6.2 Respiratory Disease

Asthma

Asthma is a chronic inflammatory airway disease characterised by reversible airflow obstruction. Typical features are wheeze, breathlessness, chest tightness, and cough, often triggered by allergens, exercise, cold air, respiratory infection, or drugs.

Acute asthma in the dental surgery

A mild attack usually responds to the patient's own salbutamol reliever inhaler. For a moderate or severe attack:

1. Stop treatment, sit the patient upright (not supine), and reassure.
2. Give the patient's salbutamol inhaler — one puff every 30–60 seconds, up to 10 puffs, repeated as needed.
3. Give high-flow oxygen (15 L/min via a non-rebreather mask) if available.
4. Call 999 if there are features of life-threatening asthma.

Acute severe vs life-threatening asthma

A silent chest, cyanosis, exhaustion, or reduced respiratory effort is a pre-terminal sign — call 999 immediately.

Dental relevance and drug triggers

• Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) precipitate bronchospasm in approximately 5–20% of asthmatics, particularly those with coexisting nasal polyps (Samter's triad). Always ask about NSAID sensitivity before prescribing ibuprofen, naproxen, or aspirin. Paracetamol is the first-line analgesic in asthmatic patients.
• Avoid prescribing beta-blockers (even eye drops) — they cause bronchospasm.
• Schedule appointments in the late morning or afternoon when asthma control is typically best, and ask the patient to bring their reliever inhaler to every visit.
• Stress can trigger attacks; use a calm environment and effective anxiety management.

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive, largely irreversible airflow obstruction caused mainly by smoking. Patients have chronic bronchitis and/or emphysema with exertional dyspnoea, wheeze, and productive cough.

Oxygen safety in COPD

A subset of COPD patients rely on hypoxic drive to maintain respiration. Giving high-concentration oxygen can depress ventilation and cause CO2 retention (type 2 respiratory failure). In an emergency:

• Use controlled low-flow oxygen and target oxygen saturation 88–92%.
• If the patient is on long-term oxygen therapy or has known hypercapnia, use a 24% or 28% Venturi mask rather than a high-flow mask.
• Reassess and escalate to hospital if the patient deteriorates.

Dental management

• Treat semi-upright; the supine position is poorly tolerated in moderate-to-severe COPD.
• Keep appointments short and avoid long sessions requiring the mouth to be open continuously.
• Patients may be on inhaled corticosteroids; counsel on oral rinsing after inhaler use to reduce the risk of oropharyngeal candidiasis.
• Smoking cessation advice is the single most effective intervention.

Tuberculosis

Tuberculosis (TB) is caused by Mycobacterium tuberculosis. Pulmonary TB presents with chronic cough, haemoptysis, night sweats, weight loss, and fever. Multidrug-resistant TB (MDR-TB) is resistant to at least rifampicin and isoniazid; extensively drug-resistant TB (XDR-TB) is additionally resistant to fluoroquinolones and second-line injectables.

Infection control in the dental surgery

• TB is spread by airborne droplet nuclei, so standard surgical masks do not protect against it.
• A patient with known active pulmonary TB should not be treated in primary care until non-infectious. Defer non-urgent treatment and refer urgent care to a hospital with negative-pressure facilities.
• If a patient is undergoing treatment, confirm with the TB team that they are non-infectious (usually after 2 weeks of effective therapy) before routine dental care.
• Staff should wear FFP3 respirators (not surgical masks) if aerosol-generating procedures on a confirmed or suspected TB case are unavoidable.

Pneumonia and Upper Respiratory Tract Infection

Pneumonia is infection of the lung parenchyma, presenting with fever, dyspnoea, productive cough, and pleuritic chest pain. Community-acquired pneumonia is usually managed in the community with antibiotics; hospitalisation is needed for severe cases.

Upper respiratory tract infection (URTI) includes the common cold, pharyngitis, and sinusitis. Dental relevance:

• Patients with an acute URTI often have nasal congestion, mouth breathing, and a cough — treat semi-upright and consider deferring if the patient is systemically unwell.
• Acute sinusitis can mimic dental pain (maxillary sinusitis referring to the upper posterior teeth); distinguish by percussion, vitality testing, and cone beam/PA radiography.

Steroid Cover and Adrenal Suppression

Patients on long-term systemic corticosteroids (e.g. prednisolone > 7.5 mg/day for more than 3 weeks) may have hypothalamic–pituitary–adrenal (HPA) axis suppression. Minor dental procedures under local anaesthetic usually do not require supplemental steroids, but for major or stressful procedures (multiple extractions, surgical extractions, or general anaesthesia) consider perioperative hydrocortisone cover in line with the patient's GP or endocrinologist. Patients on inhaled steroids alone generally do not need cover.

Smoking and Oral Health

Smoking is the dominant risk factor for COPD and is also a major cause of oral cancer, periodontitis, delayed wound healing, and staining. Brief opportunistic smoking cessation advice at every dental visit is effective and is a standard part of the dental recall.