Week 7 - Respiratory Medicine

Question 1

what is the principle role of the respiratory system

Answer 1

gas exchange: oxygen in, CO2 out

Question 2

what are the 3 main disturbances in respiratory disease?

Answer 2

• reduced transfer of oxygen
• reduced ventilation of lungs
• reduced perfusion of lungs

Question 3

general respiratory symptoms?

Answer 3

• dyspnea: caused by one of 3 main disturbances
• wheeze: due to narrowing of airways
• cough
• sputum production
• chest pain: “pleuritic pain”

Question 4

what is pleuritic pain?

Answer 4

pain on inspiration, sneezing or coughing. induced with any kind of respiratory effort

Question 5

asthma: what kind of disease?

Answer 5

• a reversible, small obstruction of the airways

- occurs due to an inflammatory, allergic condition

Question 6

asthma (chronic & acute) - symptoms?

Answer 6

• wheeze
• breathlessness
• cough

Question 7

asthma - assessment? when will assessment be different?

Answer 7

• peak flow recordings: plot by age, sex, height
• standardized recording technique
• assessment could be poorer in the morning (diurnal variation)

Question 8

asthma - precipitants?

Answer 8

• allergens: house dust mite, pet dander
• irritants: dust, smoke
• exertion
• NSAIDs
• emotion

Question 9

chronic asthma - what are indicators of severity?

Answer 9

• restriction of activities
• inhaler use: particular types?
• peak flow recordings (diary)

Question 10

chronic asthma - management?

Answer 10

• medication mainly delivered through inhaled route
• step wise increase in medications: inhaled salbutamol-> salmeterol-> inhaled steroids->combinatiaon inhalers-> other medications, anti-leuklotrienes

Question 11

asthma - dental aspects

Answer 11

• assess current symptoms: exercise tolerance? worsening symptoms? recent medication changes?
• management of acute attack
• recognition of unstable symptoms: delay tx, refer to gp
• avoid NSAIDs
• oral candidiasis, altered taste, dry mouth: side effects of inhaled medication, advise gargling after use

Question 12

definition of COPD:

• characterized by?
• predominantly caused by?
• when do exacerbations occur?
• definition of COPD: FEV/FVC ratio?
• if FEV1 is 80% predicted normal?

Answer 12

• airflow obstruction that is not fully reversible. obstructions does not change markedly over months, progressive in the long term
• smoking, also occupational exposures
• when there is rapid and sustained worsening of symptoms beyond normal day-to-day variations
• 0.7
• diagnosis of COPD should only be made when there are symptoms present e.g. breathlessness

Question 13

COPD - pathophysiology?main processes of disease?

Answer 13

• damage to lung parenchyma

1. emphysema: lung tissue for gaseous exchange damaged. e.g. alveolar destruction-> reduced area for gas exchange
2. bronchitis:
   - airway inflammation
   - increased mucous production -> increased ventilation

Question 14

COPD - symptoms?

Answer 14

• breathlessness: linked to exertion
• wheeze: consistent
• chronic cough and sputum production
• frequent infections (stagnant mucous)

Question 15

COPD - investigations?

Answer 15

• pulmonary function tests: checks lung function, spirometry, FEV1, FVC

Question 16

COPD - management?

Answer 16

• progressive addition of oral and inhaled therapies, depending on symptoms: tiotropium (spiriva)
• stop smoking
• exercise
• severe-> home o2

Question 17

home oxygen: how is it delivered?

Answer 17

• usuall via nasal cannulae
• face mask (drying to oral tissues)
• o2 in cylinder or concentrator
• safety briefing important

Question 18

acute exacerbation of COPD - management:

• depends on?
• may need?
• what medications?
• acute exacerbation in chair: what to do?

Answer 18

• depends on severity
• may need hospitalization
• increased inhalers/nebulizers
• steroids
• antibiotics
• stop tx, sit up, check ABC
• give oxygen, no high flow unless very unwell
• bronchodilator: spacer or nebulizer
• hospitalization

Question 19

COPD - dental aspects:

• what to assess?
• what to do when unstable COPD?
• avoid what drugs?
• be aware of?

Answer 19

• assess ability to lie flat, for worsening symptoms
• if unstable, avoid tx
• avoid NSAIDs
• be aware of diminished respiratory reserve (avoid sedation)

Question 20

pneumonia:
infection of?
may affect which areas in the lung?

Answer 20

• infection of lung tissue

- may be diffuse or affect certain lobes

Question 21

pneumonia - acute illness symptoms?

Answer 21

• cough + green sputum
• breathlessness
• fever
• pleuritic chest pain

Question 22

pneumonia - investigations?

Answer 22

sputum exams: examine for infectious agent

chest radiographs: grey area indicates infection

Question 23

pneumonia - management?

Answer 23

• antibiotics

- may require hospitalization: oxygen, intravenous fluids, airway support

Question 24

pneumonia - severity: hospitalization if?

Answer 24

• pulse: >100bmp
• respiratory rate: >20breaths/min
• BP: lower than 90/50mmHg
• capillary return time >2 secs
• oxygen saturation <96%

Question 25

pneumonia severity - CURB 65 criterias?

Answer 25

- confusion - urea >/= 19mg/dl - respiratory rate >/= 30 breaths a min - BP lower than 90/50mmHg - age 65 and above

Question 26

pneumothorax: what is it? what are the types of peope susceptible?

Answer 26

- leak of air into pleural space-> sudden onset of breathlessness and pain - tall young people (esp if smokers) - chronic lung disease

Question 27

pneumothorax - diagnosis?

Answer 27

chest radiograph; loss of lung markings

Question 28

pneumothorax - management?

Answer 28

- main aim is to get rid of air - aspirate - chest drain - occasionally requires surgery: if chest drain fails, or if recurrent case

Question 29

sleep apnoea - what is it? symptoms?

Answer 29

- collapse of upper airway during sleep (associated with obesity) - snoring, daytime sleepiness, irritability, headaches - "microsleeps"

Question 30

sleep apnoea - risk factors?

Answer 30

- being overweight or obese - having a large neck - sedative medication - sleeping tablets - unusual structure of neck - smoking/drinking alcohol before sleep

Question 31

what type of unusual traits of the neck are present in those at risk of sleep apnoea?

Answer 31

- narrow airway - large tonsils/adenoids/tongue - small lower jaw

Question 32

sleep apnoea - management?

Answer 32

- lifestyle changes: lose weight, cut alcohol, sleeping on their side - continuous positive airways pressure device (CPAP): pressure prevents the airway closing while patients sleep - mandibular advancement device (MAD): holds jaw & tongue forward

Question 33

sleep apnoea - dental aspects?

Answer 33

- refer to GP or sleep apnoea clinic - caution while lying flat on chair, in case pt falls asleep - consider alternative cause for snoring, nasal pathology? - caution if considering providing a mandibular advancement device (requires training)

Question 34

interstitial lung disease - pathophysiology?

Answer 34

- inflammation of lung tissue that can progress to fibrosis - irreversible damage/restrictive lung defect

Question 35

interstitial lung disease - causes?

Answer 35

- cryptogenic (no idea) - allergens: birds, occupational, drugs - direct damage: asbestos, coal - autoimmune disease: rheumatoid, sarcoidosis, systemic sclerosis

Question 36

interstitial lung disease: symptoms?

Answer 36

breathlessness & cough

Question 37

interstitial lung disease: management?

Answer 37

- remove underlying cause | - suppression of immune system: steroids, prednisolone + other immunosuppressive medication

Question 38

interstitial lung disease: dental aspects?

Answer 38

- risk of respiratory compromise: so avoid sedation | - oral side effects of treatment?

Question 39

cystic fibrosis: aetiology? | what kind of inheritance? how common?

Answer 39

gene defect-> abnormal chloride ion channels -> high viscosity mucous - lungs, pancreas, male gonadal function - autosomal recessive - 1/20carriers, 1/2000 births affected

Question 40

cystic fibrosis - symptoms in childhood?

Answer 40

- recurrent respiratory infections-> lung destruction - malabsorption - pancreatic duct obstruction-> cirrhosis - bowel obstruction in infants

Question 41

cystic fibrosis - symptoms in adulthood?

Answer 41

- male infertility - diabetes - osteoporosis

Question 42

cystic fibrosis - diagnosis? management?

Answer 42

- blood test at birth - sweat test - prompt treatment of infections - prophylactic antibiotics - nutrition - physiotherapy - heart-lung transplant - future: inhaled gene therapy

Question 43

cystic fibrosis - dental aspects?

Answer 43

- risk of respiratory compromise: avoid sedation - will be on immunosuppresants if transplant recipient - take note: more than just lung disease present - treatment with special care dentist may be more appropriate, depending on morbidity

Question 44

DVT & PE: pathophysiology? | where does the clot affect body for each?

Answer 44

- clot formation in peripheral veins - usually legs: DVT - clot migrates to lungs: PE

Question 45

DVT & PE: predisposing facors?

Answer 45

- obstruction to blood flow - increased coagulability of blood - immobility - surgery (often more than one factor present)

Question 46

DVT - symptoms?

Answer 46

- painful lower leg (sometimes upper) | - may be dilated veins, hot, red, swollen

Question 47

PE - symptoms?

Answer 47

- pleuritic chest pain - breathlessness - haemoptysis (vomiting blood from respiratory tract) - collapse - sudden death

Question 48

DVT & PE diagnosis?

Answer 48

DVT: ultrasound of limb PE: chest CT pulmonary angiogram ventilation-perfusion scan

Question 49

DVT & PE: management?

Answer 49

- anticoagulation: immediate anticoagulation with low molecular weight heparin - long term anticoagulation: warfarin/new agents

Question 50

DVT & PE - dental aspects?

Answer 50

- anticoagulated patients: be aware of SDCEP guidelines | - do not stop anticoagulation therapy unless guidance clearly says so, or GP consulted