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TB and Pleural Diseases

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

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  1. TB and Pleural Diseases Sarah McPherson March 21, 2002

  2. Outline • Spontaneous pneumothorax • Causes • Treatment • Pleural Effusion • Causes • Work up • Treatment • Tuberculosis • Presentation • CXR findings • management

  3. 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

  4. 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

  5. Spontaneous Pneumothorax • Complications: • Pneumomediastinum & subcutaneous emphysema • Hemopneumothorax • Reexpansion pulmonary edema • Failure to reexpand (4-14%) • Recurrence (10-50%)

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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)

  15. 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

  16. 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

  17. 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

  18. Pleural Effusions - management • Treat underlying cause • Relieve symptoms • Therapeutic thoracentesis • Chest tube

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. TB – Clinical features • Fever (night sweats) • Weight loss • Malaise • Anorexia • Cough (most common pulm TB symptom) • Hemoptysis • Infants, elderly & immunocompromised present atypically

  25. 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

  26. TB - Management • Massive hemoptysis • ETT intubation with #8 ETT • Position with bleeding lung dependant • Emergent consult for bronchoscopy+/-surgery

  27. 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

  28. 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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