5.Respiratory Distress Dental Lecture
Transcript of 5.Respiratory Distress Dental Lecture
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RESPIR TORY DISTRESSCAUSES:
HyperventilationVasodepressor syncope
AsthmaHeart failureHypoglycaemiaOverdose reaction
Acute MI Anaphylaxis
Angioneurotic edemaCerebrovascular accidentEpilepsyHyperglycemic reaction
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PATHOPHYSIOLOGYBRONCHIOLES-primary site ofasthmaHEART FAILURE PTS-respiratorydistress 1 st symptomHYPERVENTILATION-Primary site-brain
ACUTE LOWER AIRWAYOBSTRUCTION-life threatening-foreign object impacts in RS tract
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MANAGEMENTRecognize respiratory distress-sounds(wheezing,cough),abnormal rate or depth of respiration
Terminate dental procedure
P---position patient supine,if unconscious,orcomfortably(upright)if conscious.
A-B-C-assess & provide BLS,as needed
D-monitor vital signs-BP,HR(PULSE),RR.Manage patient anxiety.
Provide definitive management of RD.
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AIRWAY OBSTRUCTION
Instruments & techniques used toprevent aspiration & swallowing ofobjects:
Rubber damOral packingChair positionDental assistantSuctionMagill intubation forcepsLigature
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SIGNS & SYMPTOMS
Sudden onset of coughingChokingWheezingShortness of breath
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MANAGEMENT
MANAGEMENT OF VISIBLEOBJECTS
IF ASSISTANT IS PRESENT:Place pt in supine or trendelenburg position.
use magill intubation forceps or suction.
IF ASSISTANT IS NOT PRESENT:Instruct pt to bend over arm of chair with head down.
Encourage pt to cough.
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Management of swallowedobjects
Consult radiologist.
Obtain app radiographsto determine location ofobject
Initiate medicalconsultation with appspecialist
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MANAGEMENT OFASPIRATED OBJECTS
Place pt in left lateral decubitusposition.
Encourage pt to cough .Object isretrieved
Initiate medicalconsult before
discharge
Object is not retrieved
Consult with radiologistor ER dept
Perform bronchoscopy tovisualize & retrieve object.
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AIRWAY OBSTRUCTION
COMPLETE
PARTIAL
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SIGNS OF COMPLETE AIRWAYOBSTRUCTION
INABILITY TO SPEAK
INABILITY TO BREATHE
INABILITY TO COUGH
UNIVERSAL SIGN FOR
CHOKING
PANIC
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Signs of partial airwayobstruction
Individual with good airflow
Forceful cough
Wheezing between cough
Ability to breath
Individuals with poor air exchange
Weak ineffectual cough
Crowing sound on inspiration
Paradoxical respiration
Absent or altered voice sounds
Possiblecyanosis,lethargy,disorientation
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Establishment of an emergencyairway
TracheostomyCricothyrotomyNon surgical-abdominal thrust orheimlich maneuverNon invasive techniques:
Back blows
Manual thrustHeimlich maneuverChest thrustFinger sweep
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Back blows:
infant: infant is straddled over therescuers arm with the head lower thanthe trunk & with the head supported by
the rescuers firm hold on the infants jaw. Using the heel of the hand therescuer delivers four back blows
forcefully btw the infants shoulderblades while resting the other hand onthe thigh.
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Manual thrusts
Consists of a series of 6-10 thrusts tothe upper abdomen or to the lowerchest.They produce a rapid increase
in intrathoracic pressure,acting as anartificial cough that can help dislodgea foreign body.
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Heimlich maneuver
Also known as subdiaphramaticabdominal thrust or abdominal thrust,was 1 st described by Dr. henry J.heimlich in 1975.If pt is conscious:
Stand behind the pt and wrap your arms around thewaist and under the armsGrasp one fist with the other hand placing the
thumb side of the fist against the victims abdomen.The hand should rest in the midline slightly abovethe umbilicus & well above the tip of the xiphoidprocessPerform repeadted inward &upward thrusts until
either the foreign body is expelled or the victimloses concsiousness
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If the victim is unconscious :1. Place the victim in the supine position.2. Open the victims airway using the head tilt -chin lift
technique and turn the head up into the neutralposition.yhe head is turned into the neutral position toavoid airway obstruction,facilitate foreign body to be
visualised.3. Whenever possible the rescuer should straddle thevictims legs or thighs.
4. Place the heel of one hand against the victimsabdomen,in the midline slightly above the umbilicus andwell above the tip of the xiphoid process.
5. Place the 2nd
hand directly on top of the 1st
hand6. Press into the victims abdomen with a quick inward andupward thrust.
7. Perform upto 5 abdominal thrusts.8. Open the victims mouth & perform the finger sweep. 9. Repeat steps 2 -8 till the obstruction is dislodged.
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Chest thrust
If victim is conscious:Stand behind the victim & place the arms directly underthe armpits,encircling the chest.Grasp one fist with the other hand, placing the thumb
side of the fist on the middle of the sternum,not on thexiphoid process or the margins of the rib cage.Perform backwardd thrusts until the foreign body isexpelled or the victim loses consciousness.
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If the victim is unconscious:Place the victim in supine position.Using the head tilt chin maneuver, open the victimsairway and place the head into the neutral position.
Either straddle or stand astride the victim, as describedin heimlich maneuver.Place the heel of one hand on the lower half of thesternum with the 2 nd hand on top of it, but not on thexiphoid process.
Perform upto 5 quick ,downward thrusts to compressthe chest cavity.Open the victims mouth and perform the finger sweep.
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Finger sweep
Should be performed in unconscious victimsonly.
A magill intubation forceps can aid in theremoval of foreign objects from the airway.
Procedure :Place the victim in the supine position with the head inneutral position.Grasp the tongue & the anterior portionof the mandible.To perform the finger sweep, place the index finger of theother hand along the inside of the victims cheek andadvance it deeply into the pharynx at the base of thetongue. Using a hooking movement try to dislodge theforeign body & move it into the mouth where either thesuction or magill intubation tube will remov it.
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HYPERVENTILATION
DEFINITION:IS defined as ventilation in excess of that required tomaintain normal blood PaO2 and PaCO2.
OCCURS MOSTLY IN PTS BETWEEN 15 -40 YRS.
Respiratory rate may exceed to 25-30 breaths perminute.
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Clinical manifestations ofhyperventilationSYSTEM SIGNS & SYMPTOMS
CARDIOVASCULAR Palpitations,tachycardia,precordialpain
NEUROLOGIC dizziness.,lightheadedness,disturbance of consciousness orvision,numbness & tingling ofextremities,tetany(rare)
RESPIRATORY Shortness of breath,chestpain,dryness of mouth
GASTROINTESTINAL Globus hystericus,epigastric pain
MUSCULOSKELETAL Muscle pain &cramps,tremors,stiffness,carpopedal tetany
PSYCHOLOGIC Tension,anxiety,nightmares
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MANAGEMENTTerminate dentalprocedure.P----position pt
comfortably(upright ) AB---C ---BLS as
neededD----definitive care: remove dental materials
from pts mouth. calm pt.
correct respiratoryalkalosis. initiate drug treatment,if
necessary.Perform subsequent dentaltreatment.
Discharge pt.
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ASTHMA
DEFINTION: DEFINED BY THE AMERICAN
THORACIC SOCIETY as a disease
characterized by an increasedresponsiveness of the trachea & bronchito various stimuli and manifested bywidespread narrowing of the airways that
changes in severity either spontaneouslyor as a result of therapy.
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Causative factors for acuteasthma
Allergy(antigen-antibody reactionRespiratory infectionPhysical exertionEnvironmental and air pollutionOccupational stimuliPharmacologic stimuliPsychologic factors
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PREDISPOSING FACTORSPSYCHIC STRESS
ANTIGEN-ANTIBODYREACTION
BRONCHIALINFECTION
NORMALBRONCHIALREACTIVITY
NORMALRESPONSE-noasthma
DUSTS,FUMES
CLIMATE HEIGHTENEDBRONCHIALREACTIVITY
ABNORMALRESPONSE--asthma
OTHERS
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EXTRINSIC ASTHMA: Also known as allergic asthma and occursmore in children amd young adults.
Allergens maybe airborne such as housedust,feathers,animal dander,furniturestuffing,fungal spores,plant pollens.foodssuch as eggs,milk,fish etcdrugs such aspenicillin,aspirin,sulfites.
INTRINSIC ASTHMA:Develops usually in adults older than 35 yrs.
Also referred as nonallergic asthma,idiopathicasthma,infective asthma.Non allergic factors: respiratory infection,physicalexertion,environmental and air pollution,occupationalstimuli.
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MIXED ASTHMA:Combination of extrinsic and intrinsic asthma
Precipitating factor---presence of infection esprespiratory tract.
STATUS ASTHMATICUS:Wheezing,dyspnea,hypoxia,cyanosis,extreme fatigue,peripheral vascularshock,dehydrationMost severe form.
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ASA CLASSIFICATION OF ASTHMA
ASA CLASS DESCRIPTION TREATMENTMODIFICATIONS
II Typical asthmatic-extrinsic orintrinsicInfrequent episodes
Easily managedNo need for emergency care of
hospitalization
Reduce stress,asneeded.Determine triggering
factors. Avoid triggeringfactors.Keep broncodilator.
III Patient with exercise inducedasthmaFearful pt.Pt with prior need for emergencycare or hospitalization
Follow ASA IImodifications.
Administer sedation-nitrous oxide & O2 ororal BZD,if indicated.
IV Pt with chronic sign and symptomsof asthma present at rest.
Obtain medicalconsultation.
Provide emergencycare only,in office.
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SIGNS & SYMPTOMS OF ACUTE ASTHMA
Feeling of chest congestionCough with or without sputum productionWheezingDyspneaPt wants to sit or stand upuse of accessory muscles of respirationIncreased anxiety & apprehensionTachypnea(>20 to>40breaths/min)Rise in BPIncrease in HRDiaphoresis
AgitationSomnolenceConfusionCyanosisSupraclavicular and intercostal retractionNasa flaring
CLINICAL SIGNS &
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CLINICAL SIGNS &SYMPTOMS OF HYPOXIA &
HYPERCARBIAHYPOXIA HYPERCARBIARestlessness,confusion,anxiety diaphoresis
cyanosis Hypertension(converting to
hypotension if progressive)diaphoresis Hyperventilation
Tachycardia,cardiac dysrhythmias Headache
Hypertension or hypotension Confusion ,somnolence
coma Cardiac failure
Cardiac or renal failure
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MANAGEMENTTerminate dental procedure
P---position pt comfortably(upright)
A---B---C----assess & perform BLS,as needed
D----initiate definitive care:
administer bronchodilator via inhalation.(episode terminates) (episode continues)
perform dental care. Administer O2.discharge pt. Summon emergency
medical services.administer parenteral drugs
hospitalize or dischrge pt.
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HEART FAILURE & ACUTEPULMONARY EDEMA
HEART FAILURE----Inability of theheart to supply sufficient oxygenatedblood for the bodys metabolic needs.
ACUTE PULMONARY EDEMA---- lifethreatening condition marked by anexcess of serous fluid in the alveolar
spaces or interstitial tissues of thelungs & is accompanied by extremedifficulty in breathing.
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PREVENTION
MEDICAL HISTORYQUESTIONNAIRE:
Any history of heart diseases?
When u walk upstairs do u stop becoz of painin chest or shortness of breath?Do ur ankles swell during the day?Do u use more than 2 pillows to sleep?
Have u lost or gained more than 10 pounds inthe past yr?Do u ever awaken from sleep short of breath?Have u ever taken any medicine or drugs
during the past 2 yrs?
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DIURETICS used to manageCHF
THIAZIDES hydrochlorothiazide,chlorthalidone,metazolone
LOOP DIURETICS---furosemide,bumetanide,ethacrynicacid
POTASSIUM SPARINGDIURETICS spironolactone,triamterene,amiloride
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Inotropic agents to treat CHF:-digoxin,dopamine,dobutamine,amrinone,milrinone,aminophylline.
Vasodilators to treat CHF:-captopril,analapril,lisinopril,quinapril,ni
troglycerin,isosorbide.
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PHYSICAL EVALUATION
VITAL SIGNS:------BP maybe elevated, with the increase in diastolicpressure greater than that in systolic pressure.insome situations BP may b decreased.
Heart pulse & resp rate usually increase Any recent large unexplained weight gain,ankleswelling.
PHYSICAL EXAMINATION:------skin & mucous membrane color---grayish blueNeck---jugular vein distension
Ankles----edema,pitting
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ASA Classification for CHF
ASA I: the pt doesnot experiencedyspnea or undue fatigue with normalexertion.
ASA II: the pt experiences milddyspnea or fatigue during exertion.
ASA III : the pt experiences dyspnes
or undue fatigue with normal activities. ASA IV: the pt experiencesdyspnes,orthopnea, and undue fatigue
at all times.
Clinical manifestations of HF and
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Clinical manifestations of HF andacute pulmonary edema
SIGNS SYMPTOMS
HEART FAILURE
Pallor,cool skin Weakness & undue fatigue
Sweating Dyspnea during exertion
Left ventricular hypertrophy Hyperventilation
Dependent edema NocturiaHepatomegaly & splenomegaly PND
Narrow pulse pressure Wheezing(cardiac asthma)
Pulsus alternans
ascites
ACUTE PULMONARY EDEMA
All signs of HF All symptoms of HF
Moist rales at base of lungs Increased anxiety
tachypnea Dyspnea at rest
Cyanosis,frothy pink sputum
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Management of HF & acutepulmonary edema
Terminate dental procedure
Remove dental materials from pts mouth
P----position pt comfortably(upright)
Summon emergency medical services
Calm pt.
A----B----C assess & perform BLS as needed.
D-----definitive care: Administer O2Monitor vital signs
Alleviate symptoms of resp distressPerform bloodless phlebotomy
Alleviate apprehension.
Discharge pt,
Modify subsequent dental treatment