Diseases of the lungs for dental hygiene students
By Elizabeth Kelley Buzbee AAS, RRT-NSP, RCP
I. COPD: “chronic obstructive lung disease” is a general grouping of similar disorders.
a. What they have in common is:
i. Chronic conditions with episode of exacerbations.
1. These disorders are almost always progressive [Egan’s]. Mild/ moderate /severe /end-stage
2. Triggers for all these disease exacerbations include: cigarette smoking [first or second hand] drugs, strong smells, any aerosol not a bronchodilator, stress, breathing through the mouth. Viral and bacterial pulmonary infections, GER,
ii. involve the lower airways [below the vocal cords]:
1. central airways such as trachea and bronchi contribute excessive secretions
2. while bronchioles will become occluded by bronchospasm, mucosal swelling and secretions
3. all COPD patients are at risk for pneumonia
iii. have increased secretions, or bronchospasm that narrows airways making WOB more difficult
iv. Narrowed airways result in air trapping of gas in the alveoli.
1. air trapping results in increased AP diameter, increased RV of the lung that shows up in the X-ray as a flattened lower diaphragm, and increased volume in the lungs
2. airtrapping that actually increases the total lung capacity is a severe degree of airtrapping
b. SOB and dyspnea: shortness of breathing is a subjective symptom seen in all COPD, as well as most other lung disorders. Like perceptions of pain, it is subjective and sometimes bares little or no relationship to the actual s/s of the disease.
i. Because SOB is subjective, one can use stress reduction to combat this.
ii. Purse-lip breathing; slow deep breathing
II. Significance to dental worker: may or may not be a problem depending on the staging of the patient’s disorder. All COPD disorders are mild, moderate or severe finally end-stage.
a. Mild/moderate/severe COPD
i. Persons who are getting inhaled or systemic steroids for treatment of inflammation associated with COPD, asthma or emphysema will have decreased immune response and may require antibiotics prior to dental work
ii. Person on inhaled anti-cholinergic bronchodilators such as Atrovent will suffer dry mouth from decreased salivation
iii. Persons with mild/moderate severe COPD may need a Beta II bronchodilator such as Albuterol, Terbutaline or Metaproterenol to handle “break-through wheezing.” NOTE: never give extra dose of Serevent tm
iv. They might benefit from a prophylactic extra puff or two before the procedure starts. While Cromolyn Na is helpful before a procedure, it is a poor rescue drug.
v. Steroids are never good rescue drugs Onset of action is in hours; not minutes
b. A person in severe and end-stage COPD frequently needs supplementary 02.
i. If a person uses 02 in the home, due to Medicare’s strict utilization regulations, we can assume his disorder is serious. If patient is supposed to wear his 02 all the time, make sure he’s on his baseline 02 during the procedure
1. picture of liquid 02 tank http://www.cairemedical.com/ps_stroller.htm
2. picture of nasal cannula http://www.salterlabs.com/home.html
3. other types of nasal cannulae http://www.o2conservers.com/O224.htm
4. picture of SCOOP http://www.transtracheal.com/
ii. He will have serious decline in his ability to perform activities of daily life. He will not be able to talk without taking a breath every few syllables. He will not be able to walk across the room without stopping and taking a breath. He may purse-lip breathe. He may be wheelchair bound.
1. Teach them to brush their teeth sitting in a chair in the bathroom.
iii. End stage COPD patient will have increased PC02 in their blood and they will be breathing from a hypoxic drive. This means that if we increase their 02 we can create apnea or hypoventilation.
1. When your patient is getting extra 02 and he gets progressively sleepy and his respirations get irregular or stop completely—turn the 02 back to baseline and talk him awake. Tell him to breathe “Breathe now Mr. Jones.” until he wakes up again. If that doesn’t work, start mouth-to-mouth and call 911.
iv. To avoid this scenario, we keep the S02 on the pulse oximeter at 92% and he will be comfortable. We rarely exceed 1-2 lpm of 02
v. Persons with moderate to severe COPD can get into trouble with sedation. They lose the ability to feel SOB if sedated too much
vi. Persons with moderate to severe COPD will frequently present with s/s of depression from limitations on activities
vii. Persons with severe COPD will present with anorexia and have poor eating habit because they feel full too quickly.
c. Chronic bronchitis: when a person has bronchitis with increased secretions and productive cough for 3 months at least 2 years, he is diagnosed with chronic bronchitis.
i. Most common cause is cigarette smoking
ii. Treatment for chronic bronchitis includes inhaled drugs to combat bronchospasm, secretion mobilization and antibiotics for recurrent pneumonias
iii. If chronic bronchitis gets bad enough it will interfere with gas transfer so that the P02 goes down and the PC02 goes up [end-stage]
d. Emphysema: when obstruction from long-standing chronic bronchitis or other obstructive disorders goes long enough, the smaller airways actually start to lose structural integrity then the airways and alveoli downstream from the terminal bronchioles get over-distended.
i. Most emphysema is the result of long-standing COPD with air trapping
ii. There is loss of elasticity in the airways, so that they are floppy
iii. Rarely; only 1% of emphysema patients are alpha antitrypsin defect. These folks are asymptomatic until they hit the early 40’s then the damage to the airways results in rapid progression of the disorder.
iv. Treatment for both types of emphysema includes inhaled bronchodilators to combat bronchospasm, secretion mobilization and antibiotics for recurrent pneumonias. Person with serious damage to lung segments or lobe can have surgical removal of these structures. And some persons with alpha antitrypsin defect might benefit from lung transplantation
e. Cystic fibrosis: inborn error at the cellular level in which all exocrine glands secrete excessively thick secretions. This disorder involves the sinus, the sweat glands, the gastric system as well as the respiratory tract. Associated with persons of northern European birth [1 in 3000 live births]
i. Children with CF are diagnosed in infancy and early childhood due to s/s of poor nutrient [FTT] and recurrent pneumonia
ii. Will start out with chronic bronchitis which leads to airtrapping, COPD and finally emphysema
iii. By pre-teens and teenagers may have may have chronic hypercapnia and breathe from a hypoxic drive so care might need to be taken with 02 administration
iv. Treatment for CF includes inhaled bronchodilators to combat bronchospasm, secretion mobilization and antibiotics for recurrent pneumonias. They get oral pancreatic enzymes to help digest fats and other foods. The most common use of lung transplantation occurs in this patient population. Usually teenagers because disease is worse and donors are usually adults.
v. Sudden Hemoptysis [blood in the sputum] while scary is rarely life threatening, but they need to see the doctor. It may require surgery if bad enough
vi. Significance for health care workers
1. All persons who have lung transplants have drug-induced immunological compromise—use care with infection control
2. oral antibiotics are poorly absorbed in the CF patient because of the mal-absorption problems with the GI tract
III. Asthma: airway hyper-sensitivity associated with episodes of airway narrowing that can be reversed almost completely.
a. Extrinsic: associated with allergens [an allergen is a foreign protein such as cat dander, or pollen] The patient’s airways contain mast cells that react to the presence of the inhaled allergen. The mast cell bursts and spills out substances that cause inflammation, bronchospasm, increased secretions
i. s/s of allergic asthma: “hay fever,” frequent sinus problems, “allergy shiners,” cough and sneezing at spring or fall; family history of allergies, contact dermatitis, runny nose, runny eyes
b. Intrinsic: cholinergic reflex bronchospasm is triggered by anything that is not an allergen. ‘Twitchy airways;” persons may start with extrinsic asthma and as the airways get better at reacting to allergens they start reacting to other stimuli. Anything can trigger reflex bronchospasm
i. The mast cell has cholinergic receptors on its surface so that the mast cell ruptures and the chemical mediators of anaphylaxis spill out and trigger the symptoms on the smooth muscle of the airways
ii. Role of panic in asthma: exercise induced asthma, ‘emotional asthma, asthma associated with cold fronts and weather changes and ‘psychosomatic’ asthma all share one thing in common. The patient breathes [laughs/cries/sings] through an open mouth rather fast so that the airway cools off. This triggers cholinergic reflex bronchospasm.
iii. The trick to get this patient to stop wheezing is to [1] get them to take the inhaled Beta II drug and [2] while the drug is taking affect work through relaxation exercises by inhaling through the nose to warm the air and exhaling through the closed lips [purse-lip] breathing
iv. Role of infection in asthma: increased secretion in the tracheal and bronchus associated with chest cold, pneumonia will trigger cholinergic reflex—especially in the asthmatic with viral pneumonia
v. Role of GER in asthma: persons who have gastric reflux frequently get reflex bronchospasm from breathing in the acid droplets or even breathing the fumes associated with vomit.
1. GER is a significant component of nocturnal asthma and once the reflux is treated, the patient’s asthma is treated.
2. Persons on many asthma drugs such as oral steroids or theophylline will have ‘acid stomach’
c. Adult onset One child in 10 has asthma, but most outgrow it. Adults who get asthma at 40 years of age or older tend to have poor prognosis compared to person who never outgrew their asthma.
d. Pediatric considerations: kids with asthma are frequently not real good about recognizing they have problems—particularly teenagers who have poor compliance with their care
e. PEFR: one important tool for monitoring asthmatic is the peak flow meter. We measure the speed they exhale and if it falls below their ‘personal best’ we expect them to come into office. Color coded: Green is good; Yellow is watch out, Red is get to the doctor’s office--now
f. The scary asthmatic: the one who has had a history of asthma treated frequently in the ER. The asthmatic, who has a history of being admitted to the ICU for his asthma. The asthmatic, who has a history of being put on a ventilator for his asthma. The one who has been placed on all the drugs: steroids, anti-inflammatory, beta II, cholinergic blockers, and theophylline and still wheezes… these are all scary asthmatics. If this person gets into respiratory distress and a couple of puffs of inhaler doesn’t work call the ambulance.
IV. Pulmonary tuberculosis: TB is a bacterial pneumonia caused by an microbe that has lived with humans for centuries. Mycobacterium TB is a wily and sneaky bacteria who can lie dormant in lung tissue for years waiting for us to get sick & debilitated [HIV, cancer, starvation]
a. Significance to dental worker: health care workers need to be tested for exposure periodically because we are at slightly higher risk than the general population. TB can infect any part of the body: pulmonary bones,
b. Persons at risk: immune defects such as AIDS, chemotherapy, leukemia De George syndrome and other congenital immunities
c. Signs/ symptoms: low grade fever, night sweats, productive cough, unexplained weight lose . Poor appetite
d. Skin test PPD or Manitou skin test are screening tests for exposure to the bacteria. They will not tell us who is contagious. We need Sputum for AFB and a positive x-ray to see who is contagious. http://z.about.com/d/p/440/e/f/3037.jpg
e. Once you have a positive skin test, you will be positive for ever so you need to be followed by X-rays
f. Persons from overseas [Asian patients ] where TB vaccination is common, will have to be followed by x-ray because skin test are +
g.
TB vaccination doesn’t always work; not done in
h. Negative skin test in AIDS patient is false - because the skin test doesn’t work—they need chest X-ray and sputum for AFB test
V. Sleep apnea syndromes
a. Obstructive sleep apnea and morbid obesity
i. Significance to dental work: some dental appliances for OSA http://www.helpguide.org/life/sleep_apnea.htm#Types_dental_appliances_sleep_apnea
ii. these folks don’t always get diagnosed if you have someone who fits the profile below, you might suggest they get into contact with the doctor
1. s/s overweight, middle aged, falls asleep way too easily [like in the dental chair] snores; then wakes suddenly Patient may have a short neck. Wife c/o frequent arousal. She may be sleeping in another room because of the snoring
2. Patient may suffer depression or seem slow or stupid due to lack of sleep.
3. Facial features: some may have short jaws; Mr Burns on the “Simpsons”.http://www.thesimpsons.com/bios/bios_townspeople_burns.htm
4.
a. When you open their mouth you will see a red inflamed uvula and soft palate due to rubbing on the tongue while asleep http://www.dentistry.vcu.edu/departments/opath/labcasex/textfiles/descriptions/sitepics/sit46.jpeg
b. the patient tends to have a overly-sensitive gag reflex http://www.ucihs.uci.edu/otohns/pictures/medical%20student%20session/ms8.htm
b. Central sleep apnea
i. s/s nothing obvious. The problem is in the brain. When we have sleep apnea we r/o obstructive-- then what is left is CSA or mixture of both
