tb and pleural diseases
Download
Skip this Video
Download Presentation
TB and Pleural Diseases

Loading in 2 Seconds...

play fullscreen
1 / 28

TB and Pleural Diseases - PowerPoint PPT Presentation


  • 218 Views
  • Uploaded on

TB and Pleural Diseases. Sarah McPherson March 21, 2002. Outline. Spontaneous pneumothorax Causes Treatment Pleural Effusion Causes Work up Treatment Tuberculosis Presentation CXR findings management. Pneumothorax. Tension Recognize, needle decompress, chest tube Spontaneous

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'TB and Pleural Diseases' - elroy


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
tb and pleural diseases

TB and Pleural Diseases

Sarah McPherson

March 21, 2002

outline
Outline
  • Spontaneous pneumothorax
    • Causes
    • Treatment
  • Pleural Effusion
    • Causes
    • Work up
    • Treatment
  • Tuberculosis
    • Presentation
    • CXR findings
    • management
pneumothorax
Pneumothorax
  • Tension
    • Recognize, needle decompress, chest tube
  • Spontaneous
    • Primary: lean, tall males
    • Secondary:
      • more common in patient > 50 yrs
      • More serious because of reduced cardiopulmonary reserve
spontaneous pneumothorax
Causes:

Pulmonary disease

COPD*

Asthma

CF

Infections

Pneumonia

PCP*

TB

Lung abscess

Neoplasm

Primary lung

Metastatic

Interstitial lung disease

Sarcoidosis

Collagen vascular disease

Miscellaneous

PE

Drug abuse

Esophageal rupture

pneumoperitoneum

Spontaneous Pneumothorax
spontaneous pneumothorax5
Spontaneous Pneumothorax
  • Complications:
    • Pneumomediastinum & subcutaneous emphysema
    • Hemopneumothorax
    • Reexpansion pulmonary edema
    • Failure to reexpand (4-14%)
    • Recurrence (10-50%)
management
Management
  • Small PSP(<15%) & asymptomatic
    • High flow oxygen for 6 hours
    • Repeat CXR
    • If no bigger then discharge home
    • Avoid strenuous activity
    • Return ASAP if dyspneic
    • Return in 24 hr for reassessment and repeat CXR
spontaneous pneumothorax management
Spontaneous Pneumothorax - Management

PSP > 15%:

  • Aspiration

Contraindications:

    • Cardiopulmonary instability
    • Significant lung disease
    • Significant concurrent medical problem
    • Pleural effusion
    • Bilateral pneumothorax
    • Effective 70% of first PPS
spontaneous pneumothorax aspiration
Spontaneous Pneumothorax – Aspiration

HOW TO:

  • Patient supine with HOB at 30 degrees
  • Local anesthesia at 2nd intercostal space @ midclavicular line
  • Advance 14 or 16 gauge angiocath cephalad until pleural space is reached
  • Advance catheter and remove needle
  • Attach 3 way stopcock
  • Aspirate with 50 ml syringe
spontaneous pneumo aspiration
Spontaneous Pneumo - Aspiration
  • If > 3L aspirated insert chest tube
  • Repeat CXR at 6 hrs if recurrence then chest tube
  • If no recurrence discharge home
  • Return ASAP if dyspneic
  • Avoid physical exertion
  • Return in 24 hr for repeat CXR
spontaneous pneumo chest tube
Spontaneous Pneumo – Chest tube

Indications:

  • Tension pneumo
  • Underlying pulmonary disease
  • Significant symptoms
  • Persistent air leak (> 3L aspirated, increase size, recurrence)
  • Need for positive pressure ventilation
  • Bilateral pneumos
  • Pleural fluid
management of ssp
Management of SSP
  • Admit
  • Chest tube (20-28 French)
  • Suction if persistent air leak or failure to reexpand with underwater seal

NEJM.2001;342(12):868-74

recurrent pneumo s
Recurrent Pneumo’s
  • Who needs definitive management?
    • Failure to reexpand after 5 days
    • > 2 episodes on the same side
    • Concurrent bilateral pneumo’s
    • Significant hemothorax
    • Large bullae
    • High-risk vocations (aviation, divers)
  • What are the recurrence rates?
    • 30%
    • Most recur within 6 months to 2 years from first episode

NEJM.2001;342(12):868-74

pleural effusions causes
Transudates:

CHF

PE

Cirrhosis

Hypoalbuminemia

Myxedema

Nephrotic syndrome

Superior vena cava obstruction

Exudates:

Pneumonia

TB

Connective tissue disease

Neoplasm

Uremia

Trauma

Drug induced

GI pathology (pancreatitis, subphrenic abscess)

Pleural Effusions - Causes
pleural fluid analysis
Pleural fluid analysis
  • Who do you tap?
    • Unexplained effusions > 10mm on lateral decubitus CXR
  • What do you send it for?
    • Protein and LDH (red top)
    • Glucose (red top)
    • Cell count (lavender top)
    • pH (blood gas tube)
    • Culture and gram stain (sterile container)
    • Cytology if indicated (need 5 green top tubes)
pleural effusions the results
Pleural Effusions – the results
  • Exudative if (99% PPV):
    • LDH > 200U
    • Fluid-blood LDH ratio > 0.6
    • Fluid-blood protein level > 0.5
  • pH:
    • <7.0 is usually only in empyema or esophageal rupture
    • <7.3 is with the above, parapneumonic effusions, malignancy, RA, TB, systemic acidosis
pleural fluid the results
Pleural fluid – the results
  • WBC
    • Normal < 1,000 WBC/mm3
    • PMNs: indicate an acute process
      • Parapneumonic effusion, PE, gastrointestinal disease, acute TB
    • Monocytes: indicate a chronic process
      • Malignant disease, TB, PE, resolving viral pleuritis

CurrOpinPulmMed.1999;5(4):245-50

pleural fluid the results17
Pleural Fluid – the results
  • Blood
    • Malignancy, PE, Trauma
  • Low glucose
    • TB, Malignant disease, Rheumatoid disease, Parapneumonic effusion
  • Elevated amylase
    • Pancreatitis, esophageal rupture, pleural malignancy
  • Elevated Adenosine diaminase (ADA)
    • TB

CurrOpinPulmMed.1999.5(4):245-50

pleural effusions management
Pleural Effusions - management
  • Treat underlying cause
  • Relieve symptoms
    • Therapeutic thoracentesis
    • Chest tube
parapneumonic effusion
Parapneumonic Effusion
  • Admit to hospital
  • Treat with antibiotics as per CAP
  • High risk PPE need drainage:
    • Purulent or putrid odor
    • Positive gram stain or culture
    • pH <7.2
    • Loculated on CT or US
    • Large effusion (1/2 hemithorax)
  • Low pleural pH (<7.20) in nonpurulent PPE found to be most accurate in identifying high risk PPE

CurrOpinPulmMed.2001;7(4):193-7

tuberculosis
Tuberculosis
  • Pathogenesis
    • Stage 1: bacilli inhaled. Macrophage phagocytoses if macrophage capability overcome will progress to next phase
    • Stage 2: bacilli replicate within macrophages forming a tubercule. Lymphatic and hematogenous spread
    • Stage 3: 2-3 weeks post infection. CMI and DTH wall off infection
    • Stage 4: reactivation. Tubercule liquifies and breaks through wall causing spread of infection and reactivation
tb risk factors
TB Risk Factors
  • Close contact with known case
  • Persons with HIV
  • Foreign-bron (Asian, African, Latin American)
  • Medically underserviced, low-income, homeless
  • Elderly
  • Residents of long-term care facilities
  • Injection drug users
  • Occupational exposures
tb rfs for reactivation
TB – RFs for Reactivation
  • HIV
  • Recent TB infection (within 2 yrs)
  • CXR suggestive of TB that was not treated
  • Injection drug user
  • Diabetes
  • Silicosis
  • Prolonged corticosteroid use
  • Immunosupressive therapy
  • H & N cancer, hematologic disease
  • End-stage renal disease
  • Chronic malabsorption syndrome, low body weight
tb clinical features
TB – Clinical features
  • Initial infection
    • usually asymptomatic
    • Clinically diagnosed with + skin test
  • 8-10%  develop clinically active TB if no prophylaxis
  • Reactivation associated with major symptoms
tb clinical features24
TB – Clinical features
  • Fever (night sweats)
  • Weight loss
  • Malaise
  • Anorexia
  • Cough (most common pulm TB symptom)
  • Hemoptysis
  • Infants, elderly & immunocompromised present atypically
tb cxr findings
TB – CXR findings
  • Primary TB :
    • Pneumonic infiltrate with hilar/mediastinal lymphadenopathy
    • Isolated mediastinal lymphadenopathy common in children
    • Miliary
    • Ghon focus (calicified scar)
    • Post primary lesion typically appears as an upper lobe infiltrate with or without cavitation
    • CXR can be normal in approx 10% of sputum + patients
tb management
TB - Management
  • Massive hemoptysis
    • ETT intubation with #8 ETT
    • Position with bleeding lung dependant
    • Emergent consult for bronchoscopy+/-surgery
tb medical therapy
TB – medical therapy
  • INH, Rifampin, & pyrazinamide for 2 month then INH for 4 more months
  • Preventative therapy: 10-15 mg/kg /day for 9 months
tb preventative therapy after inadvertent exposure
TB – preventative therapy after inadvertent exposure
  • Healthy people exposed who remain – on PPD do not need prophylaxis
  • If exposure is immediately known start INH x 3 month if PPD – then can stop
  • Conversion to, or new + PPD post exposure need 9 month of prophylaxis
ad