PULMONOLOGYPULMONOLOGY

Cardinal Cardinal RRespiratory espiratory SSymptoms and ymptoms and SSignsigns

COUGHCOUGH DYSPNEADYSPNEA SPUTUM PRODUCTION & SPUTUM PRODUCTION &

HEMOPTYSISHEMOPTYSIS CHEST PAIN – PLEURITICCHEST PAIN – PLEURITIC WHEEZINGWHEEZING CYANOSISCYANOSIS SNORINGSNORING

Cough –CausesCough –Causes

AcuteAcute URTIURTI Post viral infectionPost viral infection Post nasal drip Post nasal drip AllergyAllergy PneumoniaPneumonia

ChronicChronic Asthma – typically at Asthma – typically at

nightnight COPD – typically in COPD – typically in

morningmorning Gastro oesphageal Gastro oesphageal

reflux – esp when lie reflux – esp when lie flatflat

SmokingSmoking ACE InhibitorsACE Inhibitors Pulmonary oedema Pulmonary oedema

(LVF)(LVF) TBTB Bronchiectasis Bronchiectasis Cystic fibrosisCystic fibrosis Post nasal drip Post nasal drip

Red Flags in Acute Red Flags in Acute CoughCough

SymptomsSymptoms HaemoptysisHaemoptysis BreathlessnessBreathlessness FeverFever Chest PainChest Pain Weight LossWeight Loss

SignsSigns

TachypnoeaTachypnoea

CyanosisCyanosis

Dull chestDull chest

Bronchial Bronchial BreathingBreathing

CracklesCracklesTHINK pneumonia, lung cancer, LVF

GET a CHEST X-Ray

DyspneaDyspnea

The sensation of breathlessness or The sensation of breathlessness or inadequate breathing, is the most inadequate breathing, is the most

common complaint of patients with common complaint of patients with cardiopulmonary diseases.cardiopulmonary diseases.

Differential Diagnosis of Differential Diagnosis of DyspneaDyspnea CardiacCardiac

Pulmonary oedema Pulmonary oedema (LVF )(LVF )

Dilated Dilated cardiomyopathycardiomyopathy

Mitral valve diseaseMitral valve disease Aortic stenosisAortic stenosis ArrhythmiasArrhythmias Pericardial effusionPericardial effusion

RespiratoryRespiratory Pulmonary embolismPulmonary embolism Pulmonary fibrosisPulmonary fibrosis Lung tumourLung tumour PneumoniaPneumonia PneumothoraxPneumothorax Pleural effusionPleural effusion AsthmaAsthma COPDCOPD BronchiectasisBronchiectasis Lung collapseLung collapse

MetabolicMetabolic Metabolic acidosisMetabolic acidosis AnaemiaAnaemia ThyrotoxicosisThyrotoxicosis Psychogenic Psychogenic

hyperventilationhyperventilation

NeuromuscularNeuromuscular KyphoscoliosisKyphoscoliosis Ankylosing spondylitisAnkylosing spondylitis Muscular dystrophyMuscular dystrophy PoliomyelitisPoliomyelitis Myasthenia gravisMyasthenia gravis Guillain-Barré syndromeGuillain-Barré syndrome

Easily Performed Diagnostic Easily Performed Diagnostic TestsTests

Chest radiographsChest radiographs

ElectrocardiographElectrocardiograph

Screening spirometryScreening spirometry

SputumSputum

The nature of the sputum is often The nature of the sputum is often helpfulhelpful Pink frothy sputum - pulmonary oedemaPink frothy sputum - pulmonary oedema Anchovy Past ( Amaebiasis )Anchovy Past ( Amaebiasis ) Clear white mucoid sputum –viral infection or Clear white mucoid sputum –viral infection or

longstanding bronchial irritation , COPD , Asthmalongstanding bronchial irritation , COPD , Asthma Thick, yellowish sputum – infectionThick, yellowish sputum – infection Foul tasting/ smelling – anaerobic bacterial Foul tasting/ smelling – anaerobic bacterial

infection – bronchiectasis , abscessinfection – bronchiectasis , abscess Rusty sputum – pneumococcal pneumoniaRusty sputum – pneumococcal pneumonia Blood streaked sputum –T.B, bronchiectasis, Blood streaked sputum –T.B, bronchiectasis,

Cancer lung Cancer lung Black –Coal dust inhalationBlack –Coal dust inhalation

Hemoptysis: CausesHemoptysis: Causes Bronchial disordersBronchial disorders

BronchiectasisBronchiectasis Bronchogenic carcinomaBronchogenic carcinoma Chronic bronchitisChronic bronchitis

Pulmo DisordersPulmo Disorders Pulmonary TBPulmonary TB PeumoniaPeumonia Lung abscessLung abscess Pulmonary embolismPulmonary embolism

Cardiovascular disordersCardiovascular disorders Acute left heart failure Acute left heart failure Mitral stenosis Mitral stenosis

OthersOthers Hematologic disease , Hematologic disease , Systemic coagulopathy, Systemic coagulopathy,

anticoagulants, anticoagulants, Vasculitis : Vasculitis : SLE, Wegeners, Goodpasture SLE, Wegeners, Goodpasture

Chest PainChest Pain

RespiratoryP.E.

Pneumothoraxpleurisy

GERDOesophageal spasm Musculoskeletal

VascularAortic

dissection

CardiacMI, IHD,

Pericarditis,myocarditis

Chest Pain

Causes of chest pain Causes of chest pain

Cardiac relate Cardiac relatedd

Angina pectori Angina pectoriss

Myocardial inf Myocardial infarctionarction

- Non cardiac relate- Non cardiac relatedd Muscle strain Muscle strain PericarditisPericarditis EsophagitisEsophagitis Hiatal hernia Hiatal hernia Pulmonary embolism Pulmonary embolism Dissecting aortic aneu Dissecting aortic aneu

rysmrysm Acute indigestion Acute indigestion Intestinal “gas” Intestinal “gas”

CyanosisCyanosis Definition of cyanosis : Definition of cyanosis : A bluish color of skin A bluish color of skin

and mucous membranes, in lips, nail beds and mucous membranes, in lips, nail beds caused by increased amount of reduced –caused by increased amount of reduced –desaturated desaturated hemoglobin (Hb) hemoglobin (Hb) > 5g/dl > 5g/dl

Central Central HHemoglobin - emoglobin - content of reduced Hb content of reduced Hb

Heart disorders – lung congestion Heart disorders – lung congestion Lung disorders Lung disorders

acute: pneumonia, lung edema acute: pneumonia, lung edema chronic: COPD, severe lung fibrosischronic: COPD, severe lung fibrosis

PeripheralPeripheral LLocal perfusion disordersocal perfusion disorders

Impaired pulmonary function1. Airway obstruction2. Pulmonary diseases3. Pleural diseases

Right-to-left shunting of blood

Tetralogy of Fallot

Central Cyanosis

Peripheral CyanosisCaused by increased oxygen consumption in peripheral tissue. Vasoconstriction Low cardiac output Exposure to cold air or water Slowing of blood flow Right heart failure

Respiratory Difficulty:Respiratory Difficulty:

AsthmaAsthma HyperventilationHyperventilation Chronic obstructive pulmonary Chronic obstructive pulmonary

disease (COPD)disease (COPD) Foreign body aspirationForeign body aspiration Gastric contents aspirationGastric contents aspiration

ASTHMAASTHMA

What is AsthmaWhat is Asthma A chronic inflammation disorder in the airwaysA chronic inflammation disorder in the airways Acute episodes “triggered” by somethingAcute episodes “triggered” by something

causes release of histamine, leukotrienescauses release of histamine, leukotrienes causes obstruction of airflowcauses obstruction of airflow

Predominant symptoms Predominant symptoms Cough (Night time or early morning coughing )Cough (Night time or early morning coughing ) BreathlessnessBreathlessness WheezingWheezing chest tightnesschest tightness FlushingFlushing

Increased heart rate and prolonged expiration Increased heart rate and prolonged expiration May be self-limiting, but severe episodes may May be self-limiting, but severe episodes may

require medical assistancerequire medical assistance

Precipitating or Aggravating Precipitating or Aggravating FactorsFactors

Exposure to irritants and occupational chemicals

Viral respiratory Infections

ExerciseEndocrine factors

Emotional expression: anger, laughing

Weather changes: cold air

Environmental changes Food additives:

sulfites

ASTHMA

PATIENTAllergens

Drugs:Aspirin Beta blockers

Manifestations of An Acute Asthmatic Manifestations of An Acute Asthmatic Episode:Episode:

Mild to moderateMild to moderate - Wheezing- Wheezing - Dyspnea- Dyspnea - Tachycardia- Tachycardia - Coughing- Coughing - Anxiety- Anxiety SevereSevere - Intense dyspnea with flaring of nostrils & use of - Intense dyspnea with flaring of nostrils & use of

accessory muscleaccessory muscle - Cyanosis of mucous membrane & nailbeds- Cyanosis of mucous membrane & nailbeds - Minimal breathing sound on auscultation- Minimal breathing sound on auscultation - Flushing- Flushing - Extreme anxiety- Extreme anxiety - Mental confusion- Mental confusion - Perspiration- Perspiration

AsthmaAsthma

Lab TestsLab Tests No one diagnostic testNo one diagnostic test Chest X - ray, skin testing, sputum smears and blood Chest X - ray, skin testing, sputum smears and blood

counts (for eosinophilia), arterial blood gasescounts (for eosinophilia), arterial blood gases Spirometry (peak expiratory flow meter) before and Spirometry (peak expiratory flow meter) before and

after bronchodilatorafter bronchodilator

Oral ComplicationsOral Complications Mouth breathing complicationsMouth breathing complications Increased gingivitis and caries secondary to beta Increased gingivitis and caries secondary to beta

agonist inhaler useagonist inhaler use Oral candidiasis secondary to steroid inhaler useOral candidiasis secondary to steroid inhaler use

Asthma: Dental Asthma: Dental ManagementManagement

Schedule late-morning appointmentsSchedule late-morning appointments Use rescue inhaler before proceduresUse rescue inhaler before procedures Use pulse oximeter during proceduresUse pulse oximeter during procedures Provide stress-free environmentProvide stress-free environment

• good rapport and opennessgood rapport and openness• may use Nmay use N22O or oral benzodiazepineO or oral benzodiazepine

Things to do

Asthma: Dental Asthma: Dental ManagementManagement

Precipitating factors Precipitating factors Barbiturates and narcoticsBarbiturates and narcotics Aspirin, NSAIDsAspirin, NSAIDs Antihistamines (or use cautiously)Antihistamines (or use cautiously) Macrolide antibiotics and ciprofloxacin Macrolide antibiotics and ciprofloxacin

(in patients on theophylline)(in patients on theophylline)

Things to avoid

Asthma: Managing an Asthma: Managing an attackattack

Warning signsWarning signs Frequent coughFrequent cough Inability to finish sentence in one breathInability to finish sentence in one breath Bronchodilator ineffectiveBronchodilator ineffective TachypneaTachypnea Tachycardia (>110)Tachycardia (>110) Diaphoresis Diaphoresis

What to doWhat to do Use short-acting beta-adrenergic agonist Use short-acting beta-adrenergic agonist

inhalerinhaler Positive-flow oxygenation Positive-flow oxygenation If severe: subcutaneous epinephrine, call EMSIf severe: subcutaneous epinephrine, call EMS

1.1. Terminate all proceduresTerminate all procedures2.2. Fully sitting positionFully sitting position3.3. Bronchodilators Bronchodilators

(Atrovent/Berotec)(Atrovent/Berotec)4.4. OO22

5.5. Check vital signsCheck vital signs

Signs & symptoms Signs & symptoms continuecontinue

S & S S & S relievedrelieved

6. Give Epi 0.3ml of 1: 6. Give Epi 0.3ml of 1: 1,000 IM1,000 IM or SQor SQ7. Build up IV line7. Build up IV line8. Monitor vital signs8. Monitor vital signs

9. Prepare to ER9. Prepare to ER10. Add steroid therapy10. Add steroid therapy

6. Monitor of recovery 6. Monitor of recovery statestate7. Consult physician7. Consult physician

S & S not S & S not relievedrelieved

AsthmaAsthma

Hyperventilation Syndrome:Hyperventilation Syndrome:

NeurologicNeurologic

- dizziness- dizziness

- tingling or numbness of fingers, toes or - tingling or numbness of fingers, toes or lipslips

- syncope- syncope RespiratoryRespiratory

- increased rate & depth of breaths- increased rate & depth of breaths

- SOB- SOB

- chest pain- chest pain

- xerostomia- xerostomia

Manifestations of Hyperventilation Manifestations of Hyperventilation Syndrome:Syndrome:

CardiacCardiac - palpitations- palpitations - tachycardia- tachycardia MusculoskeletalMusculoskeletal - myalgia- myalgia - muscle spasm- muscle spasm - tremor- tremor - tetany- tetany PsychologicPsychologic - extreme anxiety- extreme anxiety

Management of Hyperventilation Management of Hyperventilation Syndrome:Syndrome:

Terminate all proceduresTerminate all procedures On fully upright positionOn fully upright position Verbally calm patientVerbally calm patient Breath COBreath CO22-enriched air-enriched air Add Valium 10mg IV Add Valium 10mg IV Monitor vital signsMonitor vital signs

Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease ( COPD )Disease ( COPD )

Chronic airflow limitation; not fully Chronic airflow limitation; not fully reversiblereversible

Two major diseases:Two major diseases:• Chronic bronchitisChronic bronchitis• EmphysemaEmphysema

COPDCOPD

PINK PUFFERS

BLUE BLOATERS

Chronic Bronchitis Signs and Chronic Bronchitis Signs and SymptomsSymptoms

Chronic cough, copious Chronic cough, copious sputumsputum >3 months>3 months

2 consecutive years2 consecutive years

““Blue bloaters”: Blue bloaters”: sedentary, overweight, sedentary, overweight, cyanotic, edematous, cyanotic, edematous, breathlessbreathless

Severity based on Severity based on spirometryspirometry

Emphysema : Pink PuffersEmphysema : Pink Puffers Chronic diseaseChronic disease Result of destruction of the alveolar wallsResult of destruction of the alveolar walls

cigarette smokingcigarette smoking exposure to “unfriendly” environmentexposure to “unfriendly” environment

Signs and SymptomsSigns and Symptoms

Severe exertional dyspnea, minimal coughSevere exertional dyspnea, minimal cough

Prolonged expiratory phaseProlonged expiratory phase

““Barrel-chested”, weight lossBarrel-chested”, weight loss

““Pink puffers”:Pink puffers”:(polycythemia)(polycythemia) non cyanotic non cyanotic

COPD: Oral COPD: Oral ManifestationsManifestations

HalitosisHalitosis Extrinsic tooth stainsExtrinsic tooth stains Nicotine stomatitisNicotine stomatitis Periodontal diseasePeriodontal disease Oral cancerOral cancer

COPD: Lab TestsCOPD: Lab Tests SpirometrySpirometry

↓ ↓ maximum expiratory maximum expiratory flow rate – not reversibleflow rate – not reversible

Chest x-ray:Chest x-ray:• Chronic bronchitis: Chronic bronchitis:

prominent vascular prominent vascular markingsmarkings

• Emphysema: over Emphysema: over distention of lungs, distention of lungs, flattening of diaphragm, flattening of diaphragm, emphysematous bullaeemphysematous bullae

COPD: Dental COPD: Dental ManagementManagement

Reschedule appointment if:Reschedule appointment if:• Short of breath worse than baselineShort of breath worse than baseline• Productive cough worse than baselineProductive cough worse than baseline• Acute upper respiratory infectionAcute upper respiratory infection• Oxygen saturation <91% (by pulse Oxygen saturation <91% (by pulse

oximeter)oximeter)

COPD: Dental Management of COPD: Dental Management of Stable PatientStable Patient

Treat in upright chair positionTreat in upright chair position Use inhalers prior to treatmentUse inhalers prior to treatment Use pulse oximetryUse pulse oximetry Use low-flow oxygen when OUse low-flow oxygen when O22 sat <95% sat <95%

unless baseline is lowerunless baseline is lower May use low-dose oral diazepamMay use low-dose oral diazepam Supplemental steroids may be requiredSupplemental steroids may be required

Things to do

COPD: Dental Management of COPD: Dental Management of Stable PatientStable Patient

NN22O sedation (in severe or very severe O sedation (in severe or very severe COPD)COPD)

Barbiturates and narcoticsBarbiturates and narcotics Antihistamines and anticholinergicsAntihistamines and anticholinergics Macrolide antibiotics and ciprofloxacin (in Macrolide antibiotics and ciprofloxacin (in

patients on theophylline) patients on theophylline) Outpatient general anesthesiaOutpatient general anesthesia

Things to avoid

PNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIA

PneumoniaPneumonia

Infection of the lung (in the alveoli)Infection of the lung (in the alveoli) Viral, bacterial, mycoplasma, or Viral, bacterial, mycoplasma, or

aspiration pneumoniaaspiration pneumonia Respiratory viruses & mycoplasma Respiratory viruses & mycoplasma

responsible for greater than 1/3 of responsible for greater than 1/3 of casescases

Spread by:Spread by: Droplets or contact with infected personsDroplets or contact with infected persons Aspiration of bacteria from nasopharynxAspiration of bacteria from nasopharynx

Viral PneumoniaViral Pneumonia Influenza A most common viral typeInfluenza A most common viral type Often epidemic in school childrenOften epidemic in school children May be secondary bacterial pneumoniaMay be secondary bacterial pneumonia Viral PneumoniaViral Pneumonia——PresentationPresentation Productive coughProductive cough Pleuritic chest painPleuritic chest pain Fever : Shaking chillsFever : Shaking chills Nonspecific complaints (elderly)Nonspecific complaints (elderly)

HA, nonproductive cough, fatigue, sore throatHA, nonproductive cough, fatigue, sore throat

Viral pneumoniaViral pneumoniaManagement /ProphylaxisManagement /Prophylaxis

Supportive treatment - decrease severity of Supportive treatment - decrease severity of symptomssymptoms

Bed restBed rest AnalgesicsAnalgesics Patients withPatients with

Airway obstruction - treat with Airway obstruction - treat with BronchodilatorsBronchodilators

Secondary bacterial infection - AntibioticsSecondary bacterial infection - Antibiotics

Atypical PneumoniaAtypical Pneumonia

Accounts for 25% of community acquired Accounts for 25% of community acquired pneumoniaspneumonias

Mild upper respiratory infection in school-age Mild upper respiratory infection in school-age children and young adultschildren and young adults

Mycoplasma/ chlamyda/legionellaMycoplasma/ chlamyda/legionella Can cause Extrapulmonary Manifestations -Can cause Extrapulmonary Manifestations -

Meningitis, Encephalitis, Pericarditis, Hepatitis, Meningitis, Encephalitis, Pericarditis, Hepatitis, Hemolytic AnemiaHemolytic Anemia

Typically bilateral infiltrates on chest x-rayTypically bilateral infiltrates on chest x-ray Treated with Antibiotics Treated with Antibiotics ( Macrolides / Doxycycline / ( Macrolides / Doxycycline /

Flouroquinone )Flouroquinone )

Bacterial PneumoniaBacterial Pneumonia Most common cause Pneumococcal followed Most common cause Pneumococcal followed

by Haemophilus influenzaby Haemophilus influenza Peaks in winter and early springPeaks in winter and early spring Responsible for 10% of hospital admissionsResponsible for 10% of hospital admissions Aspiration of oropharyngeal contentsAspiration of oropharyngeal contents Patients with a chronic disease are at an Patients with a chronic disease are at an

increased risk of contracting pneumoniaincreased risk of contracting pneumonia Unilateral infiltrate on x-rayUnilateral infiltrate on x-ray High mortality in elderly populationHigh mortality in elderly population

Bacterial Pneumonia Bacterial Pneumonia PresentationPresentation

Fever - chillsFever - chills TachypneaTachypnea TachycardiaTachycardia MalaiseMalaise AnorexiaAnorexia Myalgias Myalgias Flank or back painFlank or back pain VomitingVomiting

Aspiration PneumoniaAspiration Pneumonia Inflammation of lung parenchyma from Inflammation of lung parenchyma from

foreign material in tracheobronchial treeforeign material in tracheobronchial tree May be:May be:

NonbacterialNonbacterial Bacterial (as a secondary complication)Bacterial (as a secondary complication)

Dyspnea, cough, bronchospasm, wheezes, Dyspnea, cough, bronchospasm, wheezes, crackles, cyanosiscrackles, cyanosis

Treatment : AntibioticsTreatment : Antibiotics

TB: DefinitionTB: Definition

Pulmonary and systemic diseasePulmonary and systemic disease Most common cause: Most common cause: M. M.

tuberculosistuberculosis Spread by respiratory dropletSpread by respiratory droplet

TB: Signs and symptomsTB: Signs and symptoms Most patients with 1° infection: no symptomsMost patients with 1° infection: no symptoms Cough (scanty, mucoid sputum; later Cough (scanty, mucoid sputum; later

purulent)purulent) Systemic symptoms: malaise, unexplained Systemic symptoms: malaise, unexplained

weight loss, night sweats, feverweight loss, night sweats, fever Extrapulmonary manifestations: Extrapulmonary manifestations:

lymphadenopathy, back pain, GI or renal lymphadenopathy, back pain, GI or renal disturbances, heart failure, neurologic deficitsdisturbances, heart failure, neurologic deficits

TB: Oral ComplicationsTB: Oral Complications Painful, deep tongue ulcers (infrequent)Painful, deep tongue ulcers (infrequent) Cervical, submandibular lymphadenitis Cervical, submandibular lymphadenitis

(scrofula)(scrofula)

TB: Lab TestsTB: Lab Tests Positive Tuberculin (Mantoux) skin test (does Positive Tuberculin (Mantoux) skin test (does

not mean infection is clinically active)not mean infection is clinically active)

X - ray findingsX - ray findings progressive primary TB: patchy infiltrates, progressive primary TB: patchy infiltrates,

cavitation, hilar lymphadenopathycavitation, hilar lymphadenopathy healed primary TB: calcified peripheral healed primary TB: calcified peripheral

nodule, calcified lymph node (Ghon nodule, calcified lymph node (Ghon complex)complex)

Sputum smear positive for acid fast organismsSputum smear positive for acid fast organisms Confirm with culture and/or molecular testsConfirm with culture and/or molecular tests

TB chest xray

TB: Medical TB: Medical ManagementManagement

Drugs chosen based on health of Drugs chosen based on health of patient, likelihood of resistant strainpatient, likelihood of resistant strain

Patients become non-infectious in 3-6 Patients become non-infectious in 3-6 monthsmonths

Prophylactic drug treatment for Prophylactic drug treatment for certain close contacts (young, HIV certain close contacts (young, HIV infected, diabetic)infected, diabetic)

TB: Dental ManagementTB: Dental Management

After 2-3 weeks of treatment: treat After 2-3 weeks of treatment: treat normallynormally

History of TB: treat normally if no active History of TB: treat normally if no active diseasedisease

Positive TB test: treat normally if no active Positive TB test: treat normally if no active diseasedisease

New, active TB: treat only urgently and in New, active TB: treat only urgently and in a hospital isolation rooma hospital isolation room

Clinical signs suggestive of TB: do not treatClinical signs suggestive of TB: do not treat

PneumothoraxPneumothorax

Pulmonary Pulmonary EmbolismEmbolism

Lung CancerLung Cancer Most 55-65 years of ageMost 55-65 years of age Smoking top causeSmoking top cause Early—Early—signs of respiratory illnesssigns of respiratory illness Late –Late –Hemoptysis , Dyspnea , Hoarseness , Hemoptysis , Dyspnea , Hoarseness ,

Dysphagia , Weight loss , WeaknessDysphagia , Weight loss , Weakness CLINICAL FEATURES OF LUNG CANCER (DO IMMEDIATE CXR)CLINICAL FEATURES OF LUNG CANCER (DO IMMEDIATE CXR) Haemoptysis Haemoptysis Unexplained or persistent (more than 3 Unexplained or persistent (more than 3

weeks)weeks)– coughcough– chest/shoulder painchest/shoulder pain– chest signschest signs– dyspnoeadyspnoea– Hoarseness Hoarseness – finger clubbingfinger clubbing

TYPES OF TUMOURSTYPES OF TUMOURS 1. Squamous Cell carcinoma1. Squamous Cell carcinoma

2. Adeno carcinoma2. Adeno carcinoma

3. Small cell carcinoma3. Small cell carcinoma

4. Large cell, undifferentiated carcinoma4. Large cell, undifferentiated carcinoma

Responding to a Patient With Breathing ProblemsResponding to a Patient With Breathing Problems