3. Medical Emergencies: Pulmonary Flashcards by J L

◦ Extrathoracic components are the ____, trachea.
◦ Intrathoracic components are the ____, primarily. Then the trachea, bronchi, bronchioles, and alveoli which are involved in gas exchange.

mouth

lungs

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Airway Physiology

● Airways become ____ as you move toward the periphery but the total cross-sectional area ____

smaller

increases

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Airway Physiology

Primary thing here is: the trachea has ____. They’ll maintain support of the area. Because they’re ____-shaped, it allows for some distensibility of that airway as well. The ____ portion is NOT cartilage, so it can change in terms of diameter. But the cartilage helps support the airway and keeps them open.

As we go further down into the bronchi, there will be ____ bronchi that go to the lobes of the right lung, and only ____ bronchi that go to the lobes of the left lung.

cartilaginous rings
C
posterior

3
2

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Airway Physiology

We’ll see the ____ here at the end. Finally, the alveolar sacs and alveoli. These are normal-looking alveoli. You can see the tremendous amount of cross-sectional area, and that is where CO2 and O2 are going to be exchanged.

terminal bronchioles

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Airway Physiology

● Airways are held open by ____ support and by ____ differences

structural

pressure

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Physiology of Breathing
● Central and peripheral respiratory and the sensory receptors
● The central chemoreceptors respond to ____ and the
peripheral chemoreceptors respond to ____
● The normal respiratory rate (RR) is ____ breaths per minute

carbon dioxide (CO2)
oxygen (O2)
14-16

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Exhalation and Inspiration

Here’s a chest xray of someone that’s taking a breath in (right). You can see the tremendous increase in lung volume. The diaphragm contracts.

And then somebody that’s exhaling (left). Diaphragm is ____, so there is less lung volume.

We also see these little vascular markings. These white markings are ____. There’s not as much air in the lungs, so you can see those prominent markings. In patients with ____, those will be very prominent. That’s one of the reads we’ll see on a chest x-ray, prominent vascular markings suggestive of CHF. You’ll also see an enlargement of the ____ (its silouhette will be larger).

On the right lung, you can’t see those vascular markings quite as much as you could during ____.

up
vascular markings
CHF
heart
exhalation

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Pulmonary Symptoms
● ____
● ____
● ____

dyspnea
wheezing
cough

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Dyspnea
● The sensation of difficulty with ____
● ____ or chronic
● Can be triggered by any stimulus that increases the need for ____

breathing
acute
oxygen

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Differential Diagnosis of Dyspnea

● Chronic obstructive
pulmonary disease 
● Asthma 
● \_\_\_\_
obstruction 
● \_\_\_\_ 
● \_\_\_\_ 
● \_\_\_\_ 
● \_\_\_\_

● Congestive heart
failure 
● \_\_\_\_ infarction 
● \_\_\_\_
disorders 
● \_\_\_\_

upper airway
aspiration
pulmonary embolism
pneumothorax
laryngospasm

myocardial
neuromuscular
anxiety

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Pulmonary Diseases
● COPD
- ____
- ____

● Asthma

bronchitis

emphysema

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COPD
● Affects 14 million people
● ____ leading cause of death

fifth

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“Causes of pure emphysema or pure chronic bronchitis are uncommon; patients usually have elements of both diseases. The disease that ____ receives the diagnostic label.”

predominates

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● Chronic bronchitis 
“Blue bloaters” 
Frequency \_\_\_\_ 
Chronic productive \_\_\_\_ Copious, \_\_\_\_ sputum
\_\_\_\_ dyspnea 
Frequent \_\_\_\_ infections

● Emphysema 
“Pink puffers” 
\_\_\_\_ chested 
\_\_\_\_ not prominent
\_\_\_\_ sputum
\_\_\_\_ dyspnea
Few \_\_\_\_ infections

overweight
cough
mucopurulent
mild
respiratory

barrel
cough
scant
severe
respiratory

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Chronic Bronchitis
“Excessive tracheobronchial mucous production sufficient to cause cough with expectoration for at least ____ months of the year for ____ consecutive years”

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Chronic Bronchitis

This is what it looks like pathologically
You’ll see ____ cells in the lining of the airway that produce mucus
Also bronchial glands: only found in the ____ glands
You’ll see thick sputum in the middle of the airway and these big mucus ____ (you have to clear the plugs in order to breathe)

goblet
larger
plugs

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Emphysema

“Distension of the air space ____ to the terminal bronchioles with destruction of ____”

distal

alveolar septa

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Emphysema and chronic bronchitis are clinically managed in an ____ fashion.

Both patients with emphysema and chronic bronchitis will be managed exactly the same way clinically.

Patients with COPD will get more ____, but patients with emphysema are also treated with antibiotics (not as frequently tho). They will be on some kind of either B-2 agonist or parasympathetic blocker.
In essence, there’s a blur between the 2 categories and patients have features of both. Ultimately, they’re not managed identically, but pretty close!

identical

antibiotics

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Pulmonary Function Tests
● \_\_\_\_
● \_\_\_\_
Measurement
● \_\_\_\_ Blood Gases

Arterial blood gases: done in a hospital-type setting when we want to know these numbers. These patients might be in an ICU for an extended period of time. We won’t get these values as quickly as we will ____ and ____ measurement.

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spirometry
peak flow
arterial

spirometry
peak flow

Lung Volumes
● Tidal Volume (TV)– the amount of air that moves into the lungs with each ____ or the amount of air that moves out of the lungs with each ____

● Vital Capacity (VC) – ____ volume a person can ____ after full inspiration

● FEV 1 (forced expiratory volume in one second)
The amount of air one can ____ in one second after full ____.
FEV1 is a ____ of vital capacity

normally > 75% of V.C. – ____ with COPD

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inspiration
expiration

maximum
exhale

expire
inspiration
percentage
decreases

Lung Volumes

VC, after full breath of air, how much air can they get out of the lung?

The only thing remaining will be the ____.

FEV1 is going to be a portion of this ____. It’s gonna vary depending on the ____.

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residual volume
vital capacity
individual

Spirometry
● Provides the most \_\_\_\_
assessment of degree of
impairment 
● Measures \_\_\_\_ and
\_\_\_\_ flow rates as well as
\_\_\_\_ 
● Values are compared to
predicted values based on \_\_\_\_, height, and \_\_\_\_

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accurate
inspiratory
expiratory
vital capacity
age
gender

Spirometry in COPD

FEV1 < ____ liters
FEV1/FVC < ____%

In spirometry, we’ll see FEV1 (the amount of air expired after taking a full breath in after one second) is going to be less than 2L in patients with COPD. It’ll be greater than 2L in patients that don’t have any lung problems.

FEV1 as a ratio over the Forced Vital Capacity is going to be less than 75% in patients with COPD. In patients that don’t have COPD, this number should be greater than 75%.

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Severity of COPD Correlated with Spirometric Measurement

Normal
% or FEV1/FVC: ____

Mild
% or FEV1/FVC: ____

Moderate
% or FEV1/FVC: ____

Severe
% or FEV1/FVC: ____

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80-100
75-79
50-74
35-49

Peak Flow Meter ● Simple to use ● Patients can track their disease and identify exacerbations ● Values greater than ____ L/min are normal ● Patient’s ____ best values are important ◆ Less than ____% of personal best value ◆ Peak flow measurement of less than ____ L/min is high risk

300 personal 50 100

Arterial Blood Gases ● PaO2 ____ mmHg in healthy youngsters and decreases to ____ mmHg in the elderly ● PaCO2 ____ mmHg; ____ with respiratory depression or COPD ● pH – 7.4; becomes ____ acid with ____ carbon dioxide retention

100 80 40 increases more increased

Summary COPD ● Spirometry: FEV 1 < ____ liters FEV1/FVC < ____% ● Arterial blood gases: PaO2 of ____mmHg

``` two 75 70 80-100 45 ```

Dental Management of the Patient with COPD ● ____ chair position ● Local anesthetic as usual, but avoid ____ mandibular or palatal blocks ● Avoid use of ____ in severe disease ● ____-flow supplemental oxygen may be helpful ● Avoid ____ inhalation sedation ● Low-dose oral ____ is acceptable ● Avoid use of ____, narcotics, antihistamines, and anticholinergics ● If patient is taking steroids, may need ____ ● Outpatient ____ contraindicated

``` upright bilateral rubber dam low nitrous oxide-oxygen benzodiazepines barbiturates supplementation general anesthesia ```

``` COPD – Treatment ● Elimination of ____ and environmental pollutants ● Aggressive treatment of ____ infections ● ____-flow oxygen ● ____ ```

smoking pulmonary low medications

Medications: Important concepts ● Sympathetic innervation causes ____ and parasympathetic innervation causes ____ ● Most therapies focus on augmenting the ____ pathways rather than blocking parasympathetic pathways ● Receptor specific drugs cause less ____ ● Aerosol therapy via a ____-dose inhaler (MDI) – a small valve allows a specific dose to be released

``` bronchodilation bronchoconstriction sympathetic side effects metered ```

``` Medications ● Bronchodilators - ____ (i.e. theophylline) - ____ stimulants (i.e. albuterol) - ____ (i.e. ipratropium) ``` ● ____ (2nd line)

methylxanthines beta-adrenergic anticholinergics corticosteroids

Asthma | “syndrome consisting of ____, cough, and wheezing caused by ____ resulting from a ____ of the tracheobronchial tree”

dyspnea bronchospasm hyperirritability

``` Asthma vs. COPD ● Asthma is a ____ obstructive disease. ● Respiratory function is fairly ____ between asthma attacks. ```

reversible | normal

``` Pathophysiology of Asthma ● Airway ____ ● Airway ____ ● During an acute attack ____, mucosal edema, and mucous ____ lead to narrowing and closure of small peripheral airways ```

reactivity inflammation bronchospasm plugging

Asthma • So similar to what we saw with patients with chronic bronchitis, this is just more of an ____ situation where you'll have: ◦ mucus in the airway ◦ edema of the lining of the airway ◦ spasm of the bronchus • So a very narrow airway for air to get through down into the alveoli for exchange of gases

acute

Incidence of Asthma ● ____ % of children ● ____% of adults

10 | 5

Common classifications of Asthma ``` Extrinsic Asthma ● ____ onset, commonly ____ with age ● ____ manifestations ● ____ response to medication ● ____, extended symptom-free periods common ``` ``` Intrinsic Asthma ● ____ onset ● No ____ allergen- antigen reaction ● ____ pharmacological efficacy ● ____ ```

``` early decreased immunological excellent seasonal ``` adult discernible reduced perennial

``` Intrinsic Asthma ● No ____ ● Non-responsive to ____ ● Normal ____ levels ● ____-aged adults ● Initiated by ____, stress, ____ ```

``` family history skin testing IgE middle exercise URI's ```

Extrinsic Asthma ● ____ and young adults ● ____ history ● ____ skin test to allergens ● ____ IgE levels

children family positive elevated

Asthma: Signs and Symptoms ``` ● Paroxysms of dyspnea ● Productive ____ ● ____ ● ____ ● ____ ``` ``` ● Mental ____ ● Fatigue ● Anxiety ● Normal to ____ BP ● ____ ```

cough wheezing tachypnea cyanosis confusion increased tachycardia

Treatment of Asthma Attack ``` 1. Eliminate ____ factor/position patient 2. ____ 3. ____ 4. ____ 5. ____ 6. ____ and ventilation ```

``` precipitating O2 inhalers epinephrine corticosteroids intubation ```

Therapeutic Agents Commonly Used by Asthmatics Bronchodialators ____ - albuterol - ____ symptomatic treatment - salmeterol - ____; not appropriate for relief of symptoms Theophylline - often used ____ for ____ asthma

B2 agonists first line long-acting prophylactically nocturnal

Mast Cell Stabilizer ____ (Intal) ``` Corticosteroids ____ Beclomethasone dipropionate (Beclovent, Vanceril) ____ (Aerobid) Triamcinolone acetonide (Azmacort) ____ (Decadron Phosphate Respinhaler) ``` Anticholinergic ____ (Atrovent)

cromolyn sodium prednisone flunisolide dexamethasone sodium phosphate ipratropium bromide

Important Points in the History of the Asthmatic Patient ● ____ of hospitalization for asthma ● ____ of intubation during an asthmatic exacerbation ● ____ and severity of asthmatic exacerbations ● Precipitating factors ● Use of a single versus multiple classes of ____ medications ● ____ and frequency of steroids use (systemic versus inhaled) ● Previous ____ or pulmonary function values ● Other associated cardiac or pulmonary diseases

history history frequency bronchodilator

Dental Management of the Patient with Asthma ● 1. Identification and assessment by ____ a. Type of asthma (allergic vs idiosyncratic) b. Precipitating factors c. Age at onset d. Frequency and severity of attacks e. How usually managed f. Medications being taken g. Necessity of emergency care ● 2. Avoidance of known ____ factors ● 3. Medical ____ for severe, active asthmatic ● 4. Have patient bring ____ to every appointment and keep it available

history precipitating consultation inhaler

Dental Management of the Patient with Asthma ● 5. Drug considerations a. Avoid ____-containing medications (use ____ b. Avoid ____ drugs NSAIDs) c. Avoid ____ and narcotics ● 6. Patients taking chronic corticosteroid medication may require ____ ● 7. Provision of ____-free environment through establishment of rapport and openness ● 8. If sedation is required, may be preferable to use ____ inhalation sedation and/or ____ sedation

``` aspirin acetaminophen NSAIDs barbiturates supplementation strss nitrous oxide-oxygen oral ```

3. Medical Emergencies: Pulmonary Flashcards

(46 cards)