1. Chronic Obstructive Pulmonary Disease (COPD) Mr. Steve Reeves

2. Steve Reeves… 60 year old male with extensive dental needs. His past medical history is significant for: –Asthma –Emphysema (COPD) –Hypertension –Congestive Heart Failure

3. Cardiovascular Disease Signs & Symptoms --> –Breathing complications –Distended neck veins –Pitting edema –Cyanosis –Ascites –Dizziness –Fatigue

4. COPD Signs & Symptoms --> –Barrel chested –Dyspnea –Orthopnea –Respiratory infections/ cough –Cyanosis

5. Major Concerns… Risk of asthma attack in office. Risk of orthopnea during dental treatment. If hypertension not under control, risk of congestive heart failure, ischemic heart disease, and cerebrovascular accident. If congestive heart failure is present, risk of myocardial infarction cerebrovascular accident, arrhythmias, and cardiac arrest.

6. Questions to ask… History of Asthma –Date of Dx & Age of onset –What type of asthma does patient have? (allergenic, mild --> severe?) –What induces an asthma attack? –Level of control? –How frequent and how severe are the attacks? –What times of day do the attacks occur? –How are the attacks managed? –Has the patient ever received emergency treatment for an acute attack?

7. Questions to ask… History of emphysema (COPD) –Date of onset? –Does he smoke? If so, how many cigarettes and for how long? –Does he have trouble sleeping? –Respiratory Infections involved? –Is sputum present with his cough? –Orthopnea? –Contributing Factors to difficulty breathing (what activities) ?

8. Questions to ask… Cardiovascular Disease: –Common symptoms of heart disease dyspnea, chest pain, fatigue, weight gain/loss, weakness –Has there been a recent change in medications? –How long has he been on the medications? –Are there any side effects with his medications? –How frequently does he take is blood pressure, and what is it usually? –How often does he have headaches, chest pain, or shortness of breath?

9. Questions to ask… Congestive Heart Failure –Does he have symptoms of congestive heart failure? –Fever, Liver pain, Exercise intolerance, Swollen ankles –Are these symptoms present at rest?

10. Other information needed… What other information do you need? CONSULT PHYSICIAN –Asthma and Emphysema Lab measures of FEV (forced expiratory volume) Establish severity of disease & previous tx or hospitalizations Pre-medications –Congestive Heart Failure Does he have any complications of congestive heart failure? Enlargement of cardiac silhouette on chest radiography? Any previously detected COPD - and any tx received for these complications?

11. Physical Evaluation for Cardiovascular Disease.. –Vital signs: blood pressure, pulse, and respirations –Does he have signs of congestive heart failure? Rapid, shallow breathing Heart murmur Distended neck veins Ascites Jaundice

12. Physical Evaluation for Asthma.. Vital signs:blood pressure, pulse, respirations Recognize signs and symptoms of an asthma attack: –Inability to finish sentences with one breath. –Ineffective bronchodialators –Tachypnea (>25 breaths/min) –Tachycardia (>110 beats/min) –Diaphoresis

13. Patient Assessment… ASA PS level III COPD due to emphysema and asthma Congestive heart failure? –prehypertensive (138/84) on medication Taking six medications –four for COPD (azmacort, albuterol, theophylline, beclomethasone) –two for congestive heart failure (furosemide, captopril)

14. Patient Assessment… Systemic diseases interfering with Mr. Reeves daily activity –wheezing –difficulty breathing in supine position –weakness and dizziness Modifications to dental treatment most likely required –ie., patient can’t fully lie back in chair

15. COPD Patient Management… Discuss smoking and if he is currently smoking and if so, encourage to quit Patient presents with shortness of breath and ask if he has had a productive cough, upper respiratory infection, or oxygen saturation level of less than 91%If this is the case, reschedule if at all possible

16. COPD Patient Management… If breathing adequate, treat in semi supine position No contraindication of anesthetics, but some mandibular blocks may cause some airway constrictions feelings in severe COPD patients - For this, use humidified low-flow oxygen If need sedative, use low-dose oral diazepam (Valium). N2O used with caution and not in severe cases

17. COPD Patient Management… No narcotics or barbiturates because of respiratory depressant properties Anticholinergics and antihistamines should be avoided because of dryness and increase in mucous Our patient is taking theophylline so avoid macrolide antibiotics (erythromycin, azithromycin) and ciprofloxacin hydrochloride because of possible toxicity. No outpatient general anesthesia for COPD

18. Asthma Patient Management.. Main goal is to prevent acute attack by learning history, like what kind and causative agents, frequency, and severity Features such as shortness of breath, wheezing, and increased respiratory rate, emergency room visit within last three months and other lab values indicate poor control- postpone dental care Late morning appointments for nocturnal asthma patients

19. Asthma Patient Management.. Reduce operatory odorants Bring inhalers Prophylactic inhalation of bronchodilator at the beginning of the appointment Provide stress free environment (N20?)

20. Asthma Patient Management.. Local anesthetic without epinephrine and levonordefrin because sulfite preservative may cause an attack Not advisable to give NSAIDs, no barbiturates and narcotics, same as above with theophylline Recognize acute attack during procedure, can’t finish sentences, more than 25 breaths a minute, over 110 beats a minute

21. Asthma Patient Management.. Use short acting beta2-adrenergic agonist inhaler, it is most effective and fastest acting bronchodilator. If severe attack, give epinephrine Oral complications include reduced salivary flow from beta2 agonist inhalers, and erosion of enamel from GI reflux from beta agonists and theophylline.

22. Emergency Tx… Call Physician for medical history regarding heart disease. NYHA class I or II congestive heart failure --> can receive routine dental care. NYHA class III or IV congestive heart failure --> treat conservatively and refer patient to a hospital dental clinic. Call Physician for medical history regarding COPD. –Don’t lean patient back in chair. Refer to hospital dental clinic due to patient’s extensive dental needs –Keep an albuterol inhaler in office in case of airway obstruction.