Pulmonary indications CC Flashcards
Sputum interpretation criteria
- The C/S results are accurate only if there are > 25 neutrophils and < 10 epithelial cells per low power field.
If more epithelial cells are present, then it is contaminated. If the patient gives you a cup with what looks like saliva mixed with a few mucoid globs, fish out these ‘goobers’ and send them to the lab (higher yield)!
Blood cultures in pneumonia should be done on patients with
- Sepsis
- Severe or unresponsive CAP
- COPD
- Liver disease
- A history of alcohol abuse
- Cavitary infiltrates
- Asplenia
- A pleural effusion
- Leukopenia
- A positive pneumococcal urine antigen test
Indications for chest drain (chest tube) insertion
- Pneumothorax in any ventilated patient
- Tension pneumothorax after initial needle relief
- Persistent or recurrent pneumothorax after simple aspiration
- Large secondary spontaneous pneumothorax in patients aged >50 years
- Malignant pleural effusions pleurodesis
- Empyema and complicated parapneumonic pleural effusion
- Traumatic hemopneumothorax
- Post-surgical (eg, thoracotomy, oesophagectomy, cardiac surgery)
Relative contraindications to chest drain insertion
- INR > 1.3
- Platelet count < 75
- Pulmonary bullae
- Pleural adhesions
Tube thoracostomy in traumatic pneumothorax indications
- Respiratory distress, hypoxia, or hemodynamic instability
- Concomitant injuries precluding the ability to monitor safely without chest tube
- Anticipated prolonged transport time or transport by air ambulance
- Increased size of pneumothorax on serial imaging
- Bilateral pneumothoraces
- Pneumothorax size greater than 15 to 20 percent of lung field or 2.5 cm on CXR (can also use the 35-mm rule based on chest CT)
- Hemopneumothorax greater than 300 mL
Management of traumatic pneumothorax
- Traumatic pneumothorax has traditionally been managed with open tube thoracostomy. Advanced Trauma Life Support (ATLS) protocols suggest any traumatic pneumothorax visible on CXR should be treated with tube thoracostomy. However, given known complications of chest tubes, other strategies such as needle aspiration, percutaneous pigtail placement, and observation of small pneumothoraces are reasonable
Thrombolytic therapy for patients with PE recommendations
- A 2012 guideline from the American College of Chest Physicians (ACCP) recommends thrombolytic therapy for patients with PE and a systolic blood pressure less than 90 mm Hg and without contraindications (for example, high bleeding risk)
Indications for hyperbaric oxygen therapy
- Air or gas embolism
- Carbon monoxide poisoning
- Clostridial myositis and myonecrosis
- Crush injury, compartment syndrome, acute traumatic ischemia
- Decompression sickness
- Enhancement of healing in selected problem wounds
- Severe anemia
- Intracranial abscess
- Necrotizing fasciitis
- Refractory osteomyelitis
- Radiation necrosis
- Delayed radiation injury
- Compromised skin grafts and flaps
- Thermal burns
- Central retinal artery occlusion
- Idiopathic sudden sensorineural hearing loss
Indications for fiberoptic bronchoscopy and bronchoalveolar lavage (BAL)
Diagnostic indications:
- Suspected lung carcinoma
- Slowly resolving pneumonia
- Pneumonia in immunosuppressed individuals (including those with HIV)
- Interstitial lung diseases (including sarcoidosis, extrinsic allergic alveolitis, histiocytosis X)
- Bronchiectasis
- Suspected tuberculosis (if sputum negative)
Bronchoalveolar lavage fluid may be sent to the lab for microscopy, culture, and cytology. Mucosal abnormalities may be brushed (cytology) and biopsied (histopathology)
Therapeutic indications:
- Aspiration of mucus plugs causing lobar collapse
- Removal of foreign bodies
- Stenting or treating tumors, such as with laser therapy
- Alveolar proteinosis
Indications for Sputum Gram Stain and Culture
- Severe or unresponsive community-acquired pneumonia (CAP)
- Admission to intensive care unit
- Failure of outpatient antibiotic therapy
- Severe obstructive or structural lung diseases
- A history of active alcohol abuse
- Cavitary lung lesions
- Pleural effusion
- Positive urine antigen tests for pneumococcus or Legionella (note: special culture needed for Legionella)
In the intubated patient, send a deep-suction aspirate or sample from bronchoalveolar lavage (BAL) as soon as possible because targeted antibiotics in the ICU do affect outcome
Thoracentesis indications
Presence of more than 10 mm of fluid from lung surface to chest wall on imaging, and any one of the following conditions:
- Unilateral, asymmetric, or nonresponsive effusions
- Pleural effusion associated with sepsis or pneumonic illness
Chest Tube Placement Indications in Pleural Effusion
- If the pleural fluid is purulent, turbid/cloudy, or contains visible frank pus (indicative of empyema thoracis)
- Pleural fluid pH < 7.2
- Pleural fluid glucose < 60 mg/dL
- Positive gram stain or culture
- Presence of loculated effusions
Note: The above information primarily adopts the British Thoracic Society (BTS) guidelines for the management of pleural effusion. Different organizations have slightly varying guidelines. For instance, while the BTS guidelines consider the need for intervention if there is any single positive finding among pH or glucose, other sources like the American College of Chest Physicians (ACCP) suggest more specific criteria, such as a pleural fluid pH less than 7.0 or a pleural fluid pH less than 7.2 in combination with glucose less than 50 mg/dL and LDH greater than 1000 IU/L
Primary pneumothorax management
- Size > 2 cm or presence of symptoms → Attempt aspiration → If unsuccessful → Insert chest tube
- If neither condition is met, outpatient management
Secondary pneumothorax management
- For patients over 50 with significant smoking history, treat as secondary. Admit for 24 hours with oxygen supplementation
- Size > 2 cm or presence of symptoms → Insert chest tube
- Moderate size (1 to 2 cm) → Attempt aspiration → If unsuccessful → Insert chest tube
- Mild size (< 1 cm) → Only admit & provide oxygen
