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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

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Tb and pleural diseases l.jpg

TB and Pleural Diseases

Sarah McPherson

March 21, 2002


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Outline

  • Spontaneous pneumothorax

    • Causes

    • Treatment

  • Pleural Effusion

    • Causes

    • Work up

    • Treatment

  • Tuberculosis

    • Presentation

    • CXR findings

    • management


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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


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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


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Spontaneous Pneumothorax

  • Complications:

    • Pneumomediastinum & subcutaneous emphysema

    • Hemopneumothorax

    • Reexpansion pulmonary edema

    • Failure to reexpand (4-14%)

    • Recurrence (10-50%)


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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


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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


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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


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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


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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


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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


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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


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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


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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)


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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


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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


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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


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Pleural Effusions - management

  • Treat underlying cause

  • Relieve symptoms

    • Therapeutic thoracentesis

    • Chest tube


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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


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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


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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


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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


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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


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TB – Clinical features

  • Fever (night sweats)

  • Weight loss

  • Malaise

  • Anorexia

  • Cough (most common pulm TB symptom)

  • Hemoptysis

  • Infants, elderly & immunocompromised present atypically


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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


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TB - Management

  • Massive hemoptysis

    • ETT intubation with #8 ETT

    • Position with bleeding lung dependant

    • Emergent consult for bronchoscopy+/-surgery


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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


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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


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