PULMONOLOGY. Cardinal Respiratory Symptoms and Signs COUGH COUGH DYSPNEA DYSPNEA SPUTUM PRODUCTION & HEMOPTYSIS SPUTUM PRODUCTION & HEMOPTYSIS CHEST PAIN

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Text of PULMONOLOGY. Cardinal Respiratory Symptoms and Signs COUGH COUGH DYSPNEA DYSPNEA SPUTUM PRODUCTION...

  • PULMONOLOGY

  • Cardinal Respiratory Symptoms and SignsCOUGHDYSPNEASPUTUM PRODUCTION & HEMOPTYSISCHEST PAIN PLEURITICWHEEZINGCYANOSISSNORING

  • Cough Causes AcuteURTIPost viral infectionPost nasal drip AllergyPneumonia

    ChronicAsthma typically at nightCOPD typically in morningGastro oesphageal reflux esp when lie flatSmokingACE InhibitorsPulmonary oedema (LVF)TBBronchiectasis Cystic fibrosisPost nasal drip

  • Red Flags in Acute CoughSymptomsHaemoptysisBreathlessnessFeverChest PainWeight LossSignsTachypnoeaCyanosisDull chestBronchial BreathingCracklesTHINK pneumonia, lung cancer, LVFGET a CHEST X-Ray

  • DyspneaThe sensation of breathlessness or inadequate breathing, is the most common complaint of patients with cardiopulmonary diseases.

  • Differential Diagnosis of DyspneaCardiacPulmonary oedema (LVF )Dilated cardiomyopathyMitral valve diseaseAortic stenosisArrhythmiasPericardial effusion

    RespiratoryPulmonary embolismPulmonary fibrosisLung tumourPneumoniaPneumothoraxPleural effusionAsthmaCOPDBronchiectasisLung collapseMetabolicMetabolic acidosisAnaemiaThyrotoxicosisPsychogenic hyperventilation

    NeuromuscularKyphoscoliosisAnkylosing spondylitisMuscular dystrophyPoliomyelitisMyasthenia gravisGuillain-Barr syndrome

  • Easily Performed Diagnostic Tests

    Chest radiographs

    Electrocardiograph

    Screening spirometry

  • SputumThe nature of the sputum is often helpfulPink frothy sputum - pulmonary oedemaAnchovy Past ( Amaebiasis )Clear white mucoid sputum viral infection or longstanding bronchial irritation , COPD , AsthmaThick, yellowish sputum infectionFoul tasting/ smelling anaerobic bacterial infection bronchiectasis , abscessRusty sputum pneumococcal pneumoniaBlood streaked sputum T.B, bronchiectasis, Cancer lung Black Coal dust inhalation

  • Hemoptysis: CausesBronchial disordersBronchiectasisBronchogenic carcinomaChronic bronchitisPulmo DisordersPulmonary TBPeumoniaLung abscessPulmonary embolismCardiovascular disordersAcute left heart failure Mitral stenosis OthersHematologic disease , Systemic coagulopathy, anticoagulants, Vasculitis : SLE, Wegeners, Goodpasture

  • Chest Pain

  • Causes of chest painCardiac relatedAngina pectorisMyocardial infarctionNon-cardiac relatedMuscle strainPericarditisEsophagitisHiatal herniaPulmonary embolismDissecting aortic aneurysmAcute indigestionIntestinal gas

  • CyanosisDefinition of cyanosis : A bluish color of skin and mucous membranes, in lips, nail beds caused by increased amount of reduced desaturated hemoglobin (Hb) > 5g/dl Central Hemoglobin - content of reduced Hb Heart disorders lung congestion Lung disorders acute: pneumonia, lung edema chronic: COPD, severe lung fibrosis PeripheralLocal perfusion disorders

  • Impaired pulmonary function1. Airway obstruction2. Pulmonary diseases3. Pleural diseasesRight-to-left shunting of bloodTetralogy of FallotCentral 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:AsthmaHyperventilationChronic obstructive pulmonary disease (COPD)Foreign body aspirationGastric contents aspiration

  • ASTHMA

  • What is AsthmaA chronic inflammation disorder in the airwaysAcute episodes triggered by somethingcauses release of histamine, leukotrienescauses obstruction of airflowPredominant symptoms Cough (Night time or early morning coughing )BreathlessnessWheezingchest tightnessFlushingIncreased heart rate and prolonged expiration May be self-limiting, but severe episodes may require medical assistance

  • Precipitating or Aggravating Factors

  • Manifestations of An Acute Asthmatic Episode:Mild to moderate - Wheezing - Dyspnea - Tachycardia - Coughing - AnxietySevere - Intense dyspnea with flaring of nostrils & use of accessory muscle - Cyanosis of mucous membrane & nailbeds - Minimal breathing sound on auscultation - Flushing - Extreme anxiety - Mental confusion - Perspiration

  • AsthmaLab Tests No one diagnostic testChest X - ray, skin testing, sputum smears and blood counts (for eosinophilia), arterial blood gasesSpirometry (peak expiratory flow meter) before and after bronchodilatorOral ComplicationsMouth breathing complicationsIncreased gingivitis and caries secondary to beta agonist inhaler useOral candidiasis secondary to steroid inhaler use

  • Asthma: Dental ManagementSchedule late-morning appointmentsUse rescue inhaler before proceduresUse pulse oximeter during proceduresProvide stress-free environmentgood rapport and opennessmay use N2O or oral benzodiazepine

    Things to do

  • Asthma: Dental ManagementPrecipitating factors Barbiturates and narcoticsAspirin, NSAIDsAntihistamines (or use cautiously)Macrolide antibiotics and ciprofloxacin (in patients on theophylline)

    Things to avoid

  • Asthma: Managing an attackWarning signsFrequent coughInability to finish sentence in one breathBronchodilator ineffectiveTachypneaTachycardia (>110)Diaphoresis What to doUse short-acting beta-adrenergic agonist inhalerPositive-flow oxygenation If severe: subcutaneous epinephrine, call EMS

  • Asthma

  • Hyperventilation Syndrome:Neurologic - dizziness - tingling or numbness of fingers, toes or lips - syncopeRespiratory - increased rate & depth of breaths - SOB - chest pain - xerostomia

  • Manifestations of Hyperventilation Syndrome:Cardiac - palpitations - tachycardiaMusculoskeletal - myalgia - muscle spasm - tremor - tetanyPsychologic - extreme anxiety

  • Management of Hyperventilation Syndrome:Terminate all proceduresOn fully upright positionVerbally calm patientBreath CO2-enriched airAdd Valium 10mg IV Monitor vital signs

  • Chronic Obstructive Pulmonary Disease ( COPD )Chronic airflow limitation; not fully reversibleTwo major diseases:Chronic bronchitisEmphysema

  • COPDPINK PUFFERSBLUE BLOATERS

  • Chronic Bronchitis Signs and SymptomsChronic cough, copious sputum>3 months2 consecutive yearsBlue bloaters: sedentary, overweight, cyanotic, edematous, breathlessSeverity based on spirometry

  • Emphysema : Pink PuffersChronic diseaseResult of destruction of the alveolar wallscigarette smokingexposure to unfriendly environmentSigns and SymptomsSevere exertional dyspnea, minimal coughProlonged expiratory phaseBarrel-chested, weight lossPink puffers:(polycythemia) non cyanotic

  • COPD: Oral ManifestationsHalitosisExtrinsic tooth stainsNicotine stomatitisPeriodontal diseaseOral cancer

  • COPD: Lab TestsSpirometry maximum expiratory flow rate not reversibleChest x-ray:Chronic bronchitis: prominent vascular markingsEmphysema: over distention of lungs, flattening of diaphragm, emphysematous bullae

  • COPD: Dental ManagementReschedule appointment if:Short of breath worse than baselineProductive cough worse than baselineAcute upper respiratory infectionOxygen saturation
  • COPD: Dental Management of Stable PatientTreat in upright chair positionUse inhalers prior to treatmentUse pulse oximetryUse low-flow oxygen when O2 sat
  • COPD: Dental Management of Stable PatientN2O sedation (in severe or very severe COPD)Barbiturates and narcoticsAntihistamines and anticholinergicsMacrolide antibiotics and ciprofloxacin (in patients on theophylline) Outpatient general anesthesiaThings to avoid

  • PNEUMONIA

  • PneumoniaInfection of the lung (in the alveoli)Viral, bacterial, mycoplasma, or aspiration pneumoniaRespiratory viruses & mycoplasma responsible for greater than 1/3 of casesSpread by:Droplets or contact with infected personsAspiration of bacteria from nasopharynx

  • Viral PneumoniaInfluenza A most common viral typeOften epidemic in school childrenMay be secondary bacterial pneumoniaViral PneumoniaPresentationProductive coughPleuritic chest painFever : Shaking chillsNonspecific complaints (elderly)HA, nonproductive cough, fatigue, sore throat

  • Viral pneumoniaManagement /ProphylaxisSupportive treatment - decrease severity of symptomsBed restAnalgesicsPatients withAirway obstruction - treat with BronchodilatorsSecondary bacterial infection - Antibiotics

  • Atypical PneumoniaAccounts for 25% of community acquired pneumoniasMild upper respiratory infection in school-age children and young adultsMycoplasma/ chlamyda/legionellaCan cause Extrapulmonary Manifestations -Meningitis, Encephalitis, Pericarditis, Hepatitis, Hemolytic AnemiaTypically bilateral infiltrates on chest x-rayTreated with Antibiotics ( Macrolides / Doxycycline / Flouroquinone )

  • Bacterial PneumoniaMost common cause Pneumococcal followed by Haemophilus influenzaPeaks in winter and early springResponsible for 10% of hospital admissionsAspiration of oropharyngeal contentsPatients with a chronic disease are at an increased risk of contracting pneumoniaUnilateral infiltrate on x-rayHigh mortality in elderly population

  • Bacterial Pneumonia PresentationFever - chillsTachypneaTachycardiaMalaiseAnorexiaMyalgias Flank or back painVomiting

  • Aspiration PneumoniaInflammation of lung parenchyma from foreign material in tracheobronchial treeMay be:NonbacterialBacterial (as a secondary complication)Dyspnea, cough, bronchospasm, wheezes, crackles, cyanosisTreatment : Antibiotics

  • TB: DefinitionPul