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