Internal Medicine Respiratory System-2 30 Oct 2021 DR. Abir Kaddar CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Definition: chronic airways obstruction which is not fully reversible. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) It includes chronic bronchitis and emphysema. 1. Chronic bronchitis: is defined as a condition with a history of cough and sputum on most days for at least 3 consecutive months for 2 or more successive years. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) 2. Emphysema: is defined as irreversible destruction and enlargement of airspaces distal to terminal bronchioles. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Etiological Factors: • Cigarette smoking • Air pollution • occupational exposure to dusts • Severe alpha-1 antitrypsin deficiency (genetic risk factor) CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Clinical Features: • Cough • sputum production • exertional dyspnea As the disease advances: dyspnea becomes more severe and occurs even during rest. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Investigations: ➢ Pulmonary function tests: airway obstruction without significant reversal. ➢ Arterial blood gas analysis (ABG): reveals hypoxemia (low O2) and hypercarbia (high CO2). CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Investigations: ➢ Chest X-ray: hypertranslucent lung fields, flattened diaphragms. flattened diaphragms normal hypertranslucent CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Treatment: Chronic Phase: a. b. c. d. e. f. Smoking cessation Oxygen therapy Bronchodilators Corticosteroids Antibiotics: in respiratory infection. Influenza vaccine is recommended annually. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Treatment: Acute Exacerbation: require hospitalization. The main steps in the treatment include: 1. Oxygen therapy. 2. Antibiotics : treat respiratory infections. 3. Bronchodilators: administered initially by nebulization. Intravenous infusion is needed if there is no response. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Treatment: Acute Exacerbation: 4. Short course of oral corticosteroid hastens recovery and reduces chances of relapses. 5. Mechanical ventilation in patients with: ✓ severe respiratory distress ✓ severe hypoxia (↓O2) ✓ Hypercapnia (↑CO2) PLEURAL EFFUSION excessive accumulation of fluid in the pleural space. Important causes of pleural effusion are: • Pneumonia • Tuberculosis • cardiac failure • Cirrhosis • malignancy PLEURAL EFFUSION Investigations: • Chest X-ray • Ultrasound • CT chest is occasionally required to diagnose the underlying pathology • The aspiration of fluid confirms the diagnosis of pleural Effusion PLEURAL EFFUSION Management: • The aspiration of fluid may be required to relieve the dyspnea in cases with large effusion. • The underlying causes should be treated. PULMONARY EMBOLISM (PE) an important cause of mortality in hospitalized patients. most common source of emboli is proximal leg and pelvic deep vein thrombosis (DVT). Dyspnea is the most frequent symptom Tachypnea is the most frequent sign Chest pain is an important symptom PULMONARY EMBOLISM (PE) Investigations: Pulmonary angiography: This is the “gold standard” method for the definitive diagnosis of PE. In the current era, the CT (CT-angio) has replaced pulmonary angiography as the former is less invasive. PULMONARY EMBOLISM (PE) Treatment: Oxygen therapy to maintain oxygen saturation over 90%. Anticoagulation: Anticoagulation prevents additional thrombus formation. TUBERCULOSIS Causative organism: Mycobacterium. • The most common agent of human disease is Mycobacterium tuberculosis. • Mycobacterium bovis, an important cause of infection in those who consume unpasteurized milk, is now uncommon. TUBERCULOSIS Transmission: Most commonly the infection is transmitted : from infected patients to other persons through droplet nuclei released by: Coughing sneezing or speaking TUBERCULOSIS Risk factors: The risk of infection is increased by factors like: • • • • • Poverty Overcrowding Diabetes Alcoholism Immunocompromised states (There is an increase in the incidence of tuberculosis because of HIV infection). TUBERCULOSIS Risk factors: Health workers are also at increased risk as they may be exposed to TB patients. TUBERCULOSIS Tuberculosis can be: pulmonary or extrapulmonary or Both Pulmonary tuberculosis is more common than extrapulmonary. TUBERCULOSIS Primary Pulmonary Tuberculosis: The bacilli enter the lung parenchyma and cause a peripheral parenchymal lesion. The bacilli eventually travel to the mediastinal lymph nodes. This is known as primary complex (Ghon). In most (80-90%), the primary complex heals within 4-6 weeks. TUBERCULOSIS Secondary Pulmonary Tuberculosis: results from reactivation of latent Infection and is localized to the upper lobes. the lesion may remit spontaneously or progress to chronic fibrosis. TUBERCULOSIS Extrapulmonary Tuberculosis: any organ may be involved due to hematogenous spread of the infection. The most common extrapulmonary site involved is lymph nodes. TUBERCULOSIS Miliary Tuberculosis: severe form of tuberculosis that results from hematogenous spread of tuberculous bacilli. This may be a form of primary tuberculosis or may occur due to reactivation of old foci. TUBERCULOSIS Miliary Tuberculosis: The lesions are characterized by granuloma (2-3 mm) that resembles millet seeds. TUBERCULOSIS Clinical features: The patients initially present with symptoms like: • Cough • low grade fever • Malaise • night sweats • loss of appetite • hemoptysis • loss of weight TUBERCULOSIS Clinical features: The chest examination: ✓ may be normal or ✓ may reveal inspiratory crackles TUBERCULOSIS Investigations: 1. demonstration of acid fast bacilli (AFB) in the sputum or in other specimens (tissue biopsy, body fluids). Ziehl-Neelsen staining is usually done for this purpose. TUBERCULOSIS Investigations: 2. Culture methods: confirmation of the diagnosis by identification of M. tuberculosis from the specimen. TUBERCULOSIS Investigations: 3. Radiological tests: infiltration of upper lobe with fibrosis and/or cavity. TUBERCULOSIS Investigations: 4. Skin test (tuberculine test): positive in: • persons infected with M. tuberculosis • those who have received BCG vaccination TUBERCULOSIS Investigations: 5. Histopathological tests: biopsy specimens from the involved tissue reveal caseous granuloma. TUBERCULOSIS Treatment: The main aims of treatment of tuberculosis are: 1. To cure the patients of tuberculosis 2. To decrease transmission of tuberculosis to others 3. To prevent relapse 4. To prevent morbidity and mortality from active tuberculosis 5. To prevent late effects of tuberculosis. TUBERCULOSIS Treatment Regimen: Initial phase: rapidly kill the bacilli and bring out sputum conversion (AFB negative) so that the patient becomes non-infectious. combination of 3-4 drugs is used for 2-3 months. TUBERCULOSIS Treatment Regimen: Continuation phase: eliminate the remaining bacilli from the lesion (sterilizing effect) so that relapse may not occur. Combination of 2 drugs for 4-6 months. IMPLICATIONS ON DENTAL PRACTICE 1. Elective dental care is deferred in acute respiratory infections including: ✓ common cold ✓ Sinusitis ✓ Pneumonia ✓ acute bronchitis 2. General anesthesia should be avoided in presence of respiratory infections. IMPLICATIONS ON DENTAL PRACTICE 3. Prolonged use of corticosteroid inhalers may lead to increased incidence of oral candidiasis. 4. Use of decongestant and antihistaminics may cause oral dryness. IMPLICATIONS ON DENTAL PRACTICE 5. Toothache may occur due to maxillary sinusitis. It should be differentiated from odontogenic infections. Pain in more than one tooth in the same maxillary quadrant suggests sinus infection. 6. Mouth breathing due to chronic sinusitis may lead to oral dryness and oral diseases such as gingivitis. IMPLICATIONS ON DENTAL PRACTICE 7. Numerous dental products and materials such as toothpaste, tooth enamel dust, methyl methacrylate may exacerbate the asthma. 8. Elective dental procedure should only be done when asthma is well controlled. Patients are asked to bring the asthma medication with them. IMPLICATIONS ON DENTAL PRACTICE 9. The history of allergy to aspirin or NSAIDs should always be asked in asthmatic patients as these agents may precipitate asthmatic attacks. 10. Drug interactions should be taken in mind. For example: Use of epinephrine containing local analgesics may precipitate arryhythmias if patient is taking theophylline or beta 2 agonists (salbutamol). IMPLICATIONS ON DENTAL PRACTICE 11. Fluoride supplement is advised for all asthmatic patients particularly those taking beta 2 agonists (dry mouth). 12. There is association between oral infections and exacerbation of COPD. Therefore maintenance of good oral hygiene is must in these patients. IMPLICATIONS ON DENTAL PRACTICE 13. Patients with COPD are better treated in upright position as they may become more breathless if laid flat. Patients may not be able to tolerate rubber dam. IMPLICATIONS ON DENTAL PRACTICE 14. Tuberculosis is unlikely to be transmitted to the dental staff unless the patient is having active pulmonary tuberculosis. dental treatment is best deferred until the active tuberculosis has been treated. IMPLICATIONS ON DENTAL PRACTICE 15. Mycobacteria are resistant to many disinfectants. Hence, heat sterilization should be used. 16. Rifampicin (anti TB drug) can cause red saliva.
