clinical correlation: lung disease

Clinical Correlation: Lung DiseaseMark Bixby, M.D. | October 22, 2013

Lung Disease

• Chronic obstructive pulmonary disease (COPD)– Chronic Bronchitis

– Emphysema

• Asthma

• Tuberculosis

Lung Disease

• Chronic obstructive pulmonary disease (COPD)– Chronic Bronchitis

– Emphysema

COPD: Definition

• Chronic airflow limitation; not fully reversible

• Two major diseases:• Chronic bronchitis• Emphysema

• Overlapping symptoms

• Distinct entities or disease progression

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

Interpreting Spirometry - definitions

FVC (forced vital capacity)

The maximum volume of air which can be exhaled or inspired

FEV1 (forced expired volume in one second)

Volume expired in the first second of maximal expiration after a maximal inspiration and is a useful measure of how quickly lungs can be emptied , normal if >80%

PEFR (peak flow)

Measured in L/min by peak flow meter and L/sec on pulmonary function testing

FEV1/FVC Ratio of the volume in one second to total volumeCOPD if <0.7

Severity of COPDBased on SpirometryFEV1/FVC

FEV1

Mild <0.7 >80%Moderate <0.7 >80% and >50%

Severe <0.7 <50% and >30%

Very Severe <0.7

<30% or <50% with chronic respiratory failure

Emphysema: Signs and Symptoms

• Severe exertional dyspnea, minimal cough

• Prolonged expiratory phase• “Barrel-chested”, weight loss• “Pink puffers”: pursing of lips,

non cyanotic

pink puffer blue bloater

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

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

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)

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

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

COPD: Oral Manifestations

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

Lung Disease

• Chronic obstructive pulmonary disease (COPD)

• Asthma

Airway Inflammation and Clinical Symptoms

Inflammation

AirwayHyperresponsiveness

AirwayObstruction

Clinical Symptoms

Precipitating or Aggravating Factors

Exposure to irritants and occupational chemicals

Viral respiratory Infections

ExerciseEndocrine factors

Emotional expression: anger, laughing

Weather changes: cold air

Environmental changes Food additives:

sulfites

ASTHMAPATIENT

Allergens

Drugs:Aspirin Beta blockers

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

Severity & Control

Well Controlled

Not Well Controlled

Very Poorly Controlled

1 Mild Intermittent

2 Mild Persistent3 Moderate Persistent

4 Severe Persistent

Impairment

Risk

Classifying Asthma Severity (age ≥12)

Intermittent Persistent Mild

PersistentMod

PersistentSevere

Impairment

Symptoms ≤2 days / week >2 days / wk Daily Throughout the day

Night Awakenings ≤2 x / month 3-4 x / month >once / week Often

7 x / week

Β-agonist Use ≤2 days / wk > 2 days / week Daily Several times per day

Interference with activity None Minor Some Extreme

Lung Function Normal Normal FEV1 60-80%

FEV1 ↓ 5%FEV1 <60%FEV1 ↓ >5%

RiskSystemic Steroids <2 x / yr ≥2 / yr ≥2 / yr ≥2 / yr

Treatment Step to InitiateStep 1 Step 2 Step 3 Step 4 or 5

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

Stepwise Therapy for Asthmafor people 12 years of age and above

Therapy

Preferred

Alternative

Step 5

High DoseICS +LABAAND

Consider omalizumab for patients

with allergies

Step 6

High DoseICS +

LABA + OCSAND

Consider omalizumab for patients

with allergies

Persistent AsthmaIntermittent Asthma

Step 1

SABA prn

Step 2

Low DoseICS

Cromolyn, LTRA,

nedocromil or

theophylline

Step 3

Low DoseICS +

LABA or theophylline or medium-dose ICS

Low-dose ICS + LTRA,

theophylline or zileuton

Step 4

Medium DoseICS +LABA

Medium-dose ICS +

LTRA, theophylline or zileuton

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

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

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

Asthma: Oral Complications

• Mouth breathing complications• Increased gingivitis and caries secondary to

beta agonist inhaler use• Oral candidiasis secondary to steroid

inhaler use

Lung Disease

• Chronic obstructive pulmonary disease (COPD)

• Asthma

• Tuberculosis

TB: Definition

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

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

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

TB chest xray

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)

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

TB: Oral Complications

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

Lung Disease

• Chronic obstructive pulmonary disease (COPD)

• Asthma

• Tuberculosis