Chronic Obstructive Pulmonary Disease (COPD)

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ChronicObstructive Pulmonary Disease (COPD)

• Mr. Steve Reeves

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Steve Reeves

• 60 year old male with extensive dental needs.
• His past medical history is significant for
• Asthma
• Emphysema (COPD)
• Hypertension
• Congestive Heart Failure

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Cardiovascular Disease

• Signs Symptoms --gt
• Breathing complications
• Distended neck veins
• Pitting edema
• Cyanosis
• Ascites
• Dizziness
• Fatigue

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COPD

• Signs Symptoms --gt
• Barrel chested
• Dyspnea
• Orthopnea
• Respiratory infections/ cough
• Cyanosis

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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.

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Questions to ask

• History of Asthma
• Date of Dx Age of onset
• What type of asthma does patient have?
  (allergenic, mild --gt 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?

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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) ?

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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?

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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?

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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?

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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

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Physical Evaluation for Asthma..

• Vital signsblood pressure, pulse, respirations
• Recognize signs and symptoms of an asthma attack
• Inability to finish sentences with one breath.
• Ineffective bronchodialators
• Tachypnea (gt25 breaths/min)
• Tachycardia (gt110 beats/min)
• Diaphoresis

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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)

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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 cant fully lie back in chair

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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 91If this is the case, reschedule
  if at all possible

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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

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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

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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

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Asthma Patient Management..

• Reduce operatory odorants
• Bring inhalers
• Prophylactic inhalation of bronchodilator at the
  beginning of the appointment
• Provide stress free environment (N20?)

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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, cant
  finish sentences, more than 25 breaths a minute,
  over 110 beats a minute

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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.

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Emergency Tx

• Call Physician for medical history regarding
  heart disease.
• NYHA class I or II congestive heart failure --gt
  can receive routine dental care.
• NYHA class III or IV congestive heart failure --gt
  treat conservatively and refer patient to a
  hospital dental clinic.
• Call Physician for medical history regarding
  COPD.
• Dont lean patient back in chair.
• Refer to hospital dental clinic due to patients
  extensive dental needs
• Keep an albuterol inhaler in office in case of
  airway obstruction.