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 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/FVCRatio of the volume in one second to total volume COPD if <0.7

7. Severity of COPD Based on Spirometry FEV1/FVCFEV1 Mild<0.7>80% Moderate<0.7>80% and >50% Severe<0.7 30% Very Severe<0.7 <30% or <50% with chronic respiratory failure

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 pufferblue 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 O 2 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) N 2 O 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. Asthma: Definition Chronic inflammatory respiratory disease Airway hyperresponsiveness Recurrent dyspnea, coughing, wheezing Stimuli: allergens, URI, exercise, cold air, medications, chemicals, smoke, anxiety

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

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

20. 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

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

22. Classifying Asthma Severity (age ≥12) IntermittentPersistent Mild Persistent Mod Persistent Severe Impairment Symptoms≤2 days / week>2 days / wkDailyThroughout the day Night Awakenings≤2 x / month3-4 x / month>once / week Often 7 x / week Β-agonist Use ≤2 days / wk > 2 days / weekDaily Several times per day Interference with activity NoneMinorSomeExtreme Lung FunctionNormal FEV 1 60-80% FEV 1 ↓ 5% FEV 1 <60% FEV 1 ↓ >5% Risk Systemic Steroids<2 x / yr≥2 / yr Treatment Step to Initiate Step 1Step 2Step 3Step 4 or 5

23. 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

24. 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

25. Stepwise Therapy for Asthma for people 12 years of age and above Therapy Preferred Alternative Step 5 High Dose ICS + LABA AND Consider omalizumab for patients with allergies Step 6 High Dose ICS + LABA + OCS AND Consider omalizumab for patients with allergies Persistent Asthma Intermittent Asthma Step 1 SABA prn Step 2 Low Dose ICS Cromolyn, LTRA, nedocromil or theophylline Step 3 Low Dose ICS + LABA or theophylline or medium- dose ICS Low-dose ICS + LTRA, theophylline or zileuton Step 4 Medium Dose ICS + LABA Medium- dose ICS + LTRA, theophylline or zileuton

26. Asthma: Medical Management Plan for avoiding triggers Inhaled drugs Corticosteroids Leukotriene inhibitors Beta-adrenergic agonists Anticholinergics

27. 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 N 2 O or oral benzodiazepine Things to do

28. 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

29. 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

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

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

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

33. 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

34. 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

35. TB chest xray

36. 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)

37. 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

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

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