Title: Clinical Correlation: Lung Disease
1Clinical Correlation Lung Disease
Mark Bixby, M.D. October 20, 2009
2Lung Disease
- Chronic obstructive pulmonary disease (COPD)
- Chronic Bronchitis
- Emphysema
- Asthma
- Tuberculosis
3Lung Disease
- Chronic obstructive pulmonary disease (COPD)
- Chronic Bronchitis
- Emphysema
4COPD Definition
- Chronic airflow limitation not fully reversible
- Two major diseases
- Chronic bronchitis
- Emphysema
- Overlapping symptoms
- Distinct entities or disease progression
5Chronic Bronchitis Signs and Symptoms
- Onset phase years
- Chronic cough, copious sputum
- gt3 months
- 2 consecutive years
- Blue bloaters sedentary, overweight, cyanotic,
edematous, breathless - Severity based on spirometry
6Interpreting Spirometry - definitions
7Severity of COPDBased on Spirometry
8Emphysema Signs and Symptoms
- Severe exertional dyspnea, minimal cough
- Prolonged expiratory phase
- Barrel-chested, weight loss
- Pink puffers pursing of lips, non cyanotic
9pink puffer
blue bloater
10COPD Lab Tests
- Spirometry
- ? maximum expiratory flow rate not reversible
- Chest x-ray
- Chronic bronchitis prominent vascular markings
- Emphysema over distention of lungs, flattening
of diaphragm, emphysematous bullae
11COPD Medical Management
- No cure, but can improve quality of life
- Early management
- Smoking cessation, ? exposure to pollutants
- Regular exercise, good nutrition, prevention of
respiratory infections, adequate hydration - Oxygen therapy when SpO2 88
- Beta agonists, anticholinergics, inhaled
corticosteroids, theophylline
12COPD Dental Management
- Encourage quitting smoking
- Reschedule appointment if
- Short of breath worse than baseline
- Productive cough worse than baseline
- Acute upper respiratory infection
- Oxygen saturation lt91 (by pulse oximeter)
13COPD Dental Management of Stable Patient
Things to do
- Treat in upright chair position
- Use inhalers prior to treatment
- Use pulse oximetry
- Use low-flow oxygen when O2 sat lt95 unless
baseline is lower - May use low-dose oral diazepam
- Supplemental steroids may be required
14COPD Dental Management of Stable Patient
Things to avoid
- Rubber dam use (in severe cases)
- N2O sedation (in severe or very severe COPD)
- Barbiturates and narcotics
- Antihistamines and anticholinergics
- Macrolide antibiotics and ciprofloxacin (in
patients on theophylline) - Outpatient general anesthesia
15COPD Oral Manifestations
- Halitosis
- Extrinsic tooth stains
- Nicotine stomatitis
- Periodontal disease
- Oral cancer
16Lung Disease
- Chronic obstructive pulmonary disease (COPD)
- Asthma
17Asthma Definition
- Chronic inflammatory respiratory disease
- Airway hyperresponsiveness
- Recurrent dyspnea, coughing, wheezing
- Stimuli allergens, URI, exercise, cold air,
medications, chemicals, smoke, anxiety
18Airway Inflammation and Clinical Symptoms
Inflammation
19Precipitating or Aggravating Factors
20Asthma Signs and Symptoms
- Predominant symptoms
- Cough
- Breathlessness
- Wheezing
- chest tightness
- Flushing
- Increased heart rate and prolonged expiration
- May be self-limiting, but severe episodes may
require medical assistance
21Severity Control
22Classifying Asthma Severity (age 12)
23Asthma Classification
- Mild symptoms last less than an hour and do not
occur daily - Moderate Daily symptoms affecting sleep and
activity level - Severe Ongoing symptoms that limit normal
activity and result in emergency hospitalizations
24Asthma Lab Tests
- No one diagnostic test
- Chest xray, skin testing, sputum smears and blood
counts (for eosinophilia), arterial blood gases - Spirometry (peak expiratory flow meter) before
and after bronchodilator
25Stepwise Therapy for Asthmafor people 12 years
of age and above
Persistent Asthma
Therapy Preferred Alternative
Step 6 High Dose ICS LABA OCS AND Consider
omalizumab for patients with allergies
Step 5 High Dose ICS LABA AND Consider
omalizumab for patients with allergies
26Asthma Medical Management
- Plan for avoiding triggers
- Inhaled drugs
- Corticosteroids
- Leukotriene inhibitors
- Beta-adrenergic agonists
- Anticholinergics
27Asthma Dental Management
Things to do
- Schedule late-morning appointments
- Use rescue inhaler before procedures
- Use pulse oximeter during procedures
- Provide stress-free environment
- good rapport and openness
- may use N2O or oral benzodiazepine
28Asthma Dental Management
Things to avoid
- Precipitating factors
- Barbiturates and narcotics
- Aspirin, NSAIDs
- Antihistamines (or use cautiously)
- Macrolide antibiotics and ciprofloxacin (in
patients on theophylline)
29Asthma Managing an attack
- Warning signs
- Frequent cough
- Inability to finish sentence in one breath
- Bronchodilator ineffective
- Tachypnea
- Tachycardia (gt110)
- Diaphoresis
- What to do
- Use short-acting beta-adrenergic agonist inhaler
- Positive-flow oxygenation
- If severe subcutaneous epinephrine, call EMS
30Asthma Oral Complications
- Mouth breathing complications
- Increased gingivitis and caries secondary to beta
agonist inhaler use - Oral candidiasis secondary to steroid inhaler use
31Lung Disease
- Chronic obstructive pulmonary disease (COPD)
- Asthma
- Tuberculosis
32TB Definition
- Pulmonary and systemic disease
- Most common cause M. tuberculosis
- Spread by respiratory droplet
33TB Signs and symptoms
- Most patients with 1 infection no symptoms
- Cough (scanty, mucoid sputum later purulent)
- Systemic symptoms malaise, unexplained weight
loss, night sweats, fever - Extrapulmonary manifestations lymphadenopathy,
back pain, GI or renal disturbances, heart
failure, neurologic deficits
34TB Lab Tests
- Positive tuberculin (Mantoux) skin test (does not
mean infection is clinically active) - Xray findings
- progressive primary TB patchy infiltrates,
cavitation, hilar lymphadenopathy - healed primary TB calcified peripheral nodule,
calcified lymph node (Ghon complex) - Sputum smear positive for acid fast organisms
- Confirm with culture and/or molecular tests
35TB chest xray
36TB Medical Management
- Drugs chosen based on health of patient,
likelihood of resistant strain - Patients become non-infectious in 3-6 months
- Prophylactic drug treatment for certain close
contacts (young, HIV infected, diabetic)
37TB Dental Management
- New, active TB treat only urgently and in a
hospital isolation room - After 2-3 weeks of treatment treat normally
- History of TB treat normally if no active
disease - Positive TB test treat normally if no active
disease - Clinical signs suggestive of TB do not treat
38TB Oral Complications
- Painful, deep tongue ulcers (infrequent)
- Cervical, submandibular lymphadenitis (scrofula)
39Lung Disease
- Chronic obstructive pulmonary disease (COPD)
- Asthma
- Tuberculosis