Respiratory history for dental examination Flashcards
Quantify impact of resp disease
Sob? -MRC scale -triggers Hx of sudden wheeze/ sob? -triggers Cough? -dry/ productive -sputum colour Haemoptysis -chest pain PND -orthopnea -SOA Courses of abx and oral CS in 12/12? GORD -hayfever and eczema Admissions to ED/ Hospital/ ITU
Drug history
Allergies inc aspirin sensitivity Inhalers (?presence of ICS) Anticoagulants (rivaroxaban, warfarin) Oxygen use (LTOT, Amb, SBOT) Nebulisers
Social history
Occupation -joiner, baker, miner Smoking Hx Etoh consumption Pets/birds Asbestos
Asthma
Sob/ wheeze/ cough
Has triggers
Classically affects young and middle aged
COPD
Sob/ wheeze on exertion
Cough
>35 years
Smoker
Bronchiectasis
Chronic sputum production
May have associated wheeze/ sob
Recurrent LRTIs
Pulmonary emboli
Sob/ pleuritic pain/ haemoptysis
May be on warfarin (min 6/12)
Long term if recurrent VTE/ risk factors
Interstitial lung disease
Soboe/ occ. dry cough
May be on steroids/ immunosuppressants
Obesity hypoventilation syndrome
Own CPAP machine; supplemental O2
Daytime somnolence
Repiratory muscle weakenss
Non-invasive ventilation
Lung cancer symptoms
Weight loss
Sob
Cough +/- haemoptysis (tumour near airways)
Chest pain
Extra-pulmonary symptoms
If post chemoRx (palliative) - risk of neutropenic sepsis
Taking a drug history
Confirm medications that can be indicative
- inhalers for Asthma & COPD only
- SABA nebules for severe asthma
- SABA & SAMA nebules sometimes given for COPD but may not reflect severity
- oral steroids for immunesuppresion in severe asthma & certain ILD processes
- amiodarone & methotrexate
- warfarin & rivaroxaban/Apixaban
- aspirin/NSAID hypersensitivity
Taking a social history
Smoking - >10PYH significant - (CPD x yrs smoked) / 20 Etoh (alcohol) use -XS use - poor dentition -risk of endocarditis -risk of lung abscess Own pets -household pets drive asthma -bird exposure - EAA Job exposure -coal miner -asbestos -baker/ dust exposure -farmer
How to identify the unwell pt
Change from baseline
- exacerbation of chronic lung disease
- > breathlessness
- worsening cough
- more sputum production
- change in sputum colour
NICE COPD Guidelines 2010
An exacerbation is a sustained worsening of the patient’s symptoms from his or her usual stable state that is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication
More sputum production and change in sputum colour
Bacterial infection - antibiotics needed
Respiratory examination
General inspection at the end of the chair
- is the pt comfortable
- what is the resp rate? (14-16/min)
- is there cyanosis
- peripheral +/- central
- accessory muscles being used?
Peripheral cyanosis
Blue discolouration to peripheries
- hypoxia
- poor peripheral circulation
- polycythemia
Central cyanosis
Look at tongue (good blood supply)
- reflects significant deoxygenated blood
- SpO2 <90% with obvious cyanosis (with normal Hb)
Accessory muscles
Sternocleidomastoids
Platysma
Strap muscles
XS use elevation of chest with > expansion
Inspection specific to COPD
Breathing through pursed lips
> AP diameter vs lateral diameter
-“barrel chest”
-hyperinflation
Audible wheee
Asthma/ COPD/ Vocal Cord Dysfunction
Stridor
Think upper aiway obstruction emergency
Hoarseness
Think recurrent laryngeal nerve injury and cancer
Check radial pulse
Assess for rate
>100bpm may reflect underlying disease
Also associated with anxiety
Inspection - hands
Clubbing – cancer/ bronchiectasis/ fibrosis
Flapping tremor – severe CO2 retention (late sign)
Wasting of muscles of hands
-bilateral – cachexia assoc. with COPD/ cancer/ motor neurone disease (late sign)
-unilateral - compression of lower brachial plexus (pancoast tumour)
Inspection of face
Pallor – check conjuctiva for anaemia
Check tongue colour
Think possible lung abscess or pneumonia as result of rotten tooth
Obese/collar>17” – OSA; at risk of ventilatory failure
Moon face – chronic oral steroid use (Asthma/ILD) (see upper panel)
Rare:
-facial plethora – SVCO (panel A&B)
ABCD
Is the airway patent? How is the breathing? -RR -SpO2 -chest movement -cyanosis How is the circulation? -pulse -blood p -peripheral circulation How is the neurological status? -disability -GCS
Unwell pt
Respiratory rate>20/min Difficulty completing sentences Using accessory muscles Cyanosis Audible Wheeze
PEF meter
Peak Expiratory Flow (PEF) Meter In benefit in pts with asthma Good correlation with symptoms -normal>75% of either predicted or best for pt Best of x3 blows; Standing position “like blowing out candles”
Pulse oximetry
Noninvasive measurement of arterial Hg saturation
Uses differential absorbance of light by oxyhemoglobin and deoxyhemoglobin to estimate the oxygensaturation
SpO2 92% roughly equal to 8kPa
Below 90-92% correlation to pO2 less reliable
Asthma: if PEF <75%
give Short Acting Brochodilator
Give 4 puffs (inhaler) via spacer
Give 2 puffs/2mins & assess response up to 10puffs
or
Salbutamol 5mg nebuliser (ideally by 6l/min O2)
Consider oral steroids
Consider immediate referral to GP/ walk-in centre/ 999
COPD: if sob/ wheezy
Give (salbutamol) ventolin 5mg dose & (ipratropium bromide) 500mcg
via nebuliser driven (not via oxygen)
If nebuliser not to hand – administer 4 puffs of short acting beta agonist via spacer
Less likely COPD patients to develop acute bronchospasm post dental intervention compared to asthma patients
Consider referring immediately to GP/walk-in centre/999
Oxygen delivery
The initial oxygen therapy is nasal cannulae at 2–6 l/min (preferably) or simple face mask at 5–10 l/min unless stated otherwise.
For patients not at risk of hypercapnic respiratory failure who have saturation <85%, treatment should be commenced with a reservoir mask at 10–15 l/min.
The recommended initial oxygen saturation target range is 94–98%.
If oximetry is not available, give oxygen as above until oximetry or blood gas results are available.
Change to reservoir mask if the desired saturation range cannot be maintained with nasal cannulae or simple face mask (and ensure that the patient is assessed by senior medical staff).
If these patients have co-existing COPD or other risk factors for hypercapnic respiratory failure, aim at a saturation of 88–92% pending blood gas results but adjust to 94–98% if the PaCO2 is normal (unless there is a history of previous hypercapnic respiratory failure requiring NIV or IPPV) and recheck blood gases after 30–60 min.
COPD: if infective exacerbation (LRTI)
Aminopenicillin
Tetracycline
Macrolide
Oral course of prednisolone (if dyspnea impact on daily life)
GP review/refer to A&E/walk-in centre
(see NICE COPD guidance 2010)
Pneumonia
Difficult to delineate from LRTI without clinical examination or CXR
Re-visit treatment for infective exacerbation of COPD (minus steroids) but ideally need assessment by GP/Walk-in centre/999
