Transcript TB and Pleural Diseases - Calgary Emergency Medicine

TB and Pleural Diseases
Sarah McPherson
March 21, 2002
Outline
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Spontaneous pneumothorax
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Pleural Effusion
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Causes
Treatment
Causes
Work up
Treatment
Tuberculosis
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Presentation
CXR findings
management
Pneumothorax
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Tension
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Recognize, needle decompress, chest tube
Spontaneous
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Primary: lean, tall males
Secondary:
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more common in patient > 50 yrs
More serious because of reduced cardiopulmonary reserve
Spontaneous Pneumothorax
Causes:
Pulmonary disease
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COPD*
Asthma
CF
Infections
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Pneumonia
PCP*
TB
Lung abscess
Neoplasm
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Primary lung
Metastatic
Interstitial lung disease
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Sarcoidosis
Collagen vascular disease
Miscellaneous
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PE
Drug abuse
Esophageal rupture
pneumoperitoneum
Spontaneous Pneumothorax
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Complications:
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Pneumomediastinum & subcutaneous emphysema
Hemopneumothorax
Reexpansion pulmonary edema
Failure to reexpand (4-14%)
Recurrence (10-50%)
Management
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Small PSP(<15%) & asymptomatic
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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
PSP > 15%:
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Aspiration
Contraindications:
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Cardiopulmonary instability
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Significant lung disease
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Significant concurrent medical problem
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Pleural effusion
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Bilateral pneumothorax
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Effective 70% of first PPS
Spontaneous Pneumothorax –
Aspiration
HOW TO:
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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
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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
Indications:
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Tension pneumo
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Underlying pulmonary disease
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Significant symptoms
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Persistent air leak (> 3L aspirated, increase size,
recurrence)
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Need for positive pressure ventilation
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Bilateral pneumos
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Pleural fluid
Management of SSP
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Admit
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Chest tube (20-28 French)
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Suction if persistent air leak or failure to
reexpand with underwater seal
NEJM.2001;342(12):868-74
Recurrent Pneumo’s
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Who needs definitive management?
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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?
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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:
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Pneumonia
TB
Connective tissue disease
Neoplasm
Uremia
Trauma
Drug induced
GI pathology (pancreatitis,
subphrenic abscess)
Pleural fluid analysis
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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
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Exudative if (99% PPV):
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LDH > 200U
Fluid-blood LDH ratio > 0.6
Fluid-blood protein level > 0.5
pH:
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<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
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WBC
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Normal < 1,000 WBC/mm3
PMNs: indicate an acute process
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Parapneumonic effusion, PE, gastrointestinal disease,
acute TB
Monocytes: indicate a chronic process
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Malignant disease, TB, PE, resolving viral pleuritis
CurrOpinPulmMed.1999;5(4):245-50
Pleural Fluid – the results
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Blood
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Low glucose
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TB, Malignant disease, Rheumatoid disease, Parapneumonic
effusion
Elevated amylase
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Malignancy, PE, Trauma
Pancreatitis, esophageal rupture, pleural malignancy
Elevated Adenosine diaminase (ADA)
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TB
CurrOpinPulmMed.1999.5(4):245-50
Pleural Effusions - management
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Treat underlying cause
Relieve symptoms
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Therapeutic thoracentesis
Chest tube
Parapneumonic Effusion
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Admit to hospital
Treat with antibiotics as per CAP
High risk PPE need drainage:
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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
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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
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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
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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
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Initial infection
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usually asymptomatic
Clinically diagnosed with + skin test
8-10%  develop clinically active TB if no
prophylaxis
Reactivation associated with major symptoms
TB – Clinical features
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Fever (night sweats)
Weight loss
Malaise
Anorexia
Cough (most common pulm TB symptom)
Hemoptysis
Infants, elderly & immunocompromised present
atypically
TB – CXR findings
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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
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Massive hemoptysis
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ETT intubation with #8 ETT
Position with bleeding lung dependant
Emergent consult for bronchoscopy+/-surgery
TB – medical therapy
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INH, Rifampin, & pyrazinamide for 2 month
then INH for 4 more months
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Preventative therapy: 10-15 mg/kg /day for 9
months
TB – preventative therapy after
inadvertent exposure
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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