Medical Emergencies I) GENERAL CONSIDERATIONS

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Theodore Dwain Barnett
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1 Steven W. Beadnell, DMD Brett A. Ueeck, DMD, MD Sunset Oral & Maxillofacial Surgery SW Barnes Rd, #110 Portland, OR

2 I) GENERAL CONSIDERATIONS Medical Emergencies A) PREVENTION OF MEDICAL EMERGENCIES 1) Recognition of risk (a) Medical history: (1) Past medical history (2) Review of systems-questions regarding symptoms they may have (3) Medications (4) Past Hospitalizations (5) Allergies (b) Careful review of medical history provides (1) Disease processes that are present (2) Opportunity to ask questions to elucidate the stability of disease processes (3) Determine what impact the disease process has on dental treatment (4) Determine what impact the dental treatment may have on disease process 2) Vital Signs - Blood Pressure referral and treatment criteria National Heart Institute 2004 Blood Pressure Classification Systolic BP (mmhg) Diastolic BP (mmhg) Normal < 120 < 80 PreHypertension Hypertension Stage 1 Hypertension Stage > 160 > 100 Management of Patient Relative to Blood Pressure SBP DBP MRF* Dentist Guidelines Yes/No Routine Tx OK; Discuss HTN guidelines Yes/No Routine Tx OK; Refer for Medical Consult No Routine Tx OK; Refer for Medical Consult Yes Urgent Tx OK; Refer for Medical Consult No No Tx w/o consult; Refer prompt Med Consult Yes No dental Tx; Refer emergent Medical Consult > 210 > 120 Yes/No No dental Tx: Refer emergent Medical Consult *MRF = medical risk factors = prior MI, angina, high coronary disease risk, recurrent stroke prevention, kidney disease, ischemic heart disease 2

3 3) Quick Medical Consult (a) Fax note or talk with nurse (b) Ask for Problem List and Medication List (c) Determine if need to investigate stability of medical conditions? (d) Possibly consult with physician regarding modifications of dental treatment needed or special precautions that need to be taken? (e) To download Referral Section, Password: soms2323 (case sensitive), Clinical References, Medical Consult Short Form B) EMERGENCY EQUIPMENT 1) Primary emergency equipment (a) Oxygen delivery system E tank, bag-valve-mask, pocket mask (b) Suction & tonsil tip portable unit (c) Syringes with needles 3cc with 21 gauge (d) IV equipment tourniquet (e) Magill intubation forceps 2) Secondary emergency equipment (a) Artificial airways oropharyngeal, nasopharyngeal (b) Intubation equipment laryngoscope, endotracheal tubes (c) King LT Airway C) EMERGENCY DRUGS 1) Primary Emergency Drugs Category Antiallergy Histamine Blocker Vasodilator Bronchodilator Antihypoglycemic Oxygen Antiplatelet 2) Secondary Emergency Drugs Drug Epinephrine Benadryl Nitroglycerin Albuterol Insta-Glucose Portable Aspirin Southern Anesthesia & Surgical, Inc Preparation 1: mg/ml Spray (0.4mg/puff) Inhaler Tube 100% 81 mg Tablet Category Anticonvulsant Analgesic Vasopressor Antihypoglycemic Corticosteroid Antihypertensive Anticholinergic Drug Midazolam (Versed) Morphine Sulfate Methoxamine (Vasoxyl) 50% Dextrose Solu-Cortef Esmolol (Brevibloc) Atropine Preparation 5mg/ml 10mg/ml 10mg/ml 50mg/ml 50mg/ml 100mg/ml 0.5mg/ml 3

This will help prevent you from placing your thumb over the black 'active' end. B) Place black tip against outer mid-thigh of the child. (Note; there is no need to 'swing and jab').

4 II)EpiPen Instructions A) Form a fist around EpiPen and pull off grey cap (do not twist). Before pulling off the grey cap you should check that your thumb is closest to the grey cap end, and not over the end of the EpiPen, as in the picture. This will help prevent you from placing your thumb over the black 'active' end. B) Place black tip against outer mid-thigh of the child. (Note; there is no need to 'swing and jab'). C) Push HARD against thigh until a click is heard or felt and hold in place for 10 seconds. Do not put thumb over end of the EpiPen D) Remove the EpiPen and then call an ambulance. The EpiPen can only be used once. If you have administered epinephrine to a patient for any reason, call 911 as patient usually needs to be evaluated in emergency room. 4

5 III) IV) Patient Assessment 1) Position 2) Circulation check pulse, chest compressions if needed 3) Airway opening head tilt, chin lift 4) Breathing artificial breathing if needed 5) Definitive management 6) Activate Emergency Medical System (EMS) early in treatment protocol UNCONSCIOUSNESS A) Mechanisms of unconsciousness 1) Inadequate blood flow to brain 2) Inadequate oxygen flow to brain 3) Metabolic deficiencies 4) Disorders of the nervous system 5) Psychic mechanisms B) Basic unconsciousness treatment Differential Diagnosis: Syncope Drug ingestions Orthostatic hypotension Seizure disorders Hypoglycemic rxn Stroke (CVA) Recognition of Unconsciousness Position patient supine, feet elevated Assess Circulation (Carotid pulse) Artificial circulation if needed Assess Breathing (Look, Listen, Feel) Artificial ventilation if needed Activate EMS if delayed recovery Definitive management of cause 5

6 C) VASODEPRESSOR SYNCOPE 1) Predisposing factors (a) Psychogenic: fright, anxiety, emotional stress, sight of blood, unwelcome news (b) Nonpsychogenic: upright position, hunger, exhaustion, male gender, age (c) Flight or fight response versus syncopal reaction (d) Clinical signs and symptoms (1) Early: feeling of warmth, pale, loss of skin color, nausea, heavy perspiration, tachycardia, feel bad, feel faint. (2) Late: papillary dilation, yawning, rapid respirations, hypotension, bradycardia (e) Management of syncope Assess level of consciousness Position supine, feet elevated Assess Circulation, Airway, Breathing Provide CPR if needed Activate EMS if recovery is not immediate sec Administer oxygen Monitor vital signs If initial recovery of patient placed in supine position takes more than seconds, reconsider possible diagnoses other than syncope. (f) Prevention of syncope (1) Patient positioning supine position during treatment (2) Anxiety relief: preoperative sedation, nitrous oxide 6

D) POSTURAL HYPOTENSION 1) Predisposing factors (a) Drug administration especially antihypertensives (b) Prolonged recumbency (c) Inadequate postural reflex (d) Pregnancy (e) Addison s disease 2)

7 D) POSTURAL HYPOTENSION 1) Predisposing factors (a) Drug administration especially antihypertensives (b) Prolonged recumbency (c) Inadequate postural reflex (d) Pregnancy (e) Addison s disease 2) Drugs that predispose to postural hypotension (a) Antianginals (b) Antiarrhythmics (c) Antidepressants (d) Antihistamines (e) Antihypertensives (f) Antipsychotics (g) Beta-blockers (h) Diuretics (i) Phenothiazines (j) Tranquilizers 3) Management of postural hypotension Most of your patients take multiple of these drugs! Assess consciousness Position supine, feet elevated Assess Circulation, Airway, Breathing Provide CPR if needed Administer oxygen Monitor vital signs (Episode terminates) (Episode continues) Slowly reposition chair, discharge Summon medical assistance 4) Avoiding postural hypotension (a) Know medical history: medications, fainting history (b) Slowly discharge from supine position 7

Aspiration usually leads to coughing, wheezing, or choking.

8 V)RESPIRATORY EMERGENCIES A) AIRWAY OBSTRUCTION 1) Methods to open the airway in unconscious patient tongue blocks airway Head Tilt, Chin Lift Jaw Thrust (Trauma patient) 2) THE LOST CROWN (a) Aspiration versus swallowing (1) Aspiration usually leads to coughing, wheezing, or choking. Symptoms present within first hour in 90% of patients, but may be delayed up to six hours. (2) Swallowing of object usually causes no symptoms 3) Management of aspiration 8

B) ASTHMA 1) Hyperreactivity of the tracheobronchial tree 2) Pathologic processes (a) Bronchial smooth muscle contraction (b) Bronchial wall edema (c) Mucus hypersecretion 3) Triggers in dental

(c) How severe are your attacks, ever had to go to ER or Hospital? (d) How do you usually manage your attacks? Does the inhaler usually abort them?

5) Clinical manifestations (a) Chest congestion, coughing, wheezing (b) Anxiety or agitation (c) Tachypnea, greater than 20 breaths per minute (d) Use of accessory muscle of respiration (e) Patient

9 B) ASTHMA 1) Hyperreactivity of the tracheobronchial tree 2) Pathologic processes (a) Bronchial smooth muscle contraction (b) Bronchial wall edema (c) Mucus hypersecretion 3) Triggers in dental office (a) Medications: Aspirn, NSAIDS (b) Latex, multiple other allergens 4) Assessment of severity and control of asthma (a) How frequent are your attacks? (b) What precipitates your attacks? (c) How severe are your attacks, ever had to go to ER or Hospital? (d) How do you usually manage your attacks? Does the inhaler usually abort them? (e) What medications are you currently taking for your asthma? (f) When was your last attack? 5) Clinical manifestations (a) Chest congestion, coughing, wheezing (b) Anxiety or agitation (c) Tachypnea, greater than 20 breaths per minute (d) Use of accessory muscle of respiration (e) Patient wants to sit up or stand 6) Identifying the severe attack (a) Pulse oximetry is below 91% (b) Bronchodilator doesn t improve symptoms after two treatments (c) Patient has difficulty speaking (1) Sentences < phrases < words < mute 7) Management of asthma Position patient comfortably (upright) C - A B BLS as needed Administer bronchodilator via inhalation (Alubuterol inhaler) (Episode terminates) (Episode continues) Complete dental treatment Discharge patient Administer oxygen, call EMS Epinephrine 0.3mg SQ or IM Discharge or hospital 9

VI) ALTERED CONSCIOUSNESS A) DIABETIC EMERGENCIES 1) Classification of diabetes mellitus (a) Type 1 Absolute insulin deficiency (b) Type 2 Insulin resistance & relative lack of insulin (c) Secondary

10 VI) ALTERED CONSCIOUSNESS A) DIABETIC EMERGENCIES 1) Classification of diabetes mellitus (a) Type 1 Absolute insulin deficiency (b) Type 2 Insulin resistance & relative lack of insulin (c) Secondary diabetes diabetes associated with other diseases (d) GDM Gestational Diabetes Mellitus 2) Blood glucose measurement Diagnosis Fasting Blood glucose level (mg/dl) Normal Impaired glucose intolerance Diabetes mellitus > 126 3) Assessing the level of control of diabetes (a) How long have you had diabetes=> presence of co-morbidities? (b) How often do you check your blood sugar? (c) What is your normal blood sugar/ What was your last HBA1C? (d) What medications do you normally take? (e) How often do you have insulin reactions? (f) Do you feel a prodrome before an insulin reaction comes on? (g) Symptoms present: polyuria, polyphagia, polydipsia 4) Dental management to avoid problems (a) Morning appointments best tolerated (b) Confirm patient took insulin and ate their usual breakfast (c) What is their blood sugar level check with glucometer (1) Blood sugar < 70mg/dL => defer treatment (2) Blood sugar > 200mg.dL => defer treatment (3) GOAL=> keep them a little sweet 10

5) HYPOGLYCEMIA (a) Altered cerebral function since brain is dependent on glucose (b) If diabetic patient has any alteration in mental status, should assume they are hypoglycemic until proven

(c) Early manifestations (1) Diminished cerebral function altered mood, lack of spontaneity (2) Weakness, dizziness (3) Pale, moist skin (4) Headache (d) Late manifestations (1) Sweating (2)

11 5) HYPOGLYCEMIA (a) Altered cerebral function since brain is dependent on glucose (b) If diabetic patient has any alteration in mental status, should assume they are hypoglycemic until proven otherwise. (c) Early manifestations (1) Diminished cerebral function altered mood, lack of spontaneity (2) Weakness, dizziness (3) Pale, moist skin (4) Headache (d) Late manifestations (1) Sweating (2) Tachycardia (3) Hypotension (4) Anxiety (5) Seizure activity and eventual unconsciousness 6) Management of hypoglycemia * * Conscious Patient * * Position patient comfortably C - A B BLS as needed Administer oral carbohydrate (InstaGlucose) * * Unconscious Patient * * Position patient supine, legs elevated C - A B BLS as needed Activate EMS - ASAP (Episode terminates) Observe one hour Discharge patient, escort? (Episode continues) Activate EMS Glucagon 1mg IM or IV Dextrose 50% 50ml IV Discharge or hospital? Parenteral Carbohydrates Dextrose 50% 50ml IV Glucagon 1mg IM or IV (Epinephrine 0.5mg SQ or IM) Oral carbohydrates after recovers Discharge or transport to hospital B) CEREBROVASCULAR ACCIDENT 1) Classification (a) Cerebral infarction 85% (1) Thrombosis or embolism (2) Ischemia causes necrosis of tissue (b) Intracranial hemorrhage 10% (1) Vessel or aneurysm ruptures, bleeds (2) Congenital aneurysms (3) Hypertension causes vessel damage (c) Transient Ischemic Attacks (TIA) ANGINA OF THE BRAIN (1) Focal ischemic events (2) Neurologic deficits last less than 24 hours, usually less than 10 minutes (3) Indicative of cerebrovascular disease 11

2) Associated risk factors (a) Hypertension (b) Atrial fibrillation (c) Abnormal heart valves (d) Smoking (e) Elevated lipids 3) Manifestations of TIA or CVA FOUR CARDINAL SIGNS (a) Hypertension,

12 2) Associated risk factors (a) Hypertension (b) Atrial fibrillation (c) Abnormal heart valves (d) Smoking (e) Elevated lipids 3) Manifestations of TIA or CVA FOUR CARDINAL SIGNS (a) Hypertension, usually > 140/90 (b) Altered consciousness (c) Hemiparesis, hemiparalysis (d) Headache, blurred vision (e) Asymmetry of face or pupils (f) Incontinence (g) Aphasia inability to speak C) Management of CVA Time is brain Position patient comfortably C - A B BLS as needed Monitor vital signs Activate EMS Administer oxygen Elevate head if BP elevated ( Definitive care ) 12

VII) SEIZURE DISORDERS A) Classification 1) Focal seizures (a) Simple partial (b) Psychomotor 2) Generalized seizures (a) Petit mal, absence (b) Grand mal, tonic-clonic 3) Status epilepticus B)

Prodromal phase (1) Change in mood (2) Aura usually related to senses (b) Preictal phase (1) Falls to floor, epileptic cry (c) Ictal phase (1) Tonic sustained, generalized contractions (2) Clonic

13 VII) SEIZURE DISORDERS A) Classification 1) Focal seizures (a) Simple partial (b) Psychomotor 2) Generalized seizures (a) Petit mal, absence (b) Grand mal, tonic-clonic 3) Status epilepticus B) Common triggering agents: flashing lights, fatigue, missed meal, emotional stress, alcohol ingestion, physical stress, hypoglycemia C) GRAND MAL SEIZURES 1) Typical seizure occurs in phases (a) Prodromal phase (1) Change in mood (2) Aura usually related to senses (b) Preictal phase (1) Falls to floor, epileptic cry (c) Ictal phase (1) Tonic sustained, generalized contractions (2) Clonic alternate extensor / flexor muscle contraction (d) Postictal phase (1) Muscle flaccidity, incontinence (2) Slowly regains consciousness 2) Management of grand mal seizure Ictal Phase Position supine, legs slightly elevated Activate EMS if new onset C - A B BLS as needed * Protect from injury * Administer oxygen Monitor vital signs To hospital Postictal Phase Keep supine, legs slightly elevated C - A B BLS as needed Monitor vital signs Reassure patient, permit recovery Discharge patient To home To physician 3) STATUS EPILEPTICUS (a) A continuous seizure or the repetitive recurrence of seizures without recovery between attacks (b) Management of status epilepticus: Versed titrated and Dextrose 50% 30-50cc 13

VIII)CARDIAC EMERGENCIES A) ACUTE CORONARY SYNDROME 1) Ischemic heart disease (a) Angina Pectoris (b) Myocardial Infarction B) ANGINA PECTORIS

shoulder, face, left arm, neck (e) Subsides with rest or nitroglycerin 2) Management of angina pectoris Position patient comfortably (upright)

6 mg SL Administer oxygen, monitor VS Repeat NTG q3-5', Total 3 doses Pain Discharge Hospital Resolves NO Activate EMS 3) Nitrogylcerin (a)

14 VIII)CARDIAC EMERGENCIES A) ACUTE CORONARY SYNDROME 1) Ischemic heart disease (a) Angina Pectoris (b) Myocardial Infarction B) ANGINA PECTORIS 1) Manifestations (a) Sudden onset with exertion or emotion (b) Substernal, squeezing chest pain (c) Heavy weight, indigestion (d) Radiates to shoulder, face, left arm, neck (e) Subsides with rest or nitroglycerin 2) Management of angina pectoris Position patient comfortably (upright) BLS as needed, monitor vital signs History of angina pectoris? Typical Angina? YES Nitroglycerin mg SL Administer oxygen, monitor VS Repeat NTG q3-5', Total 3 doses Pain Discharge Hospital Resolves NO Activate EMS 3) Nitrogylcerin (a) Prophylactic use 3-5 minutes prior to local anesthetic injections (b) Avoid in patients on erectile dysfunction drugs (Viagra, Cialis) within 12 hours (c) Avoid if systolic BP falls below 100mmHg 14

C) MYOCARDIAL INFARCTION 1) Clinical manifestations (a) Retrosternal, severe to intolerable pain (b) Prolonged, usually > 30 minutes (c) Crushing, choking (d) Radiates to left arm, neck, epigastrum

NTG or rest 3) Management of myocardial infarction Position comfortably BLS, oxygen, NTG X 3 doses as in angina ** If no response or if pain resolves, but returns ** Activate EMS Administer

15 C) MYOCARDIAL INFARCTION 1) Clinical manifestations (a) Retrosternal, severe to intolerable pain (b) Prolonged, usually > 30 minutes (c) Crushing, choking (d) Radiates to left arm, neck, epigastrum (e) Nausea, vomiting (f) Weakness, palpitations, dyspnea (g) Sense of impending doom 2) Assume MI, not angina, if: (a) New onset chest pain (b) Change in previous chest pain (c) Pain unrelieved by NTG or rest 3) Management of myocardial infarction Position comfortably BLS, oxygen, NTG X 3 doses as in angina ** If no response or if pain resolves, but returns ** Activate EMS Administer fibrinolytics (ASA) Monitor vital signs Manage pain - narcotics Morphine 2-15mg IV q15 minutes Nitrous oxide is option 23% mortality reduction Transport to hospital - - ACLS 4) Post-MI management (a) Considerations: Electrical irritability, Re-infarction rate, Cardiac instability (b) MI within one month + residual ischemic symptoms (1) Major cardiac risk, no elective dental care (c) MI within one month without residual ischemic symptoms (1) Intermediate cardiac risk (d) Reasonable to delay treatment 4-6 weeks 15

D) CARDIAC ARREST 1) Possible causes (a) Myocardial infarction (b) Sudden cardiac death (c) Airway obstruction (d) Anaphylaxis (e) Acute adrenal

Defibrillation Less than one minute 90% One to two minutes 80% Each additional minute Decreases 10% 4) Automated External Defibrillator AED (a)

defibrillator pads (2) Follow verbal instructions 5) Management of cardiac arrest (a) Primary Survey (1) Circulation provide chest compressions

16 D) CARDIAC ARREST 1) Possible causes (a) Myocardial infarction (b) Sudden cardiac death (c) Airway obstruction (d) Anaphylaxis (e) Acute adrenal insufficiency 2) Ventricular fibrillation is cause in 90% of cases 3) Efficacy of defibrillation Time in Ventricular Fibrillation Success of Defibrillation Less than one minute 90% One to two minutes 80% Each additional minute Decreases 10% 4) Automated External Defibrillator AED (a) Criteria for use (1) Patient is unconscious (2) Patient is not breathing (3) Patient has no pulse (b) Instructions for use (1) Apply defibrillator pads (2) Follow verbal instructions 5) Management of cardiac arrest (a) Primary Survey (1) Circulation provide chest compressions (2) Airway open the airway (3) Breathing provide positive pressure ventilation (4) Defibrillate ventricular fibrillation or pulseless ventricular tachycardia 16

IX) DRUG-RELATED EMERGENCIES A) ALLERGIC REACTIONS 1) Common dental allergens (a) Antibiotics penicillin, cephalosporins, tetracyclines (b) Analgesics aspirin, nonsteroidal anti-inflammatory agents

and vasodilation (b) Signs and symptoms clinical manifestations (1) Urticaria/hives (2) Pruritis (3) Tingling and warmth (4) Flushing 3) Respiratory allergic reactions (a) Mechanisms (1) Increased

17 IX) DRUG-RELATED EMERGENCIES A) ALLERGIC REACTIONS 1) Common dental allergens (a) Antibiotics penicillin, cephalosporins, tetracyclines (b) Analgesics aspirin, nonsteroidal anti-inflammatory agents (c) Opioids Meperdine, Codeine (d) Antianxiety agents barbiturates (e) Local anesthetics esters, benzocaine, sodium sulfite 2) Allergic skin reactions (a) Mechanism: increased vascular permeability and vasodilation (b) Signs and symptoms clinical manifestations (1) Urticaria/hives (2) Pruritis (3) Tingling and warmth (4) Flushing 3) Respiratory allergic reactions (a) Mechanisms (1) Increased vascular permeability and vasodilation (2) Increased exocrine gland secretions (3) Bronchial smooth muscle contraction (b) Signs and symptoms clinical manifestations (1) Rhinitis nasal congestion, nasal itching, rhinorrhea (2) Bronchospasm coughing, wheezing, tachypnea (3) Laryngeal edema dyspnea, hoarseness, stridor 4) Cardiovascular allergic reactions (a) Mechanisms (1) Increased vascular permeability and vasodilation (2) Decreased cardiac output (3) Loss of vasomotor tone (b) Signs and symptoms clinical manifestations (1) Circulatory collapse weakness, lightheadedness, syncope, ischemic chest pain (2) Dysrhythmias weakness, palpitations (3) Cardiac arrest pulselessness, ventricular fibrillation 5) Prediction of the severity of the allergic reaction is related to: (a) The rapidity of onset in relation to introduction of the allergen (b) The rapidity of progression of the signs and symptoms 6) Drugs used for allergic reactions (a) Epinephrine reverses pathologic processes involved in the allergic reaction (b) Benadryl histamine competitive antagonist, stops progression of allergic reaction 17

18 7) MANAGEMENT OF DELAYED-ONSET SKIN REACTION 8) MANAGEMENT OF RAPID-ONSET SKIN REACTION 18

9) MANAGEMENT OF RESPIRATORY ALLERGIC REACTION 10) GENERALIZED ANAPHYLAXIS (a) Usual progression of symptoms very orderly (1) SKIN warmth, tingling, pruritis, flushing, urticaria (2) EYES, NOSE, GI

19 9) MANAGEMENT OF RESPIRATORY ALLERGIC REACTION 10) GENERALIZED ANAPHYLAXIS (a) Usual progression of symptoms very orderly (1) SKIN warmth, tingling, pruritis, flushing, urticaria (2) EYES, NOSE, GI conjunctivitis, rhinitis, abdominal cramping, nausea, vomiting (3) RESPIRATORY SYSTEM dyspnea, cough, wheeze, throat tightness, laryngeal edema (4) CARDIOVASCULAR SYSTEM pallor, palpitations, lightheadedness, hypotension, tachycardia, dysrhythmias (b) Management of generalized anaphylaxis 19

20 11) ANGIOEDEMA (a) Noninflammatory, nonpruitic edema involving the skin, subcutaneous tissue, underlying muscle, and mucus membranes, especially those of the GI and upper respiratory tracts. (b) Three types (1) Allergic angioedema (2) Hereditary angioedema (3) Idiopathic angioedema (c) Mechanism of angioedema => increased Bradykinin levels (d) Allergic angioedema symptoms (1) Marked skin swelling (i) Eyes, mouth, hands, feet, throat (ii) Usually does not itch, may burn or be painful (iii)may be asymmetric (2) Abdominal pain or cramping swollen mucosa (3) Hives possibly present (4) Laryngeal edema, hoarseness (e) Treatment (1) Remove trigger (2) Secure airway (3) Transfer to hospital (4) Medications: (i) Antihistamines (Benadryl) (ii) Adrenalin (Epinephrine) (iii)bronchodilator (Terbutaline) (iv)cimetidine (Tagamet) (v) Corticosteroids 20

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Medical Emergencies Update (Part 2) 2016

Medical Emergencies Update (Part 2) 2016 1 2 3 4 Hyperactivity of tracheobronchial tree Bronchial smooth muscle contraction Bronchial wall edema Mucus hypersecretion Narrowed airways Wheezing Shortness of breath Coughing 5 Medical Management