TB and Pleural Diseases Sarah McPherson March 21, 2002
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– 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
Complications:– Pneumomediastinum & subcutaneous emphysema– Hemopneumothorax– Reexpansion pulmonary edema– Failure to reexpand (4-14%)– Recurrence (10-50%)
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
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
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
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:1. Tension pneumo2. Underlying pulmonary disease3. Significant symptoms4. Persistent air leak (> 3L aspirated, increase size,
recurrence)5. Need for positive pressure ventilation6. Bilateral pneumos7. Pleural fluid
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
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 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
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
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 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
Treat underlying cause Relieve symptoms
– Therapeutic thoracentesis– Chest tube
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
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
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
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
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 features
Fever (night sweats) Weight loss Malaise Anorexia Cough (most common pulm TB symptom) Hemoptysis Infants, elderly & immunocompromised present
atypically
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
Massive hemoptysis– ETT intubation with #8 ETT– Position with bleeding lung dependant– Emergent consult for bronchoscopy+/-surgery
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
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