Pulmonary Disease Flashcards
Asthma
Chronic inflammatory airway disorder
(3)
- Airway hyper-responsiveness to stimuli
- Bronchial edema
- Narrowing of the airways i.e., obstruction
Asthma
Signs and Symptoms
Recurrent, reversible episodes of:
(4)
*Dyspnea (shortness of breath)
*Wheezing
*Coughing
*Tightness of chest
Which of the following is a “true”
asthma symptom?
*Dyspnea (shortness of breath)
*Wheezing
*Coughing
*Tightness of chest
*Tightness of chest
Asthma
Aggravating/Complicating Factors
(2)
● Smoking
● Air pollutants (quality)
- urban
- industrial
Asthma
Staging Asthma
(3)
- Controlled
- Partially Controlled
- Uncontrolled
Asthma
Types of Asthma
(4)
- Extrinsic
- Exercise Induced
- Intrinsic
- Drug Induced
- Extrinsic (allergic or atopic)
(5)
*Most common
*Children and young adults
*Typical positive family history
*Triggered by allergens (pollen, dust, house
mites, animal dander, mold etc.)
*Exaggerated inflammatory response
Exaggerated inflammatory response
Allergen → T Helper Lymphocyte Type 2 (Th2)→ antibody production of high levels of IgE → activation of mast
cells, basophils and eosinophils → bradykinin, histamine, leukotrienes → bronchoconstriction
- Exercise-induced
(4)
*Unknown pathogenesis
*Children and young adults
*Triggered by exercise and thermal changes
*Cold air irritates mucosa resulting in airway
hyperactivity
- Mucosal inflammatory response to cold air or other irritant
Allergen → activation of mast
cells, basophils and eosinophils → bradykinin, histamine, leukotrienes → bronchoconstriction
- Intrinsic (idiosyncratic, nonallergic, nonatopic)
(5)
- Second most common
- Middle-aged individuals
- Triggered by respiratory irritants (tobacco, air
pollution, emotional stress, gastroesophageal reflux
disease (GERD) - Infrequently associated with family history
- Normal IgE levels
- Normal IgE levels
Allergen → lymphocytes→ activation of mast cells,
basophils and eosinophils → bradykinin, histamine,
leukotrienes, interleukins → bronchoconstriction
- Drug-induced
(2)
- Subset of intrinsic
- Affects children, young adults & middle-aged adults
- Drug-induced
* Common antigens
(6)
➢NSAIDs, ASA (acetyl salicylic acid)
➢β-blockers
➢ACE (angiotensin-converting enzyme) inhibitors
➢Anticholinergic drugs (?)
➢Food dye
➢Metabisulfites in food and in local anesthetics with
epinephrine
Asthma
Treatment
(3)
Inhaled beta-2 (ẞ2)agonists
Short acting ẞ2 agonists
Long acting ẞ2agonists
Inhaled beta-2 (ẞ2)agonists
bind to ẞ2
receptors in lungs
smooth muscle relaxation
i.e., bronchodilation
Short acting ẞ2 agonists
are single use (rescue) medications used alone
Long acting ẞ2agonists
used in combination with steroids on a scheduled protocol
used alone leads to CVD complications ( arrythmias, etc.)
Asthma
Treatment
Side Effects
(4)
Tremors, tachycardia
Increases blood sugar
Cough
K decrease
Asthma
Oral Signs
(6)
*Mouth breather (high palatal vault, overjet,
crossbite, greater facial height)
*Dry mouth
*Candida
*Enamel defects and caries
*Gingivitis/periodontitis
*Enamel erosion possible with GERD
Unstable Asthma
* Dental treatment should be limited to
* Treatment of (3)
urgent care
only
acute pain, bleeding, or infection
Stable Asthma
(2)
- Any indicated dental treatment may be provided if
management protocols are considered - Consult with physician for severe persistent
asthma
Drug Interactions - I
(4)
- Aspirin can trigger asthma
- NSAIDs can trigger asthma
- Opioids and barbiturates
- Sulfites in epinephrine preparation of local anesthetics
- Aspirin can trigger asthma
➢Avoid in susceptible patients
- NSAIDs can trigger asthma
➢ Avoid in susceptible patients
- Opioids and barbiturates
➢ Worry about respiratory depression; avoid use
- Sulfites in epinephrine preparation of local anesthetics
➢Avoid in susceptible patients
Drug Interactions - II
(2)
- Theophylline and macrolides or ciprofloxacin
- Cholinergic agonists
- Theophylline and macrolides or ciprofloxacin
(3)
➢Potent inhibition of CYP3A4
➢Increases levels of theophylline
➢Toxicity (arrhythmia and seizures)
- Cholinergic agonists
(2)
➢Effect of cholinergic agents promotes bronchoconstriction
➢Sialogogues are contraindicated in patients with uncontrolled
asthma
Status Asthmaticus →
Severe prolonged asthma attack (more than 24 hours)→ life threatening
- Identify patients with asthma by history
(2)
➢Do you have asthma?
➢When did you first develop asthma?
- Determine character of asthma
(1)
➢Type (allergic or non-allergic)
oWhat type of asthma do you have?
➢Precipitating factors
(5)
oWhat triggers an asthma attack for you?
oDoes anxiety or stress bring on an attack?
oDo you have dental anxiety?
oHave you ever had local anesthesia for dental
procedures?
oHave you ever had a problem with dental anesthesia
Management
➢Medications
oWhich medications are you taking for your asthma?
skipped
➢Level of Control/Severity
(6)
oHow often do you use your inhaler?
oDoes your inhaler have a spacer?
oHow many asthma attacks/week?
oDo you have any night time attacks?
oHave you ever been to the emergency room or been
hospitalized for an asthma attack?
oDo you have a spirometer to keep a record of your lung
function
Dental Treatment Considerations
* Avoid known — factors
* Reduce risk of attack:
(2)
precipitating
➢Have patient bring medication inhaler to each
appointment
➢Recommend prophylaxis with inhaler before
appointments for those with moderate to severe
asthma.
Drugs to avoid:
(2)
➢Aspirin, NSAIDs, Narcotics, Macrolide antibiotics
like erythromycin.
➢Sulfite (preservative) containing local anesthetics
may need to be avoided.
Sedation for Dental Anxiety
(2)
➢Nitrous (better)
➢Short-acting benzodiazepine
- — for severe persistent asthma
Med Consult
SoD Asthma Emergency
Patient presentation
(3)
- Respiratory rate >25 breaths/min, labored breathing
- Tachycardia >110 beats/min
- Flushed appearance
SoD Asthma Emergency
Stop treatment, inform supervising faculty, administer —
, and call —
➢ Remove all items from patient’s mouth
➢ Record the — attack began
➢ — the dental chair
➢ Give —
-adrenergic agonist inhaler
➢ Administer —
o Administer —
o Call an ambulance
o Re-administer —
-adrenergic agonist inhaler every –
minutes until EMS arrive
o The emergency team will continue treating the patient with
bronchodilators and oral systemic corticosteroids
O2, 4444
time
Raise
short-acting β2
oxygen
0.3-0.5 ml of 1:1000 epinephrine –small doses are SM dilators
short-acting β2
20
I. Chronic obstructive bronchiolitis (obstruction small airways)
- Excessive tracheobronchial mucus production to cause
coughing and sputum production for >3 months for >2
consecutive years in the absence of infection or other causes
of chronic cough
II. Emphysema
(3)
- Longterm Chronic obstructive bronchiolitis leads to destruction
of lung parenchyma and alveolar walls - Decreased elastic recoil
- Difficulty in maintaining airway opening during expiration
Type II is a progression of
Type I leading many to just use these
as descriptive terms for COPD.
3rd leading cause of death in USA
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease (COPD)
Characteristics
Corticosteroid-resistant progressive chronic inflammatory
disease
* Poorly reversible/irreversible airway obstruction
* Entrapment of air and dyspnea upon exertion
Chronic Obstructive Pulmonary Disease (COPD)
Aggravating/Complicating Factors
(3)
● Smoking
● Air pollutants (quality)
- urban
- industrial
● CVD
- comorbidity
Chronic Obstructive Pulmonary Disease (COPD)
Signs and Symptoms
(3)
- Dyspnea
- Cough
- Sputum
Staging COPD
Exacerbations
Triggered by viral or bacterial infections
(3)
- Haemophilus influenza
- Moraxella catarrhalis
- Streptococcus pneumoniae
Staging COPD
Complications
(4)
- Pulmonary hypertension
- Cor pulmonale (R-sided heart enlargement)
- Thoracic bullae
- Nocturnal hypoxia
Staging COPD
Comorbidities
(6)
- Hypertension
- Ischemic heart disease
- Heart failure
- MI
- Muscle wasting
- Osteoporosis
Chronic Obstructive Pulmonary Disease (COPD)
Treatment
(3)
- Inhaled long-acting bronchodilators
- Corticosteroids if asthma also present and/or more reversible
obstruction - Smoking cessation is only intervention that actually reduces
disease progression
Chronic Obstructive Pulmonary Disease (COPD)
Oral Manifestations
(2)
- Dry mouth
- Steven-Johnson syndrome
with theophylline
Exacerbates Smoking Side
Effects of:
(6)
- Halitosis
- Tooth staining
- Nicotine stomatitis
- Periodontal disease
- Oral potentially malignant disorders
- Oral squamous cell carcinoma
- Oral potentially malignant disorders
(2)
- Leukoplakia
- Erythroplakia
Determine stage and severity of COPD
➢ Medical consultation for
➢ If COPD Stage III or higher or who have respiratory and
heart failure
o Consider
mild to moderate COPD to
determine the presence of respiratory failure right-sided
heart failure
dental treatment in a hospital setting
If < Stage III COPD
➢ Place the patient in a semi-supine position to avoid —
➢ Avoid using a —
➢ Avoid treating if — is present
➢ Local anesthetic with — is acceptable and — flow O2 (2
L/min) can be used
o May need to limit epi if concomitant CVD
respiratory distress
rubber dam (??)
upper respiratory infection
epi, low
Dental Treatment Considerations
Avoid medications that cause respiratory depression
(4)
➢Barbiturates
➢Narcotics
➢Nitrous oxide is contraindicated
➢Benzodiazepines (low dose may be acceptable in
certain situations)
o Consult physician
- (3) should not be prescribed to COPD
patients already taking theophylline
Erythromycin, macrolide antibiotics (clarithromycin, azithromycin, etc.)
and ciprofloxacin
Tuberculosis (TB)
Granulomatous infectious disease caused by
—
— are most common site of infection
Due to the multiple species of Mycobacterium (m.
bovis, m. abscessus, m.microti, m.africanuum,
etc.), TB can also affect (2)
Mycobacterium tuberculosis
Lungs
cutaneous, lymphatic and
other tissues
Tuberculosis (TB)
WHO estimates — of human population is infected
(~2 x 109 people)
Greatest universal — pathogen killer of humans
Not as morbid to the — population
1900 AD ~ 500 per 100,000 incidence
1980 AD ~ 9.3 per 100,000 incidence
1985-1992 ~10.6 per 100,000 incidence
2009 ~ 3.8 per 100,000 incidence
1/3
single
US
US rates low because of
(3)
- better sanitation
- improved hygiene
- more efficient delivery of anti TB medications
TB
—% of new USA cases are in foreign born
migrants or travelers; this rate has been on the
increase since 1993
54
TB
At risk populations in the US include:
(3)
- Racial and ethnic minorities
- Inner city residents in congregate facilities
- immunocompromised patients (HIV, medication
suppressed, DM, etc.
TB
Disproportionate affected populations are (3)
India,
eastern Europe, China (PRC)
TB
Airborne Transmission via infectious
respiratory droplets from
(4)
- Coughing
- Sneezing
- Talking
- Singing
TB
Signs and Symptoms
(7)
- Persistent, unexplained cough
- Fever
- Malaise
- Night sweats
- Unintentional weight loss
- Hemoptysis
- Dyspnea
TB
Risk Factors
(4)
- Individuals from countries with high incidence or prevalence
of TB - Individuals who visited areas with high prevalence of active
TB - Close contact with individuals who have TB
- Individuals who reside or work in facilities with high risk
exposure
- Individuals who reside or work in facilities with high risk
exposure
(5)
➢Health care facilities
➢Nursing homes
➢Correctional facilities
➢Homeless shelters
➢Accommodations for the mentally disabled
TB
Risk Factors
(3)
- Individuals who have had skin test
conversion within the past 2 years - Individuals at increased risk of latent TB
- Infants, children and adolescents exposed to
- Individuals at increased risk of latent TB
(3)
➢Medically disadvantaged/underserved
➢Low income
➢Alcohol or drug use disorder
- Infants, children and adolescents exposed to
(2)
➢Individuals at increased risk of latent TB
or active TB
➢Individuals with a positive TB skin test
Tuberculosis (TB)
Oral Signs
(2)
- uncommon
- SCROFULA
TB oral
* More frequent presentation:
(2)
➢Deep irregular, painful ulcer on the tongue dorsum
➢ May occur in other areas as well (gingiva, lips,
palate, buccal mucosa)
- SCROFULA
(3)
- TB involvement of cervical and submandibular
lymph nodes - Lymph nodes are enlarged and painful
- Abscess with purulence may be present
Tuberculosis (TB)
Risk of Progression to Active TB
- HIV positive individuals
- Infants/children < 5 ys old
- Immunosuppressed individuals
➢ Systemic corticosteroids (≥15mg/day of
prednisone)
➢ TNF-⍺ inhibitors and other immunosuppressants
➢ Immunosuppressant therapy related to
transplantation - Recent TB infection (within past 2 yrs)
- History of untreated or inadequately treated TB
- Populations who have increased incidence of active
TB - Tobacco (cigarette), alcohol, and drug use
- Disease-specific
➢ Silicosis
➢ Diabetes mellitus
➢ Chronic renal failure
➢ Leukemia
➢ Lymphoma
➢ Solid organ transplant
➢ Head and Neck Cancer
➢ Lung Cancer - Individuals with history of gastrectomy or
jejunoileal bypass - Individuals who weigh <90% of ideal body weight
- Malnourished individuals
Tuberculosis (TB)
Treatment
Antibiotic Regimen
(Drug-Susceptible)
Intensive phase (8 weeks)
- Isoniazid
➢ Hepatotoxic; avoid acetaminophen;
P450 inhibitor – ↑ concentration of
other drugs - Rifampicin
➢ Hepatotoxic; impaired healing;
increased gingival bleeding; P450
inducer - ↓ concentration of other
drugs - Pyrazinamide
- Ethambutol
TB tx
Continuous phase (18 weeks or longer)
(2)
- Isonizaid
- Rifampicin
TB tx
Antibiotic Regimen
(Multi-drug resistant; 8-20 mos)
(5)
- Pyrazinamide
- A fluoroquinolone (ciprofloxacin, levofloxacin)
- Amikacin or kanamycin
➢ Avoid aspirin - Ethionamide
- Cycloserine or para-aminosalicylic acid
TB
Dental Treatment Considerations
Determining if a Patient is Noninfectious
* Patient has taken standard multidrug therapy for TB for —
* Patient has been compliant with standard — therapy for TB
* — consecutive negative sputum smears on acid-fast bacillus (AFB) testing
* Patient is clinically improved
* Unlikely (negligible) — TB
* All close contacts were identified, evaluated, and began treatment for — TB, if necessary
2-3 weeks
multidrug
Three (3)
multidrug-resistant
latent
TB
Dental Treatment Considerations
Active Sputum-Positive TB
* Emergency care only in hospital
environment
(3)
* If hospital unavailable treat urgent dental
problems with —
* Consult physician before treatment
(3)
➢ Isolation
➢ Negative pressure ventilation
➢ Respiratory protection
palliative care
(medications: analgesics, antibiotics)
➢ Place patient in an isolated area
➢ Provide patient with a mask
➢ Arrange transportation
TB
Recent Conversion to Positive Tuberculin Skin Test
(2)
- Consult physician
➢ Rule out active TB
➢ Verify adequate completion of therapy (9
months) - If ”no clinically active tuberculosis” → treat as normal
patient (noninfectious)
If signs and symptoms of TB
approach as if —positive
sputum
Dental Treatment Considerations
History of TB
* If consistently negative sputum
➢ Treat as —
* History
(5)
* Consult physician before treatment
* Request
➢ Results from —
➢ Results from recent —
* Postpone treatment if
(3)
normal (non-infectious)
➢ When
➢ How treated
➢ Exposures
➢ Treatment duration
➢ Review of systems
periodic chest radiographs
physical examinations
➢ Treatment time reported seems questionable
➢ Follow-up protocols since TB treatment are
inadequate
➢ Signs and symptoms of reactivation/relapse
History of Latent TB
* Similar to history of TB
➢ Medical history
➢ Review of systems
➢ Consult physician to rule out active disease
* Verify —
* Treat as —
prophylactic isoniazid therapy (at least 6
months of therapy)
non-infectious
