Pulmonary Disease Flashcards
What are the types of pulmonary disease?
- asthma
- chronic obstructive pulmonary disease (COPD)
— bronchitis (stage 1)
— emphysema (stage 2) - tuberculosis (TB)
What is asthma?
Chronic inflammatory airway disorder
* Airway hyper-responsiveness to stimuli
* Bronchial edema
* Narrowing of the airways (obstruction)
What are the signs and symptoms of asthma?
Recurrent, reversible episodes of:
*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
- you cannot measure this
What are the aggravating/complicaing factors for asthma?
● Smoking
● Air pollutants (quality)
— urban
— industrial
What are the stages of asthma?
- Controlled
- Partially Controlled
- Uncontrolled
What are the daytime symptoms of controlled asthma?
twice or less per week
What are the daytime symptoms of partially controlled asthma?
more than twice a week
What are the daytime symptoms of uncontrolled asthma?
three or more features of paritally controlled asthma present in any week
What are the following for controlled asthma…
limitations of actions
nocturnal symptoms
need for rescue medications
lung function
limitations of actions - none
nocturnal symptoms - none
need for rescue medications - twice or less per week
lung function - normal
What are the following for partially controlled asthma…
limitations of actions
nocturnal symptoms
need for rescue medications
lung function
limitations of actions - any
nocturnal symptoms - any
need for rescue medications - more than twice a week
lung function - <80% predicted
What are the different types of asthma?
- Extrinsic
- Exercise Induced
- Intrinsic
- Drug Induced
What is extrinsic asthma?
allergic or atopic
- Exaggerated inflammatory response
What are the features of extrinsic asthma
- Most common
- Children and young adults
- Typical positive family history
- Triggered by allergens (pollen, dust, house mites, animal dander, mold etc.)
- Exaggerated inflammatory response
Extrinsic and exercise Asthma has antibody production of high levels of ____
IgE
What is the immune response in asthma (extrinsic/exercise)?
- 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
What are the features of exercise-induced asthma?
- Unknown pathogenesis
- Children and young adults
- Triggered by exercise and thermal changes
- Cold air irritates mucosa resulting in airway hyperactivity
What is exercise-induced asthma?
Mucosal inflammatory response to cold air or other irritant
What is intrinsic asthma (idiosyncratic, nonallergic, nonatopic)?
- 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
What is the immune response in intrinsic asthma?
- Allergen →
- lymphocytes→
- activation of mast cells, basophils and eosinophils →
- bradykinin, histamine, leukotrienes, interleukins →
- bronchoconstriction
What are the features of drug-induced asthma?
- Subset of intrinsic
- Affects children, young adults & middle-aged adults
- Common antigens
➢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
What are the types of asthma treatment?
- Inhaled beta-2 (ẞ2) agnosits
- Short acting ẞ2 agonists
- Long acting ẞ2 agonists
What are inhaled beta-2 (ẞ2) agonists used for?
bind to ẞ2 receptors in lungs smooth muscle relaxation
i.e., bronchodilation
What are short acting beta-2 (ẞ2) agonists used for?
are single use (rescue) medications used alone
What are long acting beta-2 (ẞ2) agonists used for?
- used in combination with steroids on a scheduled protocol
- used alone leads to CVD complications (arrythmias, etc.)
What are the side effects of beta-2 agonists for asthma treatment?
Tremors, tachycardia
Increases blood sugar
Cough
K decrease
What are examples of short-acting B2 agonists?
asthma treatment
Albuterol
What are examples of anti-cholinergics?
asthma treatment
Atrovent
Spiriva
What are examples of methylxanthines?
asthma treatment
theophylline
What are examples of mast cell stabilizers?
asthma treatment
cromolyn
What examples of corticosteroids?
asthma treatment
dexamethasone
fludrocortisone
methylprednisolone
prednisone
What are examples of leukotriene receptor antagonists?
asthma treatment
singulair
What are examples of combination inhalers?
asthma treatment
Advair Diskus
Symbicort
What are the oral signs of asthma?
- Mouth breather (high palatal vault, overjet, crossbite, greater facial height)
- Dry mouth
- Candida
- Enamel defects and caries
- Gingivitis/periodontitis
- Enamel erosion possible with GERD
What dental treatment can you do with unstable asthma?
- Dental treatment should be limited to urgent care only
- Treatment of acute pain, bleeding, or infection
What dental treatment can you do with stable asthma?
- Any indicated dental treatment may be provided if management protocols are considered
- Consult with physician for severe persistent asthma
What are drug interactions that trgger asthma?
- Aspirin (drug-induced asthma)
- NSAIDs (drug-induced asthma)
- Opioids and barbiturates (respiratory depression and misuse)
- Sulfities in epinephrine preparation fo local anesthetics
Why should asthma patients avoid Theophylline and macrolides or ciprofloxacin?
➢ Potent inhibition of CYP3A4
➢ Increases levels of theophylline
➢ Toxicity (arrhythmia and seizures)
Why should asthma patients avoid Cholinergic agonists?
➢ Effect of cholinergic agents promotes bronchoconstriction
➢ Sialogogues are contraindicated in patients with uncontrolled asthma
How do you reduce risk of an asthma attack?
➢ Have patient bring medication inhaler to each appointment
➢ Recommend prophylaxis with inhaler before appointments for those with
moderate to severe asthma
Short-acting Beta2-adrenergic agonist (inhaler) is the drug of choice for an ______ asthma attack
acute
What sedation can you use for dental anxiety?
➢Nitrous (better)
➢Short-acting benzodiazepine
What are the general drugs to avoid with asthma?
➢ Aspirin, NSAIDs, Narcotics, Macrolide antibiotics like erythromycin
➢ Sulfite (preservative) containing local anesthetics may need to be avoided
What is an asthma emergency?
- Respiratory rate >25 breaths/min, labored breathing
- Tachycardia >110 beats/min
- Flushed appearance
What do you do if a patient is having an asthma emergency?
- Stop treatment, inform supervising faculty, administer O2, and call 4444
➢Remove all items from patient’s mouth
➢Record the time attack began
➢Raise the dental chair
➢Give short-acting β2-adrenergic agonist inhaler
➢Administer oxygen
What is 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
What is emphysema?
- Longterm Chronic obstructive bronchiolitis leads to destruction of lung parenchyma and alveolar walls
- Decreased elastic recoil
- Difficulty in maintaining airway opening during expiration
Why are chronic obstructive bronchiolitis (type 1) and emphysema (type 2) both COPD?
Type II is a progression of Type I leading many to just use these as descriptive terms for COPD
Chronic Obstructive Pulmonary Disease (COPD) is the ___ leading cause of death in the USA
3rd
What are the characteristics of COPD?
Corticosteroid-resistant progressive chronic inflammatory disease
* Poorly reversible/irreversible airway obstruction
* Entrapment of air and dyspnea upon exertion
What are the aggravating/complicating factors of COPD?
● Smoking
● Air pollutants (quality)
— urban
— industrial
● CVD
— comorbidity
What are the signs and symptoms of COPD?
- Dyspnea
- Cough
- Sputum
What are the stages of COPD?
I - mild
II - moderate
III - severe
IV - very severe
What is stage I (mild) COPD?
- FEV1/FVC <0.7 and FEV1≥80% predicted
- Chronic cough and sputum production may be present
What is stage II (moderate) COPD?
- FEV1/FVC <0.7 and FEV1≥50% but <80% predicted
- Dyspnea on exertion may be present
What is stage III (severe) COPD?
- FEV1/FVC <0.7 and FEV1≥30% but <50% predicted
- Worsening airflow limitation; exacerbations; reduced quality of life
What is stage IV (very severe) COPD?
- FEV1/FVC <0.7 and FEV1<30% predicted
- Chronic respiratory failure and potentially life threatening exacerbations; rightsided heart failure may be present
What viral and bacterial infections exacerbate COPD?
- Haemophilus influenza
- Moraxella catarrhalis
- Streptococcus pneumoniae
What are conditions that complicate COPD?
- Pulmonary hypertension
- Cor pulmonale (R-sided heart enlargement)
- Thoracic bullae
- Nocturnal hypoxia
What are the comorbidities with COPD?
- Hypertension
- Ischemic heart disease
- Heart failure
- MI
- Muscle wasting
- Osteoporosis
What are the treatments for COPD?
- Inhaled long-acting bronchodilators
- Corticosteroids if asthma also present and/or more reversible obstruction
- Smoking cessation is only intervention that actually reduces disease progression
What types of medications do people with COPD take?
the same as asthmatics
What are the oral manifestations of COPD?
*Dry mouth
*Steven-Johnson syndrom with theophylline
What smoking signs/symptoms does COPD exacerbate?
- Halitosis
- Tooth staining
- Nicotine stomatitis
- Periodontal disease
- Oral potentially malignant disorders
— Leukoplakia
— Erythroplakia - Oral squamous cell carcinoma
What dental treatment can you do on mild/moderate COPD?
Medical consultation for mild to moderate COPD to determine the presence of respiratory failure right-sided heart failure
What dental treatment can you do on stage III or higher COPD?
Consider dental treatment in a hospital setting
If you do dental treatment on a patient less than stage III COPD what should you do?
➢ Place the patient in a semi-supine position to avoid respiratory distress
➢ Avoid using a rubber dam (??)
➢ Avoid treating if upper respiratory infection is present
➢ Local anesthetic with epi is acceptable and low flow O2 (2 L/min) can be used
o May need to limit epi if concomitant CVD
In patients with COPD avoid medications that cause respiratory depression such as…
➢Barbiturates
➢Narcotics
➢Nitrous oxide is contraindicated
➢Benzodiazepines (low dose may be acceptable in certain situations)
o Consult physician
Erythromycin, macrolide antibiotics (clarithromycin, azithromycin, etc.) and ciprofloxacin should not be prescribed to COPD patients already taking _____________
theophylline
What is tuberculosis (TB)?
- Granulomatous infectious disease caused by Mycobacterium tuberculosis
- Lungs are most common site of infection
- TB can also affect cutaneous, lymphatic and other tissues due to the multiple species of Mycobacterium
What are the different types of Mycobacterium associated with TB?
m. kansasii
m. bovis
m. avium complex
m. abscessus
m. microti
m. canetti
m. africanum
What type of mycobacterium was first described in 1952 after being identified as the cause of two cases of disease resembling human pulmonary tuberculosis at Kansas City General Hospital and the University of Kansas Medical Center?
m. kansasii
WHO estimates _____ of human population is infected
1/3
(~2 x 109 people)
Greatest universal single pathogen killer of humans is…
TB
US rates of TB are low because of…
- better sanitation
- improved hygiene
- more efficient delivery of anti TB medications
___% of new USA cases are in foreign born migrants or travelers; this rate has been on the increase since 1993
54%
At risk populations for TB in the US include:
- Racial and ethnic minorities
- Inner city residents in congregate facilities
- immunocompromised patients (HIV, medication suppressed, DM, etc.
Disproportionate TB affected populations are…
India, eastern Europe, China (PRC)
Airborne Transmission of TB via infectious respiratory droplets from…
- Coughing
- Sneezing
- Talking
- Singing
What are the signs and symptoms of TB?
- Persistent, unexplained cough
- Fever
- Malaise
- Night sweats
- Unintentional weight loss
- Hemoptysis
- Dyspnea
What are the risk factors for TB?
- 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
➢ Health care facilities
➢ Nursing homes
➢ Correctional facilities
➢ Homeless shelters
➢ Accommodations for the mentally disabled
➢ Refugee shelters - Individuals who have had skin test
conversion within the past 2 years - Individuals at increased risk of latent TB
➢Medically disadvantaged/underserved
➢Low income
➢Alcohol or drug use disorder - Infants, children and adolescents exposed to
➢Individuals at increased risk of latent TB or active TB
➢Individuals with a positive TB skin test - Other individuals at increased risk of TB
How do you test for TB?
TST (tuberculin skin test)
IGRA (Interferon-gamma Release Assay)
What are the oral signs of TB?
- uncommon
- More frequent presentation:
➢Deep irregular, painful ulcer on the tongue dorsum
➢May occur in other areas as well (gingiva, lips, palate, buccal mucosa) - SCROFULA
➢TB involvement of cervical and submandibular lymph nodes
➢Lymph nodes are enlarged and painful
➢Abscess with purulence may be present
What increases risk of progression to active TB?
- HIV positive individuals
- Infants/children < 5 ys old
- Immunosuppressed individuals
- 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
- Individuals with history of gastrectomy or
jejunoileal bypass - Individuals who weigh <90% of ideal body weight
- Malnourished individuals
- Disease-specific
What are the treatments for TB in the intensive phase (8 weeks)?
- isoniazid
- rifampicin
- pyrazinamide
- ethambutol
What are the treatments for TB in the continuous phase (18 weeks or longer)?
- Isonizaid
- Rifampicin
What are the treatments for TB when multi-drug resistant (8-20 months)?
- Pyrazinamide
- A fluoroquinolone (ciprofloxacin, levofloxacin)
- Amikacin or kanamycin
➢Avoid aspirin - Ethionamide
- Cycloserine or para-aminosalicylic acid
How do you determine if a patient is noninfectious before doing dental work?
- Patient has taken standard multidrug therapy for TB for 2-3 weeks
- Patient has been compliant with standard multidrug therapy for TB
- Three (3) consecutive negative sputum smears on acid-fast bacillus (AFB) testing
- Patient is clinically improved
- Unlikely (negligible) multidrug-resistant TB
- All close contacts were identified, evaluated, and began treatment for latent TB, if necessary
What dental work can you do in a patient with active sputum-positive TB?
- Emergency care only in hospital environment
➢ Isolation
➢ Negative pressure ventilation
➢ Respiratory protection - If hospital unavailable treat urgent dental problems with palliative care (medications: analgesics, antibiotics)
- Consult physician before treatment
What dental work can you do in a patient with recent conversion to positive tuberculin skin test?
- Consult physician
➢ Rule out active TB
➢ Verify adequate completion of therapy (9 months) - If ”no clinically active tuberculosis” → treat as normal patient (noninfectious)
