RESPIRATORY MEDICINE

Dr Gabriella Rizzo
Clinical tutor, CUH-2017
Respiratory Tract and Respiratory Symptoms

• Major symptoms
• Cough
• Sputum
• Haemoptysis
• Dyspnoea and Stridor
• Wheeze
• Chest pain
• Fever
• Hoarseness
• Night sweats
Cough
• “coughing is a protective response to irritation of sensory receptors in the sub
mucosa of the upper airways or bronchi”

• Character
• Dry (i.e. gastro-oesophageal reflux, ACE inhibitors)
• Productive (i.e. infection, bronchiectasis)

• Quality
• barking quality (inflammation of the epiglottis)
• loud and brassy (tracheal compression by a tumour)
• hollow sound (recurrent laryngeal nerve palsy)

• Timing
• i.e. nocturnal (asthma, heart failure)

• Duration
• Acute (<3-4 weeks)
• URTI, cold, pneumonia, exacerbation of COPD/Asthma
• Chronic (> 8 weeks)
• Chronic bronchitis, Asthma, Bronchiectasis, Sinusitis, medications (ACE inh), cancer
Sputum
Colour

• Mucoid (white, i.e. asthma)

• Mucopurulent (greenish or yellowish, i.e. acute bronchitis, pneumonia)
• Purulent (green or brown, i.e. bronchiectasis, lung abscess, pneumonia)
• Blood stained
• Haemoptysis (“coughing up blood”)

Volume

• Large amount (coupfull, i.e. bronchiectasis)

Timing

• Mucoid and in the morning (asthma)

Haemoptysisis
• Definition: coughing up of blood

Respiratory Cardiovascular Bleeding disorders

Acute or Chronic
Mitral stenosis
Bronchitis
Acute left ventricular
Lung cancer
failure
Bronchiectasis

Cystic fibrosis

Pneumonia

Tuberculosis, etc
Dyspnoea
• “Unexpected awareness of breathing or subjective sensation of difficulty of breathing”
• Breathlessness
• Shortness of breath
• Chest tightness
• On examination:
→Use of accessory muscles, unable to finish sentences
• Severity
• Impact that dyspnoea has in patient life; rough assessment of the ability to perform the cardiovascular work
• On exertion
• Walking distance on flat ground
• Ability to climb stairs
• Tasks of daily living (dressing, washing)
• At rest or minimal exertion
Causes of dyspnoea

Respiratory Cardiac

• Left ventricular failure

• Airways diseases • Mitral valve diseases
• Chronic bronchitis and emphysema • Cardiomyopathy
• Asthma • Pericardial effusion
• Bronchiectasis
• Cystic fibrosis etc. Anaemia
• Parenchymal diseases
• Pneumonia
• Sarcoidosis Psychogenetic
• Fibrosis
• Anxiety
• Pulmonary circulation
• Pulmonary embolism
• Chest wall and pleura
• Pleural effusion Obesity
• Fractured ribs
• Kyphoscoliosis
Lack of physical fitness
Chest pain
• Source: pleural and central airways

Tracheal Pleuritic Chest wall Nerve root Mediastinal

• Character • Character • Acute: as pleuritic • Nerve root • Dull, aching

• Retrosternal • Sharp, stabby but worse on distribution
• Burning • Worse on movement
inspiration and • Chronic: dull,
coughing constant

• Causes • Causes • Causes

• Causes • Causes
• Viral pleurasy • mesothelioma • Vertebral fracture
• Acute tracheo- • Tumours
bronchitis • Pulmonary emboli • Varicella-Zoster
• Pneumothorax
• Pneumonia
 Wheeze Other symptoms
• Fever at night
• “Continuous whistling noise during
breathing” • Tuberculosis
• Pneumonia
• mesothelioma
• Musical quality
• Sweating at night (Tuberculosis)
• Due to continuous oscillation of opposite airways • Hoarsness
walls and imply significant airway narrowing
• Transient inflammation of the vocal cords

• Tend to be louder in expiration and is accompanied (laryngitis)

by prolonged expiration; but an inspiratory wheeze
implies severe airway narrowing
• Asthma
• Airways obstruction (foreign body or tumour)
• i.e. vocal cord tumour, recurrent laryngeal
nerve palsy
• Excessive snoring, apnoea episodes, day time
somnolence and fatigue
• Obstructive sleep apnoea syndrome
• Stridor
• Harsh noise classically on inspiration and is
caused by partial obstruction of the upper
airways
Common respiratory Infections

URTI
• Sinusitis, pharyngitis, tonsillitis, laryngitis, whooping cough (Pertussis), Otitis
media
• Dyphteria
• Common cold
• Influenza
• Croup (laryngotrachobronchiolitis)
• Glandular fever (Mononucleosis)

LRTI
Pneumonia
Bronchitis
Bronchiolitis
Pharyngitis
• Presentation
• sore throat, particularly when swallowing
• fever
• headache or malaise
• anterior neck pain
• symptoms associated with a viral upper respiratory infection (nasal congestion, hoarseness, sinus discomfort

or tenderness, ear pain, or cough)

• Physical examination
• pharyngeal erythema, often associated with tonsillar hypertrophy, and purulent exudate
• anterior cervical lymph nodes are typically tender and enlarged
• Palatal petechiae may be present
 Causes
 Group A streptococcus (5-15%)
 Viruses: Influenza, Mononucleosis, HIV, HSV
 Other bacteria

• Treatment is usually symptomatic

Pneumonia

• Inflammation of the lungs with exudation into the alveoli

• The signs of pneumonia are referred to clinically as a “consolidation”

Symptoms

• Fever/chills /sweats
• Productive cough
• Sputum: mucopurulent→haemoptysis
• Dyspnoea
• Tachypnoea
• Pleuritic chest pain
Pneumonia-CAP (typical and atypical)
Typical: Streptococcus pneumoniae or Haemophilus influenzae
•Reservoir: upper respiratory tract (URT)
•Route of transmission: airborne
•Epidemiology: more common in winter, in patients with chronic respiratory diseases (Asthma, COPD),
splenectomy patients, HIV; H. influenzae: children <5years old, alcoholism
•Presentation
•-abrupt onset with fever and rigor; Lobar consolidation
•-Herpetic cold sores maybe associated
•Immunization: Pneumovax (every 5 years)
•Treatment: amoxicillin, ceftriaxone, clarithromycin. For pen-resistant: quinolones, vancomycin
Atypical: Mycoplasma pneumoniae and Legionella pneumophila

• Route of transmission: airborne; Legionella: airborne, outbreaks, air conditioning

• Epidemiology: young adults
• Presentation: 5-10 days, flu-like syndrome followed by fever and dry cough. Extrapulmonary features (arthralgia,
myalgia, anaemia, rash, hepatitis, diarrhoea, vomiting)
• Investigations
• Mycoplasma: Bilateral infiltrate on CXR, ↓ Na, ↑AST/ALT, Cold agglutinins→ hemolitic anaemia. Serology
• Legionella: lymphopenia, Urinary legionella Antigen, Direct immunofluorescence, Serology
• Treatment: macrolide (Clarithromycin, erythromicin), tetracycline
Pneumonia
Community acquired pneumonia (continuation)

• Staphylococcus aureus (post Influenza)

• Chlamydia
• Viruses (15%)

Hospital acquired
• >48h after hospital admission
• Aetiology
• Gram negative, anaerobes and resistant bacteria

Aspiration pneumonia
• Patients with stroke, myasthenia, ↓level of consciousness

Immunocompromised patients
• Fungi, Gram negative
ASTHMA
 Asthma is a chronic inflammatory disorder of the airways in
which many cells and cellular elements play a role

 The chronic non-infective inflammation is associated with airway hyper-responsiveness

and diffuse bronchoconstriction that leads to recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing, particularly at night or in the early morning

 These episodes are usually reversible either spontaneously

or with treatment

• 235 million people currently suffer from asthma

• It is the most common chronic disease among children

https://www.asthma.ie/
 ETIOLOGY
Host Factors

 Genetic
 Susceptible genes are thought to include those for T helper 1 and 2 cell, IgE. Cytokine (IL-3,-4, -5, -9, and
-13), GM-CSF, TNFα and ADAM33, which stimulate smooth muscle and fibroblasts
→ Atopy
→ Airway hyper-responsiveness

 Gender (male before puberty/female after puberty), Obesity ?, Ethnicity ?

Environmental Factors are also triggers

• Indoor allergens (domestic mites, animal allergens, cockroaches allergens, fungi)
• Outdoor allergens (pollens, fungi)
• Occupational sensitizers
• Tobacco smoke/Passive smoking
• Air Pollution (mostly a trigger factor)
• Respiratory Infections (viruses)
• Diet (low in vitamin C and A and Omega 3)
• Perinatal factors (young maternal age, prematurity, low birth weight , lack of breast feeding)
Symptoms and signs
• Intermittent but may become persistent in severe disease
• Wheezes
• Cough
• Usually non productive or mucoid
• Muco-purulent in case of infection
• Shortness of breath
• Chest discomfort
• Due to respiratory effort
• Nocturnal symptoms
• Not controlled asthma
• Troublesome cough, particularly at night
• Awakened by coughing
• Colds that last more than 10 days
• Increased nasal secretions or nasal polyps
• Atopic dermatitis, eczema, or other allergic skin conditions

• Breathing problems during particular seasons, after exposure to allergens, after physical activity
 ACUTE SEVERE EXACERBATION

• Severe attack
• Unable to complete sentences
• RR >25/ min
• Pulse 110/min
• PEF <50%of predicted or best

• Life threatening
• PEF<33% of predicted or best
• Silent chest, cyanosis, feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion → confusion → coma
• ABG: normal /high PCO2
• PO2 <8kPa (60 mmHg)
• Low pH <7.35
DIAGNOSIS
 Clinical evaluation
 Symptoms

 Medical history

 Pulmonary function test

 Spirometry

 Peak flows

 Airways responsiveness (methacholine, histamine)

 CXR

 Allergy testing (RAST, Skin test)

 Specific IgE
 TREATMENT
• Corticosteroids
• Bronchodilators • Reduce the airway inflammation

• Short acting • Used as prophylaxis treatment

• immediate relief of symptoms, action lasts for • Alone or in combination with long-
3-5 hrs acting B2 agonists
• Long acting • Beclometasone (Qvar, Becotide)
• prophylactic treatment, action lasts for 12 hrs • Budesonide (Pulmicort)
• Fluricasone (Flixotide), etc
• B2 adrenoreceptor agonists • Combination long-acting bronchodilators and
corticosteroids
• Salbutamol (Ventolin)
• Seretide (Salmeterol/Fluticasone)
• Terbutaline (Brycanil)
• Symbicort (Formeterol/Budesonide)
• Salmeterol, Formeterol

• Antimuscarinics
• Ipratropium bromide (Atrovent)
• Tiotropium Bromide (Spiriva)
Implications for Dental practice
1. Asthmatic attack during dental procedure:
 Stop procedure and remove all the intraoral devices
 Place the patient in a sitting position
 Ask the patient to take his short acting β2 agonist inhalers (salbutamol, terbutaline) or use nebulizer
 Give oxygen
 Call medical assistance
2. Prolonged used of inhaled corticosteroid can lead to increase incidence of oral candidiasis
3. Long term use of beta 2 agonist inhalers can reduce salivary flow and increase caries (fluoride
supplements)
4. Use of decongestant of antihistamines can cause oral dryness
5. Numerous dental product such as toothpaste, tooth enamel dust methyl methacrylate, may
exacerbate asthma
6. Elective dental procedure should only be done when asthma is under control. Before starting the
procedure make sure the patients have their inhalers with them
7. Remember Aspirin or NSDAIs can trigger an asthmatic attach
8. Drug interaction should be always taken in mind when prescribing:
 Macrolides increase theophylline levels
 Local anaesthetics containing epinephrine may precipitate arrhythmias in patients on theophylline
 COPD
The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) [2010] defines COPD as:
• a preventable and treatable disease with some extra pulmonary effects that may contribute to severity in
individual patients
 According to the latest WHO estimates:
 64 million people have COPD
 WHO predicts that COPD will become the third leading cause of death worldwide by 2030 (after Heart
diseases and Cancer)

• is characterized by progressive persistent airflow limitation that is not fully reversible with medications

• Chronic bronchitis
the presence of cough and sputum production for at least 3 months in each two consecutive years (not necessarily associated
with airflow limitation)
• Emphysema
“Is a pathological diagnosis defined as the permanent destructive enlargement of the air spaces distal to the terminal
bronchioles, resulting in loss of alveolar surface area and reduction of oxygen exchange”
Aetiology
It related to the total burden of inhaled particles a person encounters over their lifetime:

 Tobacco smoke (cigarettes, pipe, cigars)

 Occupational dusts and chemicals (vapours, irritants, fumes) if the exposure is intense and
prolonged
 Indoor air pollution (biomass fuel for heating and cooking)

 Outdoor air pollution (small effect)

 Contributing factors (affecting lung growth)

 Low weight at birth

 Recurrent infections affect lung growth
 Nutrition
 Socioeconomic status
Symptoms and Signs
• Dyspnoea

• Progressive-Worse with exercise-Persistent

• Chronic cough (intermittent/productive or unproductive) and sputum production

• History of exposure to risk factors (Tobacco smoke)

• Central cyanosis (blue oral mucosa, under the tongue)

• Barrel-shaped” chest, and protruding abdomen

• Resting respiratory rate > 20 b/min and breathing can be relatively shallow

• Pursed-lip breathing (serve to slow expiratory flow and permit more efficient lung emptying)

• Use of accessory muscles

• Ankle or lower leg oedema (Cardiac Failure)

• Cachexia
Diagnosis

Assessment of symptoms

• COPD assessment Test (CAT)/Clinical COPD questionnaire (CCQ)

• http://www.catestonline.org/

Assess Degree of Airflow limitation

• Spirometry

• CXR

• ABG

• Alpha 1 antitrypsin deficiency screening

Treatment

• Smoking cessation
• Occupational exposure/ Indoor and
outdoor air pollution
• Regular Physical activity
• Vaccines (Seasonal Flu, Pneumovax)
• Nutrition
• Rehabilitation
• Surgery
• Bronchodilators
• Antimuscarinics
• Beta2 agonists
• Inhaled corticosteroids (improves
symptoms, lung function, reduces
exacerbations)
• Phosphodoesterase-4 Inhibitors
(Roflumilast): in GOLD 3 and 4 with
recurrent exacerbations
• Mucolytic agents
• Oxygen
• Antibiotics for exacerbations

Non-Pharmacological Pharmacological
Implications on Dental practice

1. Elective dental care and general anaesthesia should be deferred in acute respiratory
infections (cold, sinisitis, pneumonia)
2. Tooth ache (particularly in more than one tooth in the same maxillary quadrant) may
occur due to maxillary sinusitis
3. Mouth breathing due to chronic sinusitis may lead to oral dryness and gingivitis
4. Poor oral health predispose to development of lower and upper respiratory infections,
due to aspiration of salivary secretions containing bacteria
5. Poor oral health can also cause exacerbation of COPD
6. Patients with COPD are better treated in an upright position as the might become more
breathless if lying flat. Patient the may also not tolerate rubber dam
Any question?