Pneumonia

Infection and a subsequent

inflammation involving the
lung parenchyma.
Can be broadly classified
as either community
acquired infections or
nosocomial infections.

Pneumonia
ETIOLOGI
Bacteria
Streptococcus pneumoniae (most common) followed by H.
influenzae
(-) P.aeruginosa, E.coli, Klebsiella pneumoniae, Acinetobacter spp
(+) S. aureus
Atypical : M. pneumoniae, Legionella, Chlamydia
Viruses
Influenza, parainfluenza, adenovirus, RSV
Fungi
Candida, Histoplasma, Cryptococcus, and Aspergillus;
Protozoa
Pneumocystis carinii (seen in immunocompromised hosts),
Nocardia, and Mycobacterium tuberculosis

Pneumonia
CLINICAL FEATURES
Fever,
Pleuritic chest pain
Coughing that produces
purulent sputum
Chills
Rigors
Dyspnea
Malaise
Decreased breath
sounds and dullness to
percussion

The possible causative organism will
be suggested by :
Clinical presentation and course of
the illness
Degree of immunocompetency of
the patient
Presence/absence of underlying
lung disease
Place of acquisition (hospital or
community)

DIAGNOSIS : clinical history, physical
examinations, sputum analysis,
cultures, chest radiography

Pneumonia
MANAGEMENT
Community acquired pneumonia
-lactams (eg, amoxicillinclavulanate), macrolides,
and fluoroquinolones.
Nosocomial pneumonia
Low risk 3
rd
cephalosporin / fluoroquinolone.
High risk antipseudomonal cephalosporin,
carbepenem, or fluoroquinolone, along w/ linezolid
or vancomycin
Pneumococcal vaccine high risk individuals (people
with asplenia, older than 65 y.o)


ORAL HEALTH CONSIDERATION
Poor oral health status is a risk factor for the development of
pneumonia oral intervention to control dental plaque.
Bronchiolitis
Infection of the lower respiratory
tract esp. bronchioles
Pathogens : RSV, human
metapneumovirus, parainfluenza
virus, influenza virus, adenovirus, M.
Pneumoniae
Pathophysiology
- Infection
- Inflammatory respone prominent
mononuclear infiltrate
- Edema, necrosis epithelial cells
lining small airways, mucosal
thickening, mucus hypersecretion,
plugging, bronchospasm

Bronchiolitis
CLINICAL AND LABORATORY FINDINGS
Infection of the upper respiratory tract
Low grade fever, profuse clear rhinorrhea, cough
Infection of the lower respiratory tract
Tachypnea, retractions, wheezing, cyanosis
Chest radiography
Peribronchial cuffing, flattening of the diaphragms,
hyperinflation, increased lung markings
Lab : Mild leukocytosis PMN mostly
DIAGNOSIS : history and physical examination, nasopharyngeal
cultures
DD : asthma, congenital heart disease, cystic fibrosis.
Bronchiolitis
MANAGEMENT
Supportive care
O
2
and Hydration must be ensured
RSV bronchiolitis with severe disease/ at risk for severe
disease
Antiviral theraphy with ribavarin aerosol up to 1 week
Respiratory failure
Mechanical ventilation
Prophylaxis of high risk infants
Intramuscular monoclonal antibody to RSV F protein,
palivizumab

Asthma
Chronic inflammatory disorder of the airways
Underlying inflammatory process characterized by recurrent
& often reversible airflow limitation
The etiology is unknown, but allergic sensitivity is seen in most
patients
Risk factors :
Family history of asthma
Atopy
Respiratory infections
Inhaled pollutants
Allergens
Food sensitivities
Other exposures (ex : tobacco smoke)
Asthma
Clinical Features
Intermittent wheezing
Coughing
Dyspnea
Chest tightness
Worsen at night & the
early morning hours
Diagnostic tools:
pulmonary function
testing/ spirometry &
allergen skin testing
Diagnosis
Suggestive history, physical findings,
and the demonstration of reversible
airflow limitation.
Factors favoring the diagnosis of
asthma include :
intermittent symptoms with
asymptomatic periods
Complete / nearly complete
reversibility with bronchodilators
The absence of digital clubbing
History of atopy
DD :
Chronic rhinitis or sinusitis, CF,
gastroesophageal reflux disease,
airway narrowing due to
compression, and COPD.
Management
Mild-persistent asthma
low dose inhaled
corticosteroids
Moderate-severe
persistent long-acting
bronchodilators with
inhaled corticosteroids
Asthma
ORAL HEALTH CONSIDERATION
Allergen from dental material and products associated
Oral candidiasis antifungal
Decreased salivary flow, increased calculus, increased gingivitis, increased
periodontal disease, increased incidence of caries maintain OH
The patient should be instructed to rinse mouth with water after using inhalers
Schedule patients appointment for late morning or later in the day to minimize
the risk of an asthmatic attack

O
2
and bronchodilators available in case of an exacerbation of asthma
Care should be used in the positioning of suction tips and rubber dam
During an acute asthmatic attack
discontinue the dental procedure,
remove all intraoral devices,
place the patient in a comfortable position,
make sure the airway is opened,
administer a R
2
-agonist and oxygen or epinephrine

Chronic Obstructive Pulmonary Disease
Characterized by airflow limitation associated with an abnormal
inflammatory response of the lungs to noxious particles or gases.
COPD
Emphysema
Condition characterized by destruction and enlargement of the lung
alveoli
Chronic Bronchitis
Condition with chronic cough and phlegm; and small airways
disease, a condition in which small bronchioles are narrowed.

Chronic Obstructive Pulmonary Disease
Risk Factors
Environmental exposures
Tobacco smoke
Heavy exposure to occupational dusts and chemicals
(vapors, irritants, fumes)
Indoor/outdoor pollution
Host factors
Hereditary deficiency in the enzyme 1-antitrypsin
PATHOPHYSIOLOGY

Chronic inflammation throughout the
airways, parenchyma, and pulmonary
vasculature; oxidative stress; imbalance
of proteases and antiproteases in the
lung
Mucus hypersecretion, ciliary
dysfunction, airflow limitation,
pulmonary hyperinflation, gas
exchange abnormalities, pulmonary
hypertension, cor pulmonale
`
CLINICAL AND LABORATORY FINDINGS
Dyspnea, cough, and sputum production
Physical findings : diffuse wheezing, respiratory
distress, tachypnea
Chest radiography : increase lung compliance, flattened
diaphragms, hyperexpansion, increase AP diameter
Spirometry : airflow limitation, with decreases in the
FEV
1
and the FEV
1
/FVC ratio
Complete pulmonary function : increase in residual
volume and total lung capacity, decrease pulmonary
diffusion capacity


Chronic Obstructive Pulmonary Disease
Diagnostic
The history and physical findings
Cough, dyspnea, and sputum production and/or a history of exposure
to risk factors
Complete pulmonary function tests
O
2
status with pulse oximetry
A determination of arterial blood gases
Chest radiography
Management
Avoidance of risk factors
Bronchodilators
Severe COPD corticosteroids
Chronic respiratory failure long term oxygen therapy
Exacerbations of COPD oral broad spectrum antibiotics
Chronic Obstructive Pulmonary Disease
Cystic Fibrosis
Multiple genetic disorder that is characterized by chronic airways obstruction
and infection and by exocrine pancreatic insufficiency GI function,
nutrition, growth, maturation
Caused by numerous mutations in the gene that encodes CFTR that helps
regulate ion flux at epithelial surfaces
Pulmonary complications are major factors affecting life expectancy in CF
patients
Cystic Fibrosis
PATHOPHYSIOLOGY
Defect in the CFTR gene
Defective chloride transport system in exocrine glands
Mucus productions occurs without sufficient water transport
into the lumen
The resultant mucus inspissation in the affected glands and
organs
In the airways viscid secretions impair mucociliary
clearence and promote airway obstruction and bacterial
colonization
Cystic Fibrosis
Management
Antibiotics
Bronchodilators
Antiinflammatory agents
slow the decline of lung
function
Proper nutrition and
exercise except those with
severe lung disease and
hypoxemia
Clinical and Laboratory
Findings
Thickened secretion in
multiple organ systems
malabsorption & intestinal
obstruction
Viscid mucus in lungs
airway obstruction,
infection, and
bronchiectasis
Sweat testing >60 mEq/L
chloride (+)
Nasal epithelial bioelectric
abnormalities
Oral Health Considerations
Tongue, buccal mucosa,
dental plaque, saliva serve
as reservoir of colonization
P. aeruginosa bacterial
pathogen for CF
Improved OH reduce
level of pathogens in mouth
and lung infection, minimize
exacerbation
Pulmonary Embolism
Result of an exogenous / endogenous material traveling to the lung Blockage of
a pulmonary arterial vessel
The embolus may originate anywhere usually lower extrimities
Other substances : neoplastic cells, air bubbles, carbon dioxide, IV catheters, fat
droplets
Risk factors :
- Prolonged immobilization
- Lower extremity trauma
- History of deep vein thromboses
- Use of estrogen containing oral contraceptives
Pathophysiology






PE
Blockage of
pulmonary
arterial vessels
Ventilation-
perfusion
mismatch
Pulmonary Embolism
CLINICAL AND LABORATORY
FINDINGS
Dyspnea
Chest pain, fever, diaphoresis,
cough, hemoptysis, syncope
Lower extremity deep venous
thrombosis, tachypnea,
crackles, rub on lung
auscultation, heart murmur
Acute PE : Hypoxemia
Measurements of arterial
blood gases : PaO
2
and PaCO
2

, pH

Pulmonary Embolism
History and physical findings
CT scan
Pulmonary arteriography
Diagnosis
Heparin
Systemic thrombolytic therapy hemodynamically
unstable
Pulmonary embolectomy unable to receive
thrombolytic therapy
Oxygen , intubation, mechanical ventilation massive PE
Placement of an inferior vena cava filter recurrent
disease
Management
Patients with PE is being managed with oral anticoagulants
Dental care PT 20 s /international normalized ratio of 2.5
Any dental care should be coordinated with their primary
medical care provider
Oral Health
Considerations
Pulmonary Neoplasm
Squamous Cell Carcinomas
Derives from bronchial epithelial cells metaplasia
Slow growing neoplasm that invades the bronchi
airway obstruction
Small Cell Carcinomas
Highest assocation with smoking
Derive from neuroendocrine cells in the airway and
metastasize rapidly
Adenocarcinomas
Glandular origin and develop in a peripheral
distribution
Grow more rapidly than SCC and tend to invade pleura
Large cell carcinomas
Anaplastic and giant cell tumors
Poorly differentiated, resemble neither SCC nor
adenocarcinoma

PATHOPHYSIOLOGY
Prolonged injury (ex. : smoking)
Metaplasia of the respiratory epithelium
Dysplastic with the loss of differentiating features
Neoplastic change occurs locally ;invasive carcinoma
usually follows after

CLINICAL AND LABORATORY FINDINGS
Chronic nonproductive cough
Sputum production may occur obstructive lesions
Variably : Hemoptysis, dyspnea
Metastatic and paraneoplastic effects depend on site
involved and size of tumor


Pulmonary Neoplasm
Pulmonary Neoplasm
Diagnosis
History and physical examination
Diagnosis depends on :
the type of lung cancer
Site and size
Presence of metastasis
Clinical status of the patient
CT scan
Sputum, pleural fluid cytology, excisional
biopsy, transthoracic needle aspiration,
bronchoscopy
Management
Complete surgical resection of localized
lung cancer
Treatment based on the stage of the
disease and patient clinical status
Early stage
Surgically managed
Locally advanced disease
Chemotherapy
Radiotherapy
Advanced disease
Supportive care and/chemotherapy