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PULMONOLOGY
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Cardinal Respiratory Symptoms and Signs
COUGH DYSPNEA SPUTUM PRODUCTION & HEMOPTYSIS CHEST PAIN – PLEURITIC WHEEZING CYANOSIS SNORING
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Cough –Causes Acute Chronic 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
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Red Flags in Acute Cough
Signs Tachypnoea Cyanosis Dull chest Bronchial Breathing Crackles Symptoms Haemoptysis Breathlessness Fever Chest Pain Weight Loss THINK pneumonia, lung cancer, LVF GET a CHEST X-Ray
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Dyspnea The sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases.
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Differential Diagnosis of Dyspnea
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
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Easily Performed Diagnostic Tests
Chest radiographs Electrocardiograph Screening spirometry
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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
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Hemoptysis: Causes Bronchial disorders Pulmo 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
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Chest Pain
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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” 11
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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
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Central Cyanosis Impaired pulmonary function Right-to-left shunting
1. Airway obstruction 2. Pulmonary diseases 3. Pleural diseases Right-to-left shunting of blood Tetralogy of Fallot
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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
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Respiratory Difficulty:
Asthma Hyperventilation Chronic obstructive pulmonary disease (COPD) Foreign body aspiration Gastric contents aspiration
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ASTHMA
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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
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Precipitating or Aggravating Factors
Drugs: Aspirin Beta blockers Viral respiratory Infections Endocrine factors Exercise ASTHMA PATIENT Weather changes: cold air Exposure to irritants and occupational chemicals Allergens Environmental changes Emotional expression: anger, laughing Food additives: sulfites 18
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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
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Asthma Lab Tests Oral Complications 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 20
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Asthma: Dental Management
Things to do 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 21
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Asthma: Dental Management
Things to avoid Precipitating factors Barbiturates and narcotics Aspirin, NSAIDs Antihistamines (or use cautiously) Macrolide antibiotics and ciprofloxacin (in patients on theophylline) 22
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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 23
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Asthma Terminate all procedures Fully sitting position
Bronchodilators (Atrovent/Berotec) O2 Check vital signs Signs & symptoms continue S & S relieved 6. Give Epi 0.3ml of 1: 1,000 IM or SQ 7. Build up IV line 8. Monitor vital signs 9. Prepare to ER 10. Add steroid therapy 6. Monitor of recovery state 7. Consult physician S & S not relieved Asthma
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Hyperventilation Syndrome:
Neurologic - dizziness - tingling or numbness of fingers, toes or lips - syncope Respiratory - increased rate & depth of breaths - SOB - chest pain - xerostomia
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Manifestations of Hyperventilation Syndrome:
Cardiac - palpitations - tachycardia Musculoskeletal - myalgia - muscle spasm - tremor - tetany Psychologic - extreme anxiety
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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
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Chronic Obstructive Pulmonary Disease ( COPD )
Chronic airflow limitation; not fully reversible Two major diseases: Chronic bronchitis Emphysema
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COPD PINK PUFFERS BLUE BLOATERS
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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 30
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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
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COPD: Oral Manifestations
Halitosis Extrinsic tooth stains Nicotine stomatitis Periodontal disease Oral cancer 32
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COPD: Lab Tests Spirometry Chest x-ray:
↓ maximum expiratory flow rate – not reversible Chest x-ray: Chronic bronchitis: prominent vascular markings Emphysema: over distention of lungs, flattening of diaphragm, emphysematous bullae 33
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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) 34
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COPD: Dental Management of Stable Patient
Things to do 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 35
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COPD: Dental Management of Stable Patient
Things to avoid 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 36
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PNEUMONIA
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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
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Viral Pneumonia—Presentation
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
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Viral pneumonia Management /Prophylaxis
Supportive treatment - decrease severity of symptoms Bed rest Analgesics Patients with Airway obstruction - treat with Bronchodilators Secondary bacterial infection - Antibiotics
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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 )
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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
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Bacterial Pneumonia Presentation
Fever - chills Tachypnea Tachycardia Malaise Anorexia Myalgias Flank or back pain Vomiting
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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
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TB: Definition Pulmonary and systemic disease
Most common cause: M. tuberculosis Spread by respiratory droplet 45
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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) 46
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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 47
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TB chest xray 48
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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) 49
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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 50
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Pneumothorax
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Pulmonary Embolism
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Lung Cancer Haemoptysis Unexplained or persistent (more than 3 weeks)
Most years of age Smoking top cause Early—signs of respiratory illness Late –Hemoptysis , Dyspnea , Hoarseness , Dysphagia , Weight loss , Weakness CLINICAL FEATURES OF LUNG CANCER (DO IMMEDIATE CXR) Haemoptysis Unexplained or persistent (more than 3 weeks) cough chest/shoulder pain chest signs dyspnoea Hoarseness finger clubbing
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TYPES OF TUMOURS 1. Squamous Cell carcinoma 2. Adeno carcinoma
3. Small cell carcinoma 4. Large cell, undifferentiated carcinoma 54
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Responding to a Patient With Breathing Problems
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