Chronic
Obstructive
Pulmonary
Disease
(COPD)
Mr. Steve Reeves
Steve Reeves…
• 60 year old male with extensive
dental needs.
• His past medical history is significant
for:
– Asthma
– Emphysema (COPD)
– Hypertension
– Congestive Heart Failure
Cardiovascular Disease
• Signs & Symptoms -->
– Breathing complications
– Distended neck veins
– Pitting edema
– Cyanosis
– Ascites
– Dizziness
– Fatigue
COPD
• Signs & Symptoms -->
– Barrel chested
– Dyspnea
– Orthopnea
– Respiratory infections/ cough
– Cyanosis
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.
Questions to ask…
• History of Asthma
– Date of Dx & Age of onset
– What type of asthma does patient have? (allergenic,
mild --> 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?
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) ?
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?
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?
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?
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
Physical Evaluation for Asthma..
• Vital signs:blood pressure, pulse, respirations
• Recognize signs and symptoms of an asthma
attack:
–
–
–
–
–
Inability to finish sentences with one breath.
Ineffective bronchodialators
Tachypnea (>25 breaths/min)
Tachycardia (>110 beats/min)
Diaphoresis
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)
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 can’t fully lie back in chair
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 91%If this is the case,
reschedule if at all possible
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
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
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
Asthma Patient Management..
• Reduce operatory odorants
• Bring inhalers
• Prophylactic inhalation of
bronchodilator at the beginning of
the appointment
• Provide stress free environment
(N20?)
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, can’t finish sentences,
more than 25 breaths a minute, over
110 beats a minute
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.
Emergency Tx…
• Call Physician for medical history
regarding heart disease.
• NYHA class I or II congestive heart failure --> can
receive routine dental care.
• NYHA class III or IV congestive heart failure -->
treat conservatively and refer patient to a hospital
dental clinic.
• Call Physician for medical history
regarding COPD.
– Don’t lean patient back in chair.
• Refer to hospital dental clinic due to patient’s
extensive dental
needs
– Keep an albuterol inhaler in office in case of airway
obstruction.