Respiratory emergencies

Chronic obstructive pulmonary disease (COPD)

A general term for pulmonary disorders characterized by chronic airflow limitation from the lungs COPD encompasses two main diseases: ○chronic bronchitis ○emphysema Primary etiology for both is inhaling tobacco smoke. Occupational and environmental pollutants are contributing factors There is no cure

Asthmatics and ASA classifications

ASA 2: well-controlled, easily managed Typical asthma (extrinsic or intrinsic) Infrequent episodes No need for emergency care or hospitalization Treatment: Use stress reduction protocol as needed to determine the triggering factors Avoid triggering factors Keep bronchodilator available during dental appointments ASA 3: asthmatics who experience acute episodes precipitated by stress or exercise or who have required emergency medical care or hospitalization to terminate an acute episode Treatment: Follow ASA 2 modifications and administer sedation -N2O-O2 or oral Benzodiapines as needed ASA 4: acute asthmatics who exhibit clinical symptoms while at rest Chronic state Clinical symptoms vary in intensity and are present almost continuously Exhibit asthma triad: cough, dyspnea, wheezing Expiration more difficult than inspiration

Mild vs. moderate vs. severe allergic reaction

MILD: Localized redness Localized pruritus Localized urticaria Edema Conjunctivitis Pale or Flushed Skin Rhinitis MODERATE: Systemic redness Systemic pruritus Systemic urticaria Edema Rhinitis Bronchospasms/dyspnea Abdominal pain Cramping Diarrhea SEVERE (ANAPHYLAXIS): Systemic redness Systemic pruritus Systemic urticaria Severe hypotension Dyspnea Angioedema of the eyes, lips and larynx Severe bronchospasms and wheezing is present Sudden onset with rapid progression within a few minutes. **BIPHASIC ANAPHYLAXIS Occasionally once the initial allergic symptoms have been resolved, the symptoms may recur The second episode can occur from 1 to 72 hours after successful treatment and resolution of the initial response More commonly within 3-10 hours Ingesting allergens Insufficient dose of epinephrine and/or delay in the administrations of epinephrine might predispose the individual to a bisphasic response

Dental implications for COPD

Assess severity of COPD and breathing difficulty Treatment may be performed on stable patients with adequate breathing Chair positioning-upright or semi upright Avoid use of power driven scalers and polishers Use anesthesia without epinephrine

Aspirated foreign bodies

Bronchoscopy: tube with a light that is placed in patient's throat and into the bronchi to view the area and to remove the foreign body. Endoscopy: long thin tube with a small camera at the end to examine the patient's esophagus and stomach area (GI). Suspected to be ingested and not radio-opaque. CT of abdomen to locate ingested objects used if perforation or abscess formation is suspected. Adults - bronchial tree lodging Aspiration suspected and foreign body not recovered, the patient should be referred to the emergency department for x-ray Untreated aspirated object can cause inflammation, infection, ulceration and granulation. DOCUMENT: Procedure being performed Precautions taken Patient's condition Actions taken by clinician Recommendation for medical evaluation How the patient was transported to the medical facility If the patient refuses further medical treatment

O2 tank components

Cylinder Various sizes Can be portable Size E recommended for dental office 30 minutes of oxygen Regulator Reducing valve and flow meter joined Regulator allows for safe release of pressurized O2 Must be turned on Flow meter Dial that allows operator to determine amount of O2 delivered Measured in liters/minute Amount determined by condition being treated and oxygen delivery device

Type I allergic reaction

First exposed to antigen (sensitizing dose) primary immune response: production of antibodies (IgE) attaches to the mast cells and basophils (dormant) until it encounters the antigen again Mast cells and basophils found in the lungs, small intestine, intravascularly and in the connective tissue. Mast cells are located interstitially. Second exposure (challenge dose) the antigen is now an allergen IgE recognizes it; mast cells and basophils undergo degranulation (cell ruptures, releasing chemical mediators "histamine" in an attempt to destroy the antigen) allergic reaction **histamine release: Causes smooth muscle contraction Increased vascular permeability Increased gastric acid secretions Systemic vasodilation Cardiovascular stimulation Flushed skin tone, edema, upset stomach, urticaria (hives), reduced blood pressure, and increased heart rate.

Foreign body airway obstruction emergency (visible)

IF VISIBLE: Chair positioning: Supine prevents syncope Trendelenburg method can be used to help retrieve an object Uses gravity Patient turned on their side and bend head into a head down position with upper body over the side of the dental chair in cases of swallowed objects Help gather items that can be swallowed if in patients mouth using: Suction Hemostats Forceps Magill intubation forceps Tongue grasping forceps

Intrinsic asthma

Intrinsic (non-allergic asthma, idiosyncratic and nonatopic asthma) Usually develops in adults older than age of 35 Non-allergic reactions: respiratory infections, physical exertion, environmental, air pollution and occupational stimuli - precipitate these episodes Non-allergic asthma Idiopathic asthma (spontaneous) Infective asthma Viral infections of the respiratory tract are most common causative factor Viral infections enhance airway reactivity in both asthmatic and non-asthmatic patients Exercise induced asthmatics experience symptoms within 6-10 minutes after the start of the exercise, followed by a more severe delayed phase of bronchospasms that develops after the individual has completed the activity. Can last up to 30-60 minutes

Tuberculosis (TB)

Is a chronic, infectious and communicable disease. Etiology: In most cases, the causative agent is Mycobacterium tuberculosis an acid-fast, nonmotile, rod-shaped microorganism Can affect any organ, but it is an obligate aerobe thus finds the lungs the best suited environment M. tuberculosis typically is transmitted by way of infected airborne droplets of mucus or saliva that are forcefully expelled from the lung Coughing, sneezing, talking, laughing and singing The disease is then spread by inhalation of infected droplets and usually demonstrates a prolonged quiescent period Infected droplets that are carried into the alveoli, where bacteria are engulfed by macrophages Conversion after exposure can take any where from weeks to decades. Immune system plays a role infected person then categorized as LTBI- Latent tuberculosis infection TB- TB disease

Acute bronchitis

Is an acute respiratory infection that involves large airways (trachea, bronchi) Primary symptom- cough with or w/o phlegm May last up to 3 weeks

Chronic bronchitis

Is excessive respiratory tract mucus production sufficient to cause a cough with expectoration for at least 3 months of the year for 2 or more years Obstruction caused by narrowing of the small airway

Pneumonia

It is a infection and subsequent inflammation of the lungs that can affect one or both of the lungs Not a single disease, can have more than 30 causes Can be of bacterial, viral fungi, parasites or mycoplasma origin Increased risk in immunocompromised patients

Primary cause of airway obstruction

mechanical; tongue falling into hypopharynx as skeletal muscle tone is lost

Status asthmaticus

Patients with moderate to severe bronchial obstruction does not respond significantly to the rapid acting β-agonist agents administered in the initial treatment protocol Bronchospasms can last hours or days without remission Extreme fatigue, dehydration, severe hypoxia, cyanosis, peripheral vascular shock and drug intoxification from intense pharmacological therapy Blood pressure may be at or below baseline Heart rate is rapid Hospitalization is needed because this can be life threatening Chronic partial obstruction can lead to patient death as a result of fatigue of the muscles of respiration and respiratory acidosis Can occur in any asthmatic Rx: Beclomethasone (inhaler/corticosteroid) Salbutamol [albuterol] (inhaler/short-acting β₂ agonist) "rescue" drug used to terminate the acute episode of bronchospasm Other countries it is named salbutamol Budesonide (inhaler) Key: long term glucocorticosteriods for patients who experience acute episodes frequently in spite of the previously mentioned forms of the therapy are at risk of adrenal insufficiency. Corticosteroids are the choice drug for asthma due to their anti-inflammatory actions-they have little to no direct bronchodilation activity.

R.E.P.A.I.R. for moderate allergic reaction

R: Recognize s and s of a moderate allergic reactions: systemic redness, pruritus, edema, urticaria, rhinitis, abdominal pain, cramping, diarrhea, bronchospasm/mild dyspnea E: Evaluate vital signs with particular attention to respiration P: Position patient supinely A: Activate CAB's of CPR - check circulation, airway, and breathing (pulse and blood pressure) I: Implement appropriate emergency protocol for moderate allergic reaction: an injection of diphenhydramine (Benadryl) 50 mg IM, administer an oral histamine blocker if it has not already been administered (chlorpheniramine 10 mg for three days), administer O2 as needed, monitor vital signs, observe patient for at least one hour to determine if symptoms are worsening. R: Refer to appropriate healthcare professional if condition does not improve; in addition, a referral for allergy testing is appropriate.

R.E.P.A.I.R. for severe allergic reaction

R: Recognize s and s of a severe allergic reaction: severe hypotension and/or dyspnea or laryngeal edema E: Evaluate vital signs and level of consciousness P: Position patient supinely with legs elevated (increase blood pressure, vena cava lowest part of body) A: Activate CAB's of CPR - check circulation, airway, and breathing (pulse and blood pressure) I: Implement appropriate emergency protocol for severe allergic reaction: epinephrine injection 0.2-0.5 IM (thigh, held in place for 10 sec. and massage for 10 sec.), administer O2 4-6L/minute, administer hydrocortisone 100-500 mg, administer diphenhydramine (Benadryl) 10-20 mg IM, monitor symptoms closely until EMS arrives, and prepare for the possibility of a biphasic reaction R: Refer to emergency department for appropriate follow-up and hospitalization.

R.E.P.A.I.R. for mild allergic reaction

R: Recognize s and s: Localized redness, pruritus, edema, urticaria, conjunctivitis, pale or flushed skin, rhinitis E: Evaluate vital signs with particular attention to respirations P: Position patient supinely A: Activate CAB of CPR -check circulation, airway, and breathing (pulse and blood pressure) I: Implement appropriate emergency protocol for mild allergic reaction: administer chlorpheniramine 10 mg orally for three days, observe the patient for at least one hour to determine if symptoms are worsening R: Refer to appropriate healthcare professional if condition does not improve; in addition, a referral for allergy testing is appropriate.

R.E.P.A.I.R. for asthma attack

R: Recognize the signs and symptoms of asthma attack: respiratory distress, increased respiration rate, wheezing, coughing, tightness in the chest, difficulty speaking, pale skin color and maintain a calm demeanor E: Evaluate respiration rate P: Position patient upright with arms forward A: Activate CAB's of CPR - check circulation, airway, and breathing (pulse and blood pressure) I: Implement appropriate emergency protocol for asthma: attempt to have patient use bronchodilator (either their own or from the emergency kit), if the dose is ineffective use a spacer device, administer oxygen 4-6 L/minute, loosen tight clothing in the neck region, monitor vital signs R: Refer to appropriate healthcare professional if condition does not improve; patient may require subcutaneous epinephrine injection and transportation to emergency room for further observation and treatment.

Respiratory distress emergency

RECOGNIZE RESPIRATORY DISTRESS -Sounds: wheeze, cough, crackling, abnormal rate or depth of breathing DISCONTINUE DENTAL TREATMENT and POSITION -Supine if unconscious; comfortably (usually upright) if conscious C A B -Assess and provide basic life support, as needed MONITOR VITALS: -Blood pressure, heart rate, respiratory rate -Manage patient's anxiety -Provide definitive management of respiratory distress -Activate EMS as needed

Tx

Relief of symptoms: aerosol bronchodilators, inhaled corticosteroids Pnuemonia and seasonal/H1N1 vaccinations Surgery: removal of part of one lung or full lung transplant Oxygen therapy: continuous flow L/min and on demand during inhalation

Foreign body airway obstruction prevention

Rubber dam Minimize occurrence of swallowed or aspirated objects Patient positioning Dental assistant Suction Magill intubation forceps Dental Floss

SS of emphysema vs. chronic bronchitis

S & S of emphysema: difficulty breathing on expiration only, minimal nonproductive cough (dry no mucous), barrel chest (enlarged chest wall), chest radiograph abnormalities, purses lips to forcibly expel air "pink puffer" S & S of chronic bronchitis Difficulty breathing inspiration and expiration, chronic cough, copious sputum, abnormal chest radiograph, overweight, cyanotic or "blue bloater"

SS of foreign body airway obstruction in trachea

Sudden onset of coughing, choking, wheezing, shortness of breath 90% of patients exhibit these signs Time lag of 1 to 6 hours before s and s may appear Symptoms may progress to cyanosis and serious signs of hypoxemia

Dental implications

The respiratory tract of a healthy person is able to defend against organisms that are aspirated into the lungs •However, with such implications as: •Diminished salivary flow •Decreased cough reflex •Swallowing disorders •Lack of ability to perform good oral hygiene, etc. ...There is an increased risk of respiratory infection

TB diagonis

Two tests to determine whether a patient has been infected with M. tuberculosis 1.Tuberculin skin test (TST) a.Aka PPD test- purified protein derivative ○The TST is 95% sensitive and 95% specific for determining whether the patient has been infected with M. tuberculosis ○The test measures the delayed hypersensitivity response by evidence of induration noted 48 to 72 hours later ○All persons who are at risk for TB should undergo tuberculin skin testing annually 2.Interferon-gamma release assay (IGRA) 1.Blood test to determine IF POSITIVE...further exam required Chest radiograph Full physical exam Laboratory culture

4 types of allergic reactions

Type I: immediate hypersensitivity caused by immunoglobulin E (common allergy) Type II: cytolytic in nature and cause cell death Type III: not immunoglobulin E mediated; anaphylaxis-type symptoms (anaphylactoid reactions) Type IV: delayed allergic response (more than 12 hours to develop)

Upper vs. lower respiratory disease

Upper Diseases of the nose, sinuses, pharynx and larynx ○Rhinitis ○Sinusitis ○Tonsillitis ○Influenza Lower Diseases of the trachea and lungs ○Acute bronchitis ○Pneumonia ○TB ○Asthma ○COPD Chronic bronchitis Emphysema ○Cystic fibrosis

SS of allergic reactions

Variable Involve multiple target organs Develop gradually with pruritus (itching) of gingiva, throat, palms, or soles of the feet, followed by urticaria or angioedema (painless swelling). Can begin with cardiovascular, respiratory, or GI symptoms Symptoms are patient specific

Etiology of respiratory diseases

Viral-most prevalent Caused by influenza virus ○No physical signs are present and is most serious in people with pre-existing heart and lung disease Other viruses: ○Rhinovirus ○Herpes simplex virus ○Respiratory Syncytial virus (RSV) Bacterial-least prevalent Nosocomial ○Pseudomonas aeruginosa ○E. coli ○Klebsiella pneumoniae ○Staphylococcus aureus ○Methicillin-resistant S. aureus (MRSA) Community acquired ○Haemophilus influenzae ○Streptococcus pneumonia*

SS of TB

Wilkings p. 995 table 65-6

Dental therapy considerations

Moderate sedation may need to be used. Contraindications: barbiturates and opioids may increase the likelihood of bronchospasms in susceptible patients Barbiturates-sensitize the respiratory reflexes Opioids- increase histamine release: provoking bronchospasms. Local anesthetic with epi has sodium bisulfate which can trigger asthma attack Not contraindicated: inhalation sedation with nitrous oxide and oxygen (n2o - o2); oral sedation with benzodiapines; and parenteral sedation via intravenous (iv), intranasal, or intramuscular routes are not contraindicated in the fearful asthmatic patient. Aspirin 3% - 19% of asthmatic patients are sensitive to aspirin administration Increased incidence in persons with nasal polyps and pansinusitis Allergy to sulfite agents, like sodium metabisulfite are added to certain drugs and chemical as an antioxidant Found in local anesthetic cartridges with vasodepressors (e.g. Epinephrine and levonordefrin) contain bisulfites to prevent oxidation of the vasopressor Minimal but bisulfite-sensitive patients have suffered acute asthmatic attacks after administration of these drugs Contraindicated to administer anesthetics with vasodepressors Not contraindicated: mepivacaine plain or prilocaine plain

Foreign body airway obstruction

More than 90% of swallowed objects that successfully pass though the esophagus into the stomach and intestines pass completely through the GI tract

Respiratory distress causes

Most Common Cause: Hyperventilation Vasodepressor syncope Common Cause: Asthma Heart failure Hypoglycemia Less Common Cause: Overdose reaction

Foreign body airway obstruction emergency (not visible)

NOT VISIBLE: Position patient upright Encourage coughing to expel object No back blows - can cause aspiration Coughing ceases and patient still cannot speak total obstruction should be suspected Complete obstruction: Patient cannot speak or cough Perform abdominal thrust/Heimlich maneuver until object is expelled Object is not expelled and patient falls unconscious UNCONSCIOUS: Position patient supinely A. Perform rescue breaths Enters lungs, CAB of CPR B. Head tilt chin lift, if rescue breath is not entering patient lungs C. Second set of rescue breaths D. Breath enters lungs CAB of CPR

SS of foreign body airway obstruction ingestion

Near oropharyngeal area are most common Feeling of something trapped in throat, mild to severe discomfort, drooling, dysphagia (inability to swallow), possible airway compromise, possible infection or perforation of anatomic structures. **in esophagus: Sensation of something in the center of chest, dysphagia, drooling, gagging, vomiting, neck or throat pain ***in GI: Abdominal distension and discomfort, fever, vomiting, rectal bleeding, or other symptoms. If object perforates the surrounding anatomical structures, the symptoms will be severe and acute.

O2 administration methods

•Nasal Cannula - 1-6 L/min. Use on conscious patient and for myocardial infarction •Non-rebreathing Face Mask - 6-12 L/min. Use on conscious patient for asthma and angina pectoris •Bag-mask device - 2 rescuers recommended to use. 8-12 L/min. Should see chest rise. Forces oxygen into the lungs. Can be used for unconscious patient. *Used for respiratory arrest when patient needs complete oxygen delivery (Use 3rd, 4th, and 5th fingers on bony portion of mandible and thumb and index finger on mask to obtain good seal)

Asthma

-Chronic inflammatory disorder characterized by REVERSIBLE obstruction of the airways -Chronic asthma can cause permanent changes in he respiratory system -Highly reactive bronchi, demonstrating significant smooth muscle hyperactivity (bronchospasms) in response to non-noxious stimuli -Clinical signs exhibited during the acute asthmatic attack are related in large part to the restricted exchange of O2 and carbon dioxide in the lungs -Most common disease of childhood

Dental implications for TB

Active TB= DO NOT treat, History of TB= consult with physician prior to tx, use caution Recent conversion to positive= med consult to rule out active TB Signs or symptoms= postpone tx and refer to physician

Acute asthma causes

Allergy (antigen-antibody reaction) Respiratory infection Physical exertion Environmental and air pollution Occupational stimuli Pharmacological stimuli Psychological factors

Cystic fibrosis (CF)

An autosomal recessive gene disorder that affects salt and water in epithelial cells of the lungs, pancreas and intestinal tract This results in thickened secretions Respiratory Tract & Lungs Airways always filled with phlegm leading to: Chronic sinusitis Bacterial lung infection Pancreas & Intestinal Tract Thick mucous clogs the pancreatic ducts This prevents the release of pancreatic enzymes into the intestinal tract, therefor food is not properly digested or absorbed

Epinephrine

Direct acting sympathomimetic agent, reverses the immediate symptoms of anaphylaxis by its effects on the alpha and beta adrenoreceptors. It reverses the peripheral vasodilation; reduces edema; induces bronchodilation; has a positive inotropic and chronotropic effect on the myocardium; suppresses the release of chemical mediators, such as histamine, from the cells. Repeated after 5 minutes if no improvement after first admin, which is common. Maximum of three doses. Decreased doses should be administered to patients taking MAOIs or tricyclic antidepressants or beta blockers as these drugs will increase the patients susceptibility to arrhythmias and can antagonize the effects of epinephrine. MAOI: Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine Tricyclic AntiD: Amitriptyline, Amoxapine Beta Blockers: Atenolol, Metoprolol, Nadolol, Propranolol

Emphysema

Emphysema is the presence of permanent enlargement (distention) of the air spaces distal to the terminal bronchioles accompanied by destruction of alveolar walls or septa

Other forms of asthma

Exercise-induced asthma, which may be worse when the air is cold and dry Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores, cockroach waste or particles of skin and dried saliva shed by pets (pet dander)

Extrinsic asthma

Extrinsic (allergic asthma) 50 % of all asthma patients Primarily seen in children and young adults Airborne: dust, feathers, animal dander, furniture stuffing, fungal spores, or plant pollens Food: cow's milk, eggs, fish, chocolate, shellfish, tomatoes. Drugs: penicillin, vaccines, aspirin, and sulfites Bronchospasms usually develop within minutes after exposure to the allergen (antigen) Type 1 hypersensitivity reaction IgE antibodies are produced in response to the allergen Acute episodes of extrinsic asthma usually occur with diminishing frequency and severity during middle and late adolescents and may disappear entirely later in life

SS of foreign body airway obstruction in lungs

Fever Pain in the chest and/or lung area Increased respiratory rate (tachypnea) Sounds when breathing and coughing Additional s and s with delayed removal: anorexia, weight loss, loss of strength