Clinical Correlation: Lung Disease

1. Clinical Correlation: Lung Disease Mark Bixby, M.D. | October 22, 2013

2. Lung Disease • Chronic obstructive pulmonary disease (COPD) • Chronic Bronchitis • Emphysema • Asthma • Tuberculosis

3. Lung Disease • Chronic obstructive pulmonary disease (COPD) • Chronic Bronchitis • Emphysema

4. COPD: Definition • Chronic airflow limitation; not fully reversible • Two major diseases: • Chronic bronchitis • Emphysema • Overlapping symptoms • Distinct entities or disease progression

5. Chronic Bronchitis Signs and Symptoms • Onset phase: years • Chronic cough, copious sputum • >3 months • 2 consecutive years • “Blue bloaters”: sedentary, overweight, cyanotic, edematous, breathless • Severity based on spirometry

6. Interpreting Spirometry - definitions

7. Severity of COPDBased on Spirometry

8. Emphysema: Signs and Symptoms • Severe exertional dyspnea, minimal cough • Prolonged expiratory phase • “Barrel-chested”, weight loss • “Pink puffers”: pursing of lips, non cyanotic

9. pink puffer blue bloater

10. 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

11. 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

12. 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 <91% (by pulse oximeter)

13. COPD: Dental Management of Stable Patient • Treat in upright chair position • Use inhalers prior to treatment • Use pulse oximetry • Use low-flow oxygen when O2 sat <95% unless baseline is lower • May use low-dose oral diazepam • Supplemental steroids may be required Things to do

14. COPD: Dental Management of Stable Patient • Rubber dam use (in severe cases) • N2O sedation (in severe or very severe COPD) • Barbiturates and narcotics • Antihistamines and anticholinergics • Macrolide and ciprofloxacin antibiotics • If the patient is on theophylline • Outpatient general anesthesia Things to avoid

15. COPD: Oral Manifestations • Halitosis • Extrinsic tooth stains • Nicotine stomatitis • Periodontal disease • Oral cancer

16. Lung Disease • Chronic obstructive pulmonary disease (COPD) • Asthma

17. Airway Inflammation and Clinical Symptoms Inflammation Airway Hyperresponsiveness Airway Obstruction Clinical Symptoms

18. Precipitating or Aggravating Factors Drugs: Aspirin Beta blockers Viral respiratory Infections Endocrine factors Exercise Weather changes: cold air Exposure to irritants and occupational chemicals ASTHMA PATIENT Allergens Environmental changes Emotional expression: anger, laughing Food additives: sulfites

19. 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

20. Severity & Control 4 Severe Persistent 3 Moderate Persistent 2 Impairment Mild Persistent 1 Mild Intermittent Well Controlled Risk Not Well Controlled Very Poorly Controlled

21. Classifying Asthma Severity (age ≥12)

22. 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

23. Stepwise Therapy for Asthmafor people 12 years of age and above Intermittent Asthma 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 Step 4 Medium Dose ICS + LABA Medium-dose ICS + LTRA, theophylline or zileuton Step 3 Low Dose ICS + LABA or theophylline or medium-dose ICS Low-dose ICS + LTRA, theophylline or zileuton Step 2 Low Dose ICS Cromolyn, LTRA, nedocromil or theophylline Step 1 SABA prn

24. Asthma: Dental Management • 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 Things to do

25. Asthma: Dental Management • Precipitating factors • Barbiturates and narcotics • Aspirin, NSAIDs • Antihistamines (or use cautiously) • Macrolide & ciprofloxacin antibiotics • If the patient is on theophylline Things to avoid

26. Asthma: Managing an attack • Warning signs • Frequent cough • Inability to finish sentence in one breath • Bronchodilator ineffective • Tachypnea • Tachycardia (>110) • Diaphoresis • What to do • Use short-acting beta-adrenergic agonist inhaler • Positive-flow oxygenation • If severe: subcutaneous epinephrine, call EMS

27. Asthma: Oral Complications • Mouth breathing complications • Increased gingivitis and caries secondary to beta agonist inhaler use • Oral candidiasis secondary to steroid inhaler use

28. Lung Disease • Chronic obstructive pulmonary disease (COPD) • Asthma • Tuberculosis

29. TB: Definition • Pulmonary and systemic disease • Most common cause: M. tuberculosis • Spread by respiratory droplet

30. TB: Signs and symptoms • Most patients with 1°infection: no symptoms • Progressive Primary Infection or Re-activation • 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

31. TB: Lab Tests • Positive tuberculin (Mantoux) skin test (does not mean infection is clinically active) • X-ray findings • progressive primary TB: patchy infiltrates, cavitation, hilar lymphadenopathy • healed primary TB: calcified peripheral nodule, calcified lymph node • Sputum smear positive for acid fast organisms • Confirm with culture and/or molecular tests

32. TB chest xray

33. 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)

34. 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

35. TB: Oral Complications • Painful, deep tongue ulcers (infrequent) • Cervical, submandibular lymphadenitis (scrofula)

36. Lung Disease • Chronic obstructive pulmonary disease (COPD) • Asthma • Tuberculosis