Management of medically compromised patients having bronchial asthma

Management of medically compromised patients having bronchial asthma

1. MANAGEMENT OF
ASTHMATIC PATIENTS IN
DENTAL OFFICE

2. A disease characterized by an increased
responsiveness of the trachea and bronchi to
various stimuli and manifested by widespread
narrowing of the airways that changes in
severity either spontaneously or as a result of
therapy.

3. Causative factors for acute asthma

Allergy (antigen-antibody reaction)
Respiratory infection
Physical exertion
Environmental and air pollution
Occupational stimuli
Pharmacologic stimuli
Psychologic factors

4. Predisposing factors
Asthma usually is classified according to
causative factors into two major categories:
extrinsic and intrinsic.

Extrinsic asthma
Extrinsic asthma, also known as allergic
asthma, accounts for 50% of asthmatics and
occurs more often in children and younger
adults.

5. Intrinsic asthma

Intrinsic asthma usually develops in adults
older than 35 years. Nonallergic factors –
respiratory infection, physical exertion,
environmental and air pollution.

6. Mixed asthma

Status asthmaticus
Status asthmatics is the most severe clinical
form of asthma. Individuals who suffer from
status asthmaticus experience wheezing,
dyspnea, hypoxia.

Prevention

7. Category Generic Proprietary
Bronchodilator
SympathomimeticAlbuterol
Salmeterol
Metaproterenol
Bitolterol
Pirbuterol
Terbutaline
Isoetharine
Isoproterenol
Epinephrine
Proventil, Ventolin
Serevent
Alupent, metaprel
Tornalate
Maxair
Brethaire, Bricanyl
Bronkometer, Bronkosol
Isuprel and others
Many brands
Commonly prescribed drugs for the management of
obstructive airway disease

8. Category Generic Proprietary
Bronchodilator
Anticholinergic

Theophylline
Ipratropium
bromide
Theophylline
Aminophylline
Atrovent

Many brands
Aminophylline
Corticosteroid
Beclomethasone
Dipropionate
Triamcinolone
acetonide
Prednisone
Beclovent, Vanceril

Azmacort

Several brands

9. Category Generic Proprietary
Corticosteroid
Methyl –
prednisolone
Sodium
succinate
Hydrocortisone
sodium
succinate
Several brands



Several brands
Antimediator
Cromolyn
sodium
Nedocromil
sodium
Intal

Tilade

10. Dental therapy considerations

Modifications in dental treatment depend
on the severity of the asthma. Barbiturates or
opioids (especially meperidine) should not be
administered. Barbiturates and opioids may
increase the risk of bronchospasm in
susceptible patients. Opioids, especially
meperidine, may provoke histamine release,
which can lead to bronchospasm.

11. Nitrous oxide does not irritate the
respiratory mucosa, is an excellent antianxiety
agent, does not provoke bronchospasm, and is
absolutely indicated for the management of
dental fears in asthmatic patients.
Between 3% and 19% of asthmatics are
sensitive to aspirin administration.
The use of local anesthetics containing
bisulfites (that is, all local anesthetics that
contain vasopressures) is absolutely
contraindicated in patients.

12. Signs and symptoms of acute asthma

Feeling of chest congestion
Cough, with or without sputum production
Wheezing
Dyspnea
Patient wants to sit or stand up
Use of accessory muscles of respiration
Increased anxiety and apprehension
Tachypnea (>20 to >40 breaths per minute in severe
cases)

13. Rise in blood pressure
Increase in heart rate (> 120 bear per minute in
severe episodes)
Diaphoresis
Agitation
Somnolence
Confusion
Cyanosis
Supraclavicular and intercoastal retraction
Nasal flaring

14. Status Asthmaticus
Status asthmaticus is a clinical state in
which a patient with moderate to severe
bronchial obstruction does not respond
significantly to the rapid-acting β-agonist
agents.

Patients in status asthmaticus exhibit signs
of extreme fatigue, dehydration, severe
hypoxia, cyanosis, peripheral vascular shock,
and drug intoxication as a result of intensive
pharmacologic therapy.

15. The status asthmaticus patient requires
hospitalizaton because the condition is life
threatening.

16. Pathophysiology

1. Neural control of the airways
2. Airway inflammation
3. Immunologic responses
4. Bronchospasm
5. Bronchial wall edema and hypersecretion of
mucous glands
6.Breathing

17. Clinical signs and symptoms of hypoxia and
hypercarbia
Hypoxia Hypercarbia
Restlessness, confusion,
anxiety
Cyanosis
Diaphoresis (sweating)
Tachycardia, cardiac
dysrhythmias
Hypertension or hypotension
Coma
Cardiac or renal failure
Diaphoresis
Hypertension (converting to
hypotension if progressive)
Hyperventilation
Head ache

Confusion, somnolence
Cardiac failure

18. Management
Acute asthmatic episode (Bronchospasm)

19. Management of acute asthma
Terminate dental procedure
↓
P – position patient comfortably
(usually upright)
↓
A-B-C – assess and perform basic life support,
as needed
↓

20. D – initiate definitive care:
↓
Administer bronchodilator via inhalation
(episode terminates) (episode continues)
↓ ↓
Perform subsequent Administer O
2
.
dental care
↓
Discharge patient

21. Administer O
2

↓
Summon emergency
medical services
↓
Administer parenteral drugs
↓
Hospitalize or discharge patient
P – Position, A – airway, B – breathing, C – circulation, D – definitive care, O
2

– oxygen; IV, intravenous