Clinical Correlation: Lung Disease

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Clinical Correlation Lung Disease
Mark Bixby, M.D. October 20, 2009
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Lung Disease

• Chronic obstructive pulmonary disease (COPD)
• Chronic Bronchitis
• Emphysema
• Asthma
• Tuberculosis

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Lung Disease

• Chronic obstructive pulmonary disease (COPD)
• Chronic Bronchitis
• Emphysema

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COPD Definition

• Chronic airflow limitation not fully reversible
• Two major diseases
• Chronic bronchitis
• Emphysema
• Overlapping symptoms
• Distinct entities or disease progression

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Chronic 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

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Interpreting Spirometry - definitions
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Severity of COPDBased on Spirometry
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Emphysema Signs and Symptoms

• Severe exertional dyspnea, minimal cough
• Prolonged expiratory phase
• Barrel-chested, weight loss
• Pink puffers pursing of lips, non cyanotic

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pink puffer
blue bloater
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COPD 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

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COPD 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

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COPD 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)

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COPD 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

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COPD 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

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COPD Oral Manifestations

• Halitosis
• Extrinsic tooth stains
• Nicotine stomatitis
• Periodontal disease
• Oral cancer

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Lung Disease

• Chronic obstructive pulmonary disease (COPD)
• Asthma

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Asthma Definition

• Chronic inflammatory respiratory disease
• Airway hyperresponsiveness
• Recurrent dyspnea, coughing, wheezing
• Stimuli allergens, URI, exercise, cold air,
  medications, chemicals, smoke, anxiety

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Airway Inflammation and Clinical Symptoms
Inflammation
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Precipitating or Aggravating Factors
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Asthma 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

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Severity Control
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Classifying Asthma Severity (age 12)
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Asthma 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

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Asthma 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

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Stepwise 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
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Asthma Medical Management

• Plan for avoiding triggers
• Inhaled drugs
• Corticosteroids
• Leukotriene inhibitors
• Beta-adrenergic agonists
• Anticholinergics

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Asthma 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

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Asthma Dental Management
Things to avoid

• Precipitating factors
• Barbiturates and narcotics
• Aspirin, NSAIDs
• Antihistamines (or use cautiously)
• Macrolide antibiotics and ciprofloxacin (in
  patients on theophylline)

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Asthma 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

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Asthma Oral Complications

• Mouth breathing complications
• Increased gingivitis and caries secondary to beta
  agonist inhaler use
• Oral candidiasis secondary to steroid inhaler use

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Lung Disease

• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Tuberculosis

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TB Definition

• Pulmonary and systemic disease
• Most common cause M. tuberculosis
• Spread by respiratory droplet

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TB 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

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TB 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

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TB chest xray
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TB 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)

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TB 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

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TB Oral Complications

• Painful, deep tongue ulcers (infrequent)
• Cervical, submandibular lymphadenitis (scrofula)

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Lung Disease

• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Tuberculosis