PULMONOLOGY

1. PULMONOLOGY

2. Cardinal Respiratory Symptoms and Signs • COUGH • DYSPNEA • SPUTUM PRODUCTION & HEMOPTYSIS • CHEST PAIN – PLEURITIC • WHEEZING • CYANOSIS • SNORING

3. Cough –Causes • Acute • URTI • Post viral infection • Post nasal drip • Allergy • Pneumonia • Chronic • Asthma – typically at night • COPD – typically in morning • Gastro oesphageal reflux – esp when lie flat • Smoking • ACE Inhibitors • Pulmonary oedema (LVF) • TB • Bronchiectasis • Cystic fibrosis • Post nasal drip

4. Symptoms Haemoptysis Breathlessness Fever Chest Pain Weight Loss Signs Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles Red Flags in Acute Cough THINK pneumonia, lung cancer, LVF GET a CHEST X-Ray

5. Dyspnea The sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases.

6. Cardiac Pulmonary oedema (LVF ) Dilated cardiomyopathy Mitral valve disease Aortic stenosis Arrhythmias Pericardial effusion Respiratory Pulmonary embolism Pulmonary fibrosis Lung tumour Pneumonia Pneumothorax Pleural effusion Asthma COPD Bronchiectasis Lung collapse Metabolic Metabolic acidosis Anaemia Thyrotoxicosis Psychogenic hyperventilation Neuromuscular Kyphoscoliosis Ankylosing spondylitis Muscular dystrophy Poliomyelitis Myasthenia gravis Guillain-Barré syndrome Differential Diagnosis of Dyspnea

7. Easily Performed Diagnostic Tests • Chest radiographs • Electrocardiograph • Screening spirometry

8. Sputum • The nature of the sputum is often helpful • Pink frothy sputum - pulmonary oedema • Anchovy Past ( Amaebiasis ) • Clear white mucoid sputum –viral infection or longstanding bronchial irritation , COPD , Asthma • Thick, yellowish sputum – infection • Foul tasting/ smelling – anaerobic bacterial infection – bronchiectasis , abscess • Rusty sputum – pneumococcal pneumonia • Blood streaked sputum –T.B, bronchiectasis, Cancer lung • Black –Coal dust inhalation

9. Hemoptysis: Causes • Bronchial disorders • Bronchiectasis • Bronchogenic carcinoma • Chronic bronchitis • Pulmo Disorders • Pulmonary TB • Peumonia • Lung abscess • Pulmonary embolism • Cardiovascular disorders • Acute left heart failure • Mitral stenosis • Others • Hematologic disease , Systemic coagulopathy, anticoagulants, • Vasculitis : SLE, Wegeners, Goodpasture

10. Chest Pain

11. Causes of chest pain Cardiac related Angina pectoris Myocardial infarction Non-cardiac related Muscle strain Pericarditis Esophagitis Hiatal hernia Pulmonary embolism Dissecting aortic aneurysm Acute indigestion Intestinal “gas”

12. Cyanosis • Definition of cyanosis : A bluish color of skin and mucous membranes, in lips, nail beds caused by increased amount of reduced –desaturated hemoglobin (Hb) > 5g/dl Central • Hemoglobin -  content of reduced Hb • Heart disorders – lung congestion • Lung disorders • acute: pneumonia, lung edema • chronic: COPD, severe lung fibrosis • Peripheral • Local perfusion disorders

13. Central Cyanosis Impaired pulmonary function 1. Airway obstruction 2. Pulmonary diseases 3. Pleural diseases Right-to-left shunting of blood Tetralogy of Fallot

14. Peripheral Cyanosis Caused by increased oxygen consumption in peripheral tissue. Vasoconstriction Low cardiac output Exposure to cold air or water Slowing of blood flow Right heart failure

15. Respiratory Difficulty: Asthma Hyperventilation Chronic obstructive pulmonary disease (COPD) Foreign body aspiration Gastric contents aspiration

16. ASTHMA

17. What is Asthma • A chronic inflammation disorder in the airways • Acute episodes “triggered” by something • causes release of histamine, leukotrienes • causes obstruction of airflow • Predominant symptoms • Cough (Night time or early morning coughing ) • Breathlessness • Wheezing • chest tightness • Flushing • Increased heart rate and prolonged expiration • May be self-limiting, but severe episodes may require medical assistance

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. Manifestations of An Acute Asthmatic Episode: Mild to moderate - Wheezing - Dyspnea - Tachycardia - Coughing - Anxiety Severe - Intense dyspnea with flaring of nostrils & use of accessory muscle - Cyanosis of mucous membrane & nailbeds - Minimal breathing sound on auscultation - Flushing - Extreme anxiety - Mental confusion - Perspiration

20. Asthma Lab Tests No one diagnostic test Chest X - ray, skin testing, sputum smears and blood counts (for eosinophilia), arterial blood gases Spirometry (peak expiratory flow meter) before and after bronchodilator Oral Complications Mouth breathing complications Increased gingivitis and caries secondary to beta agonist inhaler use Oral candidiasis secondary to steroid inhaler use

21. 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

22. Asthma: Dental Management Precipitating factors Barbiturates and narcotics Aspirin, NSAIDs Antihistamines (or use cautiously) Macrolide antibiotics and ciprofloxacin (in patients on theophylline) Things to avoid

23. 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

24. Terminate all procedures • Fully sitting position • Bronchodilators (Atrovent/Berotec) • O2 • Check vital signs S & S relieved Signs & symptoms continue 6. Monitor of recovery state 7. Consult physician 6. Give Epi 0.3ml of 1: 1,000 IM or SQ 7. Build up IV line 8. Monitor vital signs S & S not relieved 9. Prepare to ER 10. Add steroid therapy • Asthma

25. Hyperventilation Syndrome: • Neurologic - dizziness - tingling or numbness of fingers, toes or lips - syncope • Respiratory - increased rate & depth of breaths - SOB - chest pain - xerostomia

26. Manifestations of Hyperventilation Syndrome: • Cardiac - palpitations - tachycardia • Musculoskeletal - myalgia - muscle spasm - tremor - tetany • Psychologic - extreme anxiety

27. Management of Hyperventilation Syndrome: • Terminate all procedures • On fully upright position • Verbally calm patient • Breath CO2-enriched air • Add Valium 10mg IV • Monitor vital signs

28. Chronic Obstructive Pulmonary Disease ( COPD ) • Chronic airflow limitation; not fully reversible • Two major diseases: • Chronic bronchitis • Emphysema

29. COPD PINK PUFFERS BLUE BLOATERS

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

31. Emphysema : Pink Puffers • Chronic disease • Result of destruction of the alveolar walls • cigarette smoking • exposure to “unfriendly” environment • Signs and Symptoms • Severe exertional dyspnea, minimal cough • Prolonged expiratory phase • “Barrel-chested”, weight loss • “Pink puffers”:(polycythemia) non cyanotic

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

33. 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

34. COPD: Dental Management Reschedule appointment if: Short of breath worse than baseline Productive cough worse than baseline Acute upper respiratory infection Oxygen saturation <91% (by pulse oximeter)

35. 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

36. COPD: Dental Management of Stable Patient 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 Things to avoid

37. PNEUMONIA

38. Pneumonia • Infection of the lung (in the alveoli) • Viral, bacterial, mycoplasma, or aspiration pneumonia • Respiratory viruses & mycoplasma responsible for greater than 1/3 of cases • Spread by: • Droplets or contact with infected persons • Aspiration of bacteria from nasopharynx

39. Viral Pneumonia • Influenza A most common viral type • Often epidemic in school children • May be secondary bacterial pneumonia • Viral Pneumonia—Presentation • Productive cough • Pleuritic chest pain • Fever : Shaking chills • Nonspecific complaints (elderly) • HA, nonproductive cough, fatigue, sore throat

40. Viral pneumoniaManagement /Prophylaxis • Supportive treatment - decrease severity of symptoms • Bed rest • Analgesics • Patients with • Airway obstruction - treat with Bronchodilators • Secondary bacterial infection - Antibiotics

41. Atypical Pneumonia • Accounts for 25% of community acquired pneumonias • Mild upper respiratory infection in school-age children and young adults • Mycoplasma/ chlamyda/legionella • Can cause Extrapulmonary Manifestations - • Meningitis, Encephalitis, Pericarditis, Hepatitis, Hemolytic Anemia • Typically bilateral infiltrates on chest x-ray • Treated with Antibiotics ( Macrolides / Doxycycline / Flouroquinone )

42. Bacterial Pneumonia • Most common cause Pneumococcal followed by Haemophilus influenza • Peaks in winter and early spring • Responsible for 10% of hospital admissions • Aspiration of oropharyngeal contents • Patients with a chronic disease are at an increased risk of contracting pneumonia • Unilateral infiltrate on x-ray • High mortality in elderly population

43. Bacterial Pneumonia Presentation • Fever - chills • Tachypnea • Tachycardia • Malaise • Anorexia • Myalgias • Flank or back pain • Vomiting

44. Aspiration Pneumonia • Inflammation of lung parenchyma from foreign material in tracheobronchial tree • May be: • Nonbacterial • Bacterial (as a secondary complication) • Dyspnea, cough, bronchospasm, wheezes, crackles, cyanosis • Treatment : Antibiotics

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

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

47. 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 (Ghon complex) Sputum smear positive for acid fast organisms Confirm with culture and/or molecular tests

48. TB chest xray

49. 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)

50. TB: Dental Management 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 New, active TB: treat only urgently and in a hospital isolation room Clinical signs suggestive of TB: do not treat