by THOMAS A. VIOLA, RPH, CCP
It was during a lunch break in the continuing education seminar I was presenting that I realized it. Between working, teaching, lecturing, and writing, I hadn't seen the sun -- other than at dawn or at dusk -- in weeks. The weather forecast called for sunny, blue skies. It was time for me to get reacquainted with my celestial friend. I saw the front door of the hotel and made a run for it.
The sweet smells of the season filled the air around me, although they were occasionally overpowered by the not-so-sweet smells from the casino next door. At least the sun was warm, the birds were chirping, and the small sitting area was empty and peaceful. I closed my eyes and tried to soak it all in.
I could hear her approaching the sitting area for what seemed like 15 minutes. A cacophony of noises, including metal-to-metal clanging, under-her-breath expletives, and labored breathing that reached a crescendo as she got closer and then suddenly stopped. I opened my eyes to find her staring down at me.
"Oh, hello!" I said, trying not to look all at once surprised and disturbed by her disheveled appearance.
"Hello," she replied, breathlessly. "Enjoying the weather?"
"Yes, I don't get outside much during the day," I said. "You?"
"Yes, I'm glad the weather is nice today." She was just sitting there next to me, but her breathing was so labored, she could barely say the words. "They make me go outside now," she said and smiled.
I've learned that you can learn a lot about a person just by "reading" the lines on their face. There was no mistaking the lines on this woman's face. As she smiled, I could see the deep grooves across her cheeks left by the nasal cannula. She had been using supplemental oxygen for quite some time. I glanced down at the oxygen tank in its rickety cart, one wheel threatening to fall off at any moment. So, that's what made all that noise.
"I guess they don't want to go boom!" she said, chuckling. Her brief laugh quickly escalated into a deep, loose, productive cough that took some time to subside.
While she recovered from her cough, I replayed the last few words of our conversation in my mind. "They make me go outside now" and "I guess they don't want to go boom!" Wait, what?
She removed the cannula from her nose and draped it across her chin. In a few seconds, she removed the cigarette and the lighter from her pocket, and, making no attempt to stop the flow of oxygen, she put the cigarette between her lips and lit it.
I closed my eyes again, but this time for a different reason. I wasn't sure if I would hear an explosion, if it happened. So I waited until my mind had finished flashing through all of the memorable moments of my life, and I could hear the birds chirping again. Then, I opened my eyes.
"Oh, don't worry," she said. "I do this all the time."
"Just breathe," I told myself, trying to not appear anxious as I watched the cigarette dance back and forth, the tip glowing more brightly each time it came perilously close to the oxygen escaping from the open cannula. Well, she wouldn't be the first person I met with COPD who continued to smoke.
What is COPD? While it's often confused with asthma, chronic obstructive pulmonary disease (COPD) is a term used to describe pulmonary disorders characterized by chronic airflow limitation that is not fully reversible.
COPD is the third leading cause of death in the United States and is estimated to affect more than 24 million people. The most common cause of COPD is tobacco smoking. Yet, not every smoker develops COPD and many non-smokers do develop COPD. So, other factors, such as exposure to environmental pollutants and genetic susceptibility, must also play a role in the development of the disease.
COPD actually represents two main diseases: chronic bronchitis and emphysema. Chronic bronchitis is characterized by a chronic cough with excessive sputum, while emphysema is characterized as permanent enlargement of air spaces with destruction of the alveolar walls. Both diseases are very closely related and may have overlapping symptoms.
COPD is a progressive disease with occasional exacerbations or "flare-ups." Continued exposure to cigarette smoke or environmental pollutants, and the resulting inflammation, causes changes in the airways and pulmonary tissue, leading to thickened bronchial walls and overproduction of mucous. Damage to the alveolar epithelium leads to a release of enzymes that destroy the alveolar walls, resulting in enlarged air spaces, which ultimately collapse.
COPD also results in increased risk of other complications (including pulmonary infection, pulmonary hypertension, and right-sided heart failure), poor quality of life (including sleep disturbances and nocturnal hypoxemia), comorbidities (including cardiovascular disease) and, ultimately, progressive deterioration of function to the point of disability.
How do you know your patient has COPD? Onset of symptoms takes years and usually begins after age 40. Symptoms develop very slowly; thus, COPD remains one of the most underdiagnosed diseases worldwide. COPD is usually diagnosed based on the presence of cough, excessive sputum production, shortness of breath, and abnormal measurements of lung function which cannot otherwise be explained.
In addition to smoking cessation agents (if applicable), pharmacologic management of the symptoms of COPD, including the use of bronchodilators and corticosteroids, is ultimately required. Since most of these agents are delivered via metered-dose oral inhalers, oral adverse effects are common. Metered-dose oral inhalers allow the medication to be delivered directly to bronchioles, allowing for greater bronchodilation at lower overall doses, and therefore less adverse effects. However, they are also difficult to use properly and are easily overused, which ultimately leads to diminished response.
Inhaled anticholinergic agents, such as ipratropium (Atrovent) and tiotropium (Spiriva), are the mainstays of therapy for COPD, since they offer the dual advantage of brochodilation and mucous reduction. Because these medications are so drying, they often induce xerostomia and altered taste. Both agents should not be used in patients with peanut and soybean allergies.
Short-acting beta-2 agonists, such as albuterol (Proventil) and levalbuterol (Xopenex), also produce bronchodilation. They are often referred to as "rescue inhalers". These medications may also induce xerostomia. Albuterol may be combined with the anticholinergic agents, such as the combination of albuterol and ipratropium (Combivent), to improve efficacy and decrease the risk of adverse effects.
Inhaled corticosteroids, such as budesonide (Pulmicort) and mometasone (Asmanex), reduce pulmonary inflammation and are used to reduce the symptoms of COPD as well as the frequency of flare-ups. These medications may also induce xerostomia. Since the use of these medications may result in oral candidiasis and fungal pharyngitis, patients are usually advised to rinse the mouth and gargle with water after using the inhaler.
Long-acting beta-2 agonists, such as salmeterol (Serevent) and formoterol (Foradil), have recently been linked to a higher risk of asthma-related death. They are often combined with inhaled corticosteroids, such as the combination of salmeterol and fluticasone (Advair), to, again, improve efficacy and decrease the risk of adverse effects. Newer agents, the PDE-4 inhibitors, such as roflumilast (Daliresp) and cilomilast (Ariflo), are bronchodilators used to reduce flare-ups in patients with more advanced COPD.
So, what is the best way to manage your patient if they have COPD? The first step is to assess the severity of the condition and the degree to which it is being controlled. If the patient's condition appears to be stable, then the goal should be to avoid a change in the patient's status during their dental procedure. Many patients with COPD continue to smoke. They should be encouraged to quit smoking at every visit.
Patients with COPD may have co-morbid conditions, such as pulmonary hypertension and cardiovascular disease, so stress should be minimized and stress-reduction techniques should be used. However, since patients with COPD may be prone to acute respiratory failure, medications used in dentistry that may induce respiratory depression, such as sedatives, opioid analgesics and nitrous oxide-oxygen, should be avoided. The patient should be placed in the semi-supine position and their short-acting beta-2 agonist inhaler (if applicable) should be available and easily accessible throughout the appointment.
I spent the few remaining minutes of my lunch break encouraging my new friend to stop smoking, especially while she was using supplemental oxygen. I advised her to schedule an appointment with her medical team, to assess her condition, and her dental team, since her few remaining teeth appeared to be in need of care. She thanked me and I left her to return to my waiting audience. As I walked back to the hotel, I prayed to hear nothing behind me but the sound of those chirping birds. RDH
THOMAS A. VIOLA, RPH, CCP, is a practicing pharmacist and also serves the professions of dentistry, dental hygiene, and dental assisting as an educator, published writer, and professional speaker. As an educator, Viola is a member of the faculty of seven dental hygiene and dental assisting programs, as well as several national board exam review courses. Visit Viola's website: www.tomviola.com.
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