Download - Asthma Posted 1018 06
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Pulmonary Disease
ASTHMAASTHMA
A chronic inflammatory pulmonary disease consisting of recurrent episodes of dyspnea,
coughing, and wheezing result from hyperresponsiveness of the tracheobronchial tree following exposure to allergen or stress
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AsthmaIn U.S., asthma is: 1) most common chronic disease of childhood affecting 5 million children < 18 yrs, 2) leading cause of school absenteeism, 3) most frequent reason for preventable hospitalization in children, 4) More often occurs in young males and older females
MMWR 9/20/96 and MMWR 8/8/97
It is the 4th leading cause of disability in childrenPrevalence rates are highest among children residing in inner cities; mortality highest in the poor and black populations.
Estimated medical costs of asthma in US increased from 4.5 billion to 6.2 billion which represents 1 to 2% of total U.S. health-care costs
1.8 million emergency room visits, 466,000 hospitalizations, and 5000 deaths occur annually in USA
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Asthma• Multifactorial disease exact etiology unknown,
may be linked to prostanglandin receptor gene
Usually benign, if treated (75% of
childhood asthma is mild)
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12-month prevalence of asthma increased 73.9% during 1980--1996
Growing disease
12 million have asthma (1990), 14 million (1995), 17.3 million (1998), ~20 million today. From 1964 to 1984 a 3-fold rise in children asthma symptoms;
3.3 million children have asthma (1990), 4.8 million or ~ 1 in 17 children (1995), 10% of children affected 2002
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Deaths from asthma increased 46% from1980 to 1990 to 1.9 per 100,000 persons
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Documented dentistry-related causes of asthma
• Tooth enamel dust (OOO 75:599,1993)
• Methyl methacrylate (Thorax 39:712, 1984; Tubercle & Lung Dis 75:99,1994)
• Menthol (J Investig Allergol Clin Immunol. 2001;11(1):56)
• Aspirin-induced (Chest. 1994 Aug;106(2):654)
• Toothpaste (J Aller Clin Immunol. 1992; N Engl J Med. 1990 323(26):1845)
• Foreign bodies: Lego (N Engl J Med. 1996 334(6):406)11
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& basophils
35%
30%
ACE inhibitors, b-blockers
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Mediators of Asthma• Released from bronchial mast cells,
alveolar macrophages, T lymphocytes and epithelial cells
• Histamine, tryptase, leukotrienes and prostglandins
• Early-phase response: injury from eosino- and neutrophils Bronchoconstriction
• Late-phase: epithelial damage, airway edema, mucous hypersecretion, hyperresponsiveness of bronchial smooth muscle
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Asthma – Clinical Presentation
• Asthma attacks often occur at night
• May follow exposure to an allergen, exercise, respiratory infection, and emotional stress
• Onset is sudden (within 10 minutes)
• Breathlessness (dyspnea)• Chest tightness
Signs and symptoms • Wheezing• Cough that is worse at
night • Flushing • Tachypnea• Prolonged expiration• At termination of attack
a productive cough with thick stringy mucus occurs
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Persistence of Asthma from Childhood to Adulthood
• 613 N. Zealand children followed from age 3 yrs to 26
• At age 26,
– 42% no symptoms and no challenged wheezing
– 31% transient or intermittent wheezing
– 12% relapsing symptoms (wheezing stopped after childhood, then recurred)
– 15% persistent wheezing.
N Engl J Med 2003; 349:1414
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What are warning signs of asthma attack?
Anticipatory Features
Restlessness during sleep Fatigue that isn't related to working or playing hard
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Warning Signs of an Asthma Attack
Irregular breathing: wheezing, labored breathing, coughDyspnea, chest tightness
Drop in FEV (<50% of optimum)
Tachypnea, tachycardia
Diaphoresis – sweating and paleness
Pulsus paradoxus (decline > 10 mm Hg in blood pressure during inspiration compared to expiration)
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Additional Features of Asthma Attack• Anxious or scared look
• Flared nostrils during inhalation
• Pursed lips breathing, Fast breathing
• Hunched-over body posture; patient can't stand or sit straight and can't relax
• Intercostal (between ribs or supraclavicular) depressions during inhalation
Poor oxygenation (pulse oximeter, blue lips, nails, struggle to breath)
Emergency
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Asthma -Complications• Most patients can expect reasonably good prognosis; however
small % of patients progress to emphysema and respiratory failure or develop status asthmaticus
• Status asthmaticus is the most serious complication associated with asthma
• consists of a severe and prolonged asthmatic attack (lasts > 24 hours) and is refractory to usual therapy
• Signs include increased dyspnea, jugular venous pulsation, cyanosis and pulsus paradoxus (a fall in systolic pressure with inspiration). It is often associated with infection
• Can lead to exhaustion, severe dehydration, peripheral vascular collapse and death
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• Chest xrays (for hyperinflation)
• Skin testing (for specific allergens)
• Histamine or methacholine chloride challenge testing,
• Sputum smears & blood counts (for eosinophilia)
• Arterial blood gases,
• Antibody-based enzyme-linked immunosorbent assay (ELISA) for measurement of environmental allergen exposure,
and spirometry (a peak expiratory flow meter that measures pulmonary function
Commonly ordered tests
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Asthma – Classification Classification Findings
Mild Intermittent
Intermittent wheezing less than 2 days per weekBrief exacerbations, asymptomatic between, nocturnal symptoms < 2 times a month, good exercise tolerance FEV1 > 80% predicted
Mild Persistent Wheezing 2-5 days per week (over several days)Attacks that affect activity and sleep, nocturnal attacks > 2 X month, limited exercise tolerance, rare ER visit, FEV1 > 80% predicted
Moderate Persistent
Daily symptoms of wheezing (over several days)Daily use of SA beta-agonist, attacks that affect activity and sleep and may last for days, nocturnal attacks at least 1/week, limited exercise tolerance, ER visit, FEV1 60% to 80% of predicted
Severe Persistent
Frequent/daily exacerbations,continual symptomsFrequent nocturnal asthma (>4/month), exercise intolerance,
FEV1 < 60% predicted, often hospitalized
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Managing Asthma • Classification• Goal: limit exposure to triggering agents,
allow normal activities, restore and maintain pulmonary function, prevent ADE of medications, minimize frequency and severity of attacks
• Choice of medicationbased on type & severity;and lifestyle change
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Drugs used by Asthmatics• Anti-Inflammatory Agents (1st agents)
• Bronchodilators (2o agents, added in, can be faster acting)
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Drugs used by Asthmatics• Anti-Inflammatory Agents (1st agents)
– Corticosteroid inhalants
– Leukotrine receptor inhibitors: Zafirlukast (Accolate), Montekulast (Singulair , Zileuton (Zyflo)
– Mast cell stabilizers (Cromolyn [Intal], Nedocromil [Tilade])
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Anti-inflammatory (1st tier) Antiasthmatic Drugs Corticosteroids – onset 2 hrs, peak 6 hrs
Beclomethasone (Vancerase)Budesonide (Pulmiocort)Flunisolide (Nasalide, AeroBid)Fluticasone (Flonase, Flovent)Triamcinolone (Azmacort)
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Bronchodilators* - B2 agonists Bronchodilators (2o agents, added in*, can
be faster acting)
• Albuterol (Proventil, Ventolin)• Metaproterenol (Alupent, Metaprel) • Terbutaline (Bricanyl, Brethine, Brethaire)
• Isoetharine (Bronkometer, Bronkosol) Isoproterenol (Isuprel, Medihaler-ISO)
• Bitolterol [Tornalate], Pirbuterol [Maxair]• Salmeterol (Serevent) only long acting
* to inhaled steroid or antileukotriene
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Sympathomimetic Bronchodilators: Pharmacologic Effects and Pharmacokinetic
Properties
Sympathomimetic
Adrenergic
receptor activity
Onset
(minutes)
Duration (hrs)
Albuterol1 1 < 2 within 20
4-8
Bitolterol1 1 < 2 3-4 5 to > 8
Isoetharine1 1 < 2 within 5 1-3
Metaproterenol1 1 < 2 ~30
2-6
Pirbuterol1 1 < 2 within 5 5
Other Bronchodilator: TheophyllineIpratropium bromide (anticholinergic) less potent bronchodilator; additive effect with B agonist
Levalbuterol
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Sympathomi
metic
Adrenergic
receptor activity
Onset
(minutes)
Duration (hrs)
Salmeterol1 1 < 2 20-30 12
Terbutaline1 1 < 2 5-15
4-8
Isoproterenoll 1 2 30
1-2
Ephedrine 1 2 within 20
3-5
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Additional Treatment approaches
Systemic steroids +/- cyclosporine or methotrexate
NEW: Recombinant injectable humanized monoclonal antibody that binds IgE (Omalizumab [Xolair]; SubQ; Genetech/Novartis) prevents IgE from binding mast cell/basophil receptors
effective in treating adults and children with asthma allowed for withdrawal of inhaled steroids successfully in 55% of asthmatics (ADES HA, fever, urticaria and pruritis)
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Managing Asthma -Moderate Persistent
Long-term Control vs.Inhaled anti-inflammatory orcorticosteroids 200-500 mg initially up to 1000 mg daily especially at night, +
bronchodilator (theophylline SR, long-acting beta agonist (3-4 x d)
Quick ReliefQuick ReliefShort acting Short acting bronchodilatorbronchodilator
BetaBeta22-agonist-agonist
EpinephrineEpinephrine
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Managing Asthma -Severe Persistent
Long-term Control:Inhaled anti-inflammatory (i.e., corticosteroids 200-500 mg initially up to 1000 mg daily especially at night,
+ bronchodilator (theophylline SR, long-acting beta agonist)
+ inhaled corticosteroids then tablets or syrup as needed
Quick ReliefShort acting Short acting bronchodilatorbronchodilator
BetaBeta22-agonist + -agonist +
additional supportive additional supportive measures as neededmeasures as needed
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Dental Management of Asthmatic Patient
• Pretreatment Assessment: STABILITY– History (f, duration, severity [recent hospitalizations,
nocturnal symptoms], respiration rate, eosinophil count, I.D. triggers)
– Taking medicines (type, how much, today?), bring inhaler
– Assign risk level - based on: • Level of control
• Peak flow meter should be > 80% usual. If not sign of impending attack
• # of medications used• Use of inhaled beta-agonists (rescue medication)• [threshold of safety 1.5 canisters / month] if > 1.5
canisters/mo, > 200 inhalation/mo or a doubling of the monthly use indicates high risk of fatal or near-fatal asthma (NEJM 336:729, 1997), referral
• Recent visits to the ER
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Dental Management of Asthmatic Patient
• Pretreatment Assessment: STABILITY– Avoid triggers: cold air, dust, feathers or
molds, animal dander, cigarette smoking, pollution, fragrances
– Prophylax with inhaler
– Being Stressed Anxiolytic: nitrous oxide, hydroxyzine (antihistamine + sedative)
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Dental Management of Asthmatic Patient• Treatment: avoid/reduce irritating odorants, sulfites,
rotary-derived particulate matter, continue anxiolytic therapy, – Avoid barbiturates and narcotics, particularly meperidine.
They are histamine-releasing drugs and can provoke an attack. Aspirin use can trigger an attack. . .
– special needs for pt on systemic steroids
• Posttreatment: avoid macrolide antibiotics with theophylline
• Asthma attack: act immediately; stop procedure, remove RD, administer SA-bronchodilator and O2, if no relief subQ epinephrine (1:1000) 0.3-0.5 mL, repeat inhaler and epinephrine q5 min as needed
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Oral Manifestations -Asthma
• Altered nasorespiratory function (mouth breathing) results in increased upper anterior and total anterior facial height, higher palatal vaults, greater overjets, higher prevlance of crossbites (Bresolin et al. Am J Orthod 1983;83:334)
• Increased prevalence of caries with moderate to severe asthma– B2 agonist decrease salivary flow by 20-35%, associated
with increased # of lactobacilli
• Mis-use of inhaled corticosteroids and risk of candidiasis