Medical Emergencies CH 10-15

CHAPTER 10
RESPIRATORY RESPIRATORY
DISTRESS: GENERAL DISTRESS
CONSIDERATIONS
1
GENERAL CONSIDERATIONS
▪ To a conscious person, difficulty breathing is quite disconcerting.
▪ This section focuses on several common causes of respiratory distress,

including hyperventilation, asthma (bronchospasm), and pulmonary edema.
▪ Because persons in these types of respiratory distress usually remain

conscious throughout the episode, this section also discusses the extremely
important psychological aspects of patient management
2
3
▪ In almost all medical emergencies involving the loss of consciousness, some

degree of airway obstruction is present.
▪ The primary cause of airway obstruction is mechanical - the tongue falling into
the hypopharynx as skeletal muscle tone is lost
▪ Two steps of basic life support - A (airway) and B (breathing) - are designed to
manage this problem
4
PREDISPOSING FACTORS
5
▪ In most of these situations a patient does not exhibit respiratory distress

unless an underlying medical disorder becomes acutely exacerbated.
▪ A major factor leading to the exacerbation of respiratory disorders is undue

stress, be it physiologic or psychological
6
▪ Hyperventilation and vasodepressor syncope - among the most frequently

encountered emergency situations in dentistry - are almost exclusively
manifestations of extreme psychological stress.
▪ Children with asthma may exhibit acute episodes of bronchospasm when

faced with stressful situations, such as dental treatment.
7
PREVENTION
▪ Adequate pretreatment medical and dental evaluations can prevent

development of some respiratory problems
8
CLINICAL MANIFESTATIONS
▪ Clinical manifestations of respiratory distress vary according to the degree of

breathing difficulty present.
▪ In most cases the patient retains consciousness throughout the acute

episode.
9
▪ Although retention of consciousness is a positive sign, indicating that the

patient is receiving at least the minimum amount of blood and O2 required for
normal cerebral function, it does create an additional problem - acute anxiety
▪ For this reason, the doctor managing the situation must maintain an
appearance of being calm and in control of the situation at all times
10
▪ The clinical symptoms of breathing difficulty and the sounds associated with it
will vary according to the cause of the problem.
▪ Asthmatic patients often exhibit characteristic wheezing sounds produced by

turbulent airflow through narrowed bronchioles.
▪ Individuals suffering heart failure and pulmonary edema often cough and
produce other sounds associated with pulmonary venous congestion.
11
PATHOPHYSIOLOGY
▪ Figure 10-1 illustrates the sites of

origin of the various respiratory
disorders.
12
PATHOPHYSIOLOGY
▪ The syndromes responsible for respiratory distress involve various segments

of the respiratory system.
▪ Bronchioles are the primary site of involvement in acute asthma.
▪ In asthmatic patients, bronchi become highly reactive, demonstrating

significant smooth muscle hyperactivity (bronchospasm) in response to
usually non-noxious stimuli.
13
PATHOPHYSIOLOGY
▪ Clinical signs and symptoms exhibited during the acute asthmatic attack are
related in large part to the restricted exchange of O2 and carbon dioxide in
the lungs
▪ Patients with heart failure usually mention respiratory distress as one of their
first symptoms.
14
PATHOPHYSIOLOGY
▪ The chronic inability of the lungs to adequately oxygenate venous blood and
the accompanying overuse of the available O2 produce respiratory distress
during heart failure.
▪ This type of respiratory distress is related to an engorgement of the

pulmonary veins with fluid exuding into alveolar air sacs, preventing portions
of the lung from participating in ventilation (removal of carbon dioxide and
absorption of O2) and leading to many of the signs and symptoms noted in
heart failure
15
PATHOPHYSIOLOGY
▪ Hyperventilation is a more generalized problem.
▪ The site of origin of this disorder is the mind (brain) of the patient, and its
clinical signs and symptoms are produced by an alteration in the chemical
composition of the blood.
16
PATHOPHYSIOLOGY
▪ Rapid breathing (tachypnea) associated with hyperventilation results in the

elimination of an excessive amount of carbon dioxide, leading to respiratory
alkalosis; this, in turn, produces many of the clinical signs and symptoms
noted in hyperventilation.
▪ Successfully managed, hyperventilation has no residual effect. However, in

heart failure and asthma - which are chronic disorders - permanent changes
in the respiratory system may occur.
17
PATHOPHYSIOLOGY
▪ Acute foreign body (lower) airway obstruction (FBAO) is a potentially life-

threatening situation in which a foreign body becomes impacted in the
respiratory tract.
▪ The level at which the airway becomes obstructed determines the severity of
the situation and, to some degree, the manner in which it is managed.
▪ If the object enters into either the right or left main-stem bronchi, the resulting
situation is critical but not immediately life threatening.
18
PATHOPHYSIOLOGY
▪ Foreign bodies most often enter into the right main-stem bronchus because of
the angle at which it branches off of the trachea.
▪ In this situation, all or part of the right lung is excluded from ventilation, but
the patient can still maintain adequate ventilation with the left lung. The patient
requires urgent medical intervention, but the condition usually is not
immediately life threatening.
19
PATHOPHYSIOLOGY
▪ In contrast, if the foreign object becomes impacted in the trachea, total airway
obstruction ensues - an acutely life-threatening situation.
▪ Immediate recognition and management are essential to prevent permanent

neurologic damage or death.
20
MANAGEMENT
21
MANAGEMENT
▪ Step 1: recognition of respiratory distress.
▪ Many respiratory disorders are associated with characteristic sounds, such as
• the wheezing of bronchospasm and
• the cough and crackling respirations (rales) of pulmonary edema.
▪ By contrast, hyperventilation does not usually produce a characteristic sound;

however, hyperventilating patients appear—and actually are—acutely anxious
and unable to control their rate of breathing.
22
MANAGEMENT
▪ Step 2: discontinue dental procedure. Dental treatment should cease as soon

as respiratory distress is recognized. Because stress is a primary precipitating
factor in most respiratory-related situations, cessation of treatment may
improve the patient’s clinical signs and symptoms significantly.
23
MANAGEMENT
▪ Step 3: P position the patient.
▪ In conscious patients experiencing respiratory distress, positioning is based

on the comfort of the patient.
▪ In the presence of near-normal or slightly elevated blood pressure (as is

almost always the case in situations of respiratory distress), most persons feel
more in control of their breathing in an upright (sitting or standing) position.
▪ However, patients can be maintained in this position only as long as they

remain conscious.
24
MANAGEMENT
▪ Step 4: C → A → B (circulation-airway-breathing), basic life support, as

needed.
▪ Patients in respiratory distress often experience two major problems - primary

breathing difficulty initially induced by their fear of dentistry and the added
problem of increased anxiety produced by their inability to breathe normally.
▪ In the unlikely event that respiratory distress leads to unconsciousness, the

patient must be placed immediately into the supine position and the steps in
the management of unconsciousness followed.
25
MANAGEMENT
▪ Step 5: D (definitive care). Response of the victim to the steps of basic life
support determines additional management.
▪ Step 5a: monitoring of vital signs. The individual’s blood pressure, heart rate
(pulse), and respiratory rate should be monitored at frequent intervals (at least
every 5 minutes) throughout the episode and recorded in a permanent
record.
26
MANAGEMENT
▪ Step 5b: definitive management of anxiety. The doctor should keep the
patient as comfortable as possible and begin to manage anxiety by speaking
calmly but firmly to the patient.
▪ The patient’s collar or other tight garments (that might restrict breathing) may
be loosened, enabling the patient to breathe more easily (even if the “ease” in
breathing is purely psychological).
27
MANAGEMENT
▪ Step 5c: definitive management of respiratory distress. After assessing the

patient’s cardiovascular status, the doctor may begin to manage the cause of
the patient’s breathing problem.
▪ Step 5d: activate emergency medical services, as needed. At any time during
the episode of respiratory distress, the doctor may activate emergency
medical services, if indicated
28
29
CHAPTER 11
FOREIGN BODY
AIRWAY OBSTRUCTION
30
INTRODUCTION
▪ Because of its frequently sudden and critical nature, acute foreign body
airway obstruction (FBAO) must be recognized and managed quickly.
▪ During dental treatment there is great potential for small objects to drop into
the posterior portion of the oral cavity and subsequently into the pharynx
▪ Published reports have documented the retrieval of rubber dam clamps,

endodontic instruments, teeth, a post and core, and a crucifix
31
INTRODUCTION
▪ In the conscious dental patient, chances are that any object lost in the
pharynx will be swallowed and pass into the esophagus or will be recovered
after being coughed up, so that the actual incidence of acute airway
obstruction or aspiration into the trachea, bronchi, and lungs is low.
▪ A high probability also exists that any object entering the airway will be small
enough in diameter to pass through the larynx (the narrowest portion of the
upper airway in the adult) without causing obstruction
32
INTRODUCTION
▪ Although an acutely life-threatening situation does not immediately exist,

certain important steps must be initiated promptly to ensure removal of the
object within a reasonable time to avoid serious consequences.
▪ The possibility does exist, however, that a foreign object may become lodged
in the larynx, completely obstructing the trachea.
▪ All dental office personnel should become familiar with proper management
of FBAO.
33
INCIDENCE
▪ The epidemiology of foreign bodies in the airway, pharynx, and esophagus

peaks at the extremes of age.
▪ The National Safety Council reported that 4600 individuals in the United
States died as a result of acute airway obstruction in 2009.
▪ More than 90% of deaths from foreign body aspiration in the pediatric age
group occur in children younger than 5 years; 65% of those deaths occur in
infants.
34
INCIDENCE
▪ Commonly aspirated items include hot dogs, rounded candies, nuts, grapes,
coins, toys, and other hard, colorful objects.17–20 Baby aspirin, with a
diameter of 7.5 mm, has obstructed airways and caused subsequent deaths in
several young children. (The diameter of the glottic opening in a 2-year-old is
about 6.5 mm.)
▪ Elderly patients, particularly those with primary neurologic disorders and

decreased gag reflexes due to alcohol, seizures, strokes, parkinsonism,
trauma, and senile dementia, are also at risk of aspiration.
35
PREVENTION
▪ Sit-down dentistry, where patients are placed in a supine or semisupine

position during treatment, has increased the likelihood of such an incident
occurring.
▪ When objects are swallowed, they usually enter the gastrointestinal (GI) tract.
36
PREVENTION
▪ During the act of swallowing, the epiglottis seals the tracheal opening so that
liquid and solid materials enter the esophagus, not the trachea.
▪ The esophagus is the most likely site in the GI tract for objects to become
impacted because of its nature - the esophagus is a collapsed tube through
which liquids and solids are forced
37
38
CHAIR POSITION
▪ The supine position, which is recommended as a means of preventing
syncope, becomes detrimental to a patient who must use the body of the
tongue when a “dropped” foreign object is being maintained tenuously
against the roof of the mouth.
▪ Gravity acts to force the object posteriorly into the pharynx.
▪ If equipment is not readily available chairside to retrieve the object, the patient
should be turned onto his or her side and leaned into a head-down
(Trendelenburg*) position with the upper body hanging over the side of the
dental chair
39
The patient should turn to the
side and bend into a head-down
position with the upper body
over the side of the dental chair
in cases of a swallowed object.
40
DENTAL ASSISTANT AND SUCTION
▪ In most offices a dental assistant is seated across from the doctor.
▪ When an object falls free and is in danger of being swallowed, the assistant
may have available one or more devices with which to retrieve it, such as
pickup forceps and a hemostat.
41
DENTAL ASSISTANT AND SUCTION
▪ If nothing is readily available, a high-volume, large-diameter suction tip may

be used to remove the object from the patient’s mouth.
▪ A trap on the suction line permits prompt retrieval of the object
▪ Saliva ejectors are not always useful in foreign body removal because the
force of the suction may not be great enough to grasp the object.
42
TONGUE GRASPING FORCEPS
▪ A tongue grasping forceps (Figure 11-8)

has serrations that allow the tongue to
be grasped firmly and pulled forward
without causing iatrogenic injury.
43
LIGATURE
▪ The use of ligature (dental floss) can aid in the prevention of aspirated or
swallowed objects and in their retrieval from the posterior regions of the oral
cavity and pharynx
▪ Dental floss should be secured to rubber dam clamps, endodontic

instruments, cotton rolls, gauze pads; around pontics in fixed bridges; or to
other small objects placed in the oral cavity during dental treatment
44
FIGURE 11-10 A, Cotton roll without floss. B,
Cotton roll with floss.
45
MAGILL INTUBATION FORCEPS
▪ The Magill intubation forceps (Figure 11-5), which is suggested for the basic
emergency kit, is designed to facilitate retrieval of large and small objects
from the posterior regions of the oral cavity and pharynx
▪ The right-angled bend in the Magill forceps permits a comfortable hand

position for the user while its blunt-ended beaks permit easy grasping of the
object.
46
▪ Magill intubation
forceps should be
included in the
office emergency
kit.
47
PROPER USE OF THE MAGILL INTUBATION FORCEPS
48
NO OTHER DEVICE, INCLUDING PICKUP FORCEPS (COTTON PLIERS)
OR HEMOSTATS, IS DESIGNED FOR RETRIEVAL OF OBJECTS.
49
MANAGEMENT
▪ When an object enters the oropharynx of a patient lying in the supine or

semisupine position, try not to allow the patient to sit up.
▪ The chair should be moved into a more reclined position (e.g., into the
Trendelenburg position, if possible) while the assistant picks up the Magill
intubation forceps.
▪ The Trendelenburg position allows gravity to move the object closer to the
anterior portion of the oral cavity, where it may be visible, aiding in its retrieval
with the Magill intubation forceps
50
MANAGEMENT
51
MANAGEMENT
▪ If the object cannot be seen (i.e., if the patient “swallows” it), radiographs are
warranted to determine its location; the patient should not be permitted to
leave the office without arrangements being made for these radiographs.
▪ Because clinical signs and symptoms do not always indicate whether the
object has entered the GI or respiratory tract, the doctor should escort the
patient (if feasible) to the emergency department of a local hospital or to a
radiology laboratory.
▪ The radiologist recommends a flat plate of the abdomen, an anteroposterior

(AP) view of the chest (Figure 11-11), or a lateral view of the chest.
52
Anteroposterior view of the chest demonstrating a
rubber prophylaxis cup (arrow).
53
Gold crown that was aspirated into the left lung of the patient.
54
MANAGEMENT
▪ If the object’s location is not apparent on the radiograph or if any question

exists as to its location or any potential complications, immediate medical
consultation is warranted
55
MANAGEMENT
▪ Usually, the signs and symptoms exhibited by the patient help determine if the
object has entered into the trachea.
▪ Signs and symptoms include: the sudden onset of coughing, choking,

wheezing, and shortness of breath.
▪ More than 90% of patients who aspirate exhibit these signs and symptoms
within 1 hour of aspiration.
▪ A few patients may experience a time lag as long as 6 hours before symptoms
become evident
56
MANAGEMENT
▪ In situations in which the foreign body presumably enters the trachea, a well-
defined protocol should be followed, beginning with ensuring that the patient
does not sit up (sitting up may propel the object deeper into the trachea or
bronchi).
▪ The patient should be placed into the left lateral decubitus position with the
head down
57
MANAGEMENT
▪ The patient may cough spontaneously; if not, coughing should be encouraged

to aid in retrieval of the object.
▪ The normal cough reflex is powerful and in many cases adequate to expel the
aspirated object.
58
MANAGEMENT
59
RECOGNITION OF AIRWAY OBSTRUCTION
▪ Acute upper-airway obstruction in the conscious person occurs most often while the
patient is eating. In adults, meat is the most common cause of obstruction
▪ Several common factors are identified in cases of the so-called cafe coronary
syndrome, including:
(1) large, poorly chewed pieces of food;
(2) elevated blood alcohol levels;
(3) laughing or talking while eating; and
(4) upper or lower dentures
60
MANAGEMENT
▪ There are two categories of foreign body airway obstruction: complete and
partial obstruction.
▪ For management purposes, partial obstruction is subdivided into two

categories: partial obstruction with good air exchange or partial obstruction
with poor air exchange.
61
COMPLETE AIRWAY OBSTRUCTION
62
The victim clutches the neck, demonstrating the
recommended universal distress signal for an obstructed
airway.
63
COMPLETE AIRWAY OBSTRUCTION
64
PARTIAL AIRWAY OBSTRUCTION
65
BASIC AIRWAY MANEUVERS
▪ Once a patient with an obstructed airway loses consciousness, basic life

support, including airway maintenance, is initiated immediately (see Chapter
5).
66
▪ In those instances, in which a lower-airway obstruction is obvious (e.g., airway

obstruction developing immediately after the individual swallows a crown or
dental instrument), the steps of basic life support are bypassed, and the
rescuer immediately proceeds to establish an emergency airway.
67
▪ Step 1: P (position). The patient should be placed into the supine position
with the feet elevated slightly
▪ Step 2: C (circulation). Check for pulse, if victim is unconscious, for not more
than 10 seconds. If no pulse or if pulse is doubtful, start chest compressions.
If pulse is present, continue to step 3.
68
SUPINE POSITION
69
▪ Step 3: head tilt–chin lift. The

patient’s neck tissues are extended
using the head tilt–chin lift
technique (Figure 11-15).
▪ In 80% of instances in which the

tongue is the cause of the airway
obstruction, this procedure
effectively opens the airway
70
▪ Step 4: A + B (airway, breathing). The

rescuer’s ear is placed 2.5 cm (1 inch)
from the victim’s mouth and nose; the
rescuer listens and feels for the passage of
air while looking toward the victim’s chest
and watching for spontaneous respiratory
movement
https://www.youtube.com/watch?v=Y0KMpF5ztxA
71
▪ Step 4a: jaw-thrust maneuver, if indicated. The rescuer places his or her fingers behind the
posterior border of the ramus of the victim’s mandible displacing the mandible anteriorly
while tilting the victim’s head backward and opening the mouth
https://www.youtube.com/watch?v=6UeMuN0TxBU
72
▪ Step 5: A + B. Repeat step 4, if necessary.
▪ Step 6: rescue breathing, if indicated. Where the tongue is the cause of

airway obstruction, implementing the preceding steps usually reestablishes
the airway
▪ When these steps are performed properly but the airway remains obstructed
(diagnosed by aphonia, suprasternal retraction, and continued absence of
“hearing and seeing”), the rescuer should consider the probability that the
obstruction is located in the lower airway (larynx or trachea) and proceed
immediately to establish an emergency airway
73
EMERGENCY AIRWAY
▪ A variety of procedures exist to accomplish this goal.
▪ Two procedures - tracheostomy and cricothyrotomy - require surgical

intervention and thus considerable knowledge and technical skill to be carried
out effectively.
74
EMERGENCY AIRWAY
▪ A third procedure, which is nonsurgical, is the procedure of choice for the

initial management of all obstructed airways when basic life support
techniques prove inadequate.
▪ This is the external subdiaphragmatic compression technique, known as the

abdominal thrust, or the Heimlich maneuver
▪ The American Heart Association and American Red Cross recommend the
abdominal thrust when lower-airway obstruction is a possibility, a situation
responsible for 4600 deaths in 2009.
75
ESTABLISHING AN EMERGENCY AIRWAY WHEN A PATIENT’S AIRWAY
IS OBSTRUCTED
▪ Victim of a partial airway obstruction who is capable of forceful coughing and
is breathing adequately (i.e., with no evidence of cyanosis or duskiness)
should be left alone.
▪ Although wheezing may be evident between coughs, a forceful cough is

highly effective in removing foreign objects
▪ If the victim of partial airway obstruction initially demonstrates poor air

exchange or if previously good air exchange becomes ineffective, the victim
must be managed as though their airway is completely obstructed.
76
ESTABLISHING AN EMERGENCY AIRWAY WHEN A PATIENT’S AIRWAY
IS OBSTRUCTED
▪ Victims of complete airway obstruction are unable to speak or make any

sounds (aphonia), breathe, or cough.
▪ The victim remains conscious as long as the cerebral O2 level of the blood is
sufficiently high.
▪ Victims may remain conscious for 10 seconds to 2 minutes, depending on

whether the obstruction occurred during inspiration (when the blood has
more O2) or expiration (when the blood has less O2).
77
BACK BLOWS
▪ Back slaps remain an integral part of the protocol for obstructed-airway

management in the infant.
▪ When back slaps are performed on the infant, the infant is straddled over the
rescuer’s arm with the head lower than the trunk and with the head supported
by the rescuer’s firm hold on the infant’s jaw.
78
BACK BLOWS
▪ Using the heel of the hand, the rescuer delivers up to five back slaps forcefully
between the infant’s shoulder blades while resting the other hand on the thigh
(Figure 11-18).
▪ Each slap should be delivered with sufficient force to attempt to dislodge the
foreign body
79
The rescuer uses the heel of one hand to deliver up to five back
slaps forcefully between the shoulder blades of an infant.
80
ABDOMINAL THRUSTS AND CHEST THRUSTS
▪ Manual thrusts to the upper abdomen (Heimlich maneuver [abdominal thrust])

or lower chest (chest thrust) are designed to produce a rapid increase in
intrathoracic pressure, acting as an artificial cough that can help dislodge a
foreign body
▪ Chest thrusts should be used for obese patients if the rescuer is unable to
encircle the victim’s abdomen.
▪ If the choking victim is in the late stages of pregnancy, the rescuer should use
chest thrusts instead of abdominal thrusts.
81
ABDOMINAL THRUSTS AND CHEST THRUSTS
▪ Chest thrust is less likely to cause regurgitation than is abdominal thrust.
▪ chest thrusts are recommended for infants because abdominal thrusts are
more likely to cause organ damage (e.g., to the liver or spleen).
▪ The abdominal thrust is recommended especially for older patients, whose

more brittle ribs are more likely to be fractured in the chest thrust, and for
children
82
ABDOMINAL THRUST (HEIMLICH MANEUVER)
▪ Recommended primary technique for relief of foreign body airway obstruction

in victims 1 year of age and older.
▪ When signs of good (mild airway obstruction) air exchange are present (e.g.,
forceful cough, speech, wheezing between coughs), the rescuer should
encourage the victim to spontaneously cough and breathe.
83
▪ The rescuer should not interfere with the victim’s own efforts to expel the
foreign body but should remain with the victim monitoring the victim’s efforts
and condition.
▪ If mild airway obstruction persists, emergency medical services should be

activated.
84
▪ Signs of severe airway obstruction include the following:
▪ Poor or no air exchange; a weak, ineffective cough or no cough at all; high-

pitched noise during inhalation or no noise at all; increasing respiratory
difficulty; presence of cyanosis of mucous membranes; aphonia; and,
clutching at the neck with thumb and fingers making the universal choking
sign.
85
▪ In the presence of severe airway obstruction, the rescuer should ask the
victim if he or she is choking.
▪ If the victim nods “yes” the rescuer identifies himself or herself as someone
who can help and asks for permission to attempt to relieve the obstruction.
▪ In the unconscious victim, consent is implied.
86
CONSCIOUS VICTIM
▪ After the rescuer confirms that the airway is obstructed by asking “Are you
choking?” and “Can I help you?” and receives an affirmative reply (e.g., nod)
to both:
▪ 1. Kneel or stand behind the victim and wrap your arms around the victim’s
waist.
▪ 2. Stabilize yourself so as not to fall backward when the procedure is carried

out.
87
CONSCIOUS VICTIM
▪ 3. Make a fist with one hand.
▪ 4. Place the thumb side of the fist against the victim’s abdomen. The hand
should rest in the midline, slightly above the umbilicus and well below the tip
of the xiphoid process
▪ 5. Grab your fist with your other hand and press your fist into the victim’s
abdomen with a quick, forceful upward thrust
88
CONSCIOUS VICTIM
89
CONSCIOUS VICTIM
▪ 6. Repeat these forceful inward and upward thrusts

until the foreign body is expelled or the victim loses
consciousness
▪ 7. Each individual thrust should be forceful enough to

dislodge the foreign object.
▪ 8. The successfully treated victim should be evaluated

for possible complications before being dismissed
from the office.
https://www.youtube.com/watch?v=7CgtIgSyAiU
90
UNCONSCIOUS VICTIM
▪ If a conscious choking victim becomes unconscious (unresponsive), the

following protocol should be performed
▪ 1. Place the victim in the supine position and call for emergency medical
services (EMS) as soon as possible.
▪ 2. Begin basic life support with 30 chest compressions—prior to checking for

a pulse.
91
UNCONSCIOUS VICTIM
▪ 3. In the adult or child victim, each time you stop compressions to open the
airway (A) and deliver two breaths (B), open the mouth wide and look in for
the object. If the object is visible, remove it using a Magill intubation forceps,
cotton pliers, or fingers.
92
UNCONSCIOUS VICTIM
▪ 4. If the object is not visible continue BLS with chest compressions repeating
steps 2 and 3 until the object is removed or EMS arrives on scene and takes
over management of the situation
▪ Current guidelines do not recommend a blind finger sweep. If the object is

visible it should be removed.
93
CHEST THRUST
▪ The chest thrust is an alternative - in special situations only - to the Heimlich

maneuver as a technique for opening an obstructed airway
94
CONSCIOUS VICTIM
▪ If an obese or pregnant FBAO victim is conscious and

either standing or sitting, the following recommended
steps should be performed after the rescuer confirms
that the airway is obstructed by asking “Are you
choking?” and “Can I help you?,” receiving an
affirmative reply (e.g., nod) to both:
▪ 1. Stand behind the victim and place the arms directly

under the armpits, encircling the chest
95
CONSCIOUS VICTIM
▪ 2. Grasp one fist with the other hand, placing the thumb side of the fist on the
middle of the sternum, not on the xiphoid process or the margins of the rib
cage.
▪ 3. Stabilize yourself so as not to fall backward when the procedure is carried

out.
▪ 4. Perform backward thrusts until the foreign body is expelled or the victim
loses consciousness.
96
UNCONSCIOUS OBESE OR PREGNANT VICTIM
▪ If a conscious obese or pregnant FBAO victim becomes unresponsive or is

found unconscious, the following steps should be performed:
▪ 1. Place the victim in the supine position and contact EMS as soon as
possible.
▪ 2. Begin basic life support with 30 chest compressions—prior to checking for

a pulse.
97
▪ 3. In the adult or child victim, each time you stop compressions to open the
airway (A) and deliver two breaths (B), open the victim’s mouth wide and look
in for the object. If the object is visible, remove it using either a McGill
intubation forceps, cotton pliers, or fingers.
98
▪ 4. If the object is not visible, continue BLS with chest compressions, repeating
steps 2 and 3 until the object is removed or EMS arrives on scene and takes
over management of the situation.
▪ Current guidelines do not recommend a blind finger sweep. If the object is

visible, it should be removed.
99
A chest thrust on an unconscious obese or pregnant
victim.
100
101
102
PROCEDURES FOR OBSTRUCTED AIRWAYS IN INFANTS
▪ A combination of back slaps and chest thrusts is still the recommended

protocol for the infant under 1 year
103
https://www.procpr.org/training_video/conscious-infant-choking
104
▪ https://www.procpr.org/training_video/unconscious-infant-
choking
105
QUESTIONS?
106
HYPERVENTILATION
CHAPTER 12
107
INTRODUCTION
▪ Hyperventilation is defined as ventilation in excess of that required to maintain

normal blood PaO2 (arterial oxygen [O2] tension) and PaCO2 (arterial carbon
dioxide [CO2] tension)
▪ It is produced by an increase in the frequency or depth of respiration, or both.
▪ Hyperventilation, a not uncommon emergency in the dental office, almost

always is a result of extreme anxiety
108
INTRODUCTION
▪ However, organic causes for hyperventilation do exist; these include pain,

metabolic acidosis, drug intoxication, hypercapnia, cirrhosis, and organic
central nervous system disorders.
▪ In most instances the hyperventilating patient remains conscious throughout

the episode.
▪ Loss of consciousness secondary to hyperventilation is extremely rare.
109
▪ Acute anxiety is the most common predisposing factor for hyperventilation.
▪ In dentistry, hyperventilation most often occurs in apprehensive patients who

hide their fears from their doctors and attempt to “tough it out.”
▪ Hyperventilation is rarely encountered in very young children, primarily

because children usually make no attempt to hide
110
▪ their fears. Instead, apprehensive children voice uncertainties in rather

obvious ways - crying, biting, kicking. When the patient’s anxieties are
released, hyperventilation and vasodepressor syncope rarely occur.
▪ hyperventilation most often occurs in patients 15 to 40 years of age. In

addition, it has been stated that hyperventilation occurs more frequently in
women;6
111
PREVENTION
▪ Medical history questionnaire
▪ An anxiety questionnaire (see Chapter 2) may be included as part of the

medical history the patient completes before the doctor begins treatment.
▪ Question 5 (Have you had problems with prior dental treatment?) offers a
patient the opportunity to mention prior bad dental office experiences or
dental fears.
112
PHYSICAL EVALUATION
▪ Shaking hands with the patient provides valuable information. Cold, wet
(clammy) hands usually indicate apprehension.
▪ In extreme instances a mild tremor of the hands may be obvious.
▪ The patient may appear either flushed or pale; in either case the forehead is
usually bathed with perspiration, and the patient may remark that the office is
unusually warm, regardless of its actual temperature.
▪ Fearful patients simply appear uncomfortable when they sit in dental chairs
and are overly concerned with the goings-on around them.
113
VITAL SIGNS
▪ The vital signs of apprehensive patients may deviate from the normal, or
baseline, values for that individual.
▪ Blood pressure is elevated, with the systolic pressure rising more than the
diastolic.
114
VITAL SIGNS
▪ The heart rate is increased, potentially to a degree significantly higher than

the baseline.
▪ the patient’s respiratory rate increases above the normal adult rate of 14 to 18
breaths per minute, whereas the depth of respiration may be either deeper or
more shallow than normal.
115
116
PATHOPHYSIOLOGY
▪ Several distinct conditions - anxiety, respiratory alkalosis, an increase in the

blood catecholamine level, and a decrease in the level of ionized calcium in
the blood - produce the spectrum of signs and symptoms associated with
hyperventilation
▪ Anxiety is responsible for both the increase in respiratory rate and depth and
the increase in the levels of the catecholamines, epinephrine and
norepinephrine, in the blood (a result of the “fight or flight” response).
117
MANAGEMENT
▪ Hyperventilation in the dental environment will almost always be a product of

dental fears that have been well hidden by the patient.
▪ The subsequent inability of the patient to control their breathing further

increases those fears.
▪ The doctor and staff members must initially attempt to calm the patient.
▪ They themselves must remain calm throughout the episode so that they do
not exacerbate the situation
118
MANAGEMENT
▪ Step 1: terminate the dental procedure. The presumed cause of the episode
(e.g., a syringe, dental handpiece, or pair of forceps) should be removed from
the patient’s line of vision.
▪ Step 2: P (position). The hyperventilating patient is conscious and will exhibit

varying degrees of difficulty in breathing.
119
MANAGEMENT
▪ The preferred position for this patient is usually upright.
▪ The supine position is normally uncomfortable for such patients because of

the diminished ventilatory volume caused by the impingement of the
abdominal viscera on the diaphragm and the perceived loss of control
patients have over their body when lying down.
▪ Most hyperventilating patients will be most comfortable sitting fully or partially

upright.
120
MANAGEMENT
▪ Step 3: C→A→B (circulation-airway-breathing), basic life support as needed.

Hyperventilating individuals rarely require basic life support. Such victims are
conscious and breathing efficiently (indeed, they are overventilating), and the
heart is quite functional.
▪ Step 4: D (definitive care).
121
MANAGEMENT
▪ Step 4a: removal of materials from the mouth. All foreign objects, such as a
rubber dam, clamps, and partial dentures, should be removed from the
patient’s mouth and any tight bindings (e.g., a tight collar, tie, or blouse),
which may restrict breathing, loosened.
▪ Step 4b: calming of the patient. In a calm and relaxed manner assure the
patient that all is well.
▪ Attempt to help the patient regain control of his or her breathing by speaking
calmly.
122
MANAGEMENT
▪ Have the patient breathe slowly and regularly at a rate of about 4 to 6 breaths
per minute, if possible.
▪ This will allow the PaCO2 to increase, reducing the pH of the blood to near
normal and eliminating (slowly) any symptoms produced by respiratory
alkalosis.
▪ In many cases of hyperventilation these are the only steps necessary to

terminate the episode.
123
MANAGEMENT
▪ Step 4c: correction of respiratory alkalosis. When the preceding steps are
ineffective, helping the patient to increase blood PaCO2 level is the next
objective.
▪ The patient may be instructed to breathe a gaseous mixture of 7% CO2 and

93% O2, which is supplied in compressed gas cylinders but is highly unlikely
to be available in a dental office.
▪ More realistically, the patient will be told to rebreathe exhaled air, which
contains an increased concentration of CO2.
124
MANAGEMENT
▪ The most practical method of increasing PaCO2 levels in the blood is to

instruct the hyperventilating victim to cup his or her hands in front of the
mouth and nose and to breathe in and out of this reservoir of CO2-enriched
exhaled air (Figure 12-2).
125
MANAGEMENT
▪ In addition to elevating PaCO2 levels, the warm exhaled air against the cold
hands will warm their hands, alleviating one of the more frightening symptoms
of hyperventilation.
▪ A full-face mask from an O2 delivery unit may also be used. However, care
must be taken not to administer O2 to the hyperventilating patient.
126
The hyperventilating victim cups
the hands together in front of
the mouth and nose as a means
of increasing the arterial carbon
dioxide tension (PaCO ).
2
127
MANAGEMENT
▪ Step 4d: drug management, if necessary
▪ Step 5: subsequent dental treatment. Once the episode of hyperventilation is

ended, with all clinical signs and symptoms resolved, the dentist must
determine the cause of the episode.
128
MANAGEMENT
▪ Like vasodepressor syncope, hyperventilation is often the first clinical

manifestation of deep-seated dental fear.
▪ Dental treatment may continue at this time if both the doctor and the patient
are comfortable in doing so.
▪ However, subsequent dental treatment should be modified, and the stress

reduction protocol consulted to prevent a recurrence of hyperventilation.
129
MANAGEMENT
▪ Step 6: discharge. After the episode has ended with all signs and symptoms
resolved, the patient may be discharged from the office as usual.
▪ If the doctor has any uncertainty about the patient’s recovery or if any CNS-
depressant drug was administered, a person with a vested interest in the
health and safety of the patient, such as a friend or relative, should be called
to take the patient home.
▪ An entry about the episode and its management should be placed in the
dental progress notes.
130
131
QUESTIONS?
132
ASTHMA
CHAPTER 13
133
▪ Asthma was defined in 1830 by Eberle, a Philadelphia physician, as

“paroxysmal affection of the respiratory organs, characterized by great
difficulty of breathing, tightness across the breast, and a sense of impending
suffocation, without fever or local inflammation.”
▪ Today, asthma is defined as “a chronic inflammatory disorder that is

characterized by reversible obstruction of the airways.”
134
▪ Asthma affects an estimated 8.2% of adults and approximately 9.5% of

children in the United States3 and between 3% and 20% worldwide
▪ Approximately 18.9 million adult and 7.1 million children in the United States,
and more than 235 million persons worldwide, suffer from asthma
▪ Typical asthmatic patient is usually free of symptoms between acute episodes

but exhibits varying degrees of respiratory distress during the acute episode.
135
▪ Although the degree of respiratory distress (dyspnea) is usually moderate,

asthma represents the third leading cause of emergency department visits
(1.9 million in 2009)6 and preventable hospitalizations (479,000 annually) in
the United States
▪ Asthma is primarily a disease of young people; half of all cases develop before
the individual reaches 10 years of age, and another third before age 40 years
136
▪ Asthma is usually classified according to causative factors into two major

categories: extrinsic (allergic asthma) and intrinsic (nonallergic asthma,
idiosyncratic asthma, nonatopic asthma
▪ Individuals with extrinsic asthma have histories of atopy (a type I

hypersensitivity or allergic reaction for which there is a genetic component),
whereas those with intrinsic asthma do not.
137
▪ One factor, however, is common in all asthmatic patients - extreme sensitivity

of the airways.
▪ This sensitivity is characterized not only by an increased contractile response

of airway smooth muscle but also by an abnormal generation and clearance
of secretions and an abnormally sensitive cough reflex.
138
PATHOPHYSIOLOGY
▪ Regardless of the type of asthma present, one finding common to all

asthmatic patients is an extreme sensitivity of the airways characterized not
only by increased contractile response of the respiratory smooth muscle
(Bronchospasm) but also by an abnormal generation and clearance of
secretions and an abnormally sensitive cough reflex.
139
PATHOPHYSIOLOGY
▪ During the mild asthmatic episode, produced primarily by bronchospasm,

moderate airway obstruction leads to a decrease in blood oxygenation.
▪ The ensuing hypoxia and increased work of breathing result in a heightened

level of anxiety, producing hyperventilation.
▪ Hyperventilation produces a decrease in the blood’s level of carbon dioxide

(hypocapnia) and subsequent respiratory alkalosis (see Chapter 12).
140
PATHOPHYSIOLOGY
▪ In the more severe asthmatic episode (greater influence of airway

inflammation) or in status asthmaticus, the greater degree of bronchial
obstruction results in a more profound decrease in blood oxygenation.
▪ The respiratory workload increases; however, the body’s responses soon

prove ineffective as the obstruction becomes greater, leading to inadequate
ventilation and carbon dioxide retention, or hypercapnia.
▪ Hypercapnia causes respiratory acidosis and may lead to respiratory failure.
141
142
143
144
145
146
MANAGEMENT ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
▪ Step 1: termination of the dental procedure. Treatment should cease immediately

when the individual exhibits signs of an acute asthmatic attack.
▪ Step 2: P (position). The patient is positioned comfortably as soon as signs become

evident. The position almost always involves sitting upright (to some degree), with the
arms thrown forward
▪ Other positions are equally acceptable, based upon the comfort and preference of
the patient.
▪ Step 3: removal of dental materials. All dental materials or instruments should be

removed from the patient’s mouth immediately.
147
148
▪ Step 4: calming of the patient. Many asthmatic patients, especially those with
histories of easily managed bronchospasm, will remain calm throughout the
episode.
▪ Others, primarily those with acute episodes that have been more difficult to
terminate, may exhibit varying degrees of apprehension.
149
▪ Dental personnel must always remain calm themselves as they attempt to

calm anxiety-ridden patients.
▪ Step 5: C→A→B (circulation-airway-breathing), basic life support as needed.
▪ During the acute asthmatic episode the patient remains conscious, is

breathing (with a partially obstructed airway), and usually has an increased
blood pressure and heart rate.
150
MANAGEMENT: ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
▪ Step 6a: administration of O2. O2 should be administered during any acute

asthmatic episode through a full-face mask, nasal hood, or nasal cannula.
151
▪ (If a nasal cannula is used, a flow of 5 to 7 L per minute is adequate.) The

presence of any clinical signs and symptoms of hypoxia and hypercarbia are
indications for O2 administration
▪ Step 6b: administration of bronchodilator. Before dental treatment on the

asthmatic patient begins, the patient’s bronchodilator aerosol inhaler should
be placed within easy reach.
▪ This medication then should be used to manage an acute episode
152
153
▪ Step 7: subsequent dental care. Once the acute episode is terminated, the
doctor should determine the cause of the attack.
▪ Appropriate steps in the stress reduction protocol should be considered as a

means to diminish the risk of future episodes.
▪ The planned dental treatment may continue at this visit if both the patient and
the doctor feel that it is appropriate.
154
▪ Step 8: discharge. Following resolution of the acute asthmatic episode, the

doctor may discharge the patient from the dental office without an escort if
the doctor believes that the patient is in stable condition.
▪ Such discharge is not usually a problem in cases of acute episodes that are
terminated quickly with bronchodilator therapy.
155
SEVERE BRONCHOSPASM
▪ Step 1: termination of dental therapy.
▪ Step 2: P. The patient should be placed in the most comfortable position.
▪ Step 3: removal of dental materials from mouth.
▪ Step 4: calming of the patient
156
SEVERE BRONCHOSPASM
▪ Step 5: C→A→B, basic life support as needed.
▪ Step 6a: administration of O2.
▪ Step 6b: administration of bronchodilator. In situations in which three doses of

the aerosolized bronchodilator fail to resolve the acute episode, additional
steps of management should be considered.
▪ Step 6c: call for assistance. When aerosolized bronchodilators fail to resolve
bronchospasm
157
SEVERE BRONCHOSPASM
▪ Step 7: disposition of patient. After the resolution of an acute episode of

bronchospasm severe enough to require administration of parenteral drugs,
the patient frequently requires hospitalization so that their long-term asthma
therapy can be reevaluated.
158
SEVERE BRONCHOSPASM
▪ In other situations, the emergency personnel may determine that the patient
does not need hospitalization.
▪ In such cases a decision about how and when the patient may leave the office
(i.e., alone or escorted) should be made before the emergency personnel
depart.
159
160
161
QUESTIONS?
162
HEART FAILURE AND
ACUTE PULMONARY
EDEMA
CHAPTER 14
163
▪ Heart failure is generally described as the inability of the heart to supply

sufficient oxygenated blood for the body’s metabolic needs.
▪ Fluid accumulates in the pulmonary circulation, systemic circulation, or both.
▪ Heart failure is a principal complication of virtually all forms of heart disease
▪ Cardinal manifestations of heart failure are dyspnea and fatigue, which may
limit exercise tolerance, and fluid retention, which may lead to pulmonary
congestion and peripheral edema
164
▪ The tendency of heart failure to begin as left ventricular failure relates to the
disproportionate workload of, and the prevalence of cardiac disease in, the left
ventricle. Disease produces heart failure in one of two basic ways:
1. Increasing the workload of the heart. For example, high blood pressure increases
resistance to the ejection of blood from the left ventricle, increasing the workload of
the myocardium. Seventy-five percent of heart failure cases have a prior history of
high blood pressure.
2. Damaging the muscular walls of the heart through coronary artery disease or
myocardial infarction.
165
▪ Any factor that increases the workload of the heart may precipitate an acute
exacerbation of preexisting heart failure, which may result in acute pulmonary
edema.
▪ Acute pulmonary edema may occur at any time, but most often at night, after
the individual has been asleep for a few hours
166
▪ In pediatric patients, heart failure may be produced by an obstruction to the

outflow of blood from the heart (e.g., coarctation of the aorta or pulmonary
stenosis).
▪ Of all children who develop heart failure, 90% do so within the first year of life
secondary to congenital heart lesions
167
PREVENTION
▪ The medical history questionnaire and the dialogue history are the best forms
of prevention.
168
169
170
171
THE ASA PHYSICAL STATUS CLASSIFICATION FOR HEART FAILURE
▪ The ASA physical status classification for heart failure:
▪ ASA 1: The patient does not experience dyspnea or undue fatigue with
normal exertion.
▪ Comment: If all items of the medical history are negative, this patient may be
considered normal and healthy.
▪ No special modifications in dental treatment are indicated. Patients with heart

failure are not ASA 1 risks.
172
THE ASA PHYSICAL STATUS CLASSIFICATION FOR HEART FAILURE
▪ ASA 2: The patient experiences mild dyspnea or fatigue during exertion.
▪ Comment: As with the ASA 1 patient, the ASA 2 patient may be managed
normally if the remainder of their medical history and physical examination
prove to be noncontributory.
▪ In addition, use of the stress reduction protocol should be considered if any

physical or psychological stress is evident or anticipated
173
DENTAL THERAPY CONSIDERATIONS
▪ ASA 3: The patient experiences dyspnea or undue fatigue with normal activities.
▪ Comment: This patient is comfortable at rest in any position but may demonstrate a
tendency toward orthopnea and have a history of paroxysmal nocturnal dyspnea.
▪ The ASA 3 patient with heart failure is at increased risk during dental treatment.
Before starting any treatment, medical consultation and use of the stress reduction
protocol and other specific treatment modifications should be given serious
consideration.
174
▪ ASA 4: The patient experiences dyspnea, orthopnea, and undue fatigue at all
times.
▪ Comment: The ASA 4 patient represents a significant risk. Even at rest this
patient’s heart cannot meet the body’s metabolic requirements.
175
▪ Any degree of stress further increasing metabolic demand may exacerbate

the condition and possibly provoke acute pulmonary edema.
▪ If physical intervention becomes necessary, this patient should be treated in a

controlled environment, such as in a hospital dental clinic, and be under a
physician’s care before, during, and immediately following the dental
procedure.
176
177
178
PATHOPHYSIOLOGY
▪ Heart failure may develop whenever the heart labors for extended periods of
time against increased peripheral resistance (increased afterload), such as
occurs with high blood pressure or valvular defects (stenosis or insufficiency),
or prolonged, continuous demands for increased cardiac output (as occurs in
hyperthyroidism).
▪ These conditions, which demand a chronic increase in cardiac workload, lead

to structural changes in the myocardium that eventually progress to muscular
weakness and produce the clinical signs and symptoms of heart failure.
179
PATHOPHYSIOLOGY
▪ Another major cause of myocardial weakness is the presence of a disease

state that directly attacks the myocardium (e.g., coronary artery disease and
myocarditis).
▪ In these conditions, cardiac muscle cannot respond normally to increases in

afterload.
▪ The increase in fiber length that occurs as a result of increased ventricular

filling is not met with the usual increase in stroke volume, and clinical heart
failure results.
180
MANAGEMENT
▪ Step 1: termination of the dental procedure. Treatment should cease as soon

as the patient begins to exhibit signs and symptoms of respiratory distress
▪ Step 2: P (position). As with patients suffering other forms of acute respiratory

distress, the patient suffering acute pulmonary edema usually remains
conscious. This patient may appear panicky and uncooperative.
181
MANAGEMENT
▪ Position the patient comfortably, which in most cases will be an upright

position.
▪ This position allows excess fluid within the alveolar sacs to concentrate at the
bases of the lungs, permitting a greater exchange of O2.
▪ If at any time the patient loses consciousness, that individual must be placed
in the supine position.
182
MANAGEMENT
▪ materials or instruments should be removed from the patient’s mouth

immediately.
▪ Step 4: activate office emergency team and summons emergency medical

services.
183
MANAGEMENT
▪ At the onset of acute respiratory distress in a patient with preexisting heart

failure, the appropriate office team member should contact emergency
medical services (9-1-1) immediately.
▪ The patient usually requires immediate emergency treatment and

hospitalization.
▪ Further medical management in the hospital may include phlebotomy, O2, and
drug therapy, such as digitalis and diuretics.
184
MANAGEMENT
▪ Step 5: calming of the patient. Dental personnel must reassure the patient
that they are making every effort to manage the problem and that they have
summoned emergency personnel.
▪ Step 6: C → A → B (circulation-airway-breathing), basic life support as

needed. In acute pulmonary edema, circulation, airway, and breathing are
(usually) adequately maintained by the patient.
185
MANAGEMENT
▪ Step 7: D (definitive care)
▪ Step 7a: administration of O2. O2 should be administered to all patients who

demonstrate signs of acute pulmonary edema or severe heart failure.
▪ Patients require high concentrations at high flow rates to prevent or alleviate

hypoxia. Face masks should be used wh a flow rate of 10 L or more of O2 per
minute.
186
MANAGEMENT
▪ Step 7b: monitoring of vital signs. Vital signs, including blood pressure, heart
rate and rhythm, and respiratory rate, should be monitored and recorded
every 5 minutes.
▪ The blood pressure, heart rate, and respiratory rate increase in patients with
acute heart failure; these changes demonstrate the presence of extreme
apprehension and cardiac and pulmonary congestion.
187
MANAGEMENT
▪ Step 7c: alleviation of symptoms. The immediate goal in the management of

acute pulmonary edema is to alleviate the patient’s breathing difficulties.
▪ Proper positioning (per patient wishes, but usually upright) is extremely

important. If respiratory distress is still evident, however, additional steps may
be required.
▪ In cases of acute pulmonary edema, the heart cannot adequately handle the
quantity of blood being delivered to it.
188
MANAGEMENT
▪ Step 7f: alleviate apprehension. Most patients suffering acute pulmonary

edema are extremely apprehensive, bordering on panic. Increased
apprehension leads to increases in cardiac and respiratory workloads, both of
which are absolutely contraindicated in these patients. For this reason dental
personnel must take special care to eliminate patient anxiety.
▪ Step 8: discharge. The patient suffering acute pulmonary edema requires

hospitalization for additional management.
189
190
QUESTIONS?
191
CHAPTER 15
RESPIRATORY DISTRESS:
DIFFERENTIAL
DIAGNOSIS
192
MEDICAL HISTORY
▪ Patients suffering acute respiratory distress almost always retain

consciousness throughout the episode.
▪ Advantage may be taken of this by asking the patient about any previous
similar episodes.
193
MEDICAL HISTORY
▪ The medical history questionnaire includes questions about respiratory

problems, such as asthma, heart failure, or a history of hyperventilation, which
facilitate a differential diagnosis.
▪ If at any time consciousness is lost, management proceeds to follow the

protocol for management of the unconscious patient (see Part 2:
Unconsciousness).
194
AGE
▪ Respiratory distress in younger patients (under the age of 10) most commonly
is related to asthma (usually allergic asthma).
▪ Hyperventilation and heart failure are significantly less common in this age
group (children with severe, uncorrected, congenital heart defects may
demonstrate respiratory distress, but their medical history will have provided
the doctor with this information).
▪ Hyperventilation is more likely to be the cause of respiratory distress for

individuals between 12 and 40 years of age.
195
AGE
▪ Asthma may also occur in this age group, but in most instances, patients
already know that they suffer from this condition.
▪ Clinically significant heart failure is rarely seen before the age of 40 years.
▪ The peak incidence of heart failure in men is between 50 and 60 years; in

women, the peak falls between 60 and 70 years.
196
SEX
▪ The incidence of hyperventilation, asthma, and heart failure does not differ
markedly between males and females
▪ The incidence of heart failure is slightly greater among males in any age
group than in females under the age of 70 years.
197
RELATED CIRCUMSTANCES
▪ Stress, whether physiologic or psychological, is present in most instances of

respiratory distress and increases in severity as the episode progresses.
▪ In the dental environment, hyperventilation is precipitated almost exclusively

by extreme apprehension.
▪ Stressful situations may acutely exacerbate asthma, especially in children,

regardless of the type of asthma (intrinsic or extrinsic).
▪ In addition, stress causes the physical condition of patients with heart failure
to progressively deteriorate.
198
CLINICAL SYMPTOMS BETWEEN ACUTE EPISODES
▪ The patient with heart failure may exhibit clinical signs and symptoms at all
times, either during physical activity or at rest.
▪ Orthopnea, dependent edema, peripheral cyanosis, dyspnea, and undue

fatigue may be evident in the patient during dental appointments, depending
on the degree of pump failure.
199
CLINICAL SYMPTOMS BETWEEN ACUTE EPISODES
▪ Asthmatic patients may be asymptomatic between acute episodes; however,

noisy breathing and chronic coughs may be present while at rest.
▪ No clinical signs and symptoms of hyperventilation are present between

episodes.
200
POSITION
▪ The position of the patient at the onset of clinical symptoms is most relevant in
patients with heart failure.
▪ Respiratory distress becomes progressively more severe as the dental chair is

reclined toward the supine position.
201
POSITION
▪ Symptoms can often be dramatically relieved by simply positioning the patient

upright.
▪ Signs and symptoms of asthma and hyperventilation do not respond to

repositioning, although most patients in respiratory distress are able to
breathe more easily in an upright position.
202
ACCOMPANYING SOUNDS
▪ Wheezing is usually present in patients with asthma.
▪ Wheezing may also be present in paroxysmal nocturnal dyspnea and

pulmonary edema (cardiac asthma), although in these circumstances it is
associated with other signs and symptoms of heart failure.
203
ACCOMPANYING SOUNDS
▪ Partial obstruction of the trachea or bronchi by a foreign object may also

produce wheezing.
▪ Individuals with heart failure may also exhibit moist, wet respirations,
especially those suffering acute pulmonary edema, which is often associated
with a frothy, pink-tinged sputum and cough.
▪ Hyperventilating individuals breathe deeper and more rapidly than normal but
produce no accompanying abnormal sounds.
204
SYMPTOMS ASSOCIATED WITH RESPIRATORY DISTRESS
▪ Most individuals in respiratory distress experience shortness of breath.
▪ In cases of heart failure, shortness of breath progressively worsens as the

patient reclines (orthopnea) and increases with exertion.
205
SYMPTOMS ASSOCIATED WITH RESPIRATORY DISTRESS
▪ Shortness of breath during episodes of hyperventilation is related to anxiety

and a feeling of suffocation; it is not related to exertion.
▪ In addition, hyperventilation is not associated with cough.
▪ Asthmatic patients exhibit shortness of breath associated with episodic

wheezing during acute periods. Some asthmatic patients are asymptomatic
between acute episodes.
206
PERIPHERAL EDEMA AND CYANOSIS
▪ Patients with heart failure may exhibit peripheral edema and cyanosis.
▪ Other possible causes of peripheral edema include renal disease, varicose

veins, and pregnancy, whereas cardiorespiratory disease and polycythemia
vera are possible causes of cyanosis.
▪ In cases of severe asthma with hypoxia or hypercarbia, cyanosis may be

present; however, peripheral edema is not noted.
▪ Neither peripheral edema nor cyanosis usually accompanies hyperventilation
207
PARESTHESIA OF THE EXTREMITIES
▪ Tingling and numbness of the fingers, toes, and perioral regions are
experienced during hyperventilation.
▪ These symptoms may also be present, but much less commonly, in milder
episodes of asthma and heart failure, produced by the patient hyperventilating
secondary to acute anxiety.
208
USE OF ACCESSORY RESPIRATORY MUSCLES
▪ The patient with acute asthma uses accessory muscles of respiration

(abdominal, back, and neck muscles) in an effort to breathe adequately. This
may also be noted with acute pulmonary edema.
209
CHEST PAIN
▪ Hyperventilating patients often experience chest pain, describing it as a

“weight,” a “pressing” sensation, or as a “shooting” or “stabbing” feeling.
▪ However, these patients rarely exhibit other clinical manifestations of cardiac

disease. The age of the hyperventilating patient (under 35 years) is usually
below that at which cardiovascular disease normally occurs.
210
CHEST PAIN
▪ Patients suffering asthma usually do not experience chest pain along with
their other clinical symptoms.
▪ When chest pain occurs in a patient with preexisting heart failure, it might be
associated with a concurrent acute myocardial infarction.
211
HEART RATE AND BLOOD PRESSURE
▪ Both heart rate and blood pressure usually increase during periods of
respiratory distress.
▪ This elevation occurs in hyperventilation and during acute asthmatic episodes

as a result of anxiety. In these cases, the blood pressure (both systolic and
diastolic) and heart rate are elevated.
212
HEART RATE AND BLOOD PRESSURE
▪ Although both the systolic and the diastolic pressures increase during heart
failure, diastolic blood pressure is usually elevated to a greater degree;
therefore, the pulse pressure (systolic minus diastolic) narrows (to 40).
▪ Heart rate increases in heart failure.
213
DURATION OF RESPIRATORY DISTRESS
▪ Respiratory distress associated with heart failure often improves dramatically

following repositioning (when the patient sits upright).
▪ However, when pulmonary edema is present, respiratory distress does not

improve until definitive management is initiated.
214
DURATION OF RESPIRATORY DISTRESS
▪ Most asthma attacks will not resolve for a considerable period without drug
management; therefore, bronchodilator therapy is employed as soon as it is
available.
▪ Status asthmaticus requires more definitive management, including

hospitalization.
▪ Hyperventilation is usually manageable without drug intervention and rarely, if

ever, requires the help of additional personnel or hospitalization.
215
QUESTIONS?
216

Medical Emergencies CH 10-15

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CHAPTER 10

▪ To a conscious person, difficulty breathing is quite disconcerting.

▪ This section focuses on several common causes of respiratory distress,

▪ Because persons in these types of respiratory distress usually remain

▪ In almost all medical emergencies involving the loss of consciousness, some

▪ In most of these situations a patient does not exhibit respiratory distress

▪ A major factor leading to the exacerbation of respiratory disorders is undue

▪ Hyperventilation and vasodepressor syncope - among the most frequently

▪ Children with asthma may exhibit acute episodes of bronchospasm when

▪ Adequate pretreatment medical and dental evaluations can prevent

▪ Clinical manifestations of respiratory distress vary according to the degree of

▪ In most cases the patient retains consciousness throughout the acute

▪ Although retention of consciousness is a positive sign, indicating that the

▪ Asthmatic patients often exhibit characteristic wheezing sounds produced by

▪ Figure 10-1 illustrates the sites of

▪ The syndromes responsible for respiratory distress involve various segments

▪ Bronchioles are the primary site of involvement in acute asthma.

▪ In asthmatic patients, bronchi become highly reactive, demonstrating

▪ This type of respiratory distress is related to an engorgement of the

▪ Hyperventilation is a more generalized problem.

▪ Rapid breathing (tachypnea) associated with hyperventilation results in the

▪ Successfully managed, hyperventilation has no residual effect. However, in

▪ Acute foreign body (lower) airway obstruction (FBAO) is a potentially life-

▪ Immediate recognition and management are essential to prevent permanent

▪ Step 1: recognition of respiratory distress.

▪ Many respiratory disorders are associated with characteristic sounds, such as

• the wheezing of bronchospasm and

• the cough and crackling respirations (rales) of pulmonary edema.

▪ By contrast, hyperventilation does not usually produce a characteristic sound;

▪ Step 2: discontinue dental procedure. Dental treatment should cease as soon

▪ Step 3: P position the patient.

▪ In conscious patients experiencing respiratory distress, positioning is based

▪ In the presence of near-normal or slightly elevated blood pressure (as is

▪ However, patients can be maintained in this position only as long as they

▪ Step 4: C → A → B (circulation-airway-breathing), basic life support, as

▪ Patients in respiratory distress often experience two major problems - primary

▪ In the unlikely event that respiratory distress leads to unconsciousness, the

▪ Step 5c: definitive management of respiratory distress. After assessing the

▪ Published reports have documented the retrieval of rubber dam clamps,

▪ Although an acutely life-threatening situation does not immediately exist,

▪ The epidemiology of foreign bodies in the airway, pharynx, and esophagus

▪ Elderly patients, particularly those with primary neurologic disorders and

▪ Sit-down dentistry, where patients are placed in a supine or semisupine

▪ Gravity acts to force the object posteriorly into the pharynx.

▪ In most offices a dental assistant is seated across from the doctor.

▪ If nothing is readily available, a high-volume, large-diameter suction tip may

▪ A trap on the suction line permits prompt retrieval of the object

▪ A tongue grasping forceps (Figure 11-8)

▪ Dental floss should be secured to rubber dam clamps, endodontic

▪ The right-angled bend in the Magill forceps permits a comfortable hand

▪ When an object enters the oropharynx of a patient lying in the supine or

▪ The radiologist recommends a flat plate of the abdomen, an anteroposterior

▪ If the object’s location is not apparent on the radiograph or if any question

▪ Signs and symptoms include: the sudden onset of coughing, choking,

▪ The patient may cough spontaneously; if not, coughing should be encouraged

(1) large, poorly chewed pieces of food;

(2) elevated blood alcohol levels;

(3) laughing or talking while eating; and

(4) upper or lower dentures

▪ For management purposes, partial obstruction is subdivided into two

▪ Once a patient with an obstructed airway loses consciousness, basic life

▪ In those instances, in which a lower-airway obstruction is obvious (e.g., airway

▪ Step 3: head tilt–chin lift. The