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. 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

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: 1. Cardiopulmonary instability 2. Significant lung disease 3. Significant concurrent medical problem 4. Pleural effusion 5. Bilateral pneumothorax  Effective 70% of first PPS

8. Spontaneous Pneumothorax – Aspiration HOW TO: Patient supine with HOB at 30 degrees Local anesthesia at 2 nd 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: 1. Tension pneumo 2. Underlying pulmonary disease 3. Significant symptoms 4. Persistent air leak (> 3L aspirated, increase size, recurrence) 5. Need for positive pressure ventilation 6. Bilateral pneumos 7. 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. 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)

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/mm 3 – 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