W14 48 respiratory medicine for dentists

Question 1

What happens in bronchial infections?

Answer 1

Airway inflammation in the lungs with excessive mucous production
Cough +/- sputum expectoration

Question 2

What is acute bronchitis?

Answer 2

Previously well people - usually a viral cause.
Often results by 3 weeks.
May be complicated by secondary bacterial infection

Question 3

What is chronic bronchitis?

Answer 3

Productive cough >= 3 months for >=2 years
Commonly associated with chronic lung disease
Consider bacterial causes eg H influenzae, P aeruginosa or M catarrhalis
Look for underlying sinus infections, post-nasal drop or gas to-oesophageal reflux

Question 4

What are the different clinical features between typical and atypical pneumonia?

Answer 4

Typical - sudden onset, fever, chills, productive cough and pleuritic chest pain, localised signs, diagnosed via culture methods, respond to b-Lactam antibiotics
Atypical - insidious onset, dry cough, myalgia, headaches, systemic upset (diarrhoea, rash), diagnosed via non-culture methods, does not respond to b-Lactam antibiotics

Question 5

What is the grading severity for pneumonia?

Answer 5

C - confusion (AMYS <=8)
U - urea >7mmol/L
R - respiratory rate >=30
B - BP if lower than either 90/60
65 - older than this
0-1 is low score, 2 is moderate, more than 3 is severe with 15-40% 30 day mortality rates

Question 6

How do you manage low severity, moderate severity and high severity CAP?

Answer 6

Low - oral amoxicillin preferred plus rest, smoking cessation, fluids and analgesics if pain
Moderate - consider hospital referral, don’t give antibiotics before referal
High - urgent hospital admission - consider giving intravenous benzylpenicillin or oral amoxicillin if life-threatening or if a delay in hospital treatment of >6hrs is likely

Question 7

Complications of CAP?

Answer 7

Respiratory failure
Septic shock
Lung abscess
Parapneumonic effusion or empyema

Question 8

What is the typical response to foreign body aspiration?

Answer 8

Choking

Question 9

What are the signs and symptoms of foreign body aspiration?

Answer 9

Cough and shortness of breath
Difficult speaking
Haemoptysis
Vomitting
Decreased breath sounds on affected side (usually RHS)
Stridor and/or wheezing

Question 10

What are the complications of foreign body aspiration?

Answer 10

Recurrent pneumonia
Lung abscess
Bronchiectasis (dilatation of airways) distal to the foreign body
Bronchial stenosis (narrowing of airways) due to inflammation
Can result in complete airway obstruction and subsequent hypoxic brain injury/death

Question 11

What should you do as soon as someone aspirates a foreign body?

Answer 11

5 back blows, 5 abdominal thrusts
CPR if not resolved

Question 12

Which lung is most likely to get foreign material stuck?

Answer 12

The right lung lobe
Since more vertical orientation

Question 13

In a spirometry test, how much air should a normal person blow out within the first second?

Answer 13

80% of their total lung capacity

Question 14

In spirometry tests for pulmonary function, what do different values of FEV1/FVC mean? (PG469 GRAPHS)

Answer 14

FEV1/FVC > 0.7 is normal
FEV1/FVC < 0.7 is airflow obstruction
FEV1/FVC > 0.7 but both FEV1 and FVC are reduced = lung restriction

Question 15

Which lung diseases are obstructive or restrictive?

Answer 15

Obstructive - asthma, COPD
Restrictive - obesity, interstitial lung disease, muscle weakness

Question 16

Why does a dentist need to know about lung disease?

Answer 16

What the disease is
How bad it is
What meds they’re on
Will they tolerate sedation or anaesthetic

Question 17

What is bronchial asthma?

Answer 17

Chronic inflammatory disorder of the airways leading to airway obstruction

Question 18

What are the 2 pathways (briefly) causing hyper responsiveness in the airways in asthma?

Answer 18

Inflammatory - by mast cells and eosinophils
Non-inflammatory - by neutrophils
Causes hyperresponsiveness of airways, remodelling, mucus production and smooth-muscle constriction and hypertrophy

Question 19

What does a normal airway vs an asthmatic airway look like? (IMG PG471)

Answer 19

An asthmatic airway has hyperresponsiveness, remodelling, mucus production, and smooth-muscle constriction and hypertrophy
Collagen proliferation, fibrocyte proliferation, leading to airway narrowing

Question 20

What are the signs and symptoms of asthma?

Answer 20

Coughing and wheezing
Chest tightness
Shortness of breath
Can be precipitated by various factors
Exacerbations lead to acute progressive worsening of symptoms

Question 21

What are some asthma triggers?

Answer 21

Allergens - moulds, dust mites, animal dander, pollens, foods
Irritants - cigarette smoke, aerosols, VOCs, ozone, particulate matter
Other - viral respiratory infections, changes in weather, exercise, endocrine factors

Question 22

How do genetic factors - alpha1-antitrypsin deficiency put you at higher risk for COPD?

Answer 22

It is an enzyme that limits the activities of proteases that are released by inflammatory cells. Inflammatory cells get into the airways and produce proteases, which if uncontrolled can lead to lung damage. In normal people the alpha-1-antitrypsin will help prevent this.

Question 23

What is the difference between a healthy lung and a COPD lung? PG473!

Answer 23

Healthy lung tissue have functioning alveolar sacs with open airways and supported by surrounding lung tissue structures like elastin etc
In COPD, an excessive inflammatory response causes destruction of the alveolus and lots of mucus plugging and increased mucus production and a narrow bronchiole. So less effective gas exchange. Also disrupted alveolar attachments so the airways are not held open as much so increasing narrowed.

Question 24

What is the MRC dyspnea scale?

Answer 24

Measures severity of airflow obstruction - breathlessness:
Grade 0 - I only get breathlessness with strenuous exercise
Grade 1 - I get short of breath when hurrying on the level or walking up a slight hill
Grade 2 - I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breathing when walking my own pace on the level
Grade 3 - I stop for breath after walking about 100meters or after a few minutes on the level
Grade 4 - I am too breathless to leave the house or I am breathless when dressing or undressing

Question 25

What are the different measures for COPD assessment?

Answer 25

mMRC dyspnoea scale - measures breathlessness, crude measurement
COPD assessment test (CAT) - more objective. Measures cough, phlegm production, breathlessness, how much they can exercise, energy levels
BODE method - lots of measures in combination to determine prognosis, eg BMI, obstruction (FEV1), dyspnea, exercise capacity (6min walk distance)
Pulse oximetry or arterial blood gas (ABG)

Question 26

Why would you do a pulse oximetry test in COPD patients?

Answer 26

In COPD patients, can get ventilator failure so you don’t get O2 moving into the lung as well as it should and get a buildup of CO2 in the bloodstream
Consider oxygen treatment, because with ventilatory failure, giving too much oxygen can be detrimental to them.

Question 27

What is the first line of treatment for COPD?

Answer 27

Inhaled therapy
No reversal of COPD damage only treatment of symptoms and management of risk factors
Less response to steroids than asthma

Question 28

What are COPD exacerbations?

Answer 28

Event characterised by dyspnoea and/or cough and sputum that worsen over days
Increased airway inflammation, mucous production and marked gas trapping
Systemic inflammation leads to increased risk of other acute events

Question 29

What do you do for the management of COPD?

Answer 29

Controlled oxygen therapy (aim sats 88-92%)
Nebulised bronchodilators (SABA inhaler via a spacer if no nebs)
Systemic steroids
Antibiotics (if increased sputum volume and purulence)

Question 30

What are the differences in clinical features between COPD and asthma?

Answer 30

COPD - nearly all have smoking history, rare symptoms under age 35, common chronic productive cough, persistent and progressive breathlessness, uncommon nocturnal symptoms, uncommon symptom variability
Asthma - possible smoking history, often symptoms under age 35, uncommon chronic productive cough, variable breathlessness, common nocturnal symptoms, common symptom variability

Question 31

What is interstitial lung disease (ILD)?

Answer 31

Heterogenous disease group affecting lung parenchyma (mainly lung tissues rather than the airways). It is characterised by inflammation and/or fibrosis of the alveolar wall and interstitium. It results in impairment of gas exchange and restrictive changes in lung volume (worse expansion of lungs)

Question 32

What happens in damaged alveoli?

Answer 32

In damaged alveoli the wall between the airway and bloodstream gets thickened so oxygen does not diffuse as well as CO2 does. So less oxygen in the bloodstream, causing breathlessness (pg478 img).

Question 33

What are the different types (just main ones) of ILD?

Answer 33

Idiopathic pulmonary fibrosis
Autoimmune ILDs
Hypersensitivity pneumonia
Sarcoidosis
Other ILDs

Question 34

What are the pointers to someone having ILD?

Answer 34

Progressive symptoms
Dry persistent cough
Reduced exercise tolerance
Signs/symptoms of connective tissue disease
History - medications, occupational history, pets, hobbies

Question 35

What investigations for ILD should you do?

Answer 35

FBC, U&E, LFTs (blood tests) - eg if breathlessness due to anaemia
Spirometry and gas transfer - to see severity and progressiveness of ILD
CXR and HRCT
Bronchoalveolar lavage - isolating the pathogen and what cells are in the lavage
Lung biopsy
Other

Question 36

What is the management of ILD?

Answer 36

Conservative - lifestyle eg exercise, weight loss, pulmonary rehab, smoking cessation
PPI (eg omeprazole) for gastric reflux
Consider lung transplant if age <65
Palliative care referral for symptom control
Long-term oxygen therapy

Question 37

What is the disease-specific management for non-specific interstitial pneumonia?

Answer 37

Immuosuppression - start with steroids
Treat associated systemic disease

Question 38

What is the disease-specific management for idiopathic pulmonary fibrosis?

Answer 38

Consider anti fibrotics eg pirfenidone, nintedanib (slows disease doesn’t completely stop)

Question 39

What is the disease-specific management for cryptic organising pneumonia?

Answer 39

Steroids

Question 40

What is the disease-specific management for hypersensitivity pneumonitis?

Answer 40

Allergen avoidance
Poor evidence for steroids

Question 41

What is the disease-specific management for sarcoidosis?

Answer 41

Steroids in severe disease

Question 42

What is the disease-specific management for respiratory bronchiolitis ILD and desquamated interstitial pneumonia?

Answer 42

Smoking cessation

Question 43

What is progressive pulmonary fibrosis?

Answer 43

Defined as 2 of the following:
- worsening respiratory symptoms
- physiological evidence of disease progression eg decline in FVC of more than 5% or decline in TLco of more than 10%
- radiological evidence of disease progression
Nintedanib is licensed for treatment in this patient group

Question 44

How does obesity cause lung restriction?

Answer 44

Obese patients have excess body weight causing the lung to not expand as well. Can also possible develop respiratory failure with need for long-term oxygen therapy.

Question 45

How can obesity affect the oral cavity?

Answer 45

High risk of diabetes and reflux which may impact dental erosion and periodontal disease. Consider weight restriction on dental chair and sedation risk in this patient group.

Question 46

What are the first line investigations for ILD?

Answer 46

Blood tests and HRCT are first line
Clinical history, examination and simple investigations like CXR will normally provide the diagnosis.

Question 47

Legalities of lung diseases?

Answer 47

Just read 481 no need to memorise