The Patient with a Respiratory Disease










The Patient with a
Respiratory Disease
Katherine Yee, RDH, BSDH, MPH and Janet B. Selwitz- Segal, RDH, CDA, MS
THE RESPIRATORY SYSTEM
I. Anatomy
II. Physiology
III. Function of the Respiratory Mucosa
IV. Respiratory Assessment
V. Classification
UPPER RESPIRATORY TRACT DISEASES
I. Modes of Transmission
II. Dental Hygiene Care
LOWER RESPIRATORY
TRACT DISEASES
ACUTE BRONCHITIS
PNEUMONIA
I. Etiology
II. Symptoms
III. Categories and Role of Oral Bacteria
IV. Medical Management
V. Dental Hygiene Care
TUBERCULOSIS
I. Etiology
II. Transmission
III. Disease Development
IV. Diagnosis
V. Medical Management
VI. Oral Manifestations
VII. Dental Hygiene Care
ASTHMA
I. Etiology
II. Atopic (Allergic) Asthma
III. Asthma Attack
IV. Medical Management
V. Oral Manifestations
VI. Dental Hygiene Care
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
I. Chronic Bronchitis
II. Emphysema
III. Medical Management
IV. Oral Manifestations
V. Dental Hygiene Care
CYSTIC FIBROSIS
I. Disease Characteristics
II. Medical Management
III. Dental Hygiene Care
SLEEP APNEA SYNDROME
I. Etiology
II. Signs and Symptoms
III. Medical Management
IV. Dental Hygiene Care
DOCUMENTATION
EVERYDAY ETHICS
FACTORS TO TEACH THE PATIENT
REFERENCES
CHAPTER OUTLINE
66
LEARNING OBJECTIVES
After studying the chapter, the student will be able to:
1. Identify and define key terms and concepts related to
respiratory diseases.
2. Differentiate between upper/lower respiratory diseases.
3. Describe the etiology, symptoms, and management of
respiratory diseases.
4. Plan and document dental hygiene care and oral hygiene
instructions for patients with compromised respiratory
function.
Wilkins9781451193114-ch066.indd 1107 07/10/15 11:39 AM

1108 SECTION IX | Patients with Special Needs
Cilia assist in removing foreign material and con-
taminated mucus by a constant beating and wavelike
motion that propels this material back into the larger
bronchi and trachea where it can be coughed up and
expectorated or swallowed.
Lack of function results when the inflammatory process
of asthma and chronic bronchitis initiates an overabun-
dance of mucus. Congestion is created and the cilia are
prevented from assisting with normal breathing.
IV. Respiratory Assessment
Respiratory disease assessment includes several objective
measures.
A. Vital Signs
Determination of vital signs (body temperature, pulse,
respiratory rate, blood pressure), and also smoking status
is considered standard procedure in dental patientcare.
Methods determining vital signs are described in Chap-
ter 11. Tobacco use is discussed in Chapter 34.
B. Spirometry
Medical test that measures various aspects of breathing
and lung function.
Used to diagnose and monitor many lower respiratory
tract diseases.
Performed with a spirometer, a device that registers the
amount of air a person inhales or exhales and the rate at
which air is moved in and out of the lungs.
Figure 66-3 shows the use of a spirometer to evaluate
lung function.
C. Pulse Oximetry
3
Medical test that measures blood oxygen saturation
levels.
Performed with a pulse oximeter.
• Color of blood varies depending upon the amount of
oxygen it contains.
• Pulse oximeter emits a light through the finger to
calculate the percentage of oxygen.
• Any finger (excluding the thumb) can be used. Nail
polish or skin callous may interfere with reading.
• Intended only as an adjunct in patient assessment
along with other methods of assessing clinical signs
and symptoms.
• Healthy patients have an oxygen saturation of
97%–100%.
• Saturation of 91% or below signifies poor oxygen
exchange.
Figure 66-4 shows the use of a pulse oximeter to mea-
sure blood oxygen saturation levels.
D. Chest Radiography (Imaging)
Indicates presence of pathological density (radiopacity)
in the lungs.
Patients with respiratory diseases have increased risks
for complications due to decreased breathing function and
treatment drug interactions.
Tobacco cessation:
• Many respiratory diseases are caused or aggravated
by use of tobacco products.
• Dental hygienists have a unique opportunity to edu-
cate their patients about this health hazard.
Emergency treatment: Patients with respiratory distress
may need emergency care, which dental hygienists are
prepared to prevent or provide when necessary.
• Signs and symptoms and medical emergency pro-
cedures for local anesthesia reactions, respiratory
failure, airway obstruction, asthma attack, hyper-
ventilation, anaphylaxis, and allergic reactions are
found in Table 8-3 (Chapter 8).
Oral–systemic link: Scientific evidence shows that
dental biofilm and microorganisms from periodontal
infections can contribute to the initiation and/or pro-
gression of certain infections in the respiratory system.
1
Dedication of the dental hygienist to the prevention
and control of periodontal infections will have a major
influence on the overall health of the patient.
Box 66-1 defines key words related to respiration and
respiratory diseases.
THE RESPIRATORY SYSTEM
I. Anatomy
2
Structures: sinuses, nasal cavity, larynx, pharynx, trachea,
bronchi, lungs, and pleura (Figure 66-1A).
II. Physiology
The respiratory tract from nasal cavity to lungs serves as a
passageway for air exchange (Figure 66-1A).
Inhaled fresh air: warmed and filtered in the nasal cavity,
enters the lungs.
Exhaled air: with carbon dioxide, leaves the body.
Gas exchange: at the cellular level, occurs in the alveoli
at the ends of the bronchioles, as shown in Figure66-1B.
Cardiovascular system: functions with the respiratory
system to pump oxygenated blood from the lungs to ev-
ery cell in the body and deoxygenated blood back to the
lungs for exhalation.
III. Function of the Respiratory Mucosa
Figure 66-2 shows ciliated epithelial cells and mucus-se-
creting goblet cells that line the respiratory tract to make
up the respiratory mucosa.
Mucus secreted from goblet cells moistens inspired air,
prevents delicate alveolar walls from becoming dry, and
traps dust and other airborne particles.
Wilkins9781451193114-ch066.indd 1108 07/10/15 11:39 AM

CHAPTER 66 | The Patient with a Respiratory Disease 1109
Acute: (of a disease or disease symptom) beginning abruptly
with marked intensity or sharpness, then subsiding after a
relatively short time; opposite of chronic.
Analgesic: relieving pain.
Allergen: see antigen.
Anaphylaxis: an exaggerated life-threatening hypersensitiv-
ity reaction to a previously encountered allergen.
Antigen: any substance that is capable of inducing a spe-
cific immune response and of reacting with the products
of that response, that is, with specific antibody or specifi-
cally sensitized T-lymphocytes or both. When used to
describe an allergic response, these antigens are called
allergens.
Antipyretic: a substance or procedure that reduces fever.
Atopy: hereditary tendency to experience immediate allergic
reactions (allergic asthma).
Atopic: adj.
Bronchodilator: a drug that relaxes contractions of the
smooth muscle of the bronchioles to improve ventilation
of the lungs.
Chronic: (of a disease or disorder) developing slowly and
persisting for a long period, often for the remainder of a
persons lifetime; opposite of acute.
Comorbid: medical condition(s) existing simultaneously but
independently with another condition.
Communicable disease: (contagious) any disease transmit-
ted from one person or animal to another. Direct: from ex-
creta or other bodily discharges. Indirect: from substances
or inanimate objects (contaminated drinking glasses,
water, insects, or toys).
Coryza: profuse discharge from mucous membrane of the
nose.
Dysphagia: difficulty in swallowing. Do not confuse with
dysphasia: loss of ability to understand language as a re-
sult of injury or disease to the brain.
Dyspnea: labored or difficult breathing.
Edema: abnormal accumulation of fluids in the intercellular
spaces of tissues causing swelling.
Exacerbation: increase in severity of a disease or any of its
symptoms.
Expiration: release of air from the lungs through the nose or
mouth. See inspiration.
Gastroesophageal reflux: backflow of stomach contents
into the esophagus where gastric juices produce a burn-
ing sensation.
Goblet cell: specialized epithelial cell that secretes mucus.
Hemoptysis: spitting of blood because of a lesion in the
larynx, trachea, or lower respiratory tract.
Hyperventilation: greater rate and volume of breathing than
metabolically necessary for pulmonary gas exchange; may
lead to dizziness and possible syncope.
Hypoxia: diminished availability of oxygen to the body tis-
sues characterized by tachycardia, hypertension, peripheral
vasoconstriction, and mental confusion.
Inspiration: inhaling air into the lungs. See expiration.
Malaise: a vague uneasy feeling of body weakness, often
marking the onset of, and persisting throughout, a
disease.
Mast cell: constituent of connective tissue; releases sub-
stances in response to injury or infection.
Mediator: a substance that effects a change in a disease state.
Morbidity: relating to disease. See comorbid.
Mortality: relating to death.
Mucus: (n.) viscous, slippery secretion of mucous membranes
and glands. Contains mucin, white blood cells, inorganic
salts, and exfoliated cells.
Mucous: adj.
Myalgia: muscle pain accompanied by malaise.
Mycoplasm: bacteria without a cell wall, more resistant to
antibiotics.
Nosocomial: pertaining to, or originating in, a healthcare
facility.
Nosocomial pneumonia: pneumonia contracted during
confinement in a healthcare facility.
Orthopnea: ability to breathe easily only in an upright
position.
Otalgia: pain in the ears.
Pathophysiology: disruption of bodily functions due to
disease.
Pleura: delicate membrane enclosing the lungs.
Pleurisy: inflammation of the pleura; may be caused by infec-
tion, injury, or tumor, or a complication of lung diseases.
Pleuritic: adj.
Pneumothorax: collection of air or gas causing the lungs to
collapse.
Pulmonary hypertension: condition of abnormally high
pressure within the pulmonary circulation.
Spirometer: instrument for measuring volume of air enter-
ing and leaving the lungs to determine lung function and
breathing capacity.
Sputum: matter expectorated (coughed up) from the re-
spiratory system, especially the lungs in a diseased state,
composed chiefly of mucus and may contain pus, blood,
or microorganisms.
Tachycardia: abnormally high heart rate (greater than
100 beats per minute) for an adult.
Tachypnea: abnormally high respiration rate (greater than
20 breaths per minute) for an adult.
Tracheostomy: direct opening into the trachea through the
neck to facilitate breathing or removal of secretions.
Wheeze: breathe with difficulty, usually with a whistling
sound.
BOX 66-1 KEY WORDS: Respiration and Respiratory Diseases
Wilkins9781451193114-ch066.indd 1109 07/10/15 11:39 AM

1110 SECTION IX | Patients with Special Needs
FIGURE 66-1 Structures of the Respiratory System. A: Structures. The major anatomic structures of the respiratory system are shown. Each bronchus branches out to the bron-
chioles. B: Gas exchange. Exchange of oxygen and carbon dioxide occurs in the alveoli of the bronchioles.
FIGURE 66-2 Lining of the Respiratory Mucosa. Ciliated epithelial cells and mucus
secreted by goblet cells help to remove foreign objects (dust particles). The material is
coughed up and either expectorated or swallowed.
Standard chest radiograph: shows a two-dimensional view
of lung tissues.
CAT or CT scan (computed or computerized axial to-
mography radiograph): shows a three-dimensional cross
section of lung tissues.
E. Blood Gas Analysis
Blood test to determine acid/base balance, alveolar
ventilation, arterial oxygen saturation, and carbon di-
oxide elimination.
F. Cytology (Body Cells and Fluids) and
Hematology Evaluation
Examination of body cells, blood, and other fluids to
determine the presence of microorganisms that cause
respiratory diseases.
Wilkins9781451193114-ch066.indd 1110 07/10/15 11:39 AM

CHAPTER 66 | The Patient with a Respiratory Disease 1111
FIGURE 66-4 Use of a Pulse Oximeter to Measure Blood Oxygen Saturation Level.
Color of blood varies depending on the amount of oxygen it contains. The pulse ox-
imeter clips on any finger (except the thumb) and emits a light through the finger
to calculate the percentage of oxygen in the blood. Nail polish and skin callous may
interfere with reading.
FIGURE 66-3 Use of a Spirometer to Evaluate Lung Function. Person being tested
takes in a full breath, seals their lips over the mouthpiece of the spirometer, and then
blows out as hard and as fast as possible for at least 6 seconds. Nose clips may be
applied to ensure no air escapes through the nose. (Courtesy of Midmark Diagnostics,
Versailles, Ohio.)
TABLE 66-1 Classification of Respiratory
Diseases
LOCATION/
STRUCTURES ACUTE CHRONIC
Upper
respiratory
tract
Diseases of the nose,
sinuses, pharynx, larynx
Rhinitis (common cold)
Sinusitis
Pharyngitis/tonsillitis
Influenza (flu)
Seasonal
Viral
Allergic rhinitis (hay
fever)
Lower
respiratory
tract
Diseases of
the trachea,
lungs
Acute bronchitis
Pneumonia
TB
Asthma
COPD
Chronic bronchitis
Emphysema
CF
Source: Centers for Disease Control and Prevention. National Center
for Immunization and Respiratory Diseases (NCIRD). Atlanta, GA:
Centers for Disease Control and Prevention. http://www.cdc.gov/
ncird/overview/websites.html. Updated May 20, 2014. Accessed
July 9, 2014.
Samples are taken from sputum, pleural cavity fluid,
bronchial biopsy, or blood.
V. Classification
Classification of respiratory diseases is listed in Table 66-1.
UPPER RESPIRATORY
TRACT DISEASES
The more common disorders of the upper respiratory tract
are caused by infections or allergic reactions that result in
inflammation.
Signs and symptoms, etiology, medical treatment,
and clinical evaluation assessment are summarized in
Table66-2.
I. Modes of Transmission
4
Inhalation of airborne droplets.
Indirectly by contaminated hands or articles freshly
soiled with discharge of nose or throat of infected
person.
II. Dental Hygiene Care
A. Disease Prevention
All healthcare professionals are expected to obtain im-
munizations for seasonal viral influenza.
Observe standard precautions including respiratory
hygiene and cough etiquette as listed in Table 66-3 to
prevent transmission of pathogens from patient to cli-
nician and to prevent healthcare-associated infections
to the patient.
5
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1112 SECTION IX | Patients with Special Needs
TABLE 66-2 Summary of Upper Respiratory Diseases: Signs/Symptoms, Etiology, Medical Management,
and Dental Hygiene Care—Clinical Evaluation Assessment
SIGNS/SYMPTOMS ETIOLOGY MEDICAL MANAGEMENT
CLINICAL EVALUATION
ASSESSMENT
Upper Respiratory Infections—Infectious Rhinitis (Common Cold)
Sneezing
Nasal congestion
Nasal discharge
(Coryza)
Headache
Watering of the eyes
Viral
Analgesic for sore throat, muscle ache
Anticholinergic agent to decrease
nasal discharge
Oral decongestant to decrease nasal
congestion
Antihistamine for itching, sneezing,
“runny nose
Fluids
May observe small round
erythematous lesions on
soft palate, enlarged tonsils,
erythema multiforme,
acute ulcerative gingivitis
Decongestants and mouth
breathing may cause dry
mouth
Allergic Rhinitis (Hay Fever)
Watering, burning
eyes
Sneezing
Nasal congestion
Seasonal triggers (grass,
trees, pollen) or perennial
triggers (dust mites, mold
spores, animal dander)
result in IgE-mediated
hypersensitivity reactions
Avoidance of the allergen
Pharmacotherapy medication:
antihistamines, decongestants
Immunotherapy: allergy injections
increase tolerance to allergens and
reduce symptoms
Dry mouth
Oral candidiasis from
long-term use of topical
corticosteroids
Sinusitis
Nasal obstruction
Fever, chills
Constant mid-face
head pain, more
severe when lying
down
Palpation over sinus
area: tenderness,
swelling
Bacterial infection of the
epithelial lining of the sinus
Triggers include upper
respiratory infections, dental
infections, direct trauma
Antibiotics
Decongestants
Fluids
Dry mouth
Sinus congestion creates
pressure on nearby
maxillary molar roots and
may cause symptoms of
toothache; important to
determine if pain originates
from tooth or sinus infection
Pharyngitis/Tonsillitis
Sore throat
Mostly viral
Rarely bacterial: Group
A beta-hemolytic
streptococcus infection
Viral: treat symptoms
Bacterial: antibiotics
Patient is no longer infective after 1
day on antibiotics
Enlarged tonsils
Erythematous tissues
Influenza (Flu)
Chills, fever
Headache, coryza,
Sore throat
Nonproductive dry
cough
Myalgia, malaise
Viral
Mode of transmission:
airborne (coughing,
sneezing) or direct (contact
with contaminated surface)
Diagnostic testing is
required to distinguish
between types of influenza
viruses.
Bed rest, fluids
Analgesics, antivirals
(amantadine, rimantadine, zanamivir,
oseltamivir)
Monitor for secondary bacterial
infection
Prevent with vaccine
For information on infection control,
vaccinations, prevention, treatment,
and updates, see: www.cdc.gov/flu/
professionals
Dry mouth
Source: Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work (Treatment guidelines for upper respiratory
tract infections). Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/campaign-materials/treatment-
guidelines.html. Updated June 30, 2009. Accessed July 9, 2014.
Wilkins9781451193114-ch066.indd 1112 07/10/15 11:39 AM

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The Patient with a Respiratory DiseaseKatherine Yee, RDH, BSDH, MPH and Janet B. Selwitz- Segal, RDH, CDA, MSTHE RESPIRATORY SYSTEM I. Anatomy II. Physiology III. Function of the Respiratory Mucosa IV. Respiratory Assessment V. ClassificationUPPER RESPIRATORY TRACT DISEASES I. Modes of Transmission II. Dental Hygiene CareLOWER RESPIRATORY TRACT DISEASESACUTE BRONCHITISPNEUMONIA I. Etiology II. Symptoms III. Categories and Role of Oral Bacteria IV. Medical Management V. Dental Hygiene CareTUBERCULOSIS I. Etiology II. Transmission III. Disease Development IV. Diagnosis V. Medical Management VI. Oral Manifestations VII. Dental Hygiene CareASTHMA I. Etiology II. Atopic (Allergic) Asthma III. Asthma Attack IV. Medical Management V. Oral Manifestations VI. Dental Hygiene CareCHRONIC OBSTRUCTIVE PULMONARY DISEASE I. Chronic Bronchitis II. Emphysema III. Medical Management IV. Oral Manifestations V. Dental Hygiene CareCYSTIC FIBROSIS I. Disease Characteristics II. Medical Management III. Dental Hygiene CareSLEEP APNEA SYNDROME I. Etiology II. Signs and Symptoms III. Medical Management IV. Dental Hygiene CareDOCUMENTATIONEVERYDAY ETHICSFACTORS TO TEACH THE PATIENTREFERENCESCHAPTER OUTLINE66LEARNING OBJECTIVESAfter studying the chapter, the student will be able to:1. Identify and define key terms and concepts related to respiratory diseases.2. Differentiate between upper/lower respiratory diseases.3. Describe the etiology, symptoms, and management of respiratory diseases.4. Plan and document dental hygiene care and oral hygiene instructions for patients with compromised respiratory function.Wilkins9781451193114-ch066.indd 1107 07/10/15 11:39 AM 1108 SECTION IX | Patients with Special Needs ▶ Cilia assist in removing foreign material and con-taminated mucus by a constant beating and wavelike motion that propels this material back into the larger bronchi and trachea where it can be coughed up and expectorated or swallowed. ▶ Lack of function results when the inflammatory process of asthma and chronic bronchitis initiates an overabun-dance of mucus. Congestion is created and the cilia are prevented from assisting with normal breathing.IV. Respiratory AssessmentRespiratory disease assessment includes several objective measures.A. Vital Signs ▶ Determination of vital signs (body temperature, pulse, respiratory rate, blood pressure), and also smoking status is considered standard procedure in dental patientcare. ▶ Methods determining vital signs are described in Chap-ter 11. Tobacco use is discussed in Chapter 34.B. Spirometry ▶ Medical test that measures various aspects of breathing and lung function. ▶ Used to diagnose and monitor many lower respiratory tract diseases. ▶ Performed with a spirometer, a device that registers the amount of air a person inhales or exhales and the rate at which air is moved in and out of the lungs. ▶ Figure 66-3 shows the use of a spirometer to evaluate lung function.C. Pulse Oximetry3 ▶ Medical test that measures blood oxygen saturation levels. ▶ Performed with a pulse oximeter.• Color of blood varies depending upon the amount of oxygen it contains.• Pulse oximeter emits a light through the finger to calculate the percentage of oxygen.• Any finger (excluding the thumb) can be used. Nail polish or skin callous may interfere with reading.• Intended only as an adjunct in patient assessment along with other methods of assessing clinical signs and symptoms.• Healthy patients have an oxygen saturation of 97%–100%.• Saturation of 91% or below signifies poor oxygen exchange. ▶ Figure 66-4 shows the use of a pulse oximeter to mea-sure blood oxygen saturation levels.D. Chest Radiography (Imaging) ▶ Indicates presence of pathological density (radiopacity) in the lungs.Patients with respiratory diseases have increased risks for complications due to decreased breathing function and treatment drug interactions. ▶ Tobacco cessation:• Many respiratory diseases are caused or aggravated by use of tobacco products.• Dental hygienists have a unique opportunity to edu-cate their patients about this health hazard. ▶ Emergency treatment: Patients with respiratory distress may need emergency care, which dental hygienists are prepared to prevent or provide when necessary.• Signs and symptoms and medical emergency pro-cedures for local anesthesia reactions, respiratory failure, airway obstruction, asthma attack, hyper-ventilation, anaphylaxis, and allergic reactions are found in Table 8-3 (Chapter 8). ▶ Oral–systemic link: Scientific evidence shows that dental biofilm and microorganisms from periodontal infections can contribute to the initiation and/or pro-gression of certain infections in the respiratory system.1 Dedication of the dental hygienist to the prevention and control of periodontal infections will have a major influence on the overall health of the patient. ▶ Box 66-1 defines key words related to respiration and respiratory diseases.THE RESPIRATORY SYSTEMI. Anatomy2Structures: sinuses, nasal cavity, larynx, pharynx, trachea, bronchi, lungs, and pleura (Figure 66-1A).II. PhysiologyThe respiratory tract from nasal cavity to lungs serves as a passageway for air exchange (Figure 66-1A). ▶ Inhaled fresh air: warmed and filtered in the nasal cavity, enters the lungs. ▶ Exhaled air: with carbon dioxide, leaves the body. ▶ Gas exchange: at the cellular level, occurs in the alveoli at the ends of the bronchioles, as shown in Figure66-1B. ▶ Cardiovascular system: functions with the respiratory system to pump oxygenated blood from the lungs to ev-ery cell in the body and deoxygenated blood back to the lungs for exhalation.III. Function of the Respiratory MucosaFigure 66-2 shows ciliated epithelial cells and mucus-se-creting goblet cells that line the respiratory tract to make up the respiratory mucosa. ▶ Mucus secreted from goblet cells moistens inspired air, prevents delicate alveolar walls from becoming dry, and traps dust and other airborne particles.Wilkins9781451193114-ch066.indd 1108 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1109Acute: (of a disease or disease symptom) beginning abruptly with marked intensity or sharpness, then subsiding after a relatively short time; opposite of chronic.Analgesic: relieving pain.Allergen: see antigen.Anaphylaxis: an exaggerated life-threatening hypersensitiv-ity reaction to a previously encountered allergen.Antigen: any substance that is capable of inducing a spe-cific immune response and of reacting with the products of that response, that is, with specific antibody or specifi-cally sensitized T-lymphocytes or both. When used to describe an allergic response, these antigens are called allergens.Antipyretic: a substance or procedure that reduces fever.Atopy: hereditary tendency to experience immediate allergic reactions (allergic asthma).Atopic: adj.Bronchodilator: a drug that relaxes contractions of the smooth muscle of the bronchioles to improve ventilation of the lungs.Chronic: (of a disease or disorder) developing slowly and persisting for a long period, often for the remainder of a person’s lifetime; opposite of acute.Comorbid: medical condition(s) existing simultaneously but independently with another condition.Communicable disease: (contagious) any disease transmit-ted from one person or animal to another. Direct: from ex-creta or other bodily discharges. Indirect: from substances or inanimate objects (contaminated drinking glasses, water, insects, or toys).Coryza: profuse discharge from mucous membrane of the nose.Dysphagia: difficulty in swallowing. Do not confuse with dysphasia: loss of ability to understand language as a re-sult of injury or disease to the brain.Dyspnea: labored or difficult breathing.Edema: abnormal accumulation of fluids in the intercellular spaces of tissues causing swelling.Exacerbation: increase in severity of a disease or any of its symptoms.Expiration: release of air from the lungs through the nose or mouth. See inspiration.Gastroesophageal reflux: backflow of stomach contents into the esophagus where gastric juices produce a burn-ing sensation.Goblet cell: specialized epithelial cell that secretes mucus.Hemoptysis: spitting of blood because of a lesion in the larynx, trachea, or lower respiratory tract.Hyperventilation: greater rate and volume of breathing than metabolically necessary for pulmonary gas exchange; may lead to dizziness and possible syncope.Hypoxia: diminished availability of oxygen to the body tis-sues characterized by tachycardia, hypertension, peripheral vasoconstriction, and mental confusion.Inspiration: inhaling air into the lungs. See expiration.Malaise: a vague uneasy feeling of body weakness, often marking the onset of, and persisting throughout, a disease.Mast cell: constituent of connective tissue; releases sub-stances in response to injury or infection.Mediator: a substance that effects a change in a disease state.Morbidity: relating to disease. See comorbid.Mortality: relating to death.Mucus: (n.) viscous, slippery secretion of mucous membranes and glands. Contains mucin, white blood cells, inorganic salts, and exfoliated cells.Mucous: adj.Myalgia: muscle pain accompanied by malaise.Mycoplasm: bacteria without a cell wall, more resistant to antibiotics.Nosocomial: pertaining to, or originating in, a healthcare facility.Nosocomial pneumonia: pneumonia contracted during confinement in a healthcare facility.Orthopnea: ability to breathe easily only in an upright position.Otalgia: pain in the ears.Pathophysiology: disruption of bodily functions due to disease.Pleura: delicate membrane enclosing the lungs.Pleurisy: inflammation of the pleura; may be caused by infec-tion, injury, or tumor, or a complication of lung diseases. Pleuritic: adj.Pneumothorax: collection of air or gas causing the lungs to collapse.Pulmonary hypertension: condition of abnormally high pressure within the pulmonary circulation.Spirometer: instrument for measuring volume of air enter-ing and leaving the lungs to determine lung function and breathing capacity.Sputum: matter expectorated (coughed up) from the re-spiratory system, especially the lungs in a diseased state, composed chiefly of mucus and may contain pus, blood, or microorganisms.Tachycardia: abnormally high heart rate (greater than 100 beats per minute) for an adult.Tachypnea: abnormally high respiration rate (greater than 20 breaths per minute) for an adult.Tracheostomy: direct opening into the trachea through the neck to facilitate breathing or removal of secretions.Wheeze: breathe with difficulty, usually with a whistling sound.BOX 66-1 KEY WORDS: Respiration and Respiratory DiseasesWilkins9781451193114-ch066.indd 1109 07/10/15 11:39 AM 1110 SECTION IX | Patients with Special NeedsFIGURE 66-1 Structures of the Respiratory System. A: Structures. The major anatomic structures of the respiratory system are shown. Each bronchus branches out to the bron-chioles. B: Gas exchange. Exchange of oxygen and carbon dioxide occurs in the alveoli of the bronchioles.FIGURE 66-2 Lining of the Respiratory Mucosa. Ciliated epithelial cells and mucus secreted by goblet cells help to remove foreign objects (dust particles). The material is coughed up and either expectorated or swallowed. ▶ Standard chest radiograph: shows a two-dimensional view of lung tissues. ▶ CAT or CT scan (computed or computerized axial to-mography radiograph): shows a three-dimensional cross section of lung tissues.E. Blood Gas Analysis ▶ Blood test to determine acid/base balance, alveolar ventilation, arterial oxygen saturation, and carbon di-oxide elimination.F. Cytology (Body Cells and Fluids) and Hematology Evaluation ▶ Examination of body cells, blood, and other fluids to determine the presence of microorganisms that cause respiratory diseases.Wilkins9781451193114-ch066.indd 1110 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1111FIGURE 66-4 Use of a Pulse Oximeter to Measure Blood Oxygen Saturation Level. Color of blood varies depending on the amount of oxygen it contains. The pulse ox-imeter clips on any finger (except the thumb) and emits a light through the finger to calculate the percentage of oxygen in the blood. Nail polish and skin callous may interfere with reading.FIGURE 66-3 Use of a Spirometer to Evaluate Lung Function. Person being tested takes in a full breath, seals their lips over the mouthpiece of the spirometer, and then blows out as hard and as fast as possible for at least 6 seconds. Nose clips may be applied to ensure no air escapes through the nose. (Courtesy of Midmark Diagnostics, Versailles, Ohio.)TABLE 66-1 Classification of Respiratory DiseasesLOCATION/STRUCTURES ACUTE CHRONICUpper respiratory tractDiseases of the nose, sinuses, pharynx, larynxRhinitis (common cold)SinusitisPharyngitis/tonsillitisInfluenza (flu) Seasonal ViralAllergic rhinitis (hay fever)Lower respiratory tract Diseases of the trachea, lungsAcute bronchitisPneumoniaTBAsthmaCOPD Chronic bronchitis EmphysemaCFSource: Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases (NCIRD). Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/ncird/overview/websites.html. Updated May 20, 2014. Accessed July 9, 2014. ▶ Samples are taken from sputum, pleural cavity fluid, bronchial biopsy, or blood.V. ClassificationClassification of respiratory diseases is listed in Table 66-1.UPPER RESPIRATORY TRACT DISEASESThe more common disorders of the upper respiratory tract are caused by infections or allergic reactions that result in inflammation. ▶ Signs and symptoms, etiology, medical treatment, and clinical evaluation assessment are summarized in Table66-2.I. Modes of Transmission4 ▶ Inhalation of airborne droplets. ▶ Indirectly by contaminated hands or articles freshly soiled with discharge of nose or throat of infected person.II. Dental Hygiene CareA. Disease Prevention ▶ All healthcare professionals are expected to obtain im-munizations for seasonal viral influenza. ▶ Observe standard precautions including respiratory hygiene and cough etiquette as listed in Table 66-3 to prevent transmission of pathogens from patient to cli-nician and to prevent healthcare-associated infections to the patient.5Wilkins9781451193114-ch066.indd 1111 07/10/15 11:39 AM 1112 SECTION IX | Patients with Special NeedsTABLE 66-2 Summary of Upper Respiratory Diseases: Signs/Symptoms, Etiology, Medical Management, and Dental Hygiene Care—Clinical Evaluation AssessmentSIGNS/SYMPTOMS ETIOLOGY MEDICAL MANAGEMENTCLINICAL EVALUATION ASSESSMENTUpper Respiratory Infections—Infectious Rhinitis (Common Cold) Sneezing Nasal congestion Nasal discharge (Coryza) Headache Watering of the eyes Viral Analgesic for sore throat, muscle ache Anticholinergic agent to decrease nasal discharge Oral decongestant to decrease nasal congestion Antihistamine for itching, sneezing, “runny nose” Fluids May observe small round erythematous lesions on soft palate, enlarged tonsils, erythema multiforme, acute ulcerative gingivitis Decongestants and mouth breathing may cause dry mouthAllergic Rhinitis (Hay Fever) Watering, burning eyes Sneezing Nasal congestion Seasonal triggers (grass, trees, pollen) or perennial triggers (dust mites, mold spores, animal dander) result in IgE-mediated hypersensitivity reactions Avoidance of the allergen Pharmacotherapy medication: antihistamines, decongestants Immunotherapy: allergy injections increase tolerance to allergens and reduce symptoms Dry mouth Oral candidiasis from long-term use of topical corticosteroidsSinusitis Nasal obstruction Fever, chills Constant mid-face head pain, more severe when lying down Palpation over sinus area: tenderness, swelling Bacterial infection of the epithelial lining of the sinus Triggers include upper respiratory infections, dental infections, direct trauma Antibiotics Decongestants Fluids Dry mouth Sinus congestion creates pressure on nearby maxillary molar roots and may cause symptoms of toothache; important to determine if pain originates from tooth or sinus infectionPharyngitis/Tonsillitis Sore throat Mostly viral Rarely bacterial: Group A beta-hemolytic streptococcus infection Viral: treat symptoms Bacterial: antibiotics Patient is no longer infective after 1 day on antibiotics Enlarged tonsils Erythematous tissuesInfluenza (Flu) Chills, fever Headache, coryza, Sore throat Nonproductive dry cough Myalgia, malaise Viral Mode of transmission: airborne (coughing, sneezing) or direct (contact with contaminated surface) Diagnostic testing is required to distinguish between types of influenza viruses. Bed rest, fluids Analgesics, antivirals (amantadine, rimantadine, zanamivir, oseltamivir) Monitor for secondary bacterial infection Prevent with vaccine For information on infection control, vaccinations, prevention, treatment, and updates, see: www.cdc.gov/flu/professionals Dry mouthSource: Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work (Treatment guidelines for upper respiratory tract infections). Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/campaign-materials/treatment-guidelines.html. Updated June 30, 2009. Accessed July 9, 2014.Wilkins9781451193114-ch066.indd 1112 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1113TABLE 66-3 Respiratory Hygiene and Cough Etiquette in Healthcare Settings5To prevent transmission of all respiratory infections in healthcare settings, incorporate the following infection control practices as one component of standard precautions:Visual alerts Post visual alerts: symptoms of respiratory infection and respiratory hygiene and cough etiquette.Respiratory hygiene and cough etiquette Use tissue to cover coughs and sneezes and discard in no-touch receptacle. Perform hand hygiene (handwashing with non-antimicrobial soap and water, alcohol-based rub, or antiseptic hand wash) after contact with respiratory secretions or contaminated objects.Masking and separation of persons with respiratory symptoms Offer masks to persons who are coughing and encourage coughing persons to sit at least three feet away from others in common waiting areas.Droplet precautions Observe droplet precautions (wearing a surgical or procedure mask for close contact) in addition to standard precautions when examining a patient with symptoms of a respiratory infection, particularly when a fever is present.Source: Centers for Disease Control and Prevention. Respiratory Hygiene/Cough Etiquette in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm. Updated February 27, 2012. Accessed July 9, 2014.B. Appointment Management6 ▶ Delay treatment until patient is no longer infectious. ▶ Noninfectivity is determined by temperature return to normal and regression of oral lesions such as erythema-tous lesions of the soft palate and erythema multiforme.C. Bacterial Resistance to Antibiotics7 ▶ Bacteria may become resistant to antibiotics within 14days. ▶ For patients currently prescribed an antibiotic for a non-dental condition (such as acute bacterial bronchitis or sinus infection): a different category of antibiotic will be necessary to treat an odontogenic (dental origin) infection.LOWER RESPIRATORY TRACT DISEASES ▶ Considered to be a more serious infection. ▶ Diseases of the lower respiratory tract are listed in Table66-1.ACUTE BRONCHITIS8 ▶ Acute bronchitis: an acute respiratory infection that involves large airways (trachea, bronchi). ▶ Primary symptom: cough with or without phlegm; may last up to 3 weeks. ▶ Lower respiratory tract disease symptoms: wheezing, shortness of breath, or chest tightness. ▶ Differentiated from pneumonia: no significant findings on chest radiography. ▶ A comparison of acute viral and bacterial bronchitis is listed in Table 66-4.PNEUMONIA9 ▶ Pneumonia, an infection and subsequent inflammation of the lungs, may be caused by either viruses, bacteria, fungi, mycoplasma, or parasites. ▶ The respiratory tract of a healthy person is able to de-fend against organisms aspirated into the lungs. ▶ With diminished salivary flow, decreased cough reflex, swallowing disorders, poor ability to perform good oral hygiene, or other physical disabilities, there is an in-creased risk of aspiration and respiratory infection.I. EtiologyA. Viral and Bacterial ▶ Comparison of viral and bacterial pneumonias is listed in Table 66-5.B. Fungal ▶ Etiologic agent of pneumocystis pneumonia is Pneumo-cystis jirovecii (yee-row-vetsee). ▶ Susceptibility is enhanced by chronic debilitating dis-ease in which immune mechanisms are impaired, such as in HIV/AIDS.Wilkins9781451193114-ch066.indd 1113 07/10/15 11:39 AM 1114 SECTION IX | Patients with Special NeedsTABLE 66-4 Comparison of Acute Viral and Bacterial BronchitisITEM VIRAL BACTERIALOccurrence Most prevalent Least prevalentMedical treatment Supportive: bed rest, fluids May need inhaled bronchodilators and/or cough suppressant Antibiotics: amoxicillin, macrolides, cephalosporinSource: Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work (Treatment guidelines for upper respiratory tract infections). Atlanta (GA): Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/campaign-materials/treatment-guidelines.html. Updated June 30, 2009. Accessed July 9, 2014.TABLE 66-5 Comparison of Viral and Bacterial PneumoniasITEM VIRAL BACTERIALOccurrence Most prevalent Least prevalentCausative agent Virus BacteriaNosocomialAerobic gram-negative bacilliExample: Pseudomonas aeruginosa Escherichia coli Klebsiella pneumoniae Gram-positive cocciExample: Staphylococcus aureusMethicillin-resistant S. aureusCommunity acquiredGram-negative cocciExample: Haemophilus influenzaeGram-positive cocciExample: Streptococcus pneumoniaSigns and symptoms Mild symptoms Cough, sputum Mild fever Dyspnea Sudden onset Cough, purulent sputum High fever Dyspnea, tachypnea Pleuritic chest painDiagnosis Patient history Physical findings Chest radiography Patient history Physical findings Chest radiography Sputum sampleMedical treatment Supportive: bed rest, fluids AntibioticsSource: American Lung Association. Symptoms, Diagnosis and Treatment. Chicago, IL: American Lung Association; 2014. http://www.lung.org/lung-disease/pneumonia/symptoms-diagnosis-and.html. Accessed July 9, 2014.II. Symptoms ▶ Fever greater than 100.4° ▶ Productive cough ▶ Chest pain ▶ Shortness of breath ▶ Visible on chest X-ray.III. Categories and Role of Oral Bacteria1,9Pneumonia is often categorized by location and/or procedure.A. Community-Acquired Pneumonia10 ▶ Infection occurring in an individual in the community (not in a healthcare facility). ▶ Person-to-person transmission.Wilkins9781451193114-ch066.indd 1114 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1115B. Healthcare-Associated (Nosocomial) Pneumonia ▶ Infection occurring 48–72 hours after admission to a healthcare facility. ▶ A major cause of death in hospitalized patients. ▶ Commonly multidrug resistant pathogens. ▶ More common in the very elderly >80 and those with comorbidities. ▶ Bacteria in periodontal pockets may serve as a res-ervoir for lung infection, especially in institutional settings. ▶ Bacteria from oral biofilm are released into saliva and can be aspirated into the lungs. ▶ Contributing factors:• Poor oral health, dependence on others to perform daily oral hygiene• Oral colonization of periodontal and respiratory pathogens• Influenced by periodontitis, are associated with nos-ocomial pneumonia. ▶ Nursing home–acquired pneumonia• Owing to dysphagia from decrease in saliva, cough reflex, and/or swallowing disorders.• Aspiration of saliva can be the main route of bacteria into the lungs and may lead to aspiration pneumonia. ▶ Hospital-acquired pneumonia• Ventilator-associated pneumonia: mechanically ventilated patients in the immediate care unit with no ability to clear oral secretions by swallowing or coughing.• Nonventilator-associated pneumonia: biofilm forms on endotracheal tubes, catheters.IV. Medical Management ▶ Viral: supportive treatment of bed rest and fluids. ▶ Bacterial: antibiotic therapy. ▶ Fungal: sulfa drugs.V. Dental Hygiene CareControl of oral disease and periodontal disease for patients in nursing homes and hospitals will help prevent aspira-tion pneumonia. ▶ Use 0.12% chlorhexidine gluconate rinse prior to be-ginning treatment to reduce the bacterial load.11 ▶ Avoid use of ultrasonic scalers due to production of aerosols.TUBERCULOSIS (TB)12 ▶ TB is a chronic, infectious, and communicable dis-ease with worldwide public health significance as a cause of disability and death, especially in developing countries. ▶ Groups at high risk for exposure to TB include those who:13• Have close contact with people infected with TB.• Reside and work in institutional settings (prisons, nursing homes).• Are from countries that have a high TB incidence/prevalence.• Provide medical/dental care for any of the aforemen-tioned high-risk groups.• People who abuse alcohol.• Patients with diabetes.• Malnourished.• Use of tobacco products. ▶ After locating and curing active TB cases, locating and treating contacts of TB patients (especially children, older adults, and those with HIV) is the highest public health priority. ▶ Box 66-2 lists key abbreviations related to TB.I. EtiologyMycobacterium tuberculosis, a rod-shaped bacterium (tuber-cle bacillus), is the most common causative agent.II. Transmission ▶ Tubercle bacilli travel in airborne droplet nuclei in infected saliva or mucus from persons with pulmonary or laryngeal TB during forceful expirations (coughing, sneezing, talking, singing). A single cough can generate 3,000 droplets.14 ▶ Inhalation and other modes of transmission are de-scribed in Chapter 4.AFB: acid-fast bacilliHIV: human immunodeficiency virusIGRA: interferon-gamma release assayLTBI: latent tuberculosis infectionMedications: ▷ EMB: ethambutol ▷ INH: isoniazid ▷ PZA: pyrazinamide ▷ RIF: rifampinMedication Resistance: ▷ MDR-TB: multidrug-resistant tuberculosis ▷ XDR-TB: extensively drug-resistant tuberculosisPPD: purified protein derivativeTB: tuberculosisTST: tuberculin skin testKey Abbreviations: TuberculosisBOX 66-2Wilkins9781451193114-ch066.indd 1115 07/10/15 11:39 AM 1116 SECTION IX | Patients with Special Needs ▶ Definitive diagnosis: When AFB are seen on a stained smear of sputum, or other clinical specimen, a diagnosis of TB disease is suspected. However, the diagnosis is not confirmed until a laboratory culture is grown and identi-fied as M. tuberculosis.V. Medical ManagementA. Commonly Prescribed DrugsCommonly prescribed TB drugs are included in Table 66-6.B. Directly Observed TherapyObserving the patient swallow anti-TB drugs is recom-mended for all LTBI and TB disease patients and will re-sult in: ▶ High medication compliance. ▶ Prevention of multidrug-resistant bacterial development. ▶ Prevention of multidrug-resistant TB disease, which is more severe and difficult to treat.C. Drug Resistance12TB bacteria can become resistant (drugs are no longer ef-fective in killing the bacteria). ▶ Types of resistance16• Primary resistance: individuals who have not been previously exposed to anti-TB drug treatments• Acquired resistance: individuals who have been pre-viously exposed to anti-TB drug treatments. This is occurs frequently when a full course of anti-TB drug treatments is not completed. ▶ Multidrug-resistant TB (MDR-TB): TB bacterial resis-tance to at least two of the first-line (most preferred) drugs, isoniazid and rifampin.17 ▶ Extensively drug-resistant TB (XDR-TB): TB bacterial resistance to isoniazid, rifampin, fluoroquinolone, and at least one of three injectable second-line drugs.VI. Oral Manifestations13 ▶ TB infrequently appears in the oral cavity from pul-monary organisms in infected sputum brought to the mouth by coughing. ▶ Classic mucosal lesion: painful, deep, irregular ulcer on dorsum of the tongue as seen in Figure 66-5. ▶ Lesions can also occur on palate, lips, buccal mucosa, and gingiva. ▶ A biopsy and laboratory culture of an oral lesion that reveals M. tuberculosis confirms a diagnosis of TB. ▶ Glandular swelling: cervical or submandibular lymph nodes infected with TB. Nodes may become enlarged.III. Disease Development ▶ Inhaled tubercle bacilli travel to the lung alveoli where local infection begins. ▶ While TB can affect any organ or tissue, M. tuberculo-sis is an aerobe and survives best in an environment of high oxygen tension, such as the lungs. ▶ Latent tuberculosis infection (LTBI)• Within 2–10 weeks following exposure, immune re-sponse will limit further growth of M. tuberculosis, although not all bacilli will be eliminated.• At this stage, the infected person is categorized as having LTBI.• Approximately 5%–10% of people infected with M. tuberculosis and not treated for LTBI will develop TB disease during their lifetime.14,15• Comparison of LTBI and active TB disease includ-ing signs/symptoms, diagnosis, and medical treat-ment with TB drugs is listed in Table 66-6.IV. DiagnosisA. Latent tuberculosis infection (LTBI)Two tests are available to determine exposure to M. tuberculosis. ▶ Tuberculin skin test (TST).• Also known as Mantoux test, purified protein de-rivative (PPD) test.• PPD is injected under the skin on the forearm. Af-ter 72 hours, the circumference of induration (hard swelling) is measured to determine exposure.• A negative TST does not exclude TB disease in a person with signs and symptoms of TB disease. ▶ Interferon-gamma release assay (IGRA).• Blood test to determine exposure to M. tuberculosis.• IGRA blood test, as with TST, cannot differenti-ate LTBI from active TB disease. Laboratory sputum smear and culture is required.B. Active TB DiseaseWhen tests to determine exposure to M. tuberculosis are positive, further examination is required to rule out active TB disease. ▶ Chest radiograph. ▶ Physical examination and evaluation of signs and symptoms. ▶ Preliminary diagnosis: Perform microscopic examination of sputum smears for acid-fast bacilli (AFB).• The waxy cell wall of tubercle bacilli does not absorb the traditional water-soluble Gram stain and cannot be identified.• However, when treated with an acid stain, the or-ganisms appear pink, and are named AFB.Wilkins9781451193114-ch066.indd 1116 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1117TABLE 66-6 Comparison of LTBI and Active TB Disease: Signs/Symptoms, Diagnosis, and Medical Management with TB DrugsITEM LTBI ACTIVE TB DISEASESigns and symptoms of pulmonary TBNone Early onset:Low-grade feverNonproductive cough lasting 3 wk or longerFatigueUnexplained weight lossSweating at nightLater onset:FeverChillsPersistent cough with purulent sputumHemoptysisHoarseness (associated with pharyngeal TB)Chest painDyspneaWellness of patient Does not feel sick Usually feels sickInfectivity Does not infect others May infect othersTST PPD, or Mantoux Positive May be positiveIGRA blood test Positive PositiveSputum sample for AFB and culture Negative May be positiveChest radiograph Normal AbnormalMedical management for adults: commonly prescribed TB drugsIsoniazid (INH) taken daily for 9 mo (twice weekly if directly observed therapy is available)OR Rifampin (RIF) taken daily for 4 moVarious combinations of drugs taken daily for a minimum of 6 moDrugs commonly prescribed:Isoniazid (INH)Rifampin (RIF)Ethambutol (EMB)Pyrazinamide (PZA)Therapy for multidrug-resistant TBBedaquiline fumarateSource: Centers for Disease Control and Prevention. Extensively Drug-Resistant TB. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/tb/topic/drtb/xdrtb.htm. Updated January 17, 2012. Accessed July 9, 2014; Center for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Provisional CDC Guidelines for the Use and Safety Monitory of Bedaquiline Furmarate (Situro) for the Treatment of Multidrug Resistant Tuberculosis. Atlanta, GA: Center for Disease Control and Prevention; 2013:12.VII. Dental Hygiene CareA. Implementation of Infection Control Measures ▶ Update medical history. ▶ Recognize signs and symptoms of TB as listed in Table66-6. ▶ Follow CDC guidelines in Appendix V, for infection control and prevention of transmission of TB in health-care settings. ▶ Create and routinely update written office/clinic pro-tocols for:• Educating and training staff.• Instrument reprocessing and operatory cleanup.Wilkins9781451193114-ch066.indd 1117 07/10/15 11:39 AM 1118 SECTION IX | Patients with Special NeedsASTHMA18Asthma is a chronic respiratory disease consisting of recur-rent episodes of dyspnea, coughing, and wheezing leading to bronchial inflammation and muscle contraction.I. EtiologyThe exact cause of asthma is not completely understood. The following types are based on pathophysiology.A. Extrinsic (Allergic or Atopic): Allergic Triggers from Outside the Body19 ▶ Most common type of asthma. ▶ Exaggerated inflammatory response triggered by inha-lation of an environmental allergen (dust, pollen, to-bacco smoke, mold, dust mites, or animal dander). ▶ Allergic stimulus leads to activation of airway epithelial mast cells. ▶ Steps of an immunoglobulin E (IgE)-mediated hyper-sensitivity reaction are shown in Figure 66-6.B. Intrinsic (Nonallergic): Nonallergic Triggers from Within the Body20 ▶ Triggers: emotional stress, gastroesophageal reflux dis-ease (GERD). ▶ Trigger may be unidentified. ▶ Obesity ▶ Usually seen in adults.C. Drug- or Food-Induced (Nonallergenic, Nonatopic) ▶ Aspirin.• Identifying, managing, and referring patients with active TB disease.• Assessing, managing, and investigating dental staff with positive TST (PPD).B. Management of Patients with Symptoms or History of TB13Potential infectivity dictates decisions regarding whether to treat a patient or refer to a physician for medical clearance. ▶ Active TB disease and sputum-positive TB• Do not treat in the dental office or any outpatient facility.• Treatment needs to be performed in a hospital with appropriate isolation, sterilization, and engineering controls. ▶ History of TB• Use caution, obtain history of disease, treat-ment duration, and discuss signs and symptoms of disease.• Consult with physician before treatment.• Also consult with physician if adequate treatment time/appropriate medical follow-up is unclear or pa-tient presents with signs or symptoms of relapse. ▶ Recent conversion to positive TST or blood test. Treat-ment is permitted after:• Patient is free of clinically active disease• Evaluation by physician to rule out active TB disease• Verification by physician of receiving isoniazid for 6months to 1 year to prevent active TB disease. ▶ When the patient has signs and symptoms of TB, postpone non-emergency treatment and refer to physician.FIGURE 66-5 Oral Ulcer on Tongue Caused by Mycobacterium tuberculosis. The clas-sic oral mucosal lesion is a painful, deep, irregular ulcer on the dorsum of the tongue. (Courtesy of the United States Department of Veteran’s Affairs. From DeLong L and Burkhart N. General and Oral Pathology for Dental Hygienists. Baltimore, MD: Lippincott Williams & Wilkins; 2008.)FIGURE 66-6 Steps of an IgE-mediated Hypersensitivity Reaction. A: Initial ex-posure. On initial exposure to an allergen (dust, pollen), immunoglobulins (IgE) are produced and bind to mast cells. B: Subsequent exposure. On subsequent exposures, allergen binds to IgE on the mast cell. C: Mast cells respond by releasing asthma me-diators (histamines, leukotrienes, prostaglandins). The asthma mediators cause bron-choconstriction, vasodilation, and mucus production, resulting in coughing, wheezing, and dyspnea.Wilkins9781451193114-ch066.indd 1118 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1119 ▶ Asthma mediators cause bronchoconstriction, vasodi-lation, and mucus production. The result is wheezing, coughing, and dyspnea.E. Summary of IgE-Mediated Hypersensitivity Reactions ▶ Local anaphylaxis:• Allergen binds to mast cell in nasal cavity: results in al-lergic rhinitis (hay fever).• Allergen binds to mast cell in bronchiole: results in asthma. ▶ Systemic anaphylaxis: Allergen (penicillin, bee venom, food substance) binds to mast cells throughout the body: results in a reaction sometimes referred to as anaphylactic shock.III. Asthma AttackA. Recognize Signs and Symptoms of Severe or Worsening Asthma Attack ▶ Chest tightness, sense of suffocation. ▶ Ineffectiveness of bronchodilator to relieve dyspnea. ▶ Wheezing, cough. ▶ Flushed appearance, sweating. ▶ Confusion due to lack of oxygen. ▶ Dilated pupils. ▶ Inability to complete a sentence in one breath. ▶ Tachypnea. ▶ Tachycardia.B. Prepare for Possible Emergency Care ▶ Recognize signs and symptoms. ▶ Stop dental hygiene treatment. ▶ Rule out foreign body obstruction. ▶ Assist with patient’s own bronchodilator inhaler. ▶ Administer supplemental oxygen by nasal cannula. ▶ Assist with the administration of subcutaneous injec-tion or inhalation of epinephrine. ▶ Monitor vital signs. ▶ Call emergency medical service and initiate emergency procedures described in Table 8-3, Chapter 8.IV. Medical Management18A. DiagnosisConduct physical examination and lung function assess-ment (spirometry).B. Achieve and Maintain Asthma Control ▶ Assess and monitor asthma severity and asthma control. ▶ The National Asthma Education and Prevention Pro-gram classification is based on four levels of severity and frequency of symptoms as well as pulmonary function assessment (spirometry).19 ▶ Nonsteroidal anti-inflammatory drugs (NSAIDs). ▶ Beta-blockers. ▶ Food substances: nuts, shellfish, milk, strawberries. ▶ Tartrazine (yellow food dye). ▶ Metabisulfite preservative in food (wine, beer, shrimp, dried fruit). ▶ Metabisulfite preservative in drugs (local anesthetic with epinephrine).D. Exercise Induced ▶ Vigorous physical activity: usually affects young people due to their level of activity. ▶ Thermal changes during inhalation of cold air may pro-voke mucosal irritation and airway hyperactivity.E. Infection Induced ▶ Lung infections caused by viruses, bacteria, or fungi may provoke asthmatic symptoms. ▶ Treatment of the infection improves breathing.II. Atopic (Allergic) AsthmaAtopic asthma is one type of IgE-mediated hypersensitiv-ity reaction.A. Immunoglobulin E ▶ One of the five types of antibodies produced by the body. ▶ Provides the primary defense against environmen-tal allergens (pollen, tobacco smoke, and food substances).B. Normal Inflammatory Reaction ▶ IgE breaks down the allergens and removes them from the body. ▶ Normally, such activity does not produce noticeable symptoms.C. Asthmatic Hypersensitivity Reaction ▶ People with asthma are believed to “hyperreact” and produce more IgE antibodies than normal. ▶ The results can be symptoms of asthma: wheezing, coughing, dyspnea.D. How Allergens Trigger AsthmaSteps in an IgE-mediated hypersensitivity reaction (Figure66-6): ▶ On initial exposure to an allergen (dust, pollen, food), immunoglobulins (IgE) are produced and bind to mast cells (Figure 66-6A). ▶ On subsequent exposures, the antigen binds to the IgE on the mast cell (Figure 66-6B). ▶ Mast cells release asthma mediators such as histamines, leukotrienes, and prostaglandins (Figure 66-6C).Wilkins9781451193114-ch066.indd 1119 07/10/15 11:39 AM 1120 SECTION IX | Patients with Special Needs• Categories and examples of asthma medications are listed in Table 66-7.• People with asthma are advised to get seasonal influenza vaccinations and may also benefit from immunotherapy (allergy injections). ▶ Asthma triggers: Potentially harmful drugs to avoid• Aspirin-containing medications (use acetaminophen).• Sulfite-containing local anesthetic solution, such as epinephrine.• NSAIDs. ▶ Avoid drugs that decrease respiratory function such as narcotics and barbiturates. ▶ Avoid harmful drug-to-drug interactions• Macrolide antibiotics (such as erythromycin) if pa-tient takes theophylline.• Intermittent.• Persistent–mild.• Persistent–moderate.• Persistent–severe. ▶ Education: Patients are advised to have a written con-trol plan from the physician explaining the process of disease, treatment options, and how to treat exacerba-tions (worsening of symptoms). ▶ Control of environmental factors (pollutants and al-lergens) and comorbid conditions that affect asthma (GERD, obesity, obstructive sleep apnea, rhinitis/ sinusitis, stress/depression). ▶ Medications:• There are two main types: Long-term control medi-cations and quick-relief medications.TABLE 66-7 Types, Categories, and Examples of Asthma MedicationsLong-Term Control: Used Daily for Persistent AsthmaCorticosteroids Anti-inflammatory Decreases airway hyperresponsiveness. Preferred: inhaled corticosteroid for all levels of persistent asthma: oral systemic corticosteroid for severe, persistent asthmaBeclomethasone dipropionate (Vanceril)PrednisoneMast cell stabilizers: for mild persistent asthma Cromolyn sodium (Intal)Immunomodulators: for severe persistent asthma with sensitivity to allergens Prevents binding of IgE to basophils and mast cellsOmalizumabLeukotriene receptor antagonist: also known as leukotriene modifiers Interferes with leukotriene mediators that are released from mast cells, eosinophils, and basophils. Alternative: for mild persistent asthmaMontelukast (Singulair) (Zafirlukast)Long-acting beta 2-agonists Inhaled bronchodilator with 12-hr duration Used in combination with other medicationsSalmeterol, FormoterolMethylxanthines: for mild persistent asthma Bronchodilator to relax smooth muscleSustained-release theophylline (Theolair, Theo24)Combination medication Anti-inflammatory medication used in combination with bronchodilator medicationShort-Term Control: Quick Relief MedicationShort-acting beta 2-agonists (SABA): home use for relief of acute symptoms Bronchodilator to relax smooth muscleAlbuterol (Ventolin, Levabuterol, Pirbuterol) Anticholinergics Used in hospital emergency room and in inhalersSystemic corticosteroids For exacerbations used with SABAs to speed recovery and prevent reoccurrence of exacerbationsSource: American Lung Association. Understand Your Medication. Chicago, IL: American Lung Association; 2014. http://www.lung.org/ lung-disease/asthma/taking-control-of-asthma/understand-your-medication.html. Accessed July 9, 2014.Wilkins9781451193114-ch066.indd 1120 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1121• Erythromycin inhibits metabolism of theophylline, which can result in an increase in serum level and possible overdose.• Discontinue cimetidine 24 hours before intravenous sedation in patients taking theophylline.V. Oral Manifestations ▶ Beta-2 agonist inhalers:• Cause a decrease in salivary flow and dental biofilmpH.• Are associated with xerostomia and a possible in-crease in caries and gingivitis in patients with less than ideal dental hygiene. ▶ Increase in GERD with use of beta-2 agonists and the-ophylline, which may contribute to enamel erosion. ▶ Oral candidiasis may occur with high dosage or fre-quency of inhaled corticosteroids.• Occurrence may decrease with use of a “spacer” or aerosol-holding chamber attached to metered-dose inhaler.• Rinse mouth with water after each use.VI. Dental Hygiene CareTable 66-8 summarizes dental hygiene care before, during, and after treatment.19,20CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)21 ▶ The term “COPD” is used to describe pulmonary disor-ders that obstruct airflow. ▶ Two of the most common diseases are chronic bronchi-tis and emphysema. ▶ Characterized as a progressive non-reversible disease.22 ▶ The primary etiology is inhaling tobacco smoke with occupational and environmental pollutants as contrib-uting factors. ▶ Tobacco use accounts for 80%–90% of COPD-related mortality in both men and women.23 ▶ Motivating a patient with COPD to begin a tobacco cessation program can be one of the most rewarding as-pects of dental hygiene practice.I. Chronic BronchitisA. EtiologyChronic bronchitis is defined as excessive respiratory tract mucus production sufficient to cause a cough with expec-toration (coughing up mucus) for at least 3 months of the year for 2 or more years.TABLE 66-8 Dental Hygiene Care for the Patient with AsthmaTIME DENTAL HYGIENE CAREBefore treatment Remind the patient to bring inhaler (rescue drug) and/or other medications. Assess risk level: Review medical history, frequency/severity of acute episodes, and triggering agents. Questions to ask: In the past 2 wk, how many times have you: Had problems with coughing, wheezing, shortness of breath, or chest tightness during the day? Awakened at night from sleep because of coughing or other asthma symptoms? Awakened in the morning with asthma symptoms? Had asthma symptoms that did not improve within 15 min of using inhaled medication? Had symptoms while exercising or playing? Evaluate current symptoms: Reappoint if symptoms are not well controlled. Review current medications. See Table 66-7 for commonly prescribed asthma medications. Ask if all prescription medication has been taken. Schedule morning appointments for patients with nocturnal asthma (symptoms worsen at night). Have bronchodilator and oxygen available. May use patient’s bronchodilator as a preventive measure before the appointment. Obtain a medical consultation for patients with unstable or severe acute asthma or if on corticosteroid to determine necessity of steroid replacement and/or antibiotics to prevent infection. Provide a stress-free environment.During treatment Prevent triggering a hypersensitive airway by properly placing cotton rolls, fluoride trays, and suction tip. Use local anesthetic without sulfites. Fluoride treatment for all patients with asthma especially those using beta-2 agonists. If asthma attack occurs, stop treatment, rule out foreign body obstruction, initiate emergency procedures shown in Chapter 8.After treatment Home care instructions: advise patient to rinse mouth with water after using inhaler to decrease oral candidiasis. Analgesic drug of choice is acetominophen (aspirin or NSAIDs may trigger attack).Wilkins9781451193114-ch066.indd 1121 07/10/15 11:39 AM 1122 SECTION IX | Patients with Special Needs ▶ Obstruction caused by narrowing of small airways, in-creased sputum (phlegm), and mucus plugging. ▶ Difficulty breathing present on inspiration (breathing in) and expiration (breathing out).B. Signs and Symptoms ▶ Chronic cough. ▶ Copious sputum. ▶ Chest radiograph abnormalities. ▶ Sedentary, overweight, cyanotic, edematous, breath-less, leading to the term “blue bloater”.II. EmphysemaA. EtiologyEmphysema is defined as a distension (widening) of the air spaces distal to terminal bronchioles due to destruction of alveolar walls (septa). ▶ Smoke injures alveolar epithelium destroying alveolar walls and creating large air spaces. ▶ Difficulty breathing only on expiration.B. Signs and Symptoms ▶ Difficulty in breathing on exertion. ▶ Minimal, nonproductive cough (dry, no mucus). ▶ Barrel chest (enlarged chest walls) due to increased use of respiratory chest muscles. ▶ Weight loss. ▶ Chest radiograph abnormalities. ▶ Purses lips to forcibly expel air, leading to the term “pink puffer.”III. Medical Management19There is no cure for COPD. To decrease exacerbations, pa-tients are encouraged to stop smoking, eliminate exposure to environmental pollutants, have adequate nutrition, drink water, and exercise regularly. Four medical interven-tion strategies are described below.21A. Assess and Monitor Disease ▶ Confirm diagnosis with spirometry and determine severity. ▶ COPD is classified into five stages: at risk, mild, moder-ate, severe, and very severe.• At-risk stage is defined by normal spirometry but pa-tients have chronic symptoms of cough and sputum production.• Mild, moderate, and severe COPD has evidence of increasing airway obstruction on spirometry in each progressive stage.• Very severe COPD is defined by severe airway ob-struction with chronic respiratory failure. At this stage, quality of life is significantly impaired and ex-acerbations may be life threatening.B. Reduce Risk Factors ▶ Tobacco cessation. ▶ Reduction of exposure to environmental indoor/out-door pollutants. ▶ Examples: Ozone and industrial air pollution, automo-bile emissions, household cleaning products. ▶ Periodontal infection, inadequate personal oral care, and lack of oral health knowledge are associated with increased risk of COPD.22C. Manage Stable COPD ▶ Relief of symptoms: aerosol bronchodilators, inhaled corticosteroids, and other medications similar to those used to treat asthma. ▶ Pneumonia and seasonal influenza vaccinations. ▶ Antibiotics for infectious exacerbations. ▶ Pulmonary rehabilitation including a structured exer-cise program to relieve symptoms and improve quality of life. ▶ Surgery• In severe emphysema, the removal of part of one or both lungs may result in more space for the remain-ing lungs to function.• Lung transplant.• Oxygen therapy: A patient who uses oxygen to im-prove breathing function may hold a portable unit during treatment as shown in Figure 66-7.• Types: Continuous flow: oxygen flows at a determined rate of liters per minute.FIGURE 66-7 Use of a Portable Oxygen Tank. A patient who uses oxygen to improve breathing function may hold a portable unit during treatment. (Picture courtesy of Anne MacNeil Photography.)Wilkins9781451193114-ch066.indd 1122 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1123CYSTIC FIBROSIS (CF)25CF is an autosomal recessive gene disorder. Both parents must carry the genetic mutation for the disease to be trans-mitted to their children. ▶ CF is progressive and ultimately fatal. ▶ With improved multifaceted healthcare, many people now live beyond 30–40 years of age. ▶ Clinical signs and symptoms are shown in Box 66-3.I. Disease CharacteristicsThe gene disorder affects the movement of salt and water in and out of epithelial cells in the respiratory tract and exocrine glands (respiratory, pancreas, gastrointestinal) and results in thickened secretions. Main systems affected are:A. Respiratory TractAirways are filled with phlegm, similar to pus, leading to: ▶ Chronic sinusitis. ▶ Opportunistic bacterial lung infection.Both are difficult to eradicate, even with antibiotics, due to the ability of Pseudomonas aeruginosa to form biofilm.25B. Pancreas and Intestinal Tract ▶ Thick mucus clogs pancreatic ducts.• On demand: oxygen flows during inhalation only, ex-tending the period of time between oxygen tank refills.• Precautions: oxygen promotes rapid burning. Keep away from heat, flame, or other ignition source (cig-arettes, Bunsen burner).D. Prevent and Manage Exacerbations ▶ Infections, inhalation of irritants, and nonadherence to management programs lead to exacerbations.IV. Oral Manifestations24 ▶ Similar to patients with asthma. ▶ Patients who use any form of tobacco have an increased risk of the following oral conditions:• Oral cancer.• Nicotine stomatitis.• Halitosis.• Periodontal infections.• Extrinsic tooth stain.V. Dental Hygiene Care24A. Before Treatment ▶ Precautions are needed when concurrent cardiovascu-lar disease is present. Emergency procedures are out-lined in Chapter 8. ▶ Assess severity of COPD and breathing difficulty. ▶ Treatment may be performed on stable patients with adequate breathing. ▶ Identify patients who may experience exacerbation of symptoms under emotional stress. ▶ Monitor blood pressure. ▶ Appointment length may need to be modified. ▶ Chair positioning: upright or semi-upright to facilitate breathing as shown in Chapter 7.B. During Treatment ▶ Use antimicrobial preprocedural rinse. ▶ Avoid the use of power-driven scalers and air polishers. ▶ Administer local anesthesia without epinephrine. ▶ Nitrous oxide–oxygen inhalation sedation: avoid with severe COPD and emphysema.C. Patient Education ▶ Encourage patients to stop smoking. Tobacco cessation strategies are described in Chapter 34. ▶ Promote oral care and oral health knowledge in pre-vention and treatment of COPD. ▶ Discuss oral–systemic link between periodontitis and COPD. ▶ Teach and promote oral cancer self-examination. ▶ Schedule frequent periodontal and maintenance visits.Early Stage ▷ In infancy, failure to thrive ▷ Persistent cough and wheezing ▷ Recurrent pneumonia ▷ Excessive appetite but poor weight gain ▷ Salty skin or sweat ▷ Bulky, foul-smelling stools (undigested lipids)Late-Stage with Pulmonary Involvement ▷ Tachypnea (rapid breathing) ▷ Sustained chronic cough with mucus production and vomiting ▷ Barrel chest ▷ Cyanosis and digital (finger) clubbing ▷ Exertional dyspnea with decreased exercise capacity ▷ Pneumothorax ▷ Right heart failure secondary to pulmonary hypertensionCystic Fibrosis Foundation. What is Cystic Fibrosis. Bethesda, MD: Cystic Fibrosis Foundation. http://www.cff.org/AboutCF/. Accessed July 9, 2014.Clinical Signs and Symptoms of Cystic Fibrosis (CF)BOX 66-3Wilkins9781451193114-ch066.indd 1123 07/10/15 11:39 AM 1124 SECTION IX | Patients with Special Needs ▶ Associated with comorbidities, motor vehicle accidents, and occupational accidents.III. Medical Management28 ▶ Continuous positive airway pressure (CPAP) machine (shown in Figure 66-8) increases air pressure in the throat so that the airway does not collapse when inhaling. ▶ Mandibular advancement device is shown in Figure 66-9. A splint that moves the mandible slightly forward which tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep. ▶ Weight loss. ▶ Positional therapy to prevent postural drainage. ▶ Surgery.IV. Dental Hygiene Care ▶ Assessment of oral tissues at each maintenance visit ▶ Assessment of temporomandibular joint ▶ Recommend nonalcohol-based mouth moisturizer/rinse ▶ Bring mandibular advancement device to each con-tinuing care appointment for evaluation.DOCUMENTATIONInclude in the patient’s permanent record: ▶ Alerts for dental personnel to the possibility of disease transmission or a medical emergency due to medical condition or allergy. ▶ Paper records: to protect patient confidentiality, place the medical alert box inside front cover. ▶ Electronic records: insert in a prominent area. ▶ Box 66-4 shows an examples of a medical alert notifications. ▶ Medical consultation: file written reports and document telephone conversations. ▶ Patient’s current health status: especially related to signs and symptoms of respiratory disease, known allergies, current medications. ▶ Vital signs: including pulse oximetry. ▶ Oral examination: with attention to oral cancer screen-ing and periodontal evaluation. ▶ Patient education: especially issues about dry mouth, to-bacco cessation, and medication compliance. ▶ Changes in respiratory signs and symptoms during treat-ment and interventions performed. ▶ A sample progress note for a patient with a positive TST is shown in Box 66-5. ▶ Clogged ducts prevent the release of pancreatic en-zymes into the intestinal tract. ▶ Without enzymes, food is not properly digested or absorbed.II. Medical ManagementPatients are encouraged to have regular physical activ-ity and to adjust their diet to include pancreatic enzyme supplements, fat-soluble vitamins, liquids with high salt intake, and caloric supplementation. Comprehensive medical care includes25: ▶ Antibiotics including inhalation solution: Tobramycin sulfate nebulizer. ▶ Bronchodilators and anti-inflammatory agents. ▶ Chest physiotherapy.• Postural drainage: patient is placed in various body positions to allow mucus to drain from the airway.• Percussion (tapping): to loosen secretions.III. Dental Hygiene CareA. Oral Manifestations ▶ No specific oral lesions related to CF. ▶ Gingivitis associated with dry mouth.B. To Facilitate Breathing ▶ Adapt chair positioning. ▶ Avoid use of rubber dam.C. Summary Guidelines for Dental Hygiene CareSummary guidelines for dental hygiene care for a patient with a respiratory disease are listed in Table 66-9.SLEEP APNEA SYNDROME26Sleep-related breathing disorders are usually due to chronic airway obstruction.I. Etiology ▶ Repetitive narrowing and closure of the of upper airway during sleep ▶ Pharyngeal airway obstruction ▶ In children, the most common cause is tonsilar hypertrophy.27II. Signs and Symptoms ▶ Interruption in sleep patterns ▶ Snoring may cause tissue inflammationWilkins9781451193114-ch066.indd 1124 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1125TABLE 66-9 Summary Guidelines for Oral Hygiene Care for Patients with a Respiratory DiseaseITEM DENTAL HYGIENE CAREMedical consultation required when: Signs or symptoms suggest respiratory disease. Examples: Cough/dyspnea at rest, hemoptysis, sputum, wheeze, chest pain, oxygen saturation level of 91% or lower as determined by pulse oximetry, or positive TB skin test (TST, PPD, Mantoux) The clinician is uncertain of the patient’s medical status, severity of disease, or level of control. Patient with systemic conditions has not seen a primary care provider within the past year. Patient has American Society of Anesthesiologists risk status class III or higher as shown in Chapter 24. Patient has taken corticosteroids within the past 12 mo. Patient unsure of medications and dosages.Stress reduction protocol Prevent asthma attack; helpful for patients with COPD. Short morning appointments. Avoid precipitating factors.Chair position Semi reclined or upright position may make breathing easier.Anxiety and pain control Local anesthetic: avoid epinephrine for patients with asthma/COPD. Nitrous oxide–oxygen may be contraindicated: For patients with upper respiratory infection or moderate/severe COPD. With upper respiratory tract obstruction or infection if nose breathing would be difficult or breathing apparatus cannot be sterilized or replaced. Be prepared to handle an emergency.Analgesia Avoid aspirin, aspirin-containing analgesics, and other NSAIDs as 10% of patients with asthma have aspirin-induced asthma.Antibiotics Patients with extrinsic asthma may have allergy to antibiotics.Infection control Standard precautions including respiratory hygiene and cough etiquette.Emergency protocol Recognize symptoms of respiratory distress. Terminate treatment. Emergency protocol is shown in Chapter 8.Use of equipment that produces aerosols Ultrasonic, sonic scalers, and polishing may be contraindicated. Septic material and microorganisms from biofilm and periodontal pockets can be aspirated into the lungs. For additional contraindications, see Chapter 41.Source: Lozano AC, Perez MGS, Esteve CG. Dental Considerations in patients with respiratory problems. J Clin Exp Dent. 2011;3(3):e222-227. http://www.medicinaoral.com/odo/volumenes/v3i3/jcedv3i3p222.pdf. Accessed August 13, 2015.Wilkins9781451193114-ch066.indd 1125 07/10/15 11:39 AM 1126 SECTION IX | Patients with Special NeedsMedical Alert Notifications should not be visible on the outside of the patient record.Medical Alert: AsthmaMedical Alert: XDR-TBExamples of Medical Alert NotificationsBOX 66-4FIGURE 66-8 CPAP. This machine is attached by a hose to the nose mask which is held in place while sleeping by straps. The CPAP machine increases the air pressure in the throat so the airway does not collapse when inhaling. (Picture courtesy of Dennis Freeman, DDS.)FIGURE 66-9 Mandibular Advancement Devise. A splint that moves the mandible slightly forward which tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep.On a beautiful spring day, Lana Thomas arrived for her 3-month continuing care visit. Vicki, the dental hygien-ist, noticed a labored breathing pattern as they walked down the hall to the dental hygiene treatment room. She rechecked the patient history before beginning the intra-oral assessment but found the information unremarkable.Lana stated that she was taking an over-the-counter product for seasonal allergies but it didn’t seem to be helping with her nasal and chest congestion. The patient also requested that she should not be placed so far back in the dental chair because it was difficult for her to breathe. Vicki began to reconsider her plan to use the ultrasonic scaler given the patient’s current condition.Questions for Consideration1. What are the ethical responsibilities of a primary health-care clinical dental hygienist when a patient presents with symptoms such as those of Lana Thomas?2. How does each of the dental hygiene core values listed in Table II-1, Section II Introduction, have an applica-tion as Vicki prepares her care plan for the immediate appointment?3. Take partners and plan a conversation between Vicki and Lana as Vicki explains:• Procedures they will follow for this appointment,• Need for medical clearance from Lana’s physician for using anesthesia and other treatments, and• Special care Lana will need for her daily care be-cause of the oral–systemic relationship that exists.EVERYDAY ETHICSWilkins9781451193114-ch066.indd 1126 07/10/15 11:39 AM CHAPTER 66 | The Patient with a Respiratory Disease 1127Example Documentation: Patient with a Positive TSTS – A 36-year-old patient presents for new patient examina-tion. Patient reports she had a positive TST test 1 year ago. She states that she was treated and is not contagious.O – Called patient’s physician (Dr Roberts). Spoke with nurse (Becky) who provided verbal summary and will also send written report to include in the patient’s record. Patient successfully completed regime of isoniazid for 9 months. Latest medical examination Findings: ▷ Chest radiograph—negative ▷ Sputum smear and culture—negative ▷ Signs and symptoms—noneA – No signs of active TB disease; patient may receive any medical dental treatment without restriction.P – Proceeded with patient assessment and dental prophylaxis.Signed: _____________________________________, RDHDate: _______________________________________BOX 66-5 ▷ Attention to respiratory hygiene and cough etiquette. ▷ The need for frequent hand washing to help prevent transmission of respiratory disease. ▷ The need for thorough daily cleaning and drying of toothbrushes to help prevent spread of infections. ▷ How using a new toothbrush and cleaning dentures/orthodontic appliances after bacterial infections can decrease possibility of reinfection. ▷ For elderly patients and those with chronic respiratory or cardiovascular disease, diabetes, or immunosup-pressed conditions, the need for pneumonia and sea-sonal influenza immunization. ▷ To improve compliance in taking all prescribed medica-tions, maintain a medication list and use pill containers that open easily and are labeled with large type. ▷ Options to combat medication-induced dry mouth. ▷ Educate the patient help avoid resistant bacteria by not requesting or taking antibiotics for a respiratory infec-tion unless the infection has been determined by their physician to be bacterial rather than viral.29,30Factors To Teach The PatientReferences1. Miyashita N, Kawai Y, Akaike H, et al. Clinical features and the role of atypical pathogens in nursing and health-care-associated pneumonia (NHCAP): differences between a teaching university hospital and a community hospital. Intern Med. 2012;51:585–594.2. McLafferty E, Johnstone C, Hendry C, et al. Respira-tory system part 1: pulmonary ventilation. Nurs Stand. 2013;27(22):40–47.3. Hall MW, Jensen AM. The role of pulse oximetry in chi-ropractic practice: a rationale for its use. J Chiropr Med. 2012;11:127–133.4. Seto WH, Conly JM, Pessoa-Silva CL, et al. Infection pre-vention and control measures for acute respiratory infec-tions in healthcare settings: an update. East Mediterr Health J. 2013;19 (Suppl 1):S39–S47.5. Centers for Disease Control and Prevention. Respiratory Hygiene/Cough Etiquette in Healthcare Settings. Atlanta, GA: Centers for Disease Control. http://www.cdc.gov/flu/profes sionals/infectioncontrol/resphygiene.htm. Updated Febru-ary 27, 2012. Accessed September 4, 2013.6. Agado BE, Crawford B, DeLaRosa J, et al. Effects of peri-odontal instrumentation on quality of life and illness in pa-tients with chronic obstructive pulmonary disease: a pilot study. J Dent Hyg. 2012;86(3):204–214.7. Davies J, Davies D. Origins and evolution of antibiotic resis-tance. Microbiol Mol Biol Rev. 2010;74(3):417–433.8. Boujaoude ZC, Pratter MR. Clinical approach to acute cough. Lung. 2010;188 (Suppl 1):S41–S46.9. Reyes S, Montull B, Martinez R, et al. Risk factors of A/H1N1 etiology in pneumonia and its impact on mortality. Respir Med. 2011;105:1404–1411.10. Ewig S, Welte T, Chastre J, et al. Rethinking the concepts of community-acquired and health-care-associated pneumo-nia. Lancet Infect Dis. 2010;10(4):279–287.11. Gupta G, Mitra D, Ashok KP, et al. Efficacy of preproce-dural mouth rinsing in reducing aeorosol contamination produced by ultrasonic scaler: a pilot study. J Periodontol. 2014;85:562–568.12. Dye C, Williams BG. The population dynamics and control of tuberculosis. Science. 2010;328:856–861.13. Pontali E, Matteelli A, Miglion GB. Drug-resistant tubercu-losis. Curr Opin Pulm Med. 2013;19(3):266–272.14. Cleveland JL, Robison VA, Panlilio AD. Tuberculosis epidemiology, diagnosis and infection control recommen-dations for dental settings. An update on the centers for disease control and prevention guidelines. J Am Dent Assoc. 2009;140(9):1092–1099.15. Humphries C. A sleeping giant. Nature. 2013;502: S14–S15.16. Lemos ACM, Matos ED. Multidrug-resistant tuberculosis. Braz J Infect Dis. 2013:17(2):239–246.17. Center for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Provisional CDC Guidelines for the Use and Safety Monitoring of Bedaquiline Furmarate (Sirturo) for the Treatment of Multidrug Resistant Tubercu-losis. Atlanta, GA: Center for Disease control and Preven-tion; 2013:12.18. U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Insti-tute. Asthma Care Quick Reference Diagnosing and Managing Asthma. Bethesda, MD: NHLBI Health Information Center; 2002. Revised 2012:12. NIH Publication No. 12-5075.19. von Mutius E, Hartert T. Update in Asthma 2012. Am J Respir Crit Care Med. 2013;188(2):150–616.Wilkins9781451193114-ch066.indd 1127 07/10/15 11:40 AM 1128 SECTION IX | Patients with Special Needs29. Fridkin S, Baggs J, Fagen R, et.al. Vital Signs: Improving Antibiotic Use Among Hospitalized Patients. MMWR. 2014;63(09):194-200. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm. Accessed August 12, 2015.30. U.S. Dept. of Health and Human Services, Centers for Dis-ease Control and Prevention. Antibiotic Resistance threats in the United States, 2013. Atlanta, GA: CDC;2013. http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed August 12, 2015.20. U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Insti-tute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report. Bethesda, MD: NHLBI Health Information Center; 2007:417. NIH Publication No. 07-4051.21. Rahman SS, Faruque M, Khan MHA, et al. Dental manage-ment of COPD patient. Bang Med J. 2011;44:21–24.22. Kucukcoskun M, Baser U, Oztekin G, et al. Initial periodon-tal treatment for prevention of chronic obstructive pulmo-nary disease exacerbations. J Periodontol. 2013;84:863–870.23. Dance A. Breathless. Nature. 2012;489:S1–S3.24. Lozano AC, Perez MGS, Esteve CG. Dental considerations in patients with respiratory problems. J Clin Exp Dent. 2011;3(3):e222–e227.25. Cystic Fibrosis Foundation. Frequently Asked Questions. Bethesda, MD: Cystic Fibrosis Foundation. http://www.cff .org/AboutCF/Faqs/. Updated May 8, 2011. Accessed Sep-tember 26, 2013.26. Maurer JT. Etiology of obstructive sleep apnea—the num-ber of nerve fibers at the base of the uvula seems important. Sleep Breath. 2012;16:939–940.27. Pinto JA, Kohler R, Wambier H, et al. Laryngeal pa-thologies as an etiologic factor of obstructive sleep ap-nea syndrome in children. Int J Pediatr Ororhinolaryngol. 2013;77:573–575.28. Chen H, Lowe AA. Updates in oral appliance therapy for snoring and obstructive sleep apnea. Sleep Breath. 2013;17:473–486.ENHANCE YOUR UNDERSTANDINGDIGITAL CONNECTIONS(see the inside front cover for access information)• Audio glossary• Quiz bankSUPPORT FOR LEARNING(available separately; visit lww.com)• Active Learning Workbook for Clinical Practice of the Dental Hygienist, 12th EditionINDIVIDUALIZED REVIEW(available separately; visit lww.com)• Adaptive quizzing with prepU for Wilkins’ Clinical Practice of the Dental HygienistWilkins9781451193114-ch066.indd 1128 07/10/15 11:40 AM

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