Copd and asthma
- 1. Respiratory disease Asthma and COPD
- 2. Chronic obstructive pulmonary disease Definition: COPD is a chronic,slowly progressive,irreversible disease,charecterized by breathlessness and wheeze,cough and sputum production . Is usually a combination of chronic bronchitis,emphysema.
- 3. Chronic bronchitis: Definition: excessive production of mucus and persistent cough with sputum production ,daily for 3 months in a year for more than 2 consecutive years. Sputum stagnates and becomes infected with S.pneumonae,M.catarrahlis,H.influenzae.
- 4. Emphysema Definition: Dilatation of air spaces distal to the terminal bronchioles with destruction of the alveoli reducing the area for air exchange.
- 5. Causes of COPD: SMOKING Environmental pollution Dust Occupational exposures to chemicals Deficiency of the aniproteolytic enzyme alpha 1- antirypsin (rare)
- 6. Clinical features: Progressive dyspnea and low oxygen saturation accumulation of carbon dioxide(hypercapnia) Acidosis eventual respiratory failure or Rt.sided heart failure. Early morning mucoid cough .
- 7. COPD is complicated by chronic hypoxemia with dyspnea on effort. Mild at first ,then deteriorates to leave respiratory cripples ,dyspneic at rest Some pts with emphysema maintain normal blood gases by Hyperventilation “pink panter”,”pink puffer” who is severely breathless and pink from vasodilation caused by co2 retention .
- 8. Those with chronic bronchitis, fail to maintain hyperventilation ,lose the co2 drive ,become hypercapnic and hypoxic, but less breathless. Chronic hypoxemia leads to central cyanosis and ankle edema and raised jugular venous pressure gives rise to “blue bloated “ appearance ,for whom the respiratory drive is from low po2 and thus o2 administration is contraindicated.
- 9. diagnosis Chest radiographs Respiratory function tests(Spirometry ). Arterial blood gas estimation . FEV1 is typically reduced, and is used to grade COPD. FEV1 and if less than 40% severe COPD. FEV1:FVC if the ratio was less than 70% confirms airways obstruction.
- 10. management Stop smoking Antibiotics amoxicillin,trimethoprim,tetracyclin. Immunization against influenza. Mucolytics carbocisteine Bronchodilators ipratropimbromide,antimuscarinics oxitropium or beta agonist or occasionally lowe dose inhaled or systemic corticosteroids or theophylline. Long term oxygen therapy Surgery Lung transplantation
- 11. Dental aspects Upright position Difficult to use rubber dam Pt on corticosteroids should be treated with precautions. Theophylline interactions with :epinephrine,clindamycin,clarithromycin,azithromycin,ery thromycin,ciprofloxacin may result in dangerously high levels of theophylline. L.A preferred, but bilateral mandibular and palatal injections should be avoided. Analgesia only if necessary and after preoperative assessment.
- 12. Diazepam and midazolam are mild respiratory depressants should not be used. G.A only if necessary. I.V barbiturates are totally contraindicated. Pt may cough and contaminate other areas of the lung if slightly anesthetized. Spirometry and carbon monoxide perfusion are essential to assess respiratory function.
- 13. Preoperatively: cessation of smoking for at least 1 week Respiratory infection must be eradicated, sputum should first be sent for culture and sensivity, but antimicrobials such as amoxicillin should be started without awaiting results. Ipratropium can cause dry mouth
- 14. Asthma Common 2-5% of the population . Males Childhood or early adulthood. About half of patients developed it before the age of 10 years.
- 15. It’s a state of bronchial hyper-reactivity causing: Paroxysmal expiratory wheezing Dyspnea Cough
- 16. Generalized reversible bronchial narrowing is caused by: excessive bronchial s.m tone ,edema and congestion, mucus hypersecretion and diminished ciliary clearance.
- 17. Types of asthma Extrinsic intrinsic
- 18. extrinsic Allergic asthma Typical in children Precipitated by: dust, animals, molds,antibiotics,NSAIDs, milk, eggs,fish, Fruit, nuts and some antibiotics. Asymptomatic between attacks. Usually patient develop other allergic diseases like eczema,hay fever ,drug sensitivities. Tends to resolve in adult life.
- 19. Extrinsic Associated with overproduction of IgE on exposure to allergens and release of mast cell products that cause bronchospasm and oedema. Mediators: histamine,leukotrines prostaglandins,bradykinins and PAF(platelet activating factor).
- 20. Intrinsic Not allergic. Mast cells instability and hyperresponsive airways. Triggered by : Emotional stress-gastro-oesophageal reflux-vagally mediated responses.
- 21. Both extrinsic and intrinsic could be initiated by the following: Infections(viral,mycoplasmal or fungal) Exercise Emotional stress Food types(nuts, shellfish,strawberriesor milk) Food additives(tartrazine) Drugs(NSAIDs,beta blockers,ACE inhibitors,aspirin) Fumes including cigarette smoke.
- 22. Clinical features Dyspnea Cough Wheezing Laboured expiration.
- 23. Children present with repeated colds with cough, malaise and fever at night. Nasal polyps specially in aspirin sensitive asthmatics. Rarely, a prolonged and often life-threatening attack refractory to treatment starts and if this persist for more than 24 h, its termed status asthmaticus and potentially lethal.
- 24. General management Chest radiographs Spirometry(important) skin tests , which may help to identify any allergens. Blood examination(usually raised total IgE and specific IgE antibody concentrations). Avoidance of identifiable irritants and allergens, use of drugs Home use of peak flow meters allows patients to monitor progress and detect any deterioration.
- 25. Drugs Beta 2 agonists (sulbutamol) Corticostroids, if there are daily symptoms. Leukotriene receptor antagonists(Zafirlukast) Omalizumab(a recombinant humanized monoclonal anti IgE antibody ) decrease the symptoms. Systemic steroids,oxygen and hospitalization in recalcitrant disease .
- 27. Dental aspects Ask pt to bring their medications. In severe asthmatics..defer elective ttt. Allergy to penicillin maybe more frequent . Theophylline interactions Patients On leuokotriene modifying drugs may have prolonged INR and bleeding tendency . Systemic steroids treatment brings with it the risks from steroid complication, and operation are dangerous on such patient without adequate preparation.
- 28. Avoid the following drugs : Aspirin increases zafirlukast levels. NSAIDs Sulphites in L.A If epinephrine containing local analgesics are indicated, thy should be given with an aspirating syringe, but contraindicated with pt on theophyline causes dyrhythmias Conscious sedation : Relative analgesia with NO and oxygen is preferable over IV sedation .
- 29. Sedatives are better to be avoided . G.A is best avoided Opioids avoided
- 30. Dental aspects Oral manifestations : -The use of corticosteroid inhalers causes oral and pharyngeal thrush and rarely angina,bullosa haemorrhagica. -Beta 2 agonists and ipratropium bromide causes dry mouth . -Anti-asthmatic drugs may Lower the salivary pH -Periodontal inflammation is more in asthmatic patients . -Gastro-oesophageal reflux is common with tooth erosion
- 31. Acute asthmatic attack Asthmatic attacks may be precipitated by -Anxiety:gentle handling and reassurance.. -drugs which include: Asprin ,NSAIDs Barbiturates Beta blockers Mefanamic acid Pentazocine Acrylic monomer Colophony and cyanocrylates .
- 32. Usually self-limiting or responds to the ptn usual drugs,..beta agonist inhaler Status asthmaticus is potentially lethal emergency.
- 33. Thank you