Respiratory DifficultyMany patients are predisposed to respiratory problems in the dental setting; these patients include patients with asthma or chronic obstructive pulmonary disease (COPD), extremely anxious patients, patients who are atopic, and those in whom a noninhalation sedative technique using respiratory depressant drugs is to be used. Special precau-tions should be taken to help prevent the occurrence of emergencies. If these patients are not treated promptly, the situation may become life threatening. Asthma. Patients with a history of asthma can be a particular challenge to safely manage if emotional stress or many pharmacologic agents easily trigger their respi-ratory problems. Most patients with asthma are aware of the symptoms that signal the onset of bronchospasm. Patients will complain of shortness of breath and want to FIG. 2-3 Management of patient having chest discomfort while undergoing dental surgery.
sit erect. Wheezing is usually audible, tachypnea and tachycardia begin, and patients start using their accesso-ry muscles of respiration. As bronchospasm progresses, patients may become hypoxic and cyanotic, with eventu-al loss of consciousness (Box 2-6). Management should start with placing patients in an erect or semierect position. Patients should then adminis-ter bronchodilators, using their own inhalers or one pro-vided from the office emergency supply. The inhaler may contain epinephrine, isoproterenol, metaproterenol, or aibuterol. Repeated doses should be administered cau- tiously to avoid overdosing the patient. Oxygen adminis-tration should follow, using nasal prongs or a face mask. In more severe asthmatic episodes or when aerosol thera-py is ineffective, epinephrine (0.3 mL of a 1:1000 dilution) may be injected SC or IM. When patients have severe res-piratory embarrassment, it may be necessary to obtain outside emergency medical assistance (Fig. 2-4). Respiratory problems caused by drug allergy may be difficult to differentiate from those resulting from asth-ma. Management of the respiratory problems is the same in either case. Hyperventilation. The most frequent cause of respi-ratory difficulty in the dental setting is anxiety that is expressed as hyperventilation, which is usually seen in patients in their teens, 20s, and 30s, and can frequently be prevented through anxiety control. Dentists should be attuned to the signs of patient apprehension and, through the health interview, should encourage patients to express their concerns. Patients with extreme anxiety should be managed with an anxiety reduction protocol. In addition, pharmacologic anxiolysis may be necessary. The first manifestation of hyperventilation syndrome is frequently a complaint of an inability to get enough air. They breathe very rapidly (tachypnea) and become agitat-ed. The rapid ventilation increases elimination of CO2 through the lungs. The patient rapidly becomes alkalotic; may complain of becoming lightheaded and of having a tingling sensation in the fingers, toes, and perioral region; and may even develop muscle twitches or convulsions.