asthma posted 1018 06

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Pulmonary Disease ASTHMA ASTHMA 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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Page 1: Asthma Posted 1018 06

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

Page 2: Asthma Posted 1018 06

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

Page 9: Asthma Posted 1018 06

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

Page 16: Asthma Posted 1018 06

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