[More] Respiratory Disorders Pulmonary Embolism, Pleural Effusion, Spontaneous Pneumothorax , Altitude Sickness & Tuberculosis

Pulmonary Embolism When blood clots form in pulmonary arteries Almost always associated with DVT Consider PE for patients complaining of chest pain/SOB Risk Factors: oral contraceptives recent travel > 2 hours recent surgery, especially orthopedic Family or personal history of clotting disorder Work up: D-dimer? (not helpful for outpatients) Stat CT of chest (VQ scan only if contrast dye contraindication) Consider: US of lower extremities

Pleural Effusion 17 mL pleural fluid created daily for lubrication Absorbed by lymphatic system Effusions form if increased exudative process Causes (many!) Hydrostatic – as in ascites or peritoneal dialysis CHF – due to increased pulmonary capillary pressure Pulmonary embolus – often due to interstitial edema Nephrotic syndrome – interstitial edema Neoplastic processes Infection Autoimmune disease Treatment: treat underlying problem. Refer for thoracentesis as indicated.

Spontaneous Pneumothorax Male college student with 10/10 chest pain Tall, thin but not remarkably so Sudden onset pain – no preceding illness Pulse Ox low 90s – but was unable to lay or sit still on table Called 911 for emergency transport to hospital Male college student with vague left upper chest pain Normal build Symptoms started 3 days ago Awareness of bubbling – like fish tank – especially when laying in bed Pain mild-moderate. Maybe some shortness of breath. Sent for outpatient chest x-ray

Spontaneous Pneumothorax Causes/Risk Factors Chest injuries, mechanical ventilation (not in primary care!) Underlying lung disease: COPD, Pneumonia, cystic fibrosis Ruptured blebs on the lung apex Usually in young, thin, tall men aged 20-40

Retrieved from: http://www. ctsnet

Spontaneous Pneumothorax

Spontaneous Pneumothorax

Altitude Sickness Occurs with rapid ascent to high elevation (mtn climbers) 1500 to 2000 m (5000 to 6500 ft)  - most have no problem > 2500 m (8000 ft) – 20% affected > 3000 m (10,000 ft)  – 40 % affected Prevention: slower ascent, sleep at lower elevations acetazolamide 250 mg po bid helps [inhibits carbonic anhydrase and thus increases ventilation; reduces the amount of periodic breathing (almost universal during sleep at high altitude), thus limiting sharp falls in blood O2.]* most will acclimate to 10k feet in about 3 days *Retrieved from: http://www.merckmanuals.com/professional/injuries_poisoning/altitude_diseases/altitude_diseases.html

Tuberculosis Mycobacterium infection – usually of lungs Spread through the air (can stay airborne for hours) Early 1900s – TB killed 1 in 7 in the US and Europe http://www.cdc.gov/tb/publications/factsheets/general/nonhealthcare_employers.htm

Tuberculosis Retrieved from: http://www.who.int/tb/country/data/visualizations/en/

Tuberculosis: MDR-TB MDR-TB 2013 – Absolute numbers Retrieved from: http://www.who.int/tb/country/data/visualizations/en/

Tuberculosis Screening Who Should Get Tested for TB? TB tests are generally not needed for people with a low risk of infection with TB bacteria. Certain people should be tested for TB bacteria because they are more likely to get TB disease, including: People who have spent time with someone who has TB disease People with HIV infection or another medical problem that weakens the immune system People who have symptoms of TB disease (fever, night sweats, cough, and weight loss) People from a country where TB disease is common (most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia) People who live or work somewhere in the United States where TB disease is more common (homeless shelters, prison or jails, or some nursing homes) People who use illegal drugs Retrieved from: http://www.cdc.gov/tb/topic/testing/

Tuberculosis Screening A TST reaction of ≥5 mm of induration is considered positive in: HIV-infected persons Recent contacts of a person with infectious TB disease Persons with fibrotic changes on chest radiograph consistent with prior TB Patients with organ transplants and other immunosuppressed patients (including patients taking the equivalent of ≥15 mg/day of prednisone for 1 month or more or those taking TNF-α antagonists) A TST reaction of ≥10 mm of induration is considered positive in the following individuals: Recent arrivals to the United States (within last 5 years) from high-prevalence areas Injection drug users Residents or employees of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, hospitals and other health care facilities, residential facilities for patients with HIV infection/AIDS, and homeless shelters) Mycobacteriology laboratory personnel Persons with clinical conditions that increase the risk for progression to TB disease Children younger than 5 years of age Infants, children, and adolescents exposed to adults in high risk categories A TST reaction of ≥15 mm of induration is considered positive in the following individuals: Persons with no known risk factors for TB Retrieved from: http://www.cdc.gov/tb/publications/ltbi/diagnosis.htm

TB Infection: active or latent? A Person with Latent TB Infection A Person with [active] TB Disease Has no symptoms Has symptoms that may include: a bad cough that lasts 3 weeks or longer pain in the chest coughing up blood or sputum weakness or fatigue weight loss no appetite chills fever sweating at night Does not feel sick Usually feels sick Cannot spread TB bacteria to others May spread TB bacteria to others Usually has a skin test or blood test result indicating TB infection Has a normal chest x-ray and a negative sputum smear May have an abnormal chest x-ray, or positive sputum smear or culture Needs treatment for latent TB infection to prevent TB disease Needs treatment to treat TB disease Retrieved from: http://www.cdc.gov/tb/topic/basics/difference.htm /

TB treatment: latent infection Table 1. Candidates for the Treatment of Latent TB Infection Persons with no known risk factors for TB may be considered for treatment of LTBI if they have either a positive IGRA result or if their reaction to the TST is 15 mm or larger. However, targeted TB testing programs should only be conducted among high-risk groups. All testing activities should be accompanied by a plan for follow-up care for persons with TB infection or disease. Groups Who Should be Given High Priority for Latent TB Infection Treatment People who have a positive IGRA result or a TST reaction of 5 or more millimeters People who have a positive IGRA result or a TST reaction of 10 or more millimeters HIV-infected persons Recent contacts of a TB case Persons with fibrotic changes on chest radiograph consistent with old TB Organ transplant recipients Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or longer, taking TNF-α antagonists) Recent immigrants (< 5 years) from high-prevalence countries Injection drug users Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities) Mycobacteriology laboratory personnel Children under 4 years of age, or children and adolescents exposed to adults in high-risk categories Retrieved from: http://www.cdc.gov/tb/publications/factsheets/treatment/ltbitreatmentoptions.htm

TB treatment: active infection TB disease can be treated by taking several drugs for 6 to 9 months. First line anti-TB agents that form the core of treatment regimens include: isoniazid (INH) rifampin (RIF) ethambutol (EMB) pyrazinamide (PZA) Regimens for treating TB disease have an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment). Regimens must be taken correctly and completed to avoid increasing MDR-TB. Retrieved from: http://www.cdc.gov/tb/topic/treatment/default.htm