DENT 419: PRINCIPLES OF MEDICINE

Dr. Arriane Mae Basco

DDM 4 – B: MIDTERM – Pulmo-Allergo-Inf
RESPIRATORY and ALLERGIC DISEASES GAS CONDUCTING SYSTEM
OBJECTIVES: - terminates in blind pouches or alveoli
1. To learn about the common pulmonary and allergic • Major Function: maintain gas tensions in the alveoli
diseases, their detection, management, and in the direction of the ambient gas
prevention • Nasal passages -> trachea -> left and right mainstem
2. To discuss cmmon diseases of the lungs and airways, bronchi -> 20-23 bifurcations -> 1 million terminal
important diagnostic tests and management of such conducting tubes -> 300 million alveoli
3. to discuss the different allergic-immunologic
diseases and their management

OUTLINE
I. Overview of Respiration
II. Signs and Symptoms
III. Physical Examination
IV. Diagnostic Tests in Pulmonology
V. Asthma
VI. Chronic Obstructive Pulmonary Disease
VII. Pulmonary Tuberculosis
VIII. Community Acquired Pneumonia BLOOD CONDUCTING SYSTEM
IX. Lung Cancer - transports venous blood to alveolar walls; the blood
X. Allergy is contained in these walls in thin walled exchange
XI. Anaphylaxis vessels or pulmonary capillaries
• The surface area of the pulmonary capillary alveolar
DEFINITIONS: interface constitutes the major area of gas exchange.
• RESPIRATION - processes that affect gas exchange
between and organism and its environment
• RESPIRATORY SYSTEM - described the organs and
tissues involved in respiration
• In this module:
o Extrapulmonary and Intrapulmonary
Airways
o Lungs
o Pleura
o Chest Wall
o Muscles of Respiration

MUSCLES OF RESPIRATION (inspiration)

• DIAPHRAGM - principal muscle of inspiration during
quiet breathing
o accounts for the movement of more than ⅔
of the air that enters the lung
OVERVIEW OF RESPIRATION • INTERCOSTAL MUSCLES - also raise the ribs during
Major Function of the Lung: inspiration -> increasing anteroposterior and
• Add oxygen to and remove carbon dioxide from transverse diameter of the chest
venous blood
o Accomplished by two conducting MUSCLES OF RESPIRATION (inspiration): Accessory Muscles
systems: • SCALENE MUSCLES - contributes during high levels
▪ Gas-Conducting System of ventilation, when the upper thorax needs to be
▪ Blood-Conducting System enlarged
• STERNOCLEIDOMASTOID MUSCLE - normally
becomes active only during severe asthmatic or
bronchitic episodes

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MUSCLES OF RESPIRATION (expiration) • COUGH - performs an essential protective function
• Expiration during quiet breathing occur passively as a for human airways and lungs
result of lung recoil o without an effective cough reflex, at risk for
• At higher levels of ventilation or in states where retained airway secretions and aspirated
expiration is impeded, some muscles are recruited: material predisposing to infection, and
o Internal intercostal muscles respiratory compromise
o Transversus o at the other extreme, excessive coughing ->
o Rectus abdominis exhausting; can be complicated by fainting,
muscular pain, or rib fractures; can
aggravate low back pain and urinary
incontinence
o Chronic cough (>2 weeks)

• HEMOPTYSIS - expectoration of blood from the

respiratory tracts
o Can arise from anywhere in the respiratory
system
▪ Glottis
▪ Alveolus
▪ Most commonly: bronchi or
medium sized airways
o Can be from infections, malignancy, or
vascular disease

COMMON SYMPTOMS OF DISEASES OF RESPIRATORY

SYSTEM
• DYSPNEA - “subjective experience of breathing
discomfort that consists of qualitatively distinct
sensations that vary in intensity”
o On physical exam, patient may present
with: SPECIALIZED ASPECTS OF THE PHYSICAL EXAMINATION OF
▪ increased work of breathing THE RESPIRATORY SYSTEM
▪ Tachypnea (rapid breathing) CYANOSIS
▪ Use of accessory muscles for • note for the color of the nailbeds and lips
breathing • Associated with hypoxemia
▪ Intercostal retractions • Distribution of cyanosis frequently provides a clue to
the cause
• Patients with respirator-related cyanosis usually
have both peripheral (nailbeds) and central (perioral)
cyanosis

CLUBBING
• used to refer to changes in the distal segment of a
digit
• Due to an increase in soft tissue
• widening of the angle formed at the junction of the
nail base and periungual skin

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 • increased curvature of the nails EXAMINATION OF THE THORAX: Percussion
• Not a specific sign for pulmonary disease • Percussion note over the thorax is determined by
• Usual associated pulmonary conditions: primary or the ratio of air to solid tissue
metastatic carcinoma of the lungs and diseases of • Resonant - percussion note over normal lung tissue
chronic suppuration (emphysema, bronchiectasis, • Dullness - normally resonant areas of chest
lung abscess) o pleural effusion
o atelectasis
o pneumonia
o solid masses

EXAMINATION OF THE THORAX: Inspection

• Rate and pattern of breathing EXAMINATION OF THE THORAX: Auscultation
• Normal respiratory rate: 12-20 bpm • Breath sounds vary according to the location of the
o abnormality should raise concern of stethoscope
inadequate oxygen and carbon dioxide • Vesicular breath sound - normal breath sounds
• Barrel chest configuration in COPD heard over the chest
• intercostal retractions • “crackles” and “wheezes” are adventitious sounds
• Skeletal abnormalities may be the cause of • Crackles - discontinuous popping sounds
respiratory symptoms (pneumonia, pulmonary edema, atelectasis)
o i.e. Abnormal curvature of the spine • Wheezes - continuous musical sounds (obstructive
lung diseases)

EXAMINATION OF THE THORAX: Palpation

• Check for presence of axillary and supraclavicular
lymph nodes
• check trachea above suprasternal notch to check for
shifting of mediastinum
• Check for vocal fremiti (vibrations induced by DIAGNOSTIC EXAMINATIONS
sounds)
• CHEST XRAY
o should be equal in both sides
o invaluable tool in the evaluation of diseases
o increased fremiti in one side may indicate
of the thorax
increased solid tissue in the lung area
o Pulmonary diseases may have similar
(pneumonia, masses with patent bronchi)
clinical manifestations and can be
o diminished in pleural effusion, lung masses
differentiated through chest xray
with collapsed bronchi

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 PNEUMONIA

HYPERINFLATED LUNGS

• OTHERS
o Arterial Blood Gas (ABG)
LUNG MASS o Radionuclide Scans
▪ Perfusion Scan
▪ Ventilation Scan
o Bronchoscopy
o Percutaneous Needle Aspiration
o Open Lung Biopsy
o Pulmonary Angiography
PLEURAL EFFUSION o Polysomnography
o Exercise Testing

RESTRICTIVE LUNG DISEASE

• reduction in lung volumes
• can develop in conditions that:
• SPUTUM EXAMINATION • stiffen the chest wall or weaken the
o May contain different types of cells respiratory muscles
o Grossly, may appear mucoid or purulent • Causes infiltrates in the lung parenchyma or
▪ Purulent Sputum - may suggest air spaces (interstitial fibrosis and
infection or allergic disorder pulmonary edema)
▪ Pink, Frothy Sputum - may suggest • Involve the pleura
pulmonary edema
• Occupy space within the thorax (effusion,
▪ None are diagnostic
tumors, cardiac enlargement)
o Microscopic examination
• after lung resection
▪ an appropriate sample should
show presence of macrophages
OBSTRUCTIVE LUNG DISEASE
▪ Eosinophils may suggest allergic
• narrowing of the tracheobronchial system
disorder
• usually found in patients with:
▪ staining may reveal presence of
• asthma
acid fast bacilli
▪ leukocytes and bacteria may be • emphysema
indicative of infection
o Cytoplasmic Examination
▪ useful in diagnosing
neoplasms/malignancies

• SPIROMETRY
o pulmonary function test
o measures how much air goes in and out of
your lungs
o used to diagnose asthma and COPD

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 ASTHMA TREATMENT
• disease process in which airway smooth muscle • Aims of Asthma Therapy:
shows increased responsiveness to variety of stimuli o Minimal (ideally no) chronic symptoms,
• Airflow obstruction is reversible, either including nocturnal
spontaneously, or through therapy o Minimal (infrequent) exacerbations
• heterogeneous disease with interplay between o No emergency visits
genetic and environmental factors o Minimal (ideally no) use of a required 𝛽2-
• asthmatics harbor a special type of inflammation in agonist
the airways that makes them more responsive than o No limitations on activities, including
non asthmatic to a wide range of triggers, leading to exercise
excessive narrowing with consequent reduced o Peak expiratory flow circadian variation
airflow and symptomatic wheezing and dyspnea <20%
o (Near) normal PEF
TRIGGERS o Minimal (or no) adverse effects from
• Allergens medicine
• upper respiratory tract viral infection
• exercise and hyperventilation • Main Drug Therapies:
• cold air o Bronchodilators – give rapid relief of
• sulfur dioxide and irritant gases symptoms through relaxation of the airway
smoot muscle
• drugs (beta-blockers, aspirin)
▪ Examples:
• stress
→ Short Beta 2 agonists (SABA)
• irritants (household sprays, paint fume)
→ Theophylline
→ Short acting anticholinergics
CLINICAL FEATURES AND DIAGNOSIS
• Characteristic symptoms (variable, both o Controllers – inhibit the underlying
spontaneously and with therapy) inflammatory process
o wheezing ▪ Examples:
o dyspnea ▪ Inhaled corticosteroids
o coughing ▪ Long Acting Beta 2 agonists (LABA)
• symptoms may be worse at night and typically ▪ Systemic corticosteroids
awaken patients in the early morning hours ▪ Antileukotrienes
• “difficulty in filling their lungs with air” ▪ Cromones
• increased mucus production ▪ Anti IgE
• Increased ventilation and use of accessory muscles
of ventilation NEBULIZATION
• Signs:
o INSPECTION: tachypnea, hyperinflation
o AUSCULTATION: ronchi, wheezing

INHALER MEDICATIONS FOR ASTHMA

DIAGNOSIS/LABORATORY FINDINGS
• SPIROMETRY: reversible airflow obstruction
• CHEST X-RAY: may be non-specific (hyperinflation in
only 30%)
o Can rule out other causes of patient’s
symptoms
• ABG: can show hypoxemia (decreased PaO2) and
hypercapnia (increased PCO2)

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ASTHMA TREATMENT: o Attempt to lessen fear of dental treatment
by gentle handling and reassurance
• Acute asthmatic attacks are usually self-limiting or
respond to the patient’s usual medication such as
beta-agonist inhaler but status asthmaticus is a
potentially fatal emergency

ACUTE SEVERE ASTHMA / STATUS ASTHMATICUS

• Acute and severe asthma exacerbation that does not
respond to aggressive medical therapy
• Life threatening condition
• Mainstay Treatment:
o High doses of short acting beta agonist
(SABA) given either by nebulizer or via a
metered dose inhaler with a spacer
• Hydration, oxygen therapy, and occasionally assisted
medical ventilation is necessary
• SEDATIVES SHOULD NEVER BE GIVEN -> depress
ventilation
ASTHMA: DENTAL ASPECTS
• Effective dental care should be deferred in severe
asthmatics until they are in a better phase
• Asthmatic patients should be asked to bring their
usual medication with them when coming for dental
treatment
• Local anesthesia (LA) is best used: occasional patient
may react to the sulfites present as preservatives in
vasoconstrictor-containing LA, so it may be better,
where possible, to avoid solutions containing CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
vasoconstrictor • May be consequence of
• Relative analgesia with nitrous oxide and oxygen is o Primary airway disease (chronic bronchitis)
preferable to intravenous sedation and gives more o Parenchymal disease (emphysema)
immediate control • Chronic bronchitis and emphysema have many
• Sedatives in general are better avoided as, in an overlapping characteristics such as reduction in
acute asthmatic attack, even benzodiazepines can expiratory flow rates that is not fully reversible and a
precipitate respiratory failure. relationship with smoking
• General anesthesia is best avoided as it may be • The conditions are considered jointly and usually
complicated by hypoxia and hypercapnia. The risk of occur simultaneously in a patient -> COPD
post-operative lung collapse or pneumothorax is also
increased. CHRONIC BRONCHITIS
• Acute asthmatic attacks may also be precipitated by • Pulmonary response to chronic irritant exposure
anxiety; (usually cigarette smoke)

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 • Presence of productive cough on most days for at
least 3 months of at least 2 consecutive years
• Characteristic findings:
o Hypertrophy of mucus glands
o Hyperplasia of goblet cells

DIAGNOSTICS
• CHEST X-RAY
o Hyperinflation in moderate to severe cases
EMPHYSEMA o Helps rule out other causes of chronic
• Consists of alveolar enlargement and destruction of cough
alveolar walls • PULMONARY FUNCTION TEST
• Can be from genetics (alpha 1 antitrypsin deficiency) o Show IRREVERSIBLE (after use of salbutamol
• Cigarette smoking remains the greatest risk factor or other bronchodilators) air flow limitation
for the development of emphysema
COPD: MANAGEMENT
• Only 3 interventions have been demonstrated to
influence the natural history of COPD
o Smoking cessation – biggest impact in
natural history of COPD
o Oxygen therapy
o Lung volume reduction surgery
▪ Segmentectomy or lobectomy of
CLINICAL MANIFESTATIONS focal emphysematous areas of the
• Usually combination of chronic bronchitis and lung.
emphysema

“Pink Puffers” “Blue Bloaters”

Emphysema predominantly Chronic bronchitis
predominantly
Pink skin, pursed-lip Chronic productive cough
breathing
Use of accessory muscles of Purulent sputum
respiration
Hyperinflation, barrel chest Cyanosis (due to
hypoxemia)
Obese

COPD: DENTAL ASPECTS

• COPD patients are best treated in an upright
position
• Local Anesthesia is preferred for dental
treatment

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 • Patients with COPD should be given relative o Lung Findings can be varied
analgesia only if absolutely necessary, and only ▪ Dullness, increased fremitus
in hospital after full pre-operative assessment ▪ Tracheal Deviation
• Do not use diazepam and midazolam ▪ Decreased Mobility Or Volume
respiratory depressants Of The Affected Hemithorax
• Patients should be given GA only if absolutely
necessary, and intravenous barbiturates are
contraindicated.
• Secretions reduce airway patency and, if lightly
anesthetized, the patient may cough and
contaminate other areas of the lung.
• Postoperative respiratory complications are
more prevalent in patients with pre-existing lung
diseases, especially after prolonged operations
and if there has been no preoperative
preparation
• The most important single factor in pre- Acid-Fast bacilli stained
operative care is cessation of smoking for at least in smear Tubercle
1 week pre-operatively. bacilli are shown in red
• Respiratory infections must also be eradicated
• Interactions of theophylline with drugs, such as
epinephrine, erythromycin, clindamycin,
azithromycin, clarithromycin or ciprofloxacin,
may result in dangerously high levels of
theophylline.
• Ipratropium can cause dry mouth.

PULMONARY TUBERCULOSIS (PTB)

• Caused by Mycobacterium tuberculosis
• Most common site of development of TB (85% of
patients)
• Most commonly transmitted from one person to
another by droplet nuclei which are aerosolized
by coughing, sneezing, or speaking
• Most infective patients: those with cavitary
pulmonary disease and laryngeal TB

CLINICAL MANIFESTATIONS:
TREATMENT: MEDICATIONS USED FOR TB
• HISTORY
o Cough of 2 weeks or more should lead to
high suspicion for PTB
o Cough may be accompanied by night
sweats, weight loss, anorexia,
unexplained fever and chills, chest pain,
fatigue, and body malaise

• PHYSICAL EXAMINATION
o Usually underestimates the extent of the
disease demonstrated in Chest X Ray

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 airborne infection isolation and fittested
disposable N-95 respirators; standard surgical
face masks do not provide enough protection.

• TREATMENT:
o INITIAL PHASE
▪ 2 months of HRZE
o CONTINUATION PHASE
▪ 4 months of HR COMMUNITY ACQUIRED PNEUMONIA
• Lower respiratory tract infection acquired in the
Weight-based treatment community within 24 hours to < 2 weeks
PULMONARY TUBERCULOSIS: DENTAL ASPECTS • Results from proliferation of microbial
pathogens at the alveolar level and the host’s
• Management of a patient with TB depends upon
response to those pathogens
the level of potential infectivity
• Most common access of microorganisms to
• Patients with active TB should not have elective
lower respiratory tract: aspiration from
dental treatment.
oropharynx
• Consultation with the patient’s physician is
necessary ETIOLOGIC AGENTS:
• Within 2-4 weeks of initial phase of anti TB • Streptococcus pneumoniae
treatment, the bacterial count is negligible. • Haemophilus influenzae
Patient can be treated in the dental setting • Chlamydophila pneumoniae
subsequent to this time period, after obtaining • Mycoplasma pneumoniae
clearance from the patient’s physician. • Moxarella catarrhalis
• Always consult and confirm with the patient’s • Enteric gram-negative bacilli
MD regarding the type of drug therapy • Legionella pneumophila
recommended for your patient and the status • Anaerobes
of the disease. • Staphylococcus aureus
• Adults presenting to the dental office who are • Pseudomonas aeruginosa
currently taking isoniazid should have a
physician’s consultation regarding liver function
tests. Some patients will develop hepatitis. CLINICAL MANIFESTATION:
• Evaluate the liver function tests (LFTs), serum • cough
creatinine, complete blood count (CBC) with • Sputum production
platelets, and WBC differential before initiating • dyspnea
dental treatment. • Fever
• Always use strict universal precautions when • Chest pain
treating all patients and not just the TB patient. • Tachypnea
• Avoid all drugs metabolized by the liver to • Tachycardia
minimize added hepatotoxicity. • Use of accessory muscles
• If emergency treatment is necessary for a • Intercostal restractions
patient suspected of having or who has been • Chest findings:
diagnosed with active TB, care should be o Diminished breath sounds
provided in a facility such as a hospital with o Ronchi

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 o Crackles DENTAL ASPECTS:
o Wheezing • An infection of the upper or lower respiratory
tracts is a contraindication to general anesthesia,
DIAGNOSTICS: which should be deferred until resolution has
occurred.

LUNG CANCER
• Most common cancer and the most common
cause of cancer death in the world
• Cigarette smokers have 10-fold or
o greater increased risk of developing lung
cancer compared to those who have
never smoked
• One genetic mutation is induced
o for every 15 cigarettes smoked
• The risk of lung cancer is lower among persons
who quit smoking than among those who
continue smoking
• Cigarette smoking increase the risk of all the
major types of lung cancer
• Environmental tobacco smoke (ETS) or second-
hand smoke is also an established cause of lung
cancer
• The risk from environmental tobacco smoke is
less than from active smoking
o 20–30% increase in lung cancer
observed among never smokers married
for many years to smokers
o In comparison to the 2000% increase
among continuing active smokers
MANAGEMENT: • “Tumors arising from the respiratory pithelium
• Antibiotic Therapy (bronchi, bronchioles, and alveoli)” – WHO
o Most bacterial pneumonias can be
FOUR MAJOR CELL TYPES:
treated for 5-7 days
• small-cell lung cancer (SCLC)
o Response to therapy is expected within
• Adenocarcinoma*
24-72 hours of initiating treatment
• squamous cell carcinoma*
o The choice of antibiotic depends on the
severity of pneumonia • large-cell carcinoma*
o Common Antibiotics used in CAP: non-small-cell carcinomas (NSCLCs)

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• All histologic types of lung cancer can develop in
current and former smokers, although squamous
and small-cell carcinomas are most commonly
associated with heavy tobacco use.
• In lifetime never smokers or former light smokers
(<10 pack-year history), women, and younger adults
(<60 years), adenocarcinoma tends to be the most
common form of lung cancer.

CLINICAL MANIFESTATIONS:
• Over half of all patients diagnosed with lung
cancer present with locally advanced or
metastatic disease at the time of diagnosis.

DIAGNOSIS:
• Chest XraY
• CT scan
• Tissue sampling is required to confirm a
• The prototypical lung cancer patient is a current or o diagnosis in all patients with suspected
former smoker of either sex, usually in the seventh lung
decade of life. o cancer (biopsy)
• A history of chronic cough with or without o Bronchoscopy with biopsy
hemoptysis in a current or former smoker with COPD o Percutaneous needle aspiration
age 40 years or older should prompt a thorough o Open lung biopsy
investigation for lung cancer even in the face of a • Sputum Cytology – confirms malignant cells in
normal CXR. 40% of cases
• The clinical presentation can vary depending on the of lung cancer
location of the mass/es

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TREATMENT:
• Chemotherapy
o Adverse effects: nausea, vomiting, hair
loss, oral mucositis, loss of taste, risk of
infection from leukopenia, risk of
bleeding from thrombocytopenia
• Surgical Resection

DENTAL ASPECTS:
• Oral Surgery needs to be planned in the context of
the patient’s medical team
• Most chemotherapy is given in cycles every 3–4
weeks, and bone marrow suppression is usually
at its worst about 10–14 days after
chemotherapy, and it is at this point that the risk
of infection or bleeding is highest.
• There is often a sensitivity to muscle relaxants
used in general anesthesia. The cancer may lead
to a reduction in respiratory reserve, which is
clinically significant.

HYPERSENSITIVITY REACTIONS
• Hypersensitivity reactions are immune-
mediated antigen-specific reactions that are
either inappropriate or excessive and result in
harm to the host
• abnormal immune response (usually a type I or
type IV hypersensitivity response) to an antigen
– a protein or allergen

ALLERGY
• abnormal immune response (usually a type I or type
IV hypersensitivity response) to an antigen – a
protein or allergen
• Is hypersensitivity = allergy?
• an allergic reaction typically refers to the signs
and symptoms a person may experience, while a
hypersensitivity reaction describes the
immunological process that occurs in the body.

HYPERSENSITIVITY REACTIONS:

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 ▪ Barbiturates
▪ Phenylbutazone
• Lesions may take any form
• “target lesion”- pathognomonic sign
• Central bullae on an erythematous base -> break
rapidly into irregular lesions

DIAGNOSTICS:
• SKIN PRICK TEST
o involves the application of a small drop
of allergen-containing solution onto the
forearm of the patient through which
the skin is pricked with a lancet
o allergic patients: a wheal and flare
ANAPHYLAXIS
reaction occurs
ETIOPATHOGENESIS:
o If the allergen then produces a wheal of
• Most severe clinical presentation of acute systemic
>3 mm this is considered to be a positive
allergic reactions
result.
• Onset of manifestations within seconds to minutes
MANAGEMENT: after introduction of the antigen
• known allergens should be avoided (easier said than
CLINICAL MANIFESTATIONS:
done!)
• Medications (block allergic mediators or the
activations of cells and degranulation):
o Antihistamines (cetirizine, loratidine)
o Corticosteroids (prednisone, prednisolone,
hydrocortisone)
o Antileukotrienes (monteleukast, zafirlukast)
• Individuals with a complex history of allergy should
be referred to a specialist allergy clinic for careful
assessment and management.
DIAGNOSIS:
DENTAL ASPECTS:
• Depends on the history revealing the onset of
• Patients who have had serious allergic reactions are
symptoms and signs within minutes after the antigen
also usually advised always to carry adrenaline
is encountered
(epinephrine) with them for subcutaneous self-
• World Allergy Organization (WAO) clinical criteria for
administration in the event of a reaction
Diagnosing Anaphylaxis
• Contact allergy to dental amalgam is most frequently
caused by mercury released during condensation
• Avoid use of medications to which the patient may
be allergic to. Use alternatives if possible
• Erythema multiforme
o Symptom complex involving the skin and
mucous membranes
o Can be caused by reactions to medications
▪ Antibiotics

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MANAGEMENT:
• Have a written emergency protocol for recognition
and treatment of anaphylaxis and rehearse it
regularly
• Remove exposure to trigger
• Assess the patient: airway, breathing, circulation,
mental status, skin, and body weight
• Call for help
• Epinephrine
o Inject intramuscularly at the mid-
anterolateral aspect of the thigh
o Dose: 1ml/mL solution
o Repeat every 3-5 minutes, as needed

• Place patient on back or in a position of comfort if

there is respiratory distress and/or vomiting
• Give high flow supplemental oxygen by face mask or
oropharyngeal airway
• Regularly monitor patient’s blood pressure, cardiac
rate, respiratory status and oxygenation

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