTE EXACERBATION: - Has sputum recently increased? - Has sputum colour recently changed to yellow or green? 2. Breathlessness - For how long? - When do you feel it?

- At rest? - On talking? - On Walking or making an effort? - Are symptoms seasonal in nature

or precipitated by exertion. - History of similar attacks of breathlessness

with or without chest wheezes

- Is there family history of similar attack or any other pattern of allergy e.g. atopy? 3. Chest pain - is it related to breathing? Does it cause holding of breath? - is it related to effort? Where is it felt and to where it radiates? 4. Coughing of blood - Do you cough blood tinged sputum or frank blood? - If yes, how much blood did you cough? 5. Also ask about:

History of smoking?

If the patient is known as a COPD case? Check the follow up registry of chronic cases.

EXAMINE ALL PATIENTS,

Check the vital signs - Count the breaths in one minute - Count heart beats in a minute - Temperature - Blood pressure. To assess neurological state look for: - Patient lethargic or unconscious? - Confused? - Agitated? To assess Dyspnea look for: - Cyanosis?

- Uncomfortable on lying down? - Using accessory muscles? - Abdominal paradox? - Patient unable to speak? - Speaks in single words only? - Speaks in phrases? - Speaks in full sentences? - Walks unaided. - Oedema of both ankles.

- Examine the chest to detect diminished breath sounds or adventious sounds

NB.

Normal respiratory rates:

- 6- 12 years = 14-22 (lower end for

older age)

- 12 years & above = 12-18

General assessment of all patients (Important point to keep in mind during history taking and examination)

8

Then determine if the patient is coming because of acute problem or for follow up of a

chronic condition

First, if the patient is coming for an acute problemIf there are dangerous

signs

Refer

If patient is coming for cough

with or without dyspnea

Not known as COPD or

asthma

less than 2 weeks:-• Pneumonia• URTI• Bronchitis• Bronchial asthma

• Avian Flu

More than 2 weeks:-

- TB, refer to TB suspect management.

- Other CRD e.g.

- COPD 1st visit .

- Bronchiectasis .

- Malignancy.

Do x-ray and refer to chest center

known as COPD or

asthma, refer to specific

management

COPD

Refer to COPD management.

Bronchial asthma

Refer to asthma management .

Any other wheezes

Refer to wheezes severity &

management.

Without wheezes With wheezes

9

Severe symptoms and signs that necessitate urgent referral Signs and Symptoms Clinical criteria for diagnosis Reasons for urgent referral

Signs of toxic

infectious syndrome

- Temperature more than 39oC

- Respiratory rate > 30 per minute

- Pulse more than 140 per minute

- Arterial systolic tension < 90 mm Hg

and / or diastolic tension < 60 mm Hg

- Mental confusion or lethargy

(drowsiness, or being lazy or sluggish) or

Agitation (excitement or restlessness)

Suspicion of severe pneumonia or

TB

Pre-referral injectable antibiotic if

transportation takes more than 4

hours.

Signs of severe

dyspnea without pain

and without fever

- Patient seated, hunched forward,

speaks only with isolated words

- Sub-sternal chest retraction

- Pulse more than 140 per minute

- Permanent cyanosis

- Edema of both legs

Acute respiratory Insufficiency

Suspicion of COPD with severe

exacerbation or severe attack of

bronchial asthma.

Right heart failure

Signs of imminent

respiratory arrest

- Patient sleepy or confused

- Unable to speak

- No wheeze

- Paradoxical respiratory movements

- Bradycardia

Suspicion of very severe asthma

attack or COPD deterioration with

imminent respiratory arrest

Sudden acute localized

chest pain

With Intense dyspnea

Retro-sternal chest pain, radiating to the

upper left arm and / or the neck Suspicion of myocardial infarction

Sharp latero-thoracic pain

Suspicion of spontaneous

pneumothorax

Latero-thoracic pain and Clinical context

(post-surgery, post-partum)

Suspicion of pulmonary

thromboembolism

Severe hemoptysis

Signs of shock (pallor, hypotension,

confusion, weak pulse) Need for intensive care

Abundant pink and

frothy expectoration

Crepitantions and rales spread over both

hemithorax

Suspicion of acute pulmonary

edema

Urgent treatment before referral:

IV furosemide, O2 2 liters /minute

through nasal prongs

Inspiratory stridor

Croupy cough, hoarseness, fever

Acute obstructive laryngitis- give

steroid IV + subcutaneous

adrenaline if there are no contra-

indications.

Extensive adhesive white membrane on

the throat, painful and large cervical

lymph nodes, fever

Presumptive diphtheria

Accidental inhalation of foreign body Foreign body

10

Classification of dyspnea or wheezing severity NB. You have to be sure first of the cause of Dyspnea: e.g. asthmatic, COPD,

Pneumothorax, Pleural effusion, Cardiac, severe hypertension. ….etc

Patient coming with acute problem with cough with or without

dyspnea and/or wheezing

Salbutamol inhaler or by nebulizer with oxygen, if no

contra-indication. If no response, repeat Salbutamol

inhalation every 20 minutes for one hour maximum

Give oxygen

Position for greatest ease in breathing

Give prednisone IV if known asthma or COPD.

If no response, immediately prepare for urgent referral to

hospital with oxygen and salbutamol

If patient improved, prepare for non-urgent referral

CALSSIFY AS MODERATE IF

THERE IS

Breathlessness on talking

And / or

Uncomfortable lying down And / or

Speaks only in phrases And / or

Use accessory muscles

CALSSIFY AS SEVERE IF THERE IS

Breathlessness at rest

And / or

Speaks in single words or can’t at

all And / or

Confused, agitated plus

breathlessness

Give oxygen 2 liters/minute through N. prongs

Do x-ray and ECG to exclude pneumothorax and cardiac

asthma.

Position for greatest ease in breathing

Immediately prepare for urgent referral to hospital with

oxygen and salbutamol after exclusion of cardiac asthma.

Inhaled salbutamol and repeat every 20 minutes, if no

response, for one hour max..

Give IV corticosteroids

If feverish (>37.2 ○C), give IM antibiotic

Refer urgently to hospital with oxygen and continue

salbutamol inhalation.

CALSSIFY AS MILD IF THERE IS

Breathlessness only on walking.

And

Comfortable lying down.

And

Speaks in full sentences.

If known as asthma or COPD patient, give Salbutamol

inhaler or by nebulizer. . If no response, repeat Salbutamol

inhalation every 20 minutes for one hour maximum

If patient improved, treat at home.

If no improvement for one hour: Give prednisone IV, do

chest x-ray to exclude pneumothorax and non-urgent

referral for assessment

11

Patient with cough with or without dyspnea but has no wheezes

1. If the patient is known as a case of COPD, exclude COPD

deterioration. See later.

2. If the patient is NOT Known as a case of COPD

If complaint is less than two weeks (acute onset) 1. Exclude URTI

The following table helps you to do so

Presenting symptoms Criteria for diagnosis Treatment

Blocked nose or

Non purulent runny nose

If less than 2 weeks, consider Coryza, acute rhinitis.

Just observation, soothing remedies and advise when to return.

If more than 2 weeks, consider allergic or vasomotor rhinitis

Oral antihistaminic

Pain when para-nasal sinuses are pressed

If without fever, without purulent nasal discharge, consider non-purulent sinusitis

Analgesic, 5 days

If with fever or purulent nasal discharge, consider purulent sinusitis

Amoxicillin or cotrimoxazole, 7 days. Refer to a specialized service if symptoms persist more than 2 weeks.

Sore throat

If red throat and/or red tonsils & temperature less than 38 ºC, consider non-streptococcal pharyngitis or tonsillitis

Paracetamol If symptoms > 3 days, give oral Penicillin or Amoxicillin for 5 days. If there is history of allergy to penicillin, Erythromycin, 5 days.

Enlarged tonsils with at least white spots & temperature more than 38ºC, consider streptococcal tonsillitis.

Oral Amoxicillin or, Erythromycin for 7 days

Malaise, white-grayish, extensive membranes attached firmly to the throat, large and painful cervical lymph nodes, fever more than 39º C,

Suspected diphtheria

Refer urgently to fever hospital. Procaine Penicillin If allergy to

penicillin, Erythromycin.

Ear pain

Normal otoscopy in a patient with acute rhino-pharyngitis, consider Otalgia

Analgesic for 5 days

Pain when pulling ear lobe, Painful otoscopy with normal

ear drum, consider Otitis externa

Analgesic. If boil (furuncle) or pus in the external ear canal use Dicloxacillin for 5 days. Local application of pack with antibiotic, antifungal and corticosteroid combination rapidly relieve the pain.

Otoscopy shows bulging red drum without discharge, consider Otitis media

Analgesic, Amoxicillin or cotrimoxazole for 7 days+ nasal decongestant. Consult to specialist.

With discharge, Purulent Otitis media

As previous.

Management of upper respiratory tract conditions

12

Hoarseness and/or aphonia and/or

dysphonia for less than a week*

Without dyspnoea, Acute Laryngitis.

Analgesic for 3 days

With stridor, Oedematous Laryngitis

Oral or parenteral corticosteroids for 3 days & subcutaneous adrenaline if not contra-indicated

History of foreign body aspiration. Foreign Body

Refer urgently to a specialized service

With cough and fever, consider laryngo-trachitis.

Analgesic and If symptoms persist for more than 3 days, Amoxicillin or cotrimoxazole for 7 days

2. Also exclude the possibility of pneumonia in such a patient (Chest x-ray is necessary to confirm diagnosis when it is possible)

Think of SEVERE PNEUMONIA: if patient is showing picture suggestive of pneumonia (fever, cough, pleuritic chest pain) in addition to one or more of the following signs: 1. Tachypnea >30/minute or 2. Very high fever (40 oC or above) or 3. Temperature less than 35 oC or 4. Heart rate 125 beats or more or 5. Systolic BP less than 90 or 6. Confusion, agitation or 7. lethargic associated with breathlessness or 8. Not able to walk unaided or 9. Uses accessory muscles or 10. Speaks only in single words or not at all or 11. Hemoptysis more than 50 ml or 12. Severe chest pain

Manage as follows: 1. Give first dose IM antibiotics 2. Give oxygen 3. Position 4. Refer urgently to hospital

Think of PNEUMONIA if patient showed the following, (Chest x-ray is necessary to confirm diagnosis when it is possible)

1. Cough 2. Tachypnea 3. Fever (37.5 oC or above) 4. Pleuritic chest pain

13

Manage as follows: 1. Give appropriate oral antibiotics. Exception: if second/third

trimester pregnancy, give first dose IM antibiotics and refer urgently to hospital.

2. If smoking, counsel to stop smoking 3. Advise when to return immediately 4. Follow-up in 2 days.

If proved to be a case of pneumonia, follow up the case as following:

After the patient being diagnosed as a case of pneumonia and

given the first line appropriate antibiotic, re-assess the patient

after 2 days: Ask and use the patient’s record to determine:

- Is the breathing slower?

- Is there less fever?

- Is the pleuritic chest pain less?

- How long has the patient been coughing?

Management - If fever or respiratory rate are the same, change to the second

line antibiotic and advise to return in 2 days, But refer to hospital if the patient:

- Has a chronic disease

- Over 60 years old

If breathing rate improved and fever is less, complete another 5 days

previously prescribed treatment and advice when to return

After exclusion of URTI and pneumonia, exclude avian flu In case of suspicion of avian flu, history of contact with birds is

mandatory. It starts as upper respiratory tract infection followed with

rapid deterioration and respiratory distress. Symptoms and signs of severe

pneumonia may detected here.

If avian flu is also excluded, manage as bronchitis and follow up the

response and manage accordingly.

FOLLOW-UP CARE FOR A CASE OF PNEUMONIA

14

if complaint lasts more than two weeks (gradual onset)

1- First exclude the possibility of TB

Identify TB suspects TB suspect is:

Every adult who has coughed for 2 weeks or more.

Ask every adult (aged 14 years and over) who attends the health facility

– Do you have a cough?

– For how long have you been coughing?

List the TB suspect in the Suspect Register

The Register of TB Suspects is a record of:

- All patients identified as TB suspects at the health facility, and

- All sputum samples sent to the laboratory.

List the name and complete detailed address of every TB suspect in the

TB Suspects Register.

1. Fill out Request for Sputum Examination and refer the patient

to chest facility for sputum examination for AFB.

2. Decide on appropriate action in response to the laboratory

results as follows:

- If two (or three) specimens are positive, the patient is sputum smear-

positive. These results mean that the patient has infectious pulmonary

TB and needs treatment for TB. If the patient does not return to the

health facility for the results, someone from the health facility must

visit the patient’s home.

- If only one specimen is positive (the other two samples are negative

or the patient could not give other samples), the clinician can make a

clinical assessment to decide whether the patient has TB. The patient

will be considered sputum smear-positive if one sputum sample is

positive and X-ray shows pattern consistent with active TB.

Management of TB suspect

15

- If all specimens are negative, and there is a high probability of

pulmonary TB either from the clinical or radiological point of view,

follow the after coming protocol to exclude or diagnose smear

negative pulmonary TB:

a. Give non-specific anti-biotic of no anti-TB activity e.g. co-

trimoxazole or amoxicillin for 1-2 weeks. Avoid antibiotics of

anti-TB effect e.g. Rifampicin, aminoglycosides (e.g. amikacin,

gentamycin, streptomycin etc..) and Fluroquinolones in adults.

b. Follow up the patient after two weeks and reassess the case

clinically, radiologically and bacteriologically (do examine

other three sputum samples as mentioned before).

c. If the case is improved clinically and radiologically, this

excludes pulmonary TB.

d. If the sputum examination revealed positivity, so smear positive

pulmonary TB is confirmed.

e. If the condition shows no improvement and sputum still

negative for TB bacilli and other pathological conditions are

excluded, a clinician decision could be made to treat the case as

smear negative pulmonary TB. Further investigations should be

done to exclude other conditions as lung cancer for instance.

Refer this patient to chest hospital.

- If the TB suspect with all samples are negative does not return to

find out the results, it is necessary to locate that patient to confirm or

exclude other conditions.

- The World Health Organization, WHO has adopted this strategy as a framework

for effective TB control.

- The DOTS strategy has been developed because:

A substantial proportion of sputum-smear positive TB patients refuse

hospitalization due to social and economic causes.

The cure rate is low due to: poor patient compliance; poor health education

to patient; long distance to chest clinic; long duration of treatment; social

problems; etc.

The development of drug resistant strains of tuberculosis should be

prevented.

There was a need to integrate TB services into the general health services

DIRECTLY OBSERVED TREATMENT WITH SHORT

COURSE CHEMOTHERAPY (DOTS)

16

- CHARACTERISTICS OF DOTS STRATEGY

The DOTS strategy aims to ensure high cure rates in TB patients. It has three

important characteristics:

Short-course Chemotherapy: the right combination of anti-TB drugs that

are given in the correct dosage and for the right duration.

Supervision and Motivation: the treatment is provided and supervised by a

trained health worker who is accessible to the patient and accountable to

the health service, and who encourages and educates that patient, and

observes that the treatment is taken correctly.

Monitoring: patients taking anti-TB treatment are evaluated to determine

the outcome of their treatment.

Role of the PHC centre in implementing DOTS strategy:

Provide TB patients with daily supervised treatment with anti-TB drugs

according to prescribed regimen, dosage and duration

Provide patients, who are unable to attend at the PHC centre on a daily

basis (e.g. handicapped patients) with supervised treatment at the patient’s

home.

DOT at the patient’s home, if necessary

Retrieve patients who did not attend the PHC centre for their daily

treatment

Record daily attendance and anti-TB drug intake in the TB treatment card

Health education and counseling to TB patients, their contacts and the

community

Timely referral of TB patients to the chest clinic for follow up sputum

examination

Order and collect the required quantity of anti-TB drugs for TB patients

Ensure that the anti-TB drugs present in the unit are not expired

Refer contacts of TB patients to chest clinic

Refer TB suspects to chest clinic

2- Exclude other CRD e.g.

- COPD 1st visit

- Bronchiectasis

- Malignancy.

Do x-ray and refer to chest center

17

If the patient presents with wheezes and

known as a case of COPD

Think that patient is having COPD with severe deterioration

if showed one or more of the following signs whether NEW COPD

case or under-treatment getting WORSE: 1. Extreme tachypnea or

2. Confusion, agitation or lethargy associated with breathlessness or

3. Not able to walk unaided or

4. Temperature less than 35 oC or

5. Oedema of both ankles or

6. Speaks only in single words or not at all or

7. Hemoptysis more than 50 ml or

8. Pleuritic chest pain

Manage as follows: 1. Give appropriate IM antibiotics.

2. Give oxygen.

3. Refer urgently to hospital with oxygen.

Consider the patient having COPD, developed ACUTE

INFECTION if showed one or more of the following signs:

1. Increased sputum production or

2. Sputum color becomes yellow or green (color change) or

3. Fever (37.5 oC or above)

Manage as follows: 1. Give appropriate oral antibiotics

2. Give routine follow-up care for known COPD (check regimen, compliance

with treatment plan from hospital. See below

3. If no treatment plan for COPD (new patient for example), refer to hospital

for evaluation.

4. If smoking, counsel to stop smoking.

5. Follow-up in 1 week

6. Advise when to return immediately

Consider the patient having STABLE COPD if showed NONE of

the above and manage as follows. 1. No new treatment

2. If smoking, counsel to stop smoking.

3. give routine follow up for known COPD care, see below

If no treatment card for COPD, refer to hospital for evaluation.

18

Staging and management of COPD whether at the first time or during follow up.

Stage IV

Stage III Stage II

Stage I Stage 0 No obstruction but at risk of

COPD

History of predisposing

factors Smoking, asthma, chronic respiratory infection, occupational dust inhalation

Symptoms

Chronic cough (>3 months) + expectoration

May be present

Chronic cough (>3 months) ± expectoration

Little or no dyspnea

Cough ± expectoration

Breathlessness on moderate

exertion

Breathlessness on any exertion or at rest, prominent cough and

wheezes.

Signs No abnormal

signs No abnormal

signs

↓ breath sounds Wheezes ± hypoxemia

(ABG or Pulse oximeter)

Cyanosis, lower limb oedema

Spirometry

FEV1> 80% of predicted

& FEV1/FVC>70%

FEV1≥ 80 % of predicted

& FEV1/FVC<70%

80>FEV1> 50 of predicted

& FEV1/FVC<70%

30 <FEV1<50% of predicted

& FEV1/FVC<70%

FEV1 < 30 % of predicted

& FEV1/FVC<70%

Classification

Chronic bronchitis

without obstruction

Mild COPD Moderate

COPD Severe COPD

Very severe COPD

Intervention Avoid risk factors e.g. smoking

Salbutamol, 3-4 puffs/day as needed

Salbutamol, 3-4 puffs/day as needed

+ Ipratropium bromide 2- 4 puffs/6 hours

Salbutamol, 3-4 puffs/day as needed

+ Ipratropium bromide 2- 4 puffs/6 hours

+ Corticosteroids

oral trial ±

Inhalation

Salbutamol, 3-4 puffs/day

as needed +

Ipratropium bromide 2- 4 puffs/6 hours

+ Corticosteroids

oral trial ± Inhalation

± Low dose of Sustained released

theophylline

If the patient presents with wheezes and

known as a case of Bronchial asthma Classify severity of wheezes and manage accordingly as mentioned before.

19

Second,

If the patient is coming for routine follow up 1- Routine follow up for patient with COPD

During the regular visits of the COPD patient, assess symptoms, side effects

and smoking.

ASK the patient if: Participating in usual physical activities?

Has any of symptoms worsened since last visit?

Sputum increased?

Sputum colour changed to yellow or green?

Developed any health problems?

Are you smoking, or still smoking if known smoker?

Have you needed any urgent medical care?

Have you been exposed to a new working environment that can be harmful for your

breathing?

If treated with theophylline; ask about any symptom of side effects: palpitations,

trembling, and abdominal pain?

Evaluate breathlessness if it is getting worse or new complaint, ask: Which effort you can make without getting short of breath? For instance, can you go up

stairs without any problem? How many blocks can you walk without any problem?

Has your breathlessness stayed the same, improved or got worse since last visit?

Has breathlessness awakened you at night?

Have you used the inhaler more than usual?

How often you actually take the medicine?

Ask about symptoms of heart failure Are your both feet swollen?

Do you need to elevate pillows to sleep?

Do you feel palpitations?

In all these patient, Listen for wheezes

Check the use of metered-dose inhaler

Look for:

Congested neck veins.

Oedema of both lower limbs

Tender enlarged liver with hepato-jugular reflux.

Listen for gallop rhythm and count heart rate per one minute.

Then do the following

1. Review treatment plan, treatment card, and treatment usage by the

patient.

2. Decide on management according to table of COPD staging and

management. See below

20

3. Plan for follow up or referral accordingly. If heart failure is a

problem refer to the hospital

4. Advice when to return for care:

Breathing gets worse

Fever

Increase in sputum

Change in color of sputum

Or new symptoms develop:

Swollen ankles

Cannot lie flat to sleep

Confusion

Problems walking

You are taking more medication than on your treatment plan

Refer to previous table of staging & management of COPD

21

2- Routine follow up for patient with Bronchial asthma:

1. Assess asthma symptoms, medication use and side effects.

Ask the patient

LOOK, LISTEN

- Has wheezing awakened you at

night? - Are you participating in your usual

physical activities? - Have you needed to use the inhaler

more than usual or prescribed? - Have you needed any urgent medical

care during the last month? - Do you feel any problems following

treatment or taking your medicine? - Have you ever stopped taking your

medicine during the last because you were feeling better?

- Are you still smoking?

Look for breathlessness. If yes, with what activity?

- At rest? - Talking? - Walking or making an effort?

- Check use of metered-dose inhaler. - Listen for wheezing.

2. Review treatment plan and determine: - In which step is the patient? - Are medications being used according to the step and written treatment plan? - Is patient in need to change the treatment plan, stepwise elevation or reduction? - Problem solve with patient/family to overcome barriers to following the plan. - Provide additional education to patient's environmental management.

22

Staging of asthma whether at the first time or during follow up

STEP IV

STEP III - Inhaled corticosteroid (Beclomethasone 2000 mcg/day on two divided doses). - SR Theophylline 200 mg/12 hours. - For uncontrolled asthma oral corticosteroids: prednisone 0.5 mgm/km/day.

- Inhaled

salbutamol as needed.

STEP II - Inhaled daily corticosteroid (Beclomethasone 1000 mcg/day on divided 2 doses). - SR thiophylline 200 mg/12 hours. - 2 puffs salbutamol when needed.

STEP I - 2 puffs salbutamol when needed. - inhaled daily low dose corticosteroids e.g. Beclomethasone* 500 mcg/day (divided on two doses)

2 puffs salbutamol when needed

Classification Mild Intermittent Mild

Persistent Moderate Persistent

Severe persistent

Clinical

characteristics

- Symptoms ≤ 2 episode per week. - Free between exacerbations. - Brief exacerbation, few hours to few days - Night-time symptoms≤ 2per month.

- Symptoms ≥ 2 episodes per week, but ≤ 1 per day. - Night-time symptoms ≥ 2 a month. - Exacerbation may affect activities.

- Daily symptoms - Exacerbation affects activity & >2 / week, may last days - Night-time symptoms >1 time a week

- Continual symptoms - Limited physical activity - Frequent exacerbations - Frequent night-time symptoms.

Measurement of peak expiratory

flow- PEF or FVC1

≥ 80% of predicted or

personal best (if known)

≥ 80% of predicted or

personal best (if known)

60-80% of predicted or

personal best (if known)

<60% of predicted or personal best

(if known)

23

DIAGNOSING COPD

COPD Definition, (American thoracic society): - COPD is a disease characterized by the presence of airflow obstruction due to

chronic bronchitis or emphysema; the airflow obstruction is generally progressive,

may be accompanied by airway hyper-reactivity and may be partially reversible.

- Chronic bronchitis is defined as the presence of chronic productive cough for

three months in each of two successive years in a patient in whom other causes of

chronic cough have been excluded.

- Emphysema is defined as an abnormal permanent enlargement of the air spaces

distal to the terminal bronchioles, accompanied by destruction of their walls and

without obvious fibrosis.

The diagnosis of COPD should be suspected based on the patient's medical history and

physical examination, but requires spirometry to determine the degree of airflow

limitation.

Signs/symptoms for which COPD may be suspected:

Wheezing, prolonged expiratory phase of respiration, rhonchi and cough

Dyspnea (exertional or at rest)

Chronic sputum production

Hyperinflation of the chest with increased anterior-posterior diameter

Use of accessory muscles of respiration

Pursed-lip breathing

Signs of cor-pulmonale:

- Increased pulmonic component of the second heart sound

- Neck vein distention

- Lower extremity edema

- Hepatomegaly

NOTE: finger clubbing is not characteristic of COPD and should alert the clinician to

another condition such as idiopathic pulmonary fibrosis (IPF), cystic fibrosis, lung cancer

or asbestosis.

COPD should also be considered if the patient has one or more of the following risk

factors:

- History of tobacco use or prolonged exposure to secondhand or environmental

smoke

- Asthma

- Environmental exposure to occupational dust and chemicals (e.g., cadmium)

- Alpha1- antitrypsin deficiency

- Chronic respiratory infections Pre- and Post-bronchodilator FEV1

It is important to distinguish COPD from asthma, because treatment and prognosis

differ. Measurement of pre- and post-bronchodilator FEV1 can assist with this

differentation. In asthma, the spirometric abnormality tends to return to normal with

bronchodilators, although this distinction between COPD and asthma is not strictly rigid.

Factors commonly used to distinguish COPD from asthma include age of onset, smoking

history, triggering factors and occupational history.

24

DIAGNOSING BRONCHIAL ASTHMA

Definition and Symptoms of Asthma

A. Definition of asthma Asthma is a chronic inflammatory disorder of the airways characterized by:

1. Airway inflammatory cells infiltration, including eosinophils, macrophages,

mast cells, epithelial cells and activated lymphocytes that release various

cytokines, adhesion molecules and other mediators.

2. Inflammation resulting in an acute, subacute or chronic process that alters

airway tone, modulates vascular permeability, activates neurons, increases

secretion of mucus, and alters airway structure reversibly or permanently.

3. Airway hyper-responsiveness in response to allergens, environmental

irritants, viral infections and exercise.

4. Airflow obstruction caused by acute bronchial constriction, edema, mucus

plugs, and frequently permanent remodeling.

B. Symptoms 1. Wheezing

2. Breathlessness

3. Cough, productive or dry

4. Chest discomfort

C. Pattern of symptoms 1. Perennial/seasonal

2. Episodic/continual

3. Diurnal

Ask for A. Symptoms suggestive of asthma:

Episodic wheezing and cough (Patient is completely free between the attacks)

1. With nocturnal, seasonal or exertional characteristics.

2. Infants and children with frequent episodes of "bronchitis" are likely to have

asthma.

B. Asthma triggers: 1. Viral respiratory infections

2. Environmental allergens

3. Exercise, temperature changes, humidity

4. Occupational and recreational allergens or irritants

5. Environmental irritants (perfume, tobacco smoke, wood-burning stoves)

6. Drugs (aspirin, NSAID, beta blocker) and food presrvatives (sulfites).

C. Family history Atopy and positive family histories for asthma..

I. Look for breathlessness

II. Listen for chest wheezes

III. Clinical testing: 1. Spirometry is recommended in every patient 5 years of age or older at the time of

diagnosis if available.

25

2. Additional studies include:

1. chest radiography, to exclude alternative diagnosis

2. Gastro-esophageal reflux disease, GERD, evaluation

3. CBC with eosinophilia,

4. sputum examination for eosinophils,

5. Stool analysis to exclude parasites. Refer to staging table

26

Appropriate antibiotics

1. Appropriate Antibiotic before referral of severely ill patients

(If delay to reach the hospital is more than 4 hours)

- For Severe Pneumonia or Very Severe Disease

First choice antibiotic: Ceftriaxone + macrolide

Second choice antibiotic: amoxicillin + aminoglycoside

- For COPD with Severe Deterioration (COPD with severe exacerbation)

First choice antibiotic: Ceftriaxone

Second choice antibiotic: Ciprofloxacine

Or Amoxicillin Clavulanate

Appropriate weight adjusted doses of some appropriate antibiotics

Weight Benzylpenicillin

Dose: 50.000 units/kg

Ceftriaxone Ciprofloxacine Amoxicillin

Clavulanate

1 000 000 units

Add 2.1 ml diluent = 2.5

ml at 400 000 units / ml

Vial

1 gram

Tablet

500 mg

Tablet

250 mg

Tablet Amoxicillin

500 mg /

Clavulanate

125 mg

30-39 kg 4 ml 1 g 1 ½ 3 2

40-49 kg 6 ml 1 g 1 ½ 3 3

50-59 kg 7 ml 1 g 1 ½ 3 3

60-69 kg 8 ml 1 g 1 ½ 3 3

2. Appropriate Oral Antibiotic for treatment at home - For Pneumonia (not severe)

First choice antibiotic: Erythromycin

Second choice antibiotic: doxycillin

Or amoxicillin.

- For COPD with Acute Infection (COPD with non-severe complication)

First choice antibiotic: Amoxicillin Clavulanate

Second choice antibiotic: erythromycin or Cotrimoxazole

27

Appropriate weight adjusted doses of antibiotics

Antibiotic Presentation Dosage

Erythromycin Tablet 500 mg 1 tablet every 6 hours

Amoxicillin Cap 500 mg 1 Cap every 8 hours

Amoxicillin-

Clavulanate

500 mg Amoxicillin +

125 mg clavulanate

2 tablets every 12

hours

Cotrimoxazole

80 mg trimethoprim +

400 mg

sulphamethoxazole

1 tablet every 12 hours

Ciprofloxacine Tablet 500 mg 1 tablet every 12 hours

28

Health education and patient information

Counsel the asthma patient and his family how to self-administer the asthma medication

Also, counsel the patients about following up his condition and the symptoms that

necessitate his urgent visit to a health center according to the following table:

RED ZONE

Breathlessness at rest Can only speak only in single words Confused, agitated, or abnormally sleepy

Immediate emergency visit, during the day

or at night, to a health centre or hospital

PINK ZONE

Symptoms of moderate asthma attack Cannot walk because of asthma

Immediate treatment for an attack: inhaled

salbutamol every 20 minutes to be repeated, if no response, for one hour max.,

If there is no response, immediate visit to a health care unit

YELLOW ZONE

Cough or frequent clinical signs of breathlessness

Asthma symptoms disturb sleep or other usual daily activities

Asthma symptoms today are worse than yesterday (getting worse)

Take extra medications for mild attacks:

inhaled salbutamol every 4 to 6 hours, and oral prednisone 0.5 mg / kg

If no improvement, visit a health centre

GREN ZONE

No asthma attacks No asthma symptoms at night Able to do usual daily activities

Good control of asthma – continue with

usual treatment plan

Explain treatment plan to patient and his family

Review asthma self-management using the 4 zones; when and where to seek care

Check patient's understanding of the indications.

Explain controller and quick-relief treatments clearly, using actual medications.

Assure adequate supply of medications until next visit, if the drugs are provided by the health service. If not, explain to the patient the need to take regularly the drugs, without interruptions, until the next visit.

Reinforce prevention plan:

- Reduce, then stop smoking - Avoid environments with tobacco smoke, wood smoke, home cleaning dust and

irritating odours such as perfumes, disinfectants and detergents. - Not to have pets such as cats and dogs at home. - Avoid sudden changes of temperature.

29

CHECK USE OF METERED-DOSE INHALER

Teach and check use of metered-dose inhaler

Use a commercial spacer with mouthpiece, except if the patient cannot tolerate it or cannot use it because of breathlessness, use a spacer with mask. Use a plastic bottle as a substitute if the patient can’t afford the spacer.

Ask patient to show how (s)he takes the inhalations.

Check whether the patient co-ordinates the in-breath with the inhaler activation.

If incorrect, demonstrate the correct technique; then ask the patient to do it, see below.

30

Metered-dose inhaler Through a spacer

& mouthpiece

Metered-dose inhaler Through a spacer

with mask

1. Remove the inhaler cap 1. Remove the inhaler cap

2. Shake the inhaler and insert it into the base of the spacer

2. Shake the inhaler and insert it into the base of the spacer

3. Breathe out slowly and steadily 3. Encourage the patient to breathe out, if (s)he can cooperate

4. Hold the mouthpiece of the spacer in your mouth – seal the lips around it

4. Put the mask over the patient's mouth and nose

5. Press the inhaler to release the correct number of puffs into the spacer

5. Press the inhaler to release the correct number of puffs into the spacer

6. Breathe in through your mouth slowly and as deeply as possible

6. Watch while the patient breathes in and breathes out 8 to 10 times

7. Hold your breathe for 10 seconds before you breathe out slowly and steadily. Withdraw the spacer before you breathe out.

7. Then withdraw the spacer with the mask and the inhaler

8. Clean the spacer with cold boiled water after each use. Discard the spacer after having used it for 3 months and purchase a new one.

8. Clean the spacer with cold boiled water after each use. Discard the spacer after having used it for 3 months and purchase a new one.

Metered-dose inhaler with a plastic bottle

I) TEACH HOW TO MAKE A SPACER WITH A PLASTIC BOTTLE

- Use one litre plastic bottle. - Cut and discard the upper third of the bottle. - Remove the inhaler cap and draw the inhaler mouth in the middle of the bottle base,

directly opposed to the open side of the bottle. - Cut a hole on the bottle base exactly, or slightly smaller than the size of the drawing

made over there. - Insert the inhaler into the bottle small hole to check the size. - Cut a small V in the border of the large open part of the bottle to fit to the patient's

nose. II) TEACH THE PATIENT HOW TO USE IT:

- Remove the inhaler cap

- Shake the inhaler and insert it into the base of the spacer bottle

- Breathe out slowly and steadily

- Put the open part of the bottle over the patient's mouth and nose

- Press the inhaler to release the correct number of puffs into the bottle

- Watch while the patient breathes in and breathes out 8 to 10 times

- Then withdraw the plastic bottle

- Clean the plastic bottle with cold boiled water after each use. Disregard the spacer after having used it for 2 weeks, make a new one.

31

EDUCATE PATIENT AND HIS FAMILY ABOUT COPD - COPD develops and progresses slowly - Smoking and indoor air pollution are the main causes of COPD. - It is essential to stop smoking and avoid the dust, the tobacco smoke, the wood smoke

and other smokes. - The lung damage cannot be reverted. But progression can be slowed and things can be

done to minimize disability from COPD: Good treatment plan, and good compliance with the plan Stop smoking Exercise regimen Correct breathing Good nutrition Good psychological and family support Avoid contact with people with colds and other respiratory infections Return to the health centre for medical follow-up when prescribed.

When to return to the health centre before the date of the scheduled visit:

- Breathing gets worse - Fever - Increase in sputum - Change in colour of sputum - New symptoms:

Swollen ankles Cannot lie flat to sleep Confusion Problems to walk Chest pain (possible pneumothorax) Haemoptysis Needs more medication than that prescribed in the treatment plan

Advise exercise regimen

- Physical reconditioning makes breathlessness to happen with less and less exertion

- Stay active. Gradually build up to an exercise regimen (some start with only a 5 minutes walking and increases gradually.

Do daily leg exercises: 10 minutes warm-up with stretching and breathing exercises; use salbutamol or

ipratropium bromide before exercise. 20-30 minutes walking (when limiting symptoms, rest, then continue) 10 minutes slow walking. Monitor periodically by seeing how far the patient can walk in 12 minutes at a

steady pace Arm exercises:

For 2 minutes, in same rhythm as breathing: lift 750 grams weight to shoulder level, then rest 2 minutes.

Build up to 5 - 6 repetitions; then gradually increase weight

* If severe COPD, refer to respiratory rehabilitation if available. If not, supervise very gradual use of the above exercise regimen. Teach exercises to improve chest movement, see below.

Teach strategies to overcome breathing problems

Breathes out slowly – count to 3 when breathing in, and to 6 when breathing out Breathe out with pursed lips Use diaphragmatic breathing (teach patient how to do this, see below)

32

Not to rush Rest between tasks Use temporary relaxation positions to ease breathing, for instance, lean against

wall. Organize to spread out energy-demanding tasks.

Diaphragmatic breathing: (to teach the patient how to use his diaphragm)

1. Lie on your back with knees bent. You can put a pillow under your knees for support. 2. Place one hand on your belly below your rib cage. Place the other hand on your chest. 3. Inhale deeply through your nose for a count of 3. (Your belly and lower ribs should

rise, but your chest should remain still.) 4. Tighten your stomach muscles and exhale for a count of 6 through slightly puckered

lips.

COPD and Exercise: When to Stop

If patient experiences any of the following signs or symptoms, stop COPD exercise program right away. Patient should sit down and keep your feet raised while resting. If patient doesn't feel better quickly, he should call doctor.

Nausea Dizziness Weakness Rapid or irregular heart beat Severe shortness of breath Pain Pressure or pain in your chest or your arm, neck, jaw, or shoulder

Counsel on nutrition

Good nutrition helps prevent infections and keeps the breathing muscles strong. If possible, refer the patient to an specialist in nutrition. Eat small, frequent meals (avoid a very full stomach which can interfere with

breathing) Eat energy- and nutrient-rich foods Avoid foods which cause bloating Drink frequent glasses of water to keep respiratory secretions thin and easy to

cough up If severe COPD with wasting, follow special diet form to regain weight. Avoid carbohydrates diet to avoid excess CO2 production.

Counsel on indoor air pollution

Keep always the kitchen or room where meals are cooked well ventilated. If possible, cook with wood in the courtyard outside the house, or build a

domestic oven with bricks and with a chimney to eliminate the smoke outside.

COUNSEL TO STOP SMOKING

Ask further questions about smoking

- How much do you smoke?

- Are you interested in quitting now?

- What triggers smoking? What are your reasons for continuing to smoke?

- Have you ever attempted to quit? What caused relapse?

33

Advice to quit. Advice should be:

- Clear: "It is important to quit smoking now. I can help you. Cutting down while you are ill is not enough"

- Strong: "Quitting smoking is the most important thing you can do to protect your current and future health"

- Personalized: Review reason for quitting: cost of smoking; impact on children and others in household; link smoking to current symptoms or illness; psychological-freedom from dependency; dirty habit (stains your fingers, gives you bad breath and yellow teeth). Smoking does control weight but it is artificial control. Quitting smoking improves health, improves sport performance, food tastes better.

If smoker has a smoking-related problem, link symptoms or illness with smoking. Common conditions attributable to smoking:

- Cough - Stomach ulcers

- Breathlessness - Vascular disease, “poor circulation”

- Bronchitis - Angina, coronary disease

- Angina, coronary disease

- Sore throat - Wrinkles - Teeth and gum problems

- Colds and other respiratory infections are more common, severe, last longer

- More respiratory infections and asthma in infants and children if someone smokes inside the home

- Smoking by pregnant woman or at her home can cause low birth weight.

Assist the smoker in quitting:

Encourage the smoker to set a quit date.

Help him prepare for quitting. The patient must:

- Inform family and friends and ask for understanding and support

- Prepare the environment: remove cigarettes. Avoid tobacco smoke in home and other places where much time is spent

- Review previous quit attempts. What helped? What led to relapse? What triggers smoking?

Give key advice:

- Quit totally - not even a single puff after the quit date. Even a single puff increases the likelihood of a full relapse.

- Alcohol often leads to relapse. Review use; plan to limit or abstain while quitting.

- Other smokers in household. Try to quit together. No smoking in the home.

- If patient can afford it, advise to use nicotine patch or gum (4 mg) and/or seek specialized help for quitting. This is especially important for heavy smokers.

- Anticipate challenges / withdrawal symptoms (moody, can't sleep, coughing, difficult concentration)

- If they feel like a cigarette:

◦ Take deep breaths

◦ Drink lots of water

◦ Do something else - keep busy especially with the hands

◦ Delay. Wait a bit and the feeling will pass

- Worst is over in 3 days but symptoms may be gone in 7-10 days

34

Follow-up smokers

If successful in quitting or significantly reducing.

- Praise patient.

- Review techniques.

- Troubleshoot.

If unsuccessful in quitting

- Encourage continued efforts.

- Study what triggered relapse.

- Discourage self-punishing thoughts.

- Even reducing number of cigarettes has some health benefits but usually ends up relapsing to more smoking.

- Set another quit date.

- Consider referral to a group for intensive smoking cessation support, if available

- Suggest nicotine patches or gum, if available.

Encourage the patient to talk about the quitting process.

- Reasons the patient wants to quit.

- Difficulties encountered while quitting.

- Success the patient has achieved.

Provide health facility support for smoking cessation

Set an example:

- Health workers should not smoke in clinic.

- Health workers should be helped to stop smoking

Make the clinic a free-smoke area,

Post clear No Smoking signs and educational posters

Devise a system to indicate smoking status in patients charts.

Special advice for patients with COPD

It is essential to stop

It is not too late

Stopping smoking is the only way to slow your lung problems getting worse.

35

رج إزاح

زذاخ ارػا٠ح الأضاض١ح إ زذاخ اؿذر

(راوس طرػف١اخ)يستخذم لىحذاخ الزعايح الأساسيح الت لن يطثك تها تزاهج طة الأسزج

:-------------- هحافظح

------------------------- الإدارج الصحيح

-------------- اسن وحذج الزعايح الأساسيح

------------------------------------ وحذج الصذر الت يتن التحىيل إليها

------------------------------------------------------- اسن الوزيط

-------- السي-------- الىع

----------------------(ههن ف حالح الاشتثا تالذرى)عىاى الوزيط تالتفصيل

------------------------------------------------------------------------------

------------------------------------------------------------------------------

----------------- ألزب تليفىى للوزيط-------------- تليفىى الوزيط

------------------------ الغزض هي التحىيل

تميين و هزاجعح خطح العلاج لوزظ السذج الزئىيح - إجزاء أتحاث و تحاليل)

(والحساسيح الصذريح

- وظائف تفس- تحليل تصاق للذرى- أشعح عل الصذر): الأتحاث الوطلىتح

(أخزي

-------------------------------

-------------------------------

رد زذج اؿذر

(يذكز تائج التحاليل أو الزأي ف خطح العلاج)

-----------------------------------------------------------------------------

------------------------------------------------------------------------------

------------------------------------------------------------------------------

------------------------------------------------------------------------------

------------------------------------------------------------------------------

------------------------------------------------------------------------------

------------------------------------------------------------------------------

36

عناوين وحدات الأمراض الصدرية اؼا ازذج اسافظح

امارج

ذ٠ح ؿر– ظ اطىح اث١ضا طرػف ؾذر اؼثاض١ح 1

ظ و١ح اذضح تدار اسذ٠مح ا١اتا١ح زا 2

طاو أطص96داخ طاو اسا٠ح أا دغ اذارش ب اسا٠ح اسراء 3

أا لط اا٠– اؼثاض١ح – ظ ار تاغا 7 طرؾف ؾذر اؼثاض١ح 4

تلأق أت اؼلأ 5خف تلأق – ظ اطثؼح الأ١ر٠ح – ١ذا ض١ذ ػثذ ادا د

اذورر اؼا

ظ ازذ ز غثرا 6

خف طرػف ض١ذ خلأي– ظ اثىر٠ح تاب اػؼر٠ح 7

اطر٠ح– رفرع ظ اؿسح – ظ اث١طار 4 اطر٠ح 8

أا لط اذرب الأزر– اذرب الأزر – ظ ػ تاغا 17 اذرب الأزر 9

1

0 تدار اد ػأج اؾر– اروس اطث ػ١ح اؾر

1

1 طاو أت ار٠ع– تدار ارأ١ ا اط١ذج ز٠ة

1

2 اا ذرضح اردارج تاخ – 22دارج – 1ث ا٠ 15

1

3 اع– اضىذر٠ح ذ٠ح اطلأ

اد١سج

اؼرا١ح– ظ ذرػح اسر ار طرػف ؾذر اد١سج 1

اد١سج– خف طرػف أ اؿر١٠ طرؾف اد١سج 2

إثاتح– تدار اطاتغ الأ١ر٠ح – ظ طؼد زرب 2 إثاتح 3

اؼ١اط اؼ١اط 4

اثذرغ١ اثذرغ١ 5

أض١ أض١ 6

اؿف اؿف 7

ام١ت١ح

23١٠أا سطح امطار 23١٠ ؾذر ارج 0 1

تدار ذ٠ر٠ح اؿسح طرػف تا 2

غث١ اماطر طرؾف غث١ اماطر 3

طرؾف غثرا اخ١ح 4

ػ١ادج اؿذر تطرػف اماطر اخ١ر٠ح اروس- اماطر اخ١ر٠ح اماطر اخ١ر٠ح 5

ػ١ادج اؿذر تطرػف ومر غىر اروس- وفر غىر ومر غىر 6

روس اثسز ا١ذا١ح ارطث١م١ح تم١ب- ل١ب اثذ ل١ب 7

اذل١ح

اؿرج طرػف ؾذر اؿرج 1

غرت١ ؾذر غرت١ 2

دورص ؾذر دورص 3

اسح ؾذر اسح 4

ػ١ح اثذار ؾذر تخ 5

غثرا ر ؾذر غثرا ر 6

١د غر ظ اسطح ػارج ؾ١ذا طرؾف ؾذر ١د غر 7

اا زذ٠ث الأضرج طرؾف ؾذر اطثلأ٠ 8

تماش–اطا طرؾف ؾذر تماش 9

1

0 ١د ات اسارز اخا طرؾف ؾذر اخا

1

1 سك تطرػف ثرج اروس طرؾف ؾذر ثرج

أض١ط

ظ ازذ زط اثالر تدار ذ٠ر٠ح اؿسح طرػف ؾذر أض١ط 1

طرػف فط اروس0 زذج ؾذر فط 2

طرػف امؾ١ح اروس زذج ؾذر امؾ١ 3

طرػف د٠رط اروس زذج ؾذر د٠رط 4

طرػف اتب اروس زذج ؾذر اتب 5

طرػف ضاز ضث اروس زذج ؾذر ضاز ض١ 6

طرػف اثذار اروس زذج ؾذر اثذار 7

طرػف أت ذ١ح اروس زذج ؾذر أت ذ١ح 8

طرػف ؾذفا اروس زذ ؾذر ؾذفا 9

37

اؼا ازذج اسافظح

1

0 زذ ؾذر اغا٠

طرػف اغا٠ اروس

د١اط ذ٠ح د١اط د١اط 1

فارضىر فارضىر 2

ت ض٠ف

ت ض٠ف طرػف ؾذر ت ض٠ف 1

افػ طرؾف ؾذر افػ 2

ااضط طرؾف ؾذر ااضط 3

تثا طرؾف ؾذر تثا 4

ضططا طرػف ؾذر ضططا 5

اؾر طرؾف ؾذ اؾر 6

اف١

ذ٠ح اف١ طرػف ؾذر اف١ 1

ضرش طرؾف ؾذر ضرش 2

اتػا طرؾف ؾذر اتػا 3

طا١ طرؾف ؾذر طا١ 4

اططا طرؾف ؾذر اططا 5

وفر اػ١خ

ظ اسافظح وفر اػ١خ طرػف ؾذر وفر اػ١خ 1

تدار طرػف ز١اخ دضق طرؾف دضق 2

طرػف ض١ذ ضا اروس طرؾف ض١ذ ضا 3

دغ اؼ١اداخ اػاح را١ اؿس طرؾف ف 4

طرػف تط١ اروس طرؾف تط١ 5

طرػف ل١ اروس طرؾف ل١ 6

طرػف ت١لأ اروس طرؾف ت١لأ 7

تدار اطرػف اروس تطتص طرؾف طتص 8

ضاج

ظ ارسر٠ر تطاج طرػف ؾذر ضاج 1

ظ اطرػف تدرخا طرػف ؾذر خرخا 2

طر٠ك اخ١ ضاج طرؾف ؾذر اخ١ 3

ظ اػ١ذ ػثذاؼ ر٠اـ طرؾف ؾذر اػاج 4

غارع اطرػف تاث١ا طرؾف ؾذر اث١ا 5

روس دار اطلأ طرؾف ؾذر دار اطلأ 6

ظ ؾلأذ ضا تططا طرؾف ؾذر ططا 7

ظ ازذ ػرات تطا طرؾف ؾذر طا 8

ذ٠ح طرذ طرػف ؾذر طرذ 1 رض طرذ

اف١ح

غث١ اى– ١د خف طرػف ؾذر غث١ اى 1

روس ف طرػف ؾذر ف 2

زا٠ح ااػرج روس اػذاء طرػف ؾذر زا٠ح ااػرج 3

اثاخر– ظ ترضؼ١ذ تدار ؾ١ذا طرؾف ؾذر اثاخر 4

روس اػذاء– طرػف اػذاء اروس طرؾف ؾذر اػذاء 5

روس ل٠طا– طرػف ل٠طا اروس طرؾف ؾذر ل٠طا 6

روس ذلأ– طرػف ذلأ اروس طرؾف ؾذر ذلأ 7

روس تروح اطثغ– طرػف تروح اطثغ اروس طرؾف ؾذر تروح اطثغ 8

الإدارج اؿس١ح تروس اغ طرؾف ؾر اغ 9

الإضىذر٠ح

اذرج- ظ اث اذش طرػف ؾذر اؼرج 1

ورز– ظ خف طرػف ؾذر و اػمافح 2

اذرج- ظ اث اذش طرؾف ؾذر اؼرج 3

تاوش– ظ اطق طرؾف ؾذر تاوش 4

سر ته–ظ ا١رز طرؾف ؾذر سر ته 5

ظ اى اا ؾر اررضاح اثسر٠ح طرؾف ؾذر امثار 6

ادرن- ظ اط١ذ سذ ور٠ طرؾف ؾذر ادرن 7

اؼار٠ح– ظ دذ اػرلا طرؾف ؾذر اؼار٠ح 8

ورز– ا٠ح ظ خف طرؾف ؾذر ورز 9

تر ضؼ١ذ ١٠ اا اضراد ترضؼ١ذ23ظ طرػف اؿر اثسر 1

سك تطرػف تر فؤاد طرؾف ؾذر تر فؤاد 2

أضا

ظ و١ح اررت١ح ؾذر اضا 1

اىفر- و اث ؾذر و اث 2

ادف ارد٠ط١ح ؾذر ادف 3

38

اؼا ازذج اسافظح

اػرل١ح

ذ٠ح اسلاز٠ك طرػف اؿذر تاسلاز٠ك 1

ذ٠ح تث١ص طرؾف ؾذر تث١ص 2

ذ٠ح فالش طرؾف ؾذر فالش 3

ذ٠ح ١ا امر طرؾف ؾذر ١ا امر 4

ذ٠ح اسط١١ح طرؾف ؾذر اسط١١ح 5

ذ٠ح ات زاد طرؾف ؾذر ات زاد 6

ذ٠ح د٠رب د طرؾف ؾذر د٠رب د 7

ذ٠ح ات وث١ر طرؾف ؾذر ات وث١ر 8

ذ٠ح وفر ؾمر طرؾف ؾذر وفر ؾمر 9

1

0 ذ٠ح ١ا طرؾف ؾذر ١ا

1

1 ذ٠ح ػري اطق طرؾف ػري اطق

1

2 ذ٠ح الأترا١١ح طرؾف ؾذر الأترا١١ح

ا١ا

ذ٠ ا١ا طر٠ك ؿر أضا طرػف ؾذر ا١ا 1

ذ٠ تدار طرػف اؼا طرػف ؾذر 2

ذ٠ ت سار طر٠ك ؿر أضا طرػف ؾذر ت سار 3

د٠ر اش اروس0ذ٠ د٠ر اش ذاتغ طرؾف ؾذر د٠ر اش 4

ات لرلاؼ اروس0ذ٠ ات لرلاؼ ذاتغ ؾذر ات لرلاؼ 5

ضا ط اروس0ذ٠ ضاط ذاتغ طرؾف ؾذر ضاط 6

طا اروس0ذ٠ طا ذاتغ طرؾف ؾذر طا 7

طرػف غاغح اؼا طرؾف ؾذر غاغح 8

اؼذج اروس0ذ٠ اؼذج ذاتغ طرؾف ؾذر اؼذج 9

اغرت١ح

ططا– ظ اد١ع تدار اؼ١ادج اػاح طرػف ؾذر ططا 1

أا ػ١ح اثىر– اسح طرػف ؾذر اسح 2

اسح اىثر– أا ػارج الألاف – ظ اد١ع طرؾف ؾذر اسح 3

أا ظ اىرتاء- ظ اطرػف امذ٠ح وفر اس٠اخ 4

ز١اخ زفر– تدار سطح امطار زفر 5

23١٠ارذاد ظ – داخ ث طرػف تط١ تط١ 6

اططح تدار روس اططح اططح 7

ظ اسطح– ضد ضد 8

طر٠ك وفر اػ١خ اسطح– لطر لطر 9

اثس١رج

ظ ادر٠ح– تدار اؼذ اطث – در طرػف ؾذر در 1

تدار طرػف وفر اذار اؼا– ظ اثسر وفر اذار 2

اغثػح– أدف١ا أدف١ا 3

ذ٠ح زظ ػ١ط– طرػف زظ ػ١ط اروس زظ ػ١ط 4

طرػف ا٠را اثارد اروس– ذ٠ح ا٠را اثارد ا٠را اثارد 4

طرػف رغ١ذ اروس– ظ اثسر – ذ٠ح رغ١ذ رغ١ذ 5

تذ٠ح غثراخ١د– اطرػف اروس غثراخ١د 6

اطرػف اروس– ذ٠ح اذداخ اذداخ 7

اطرػف اروس– ذ٠ح أت اطا١ر أت اطا١ر 8

ذ٠ح أت زؽ– اروس اطث تأت زؽ أت زؽ 9

1

0 ذ٠ح و زاد– طرػف و زاد اروس و زادج

1

1 اسد٠ح– ظ ذرػح ارغ١ذ٠ح – اسد٠ح اروس اسد٠ح

1

2 ارزا١ح– طرػف ارزا١ح اروس ارزا١ح

لا

(اطرػف١اخ ضاتما ) ١٠ 26ظ طرػف ؾذر لا 1

ارجطرؼر طرػف ؾذر اضا 2

طرػف دغا اروس طرؾف ؾذر دغا 3

طرػف دغ زاد اروس طرؾف ؾذر دغ زاد 4

طرػف فرغط اروس طرؾف ؾذر فرغط 5

ظ اطرػف– طرػف ات ذػد اروس طرؾف ؾذر ات ذػد 6

ظ ادر٠ح– طرػف لؼ اروس طرؾف ؾذر لؼ 7

39

اؼا ازذج اسافظح

طرػف ارد اروس طرؾف ؾذر ارد 8

ااد ادذ٠ذ روس اخارخح طرػف ؾذر اخارخح 1

ذ٠ح ط– روس اذاخح طرػف ؾذر اذاخح 2

ذ٠ح اط٠ص طرػف ؾذر اط٠ص 1 اط٠ص

ذ٠ح الاضاػ١١ح طرػف ؾذر الأضاػ١١ح 1 الأضاػ١١ح

الالؿر الألؿر 1 الألؿر

اغردلح اغردلح 1 اثسر الأزر

اؼر٠ع طرػف ؾذر اؼر٠ع 1 غاي ض١اء

- - خب ض١اء