Pulmonology #5 (Atelectasis, Post-Op Fever, Pleural Diseases) Flashcards
What exactly is atelectasis?
Explain some patients who are at risk for this condition?
Alveoli or a lobe of the lung is collapsed. This leads to issues with gas exchange.
Surgical patients, on narcotic meds, CF, patients in pain, sleep apnea, myasthenia gravis, smokers, elderly, decreased mobility, COPD, asthma
There are three types of atelectasis. Describe them:
Obstructive
Post-Operative
Non-Obstructive
Obstructive: foreign body in lung (seeds, tumors, mucus plug in CF)
Post-Operative: due to pain or immobility. In the first few days post-op.
Non-Obstructive: Pneumothorax, pleural effusion, surfactant deficiency
Symptoms of atelectasis
-Dyspnea, SOB
-Wheezing, coughing
-Tachypnea, shallow breathing
-Diminished breath sounds in affected area
-Low-grade fever
What is seen on a CXR in a patient with atelectasis?
Shifting of mediastinum TOWARD the collapsed lobe
What is the treatment for atelectasis?
-Coughing, deep breathing
-Pain control
-Ambulation
-Incentive Spirometer
Regarding Post-Operative Fever, what conditions MC occur on the following days. What is the phrase to remember them?
Wind, Water, Wound, Walking, Wonder Drugs
-Days 1-2: Wind (Atelectasis): Ipsilateral tracheal deviation
-Days 3-5: Water (UTI): frequency, urgency, hematuria, dysuria
-Days 5-7: Wound (Staph Aureus MCC)
-Days 5+: Walking (Thrombophlebitis, DVT
-1 week post-op: Wonder Drugs (Anesthestics, sulfa drugs, etc.
A pleural effusion is excess fluid in the pleural cavity –> lungs are trapped and can’t expand fully. What are the following types of pleural effusion
-Parapneumonic:
-Empyema:
-Hemothorax:
-Chylothorax:
Parapneumonic: noninflected pleural effusion due to bacterial PNA
Empyema: direct infection of the pleural space
Hemothorax: gross blood (malignancy, trauma)
Chylothorax: increased lymph
There are two main etiologies of a pleural effusion. Name and describe them.
Transudate: CHF (MCC), Nephrotic Syndrome, Cirrhosis
–Fluid not being reabsorbed fast enough and becomes infected
Exudate: Malignancy, PE
–Damaged capillaries leak fluid into the pleural space. Any condition associated with infection or inflammation.
Symptoms of a pleural effusion
-Dyspnea, Cough, Pleuritic chest pain
-Dullness to percussion
-Decreased fremitus
-Decreased breath sounds
-Egophony
-Pleural Friction Rub
What is seen on CXR for a pleural effusion? is this the initial test done?
What is the best position to take the CXR?
Yes, it is the initial test
-Blunting of costophrenic angles (meniscus sign)
-Have patient lay in left lateral decubitus position
What is the GOLD STANDARD diagnostic for pleural effusion?
Thoracentesis
-remove a small sample of fluid from the pleural space
What is Light’s Criteria and what does it mean?
Exudate present if any of the 3 are present
-Pleural fluid protein: serum protein > 0.5
-Pleural fluid LDH: serum LDH > 0.6
-Pleural fluid LDH > 2/3 upper limit of normal
The treatment for a pleural effusion varies but treating the underlying cause is the mainstay.
______: Can be diagnostic and therapeutic
_______: obliteration of pleural space if malignant or chronic
Thoracentesis
Pleurodesis (Talc, Doxycycline)
What treatment is done for an empyema and how do you know this is the cause of the pleural effusion?
Chest tube drainage
pH < 7.2, glucose <40, or positive gram stain
What is a pneumothorax and what are some symptoms?
Air in pleural space leading to collapse of the lung from positive intrapleural air pressure
-Chest pain (pleuritic, unilateral, non-exertional, sudden)
-Dyspnea
-Hyperresonance to percussion
-Decreased fremitus
-Tachycardia
-Unequal respiratory expansion
What are the five types of pneumothorax?
-Primary Spontaneous (PSP): atraumatic and idiopathic with no underlying lung disease. Affects tall, thin men 20-40 years old, smokers, family history.
-Secondary: underlying lung disease
-Tension: any type which positive air pressure pushes the trachea, great vessels, and heart to contralateral side
-Catamenial: during menstruation
-Traumatic: iatrogenic (during CPR, thoracentesis, subclavian line placement, MVA)
What view of CXR do you get for a pneumothorax and what do you see?
Expiratory upright view
Decreased peripheral markings, companion lines, contralateral mediastinal shift
Treatment for the following pneumothorax:
1) Small PSP < 3cm
2) Large PSP > 3cm
3) Stable SSP
4) Tension
1) Observation + Oxygen
2) Needle or catheter aspiration vs chest tube
3) chest tube or catheter thoracostomy + admission
4) Needle aspiration then chest tube thoracostomy
Tuberculosis, infection of respiratory system by Mycobacterium tuberculosis, infects how?
What are risk factors for TB?
-After inhalation, Mtb goes to alveoli, gets incorporated into macrophages, and then can disseminate from there
-RF: Close contact, immunocompromised, immigrants, crowded conditions, low socioeconomic status, HIV*****
Explain what chronic (latent) TB is
-90% of patients
-In a normal, healthy person they are exposed to TB and macrophages go in and put a cage around it (caseating granuloma)
What three things does a patient need to be not contagious with chronic (latent) TB?
+ PDD, no symptoms, no imaging findings of active infection of TB
What is progressive/primary TB?
What part of the lung does this MC occur in?
-Immunocompromised patients cannot fight off the infection and building the cage (granuloma) around the TB
-These patients are contagious
-MC in middle/lower lobes of the lungs
What is secondary (reactivation) TB?
Where does this MC occur in the lungs?
-Reactivation of latent TB with weakened immune system (elderly, HIV, steroid use, malignancy)
MC occurs in the upper lobes/apex with cavitary lesions
-These patients are contagious as well
Symptoms of TB
-There are two SPECIFIC exam findings of this
-Cough, hemoptysis, fever, night sweats, chills, weight loss
-Pott’s Disease: TB of vertebrae
-Scrofula: TV of Cervical lymph nodes
Initially, for TB, you get a CXR. What is seen with the following conditions:
Primary:
Reactivation/Secondary:
Miliary:
Ghon Complex:
Primary: middle/lower lobe consolidation
Secondary: apical upper lobe consolidation
Miliary: small, millet-seed nodular lesions
Ghon Complex: residual evidence of healed primary TB
What other diagnostics can you get for TB?
Sputum Acid Fast Staining: 3 samples in 3 consecutive days must be negative to rule out
Sputum Cultures: 3 samples on 3 separate days
–MOST ACCURATE but takes 8 weeks to get back
NAAT (PCR): more sensitive than sputum smears
What does a PPD test for TB do?
What needs to be done if you get a positive PPD?
Measure area of induration within 48-72 hours
Any positive test needs a CXR to rule out active disease
What can give a false positive PPD?
BCG vaccine
Explain what this means in regards to the PPD test and who is included in each category.
-The less of a risk you are, the bigger the induration you can have.
-HIV, Immunosuppression, close contact with active TB, CXR consistent with old/healed granuloma = 5 mm or greater
-All other high risk populations (residents, healthcare workers, DM) = 10 mm or greater
-Everyone else with no known risk factors for TB = 15 mm or greater
What are some positives of the Interferon Gamma Release Assay test for TB?
-Improved specificity, but expensive
-One time test
-Not affected by prior BCG vaccine
What is the treatment regimen for active TB
RIPE or RIPS for 6 months
–RIPE for 2, then RI for 4 months
-Rifampin + Isoniazid + Pyrazinamide + Ethambutol
-Can substitute Streptomycin for Ethambutol though
What are the side effects you should know about the following medications:
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin
Rifampin: thrombocytopenia, orange colored secretions
Isoniazid: Hepatitis, peripheral neuropathy (give B6 with this)
Pyrazinamide: hepatitis, hyperuricemia, photosensitive dermatologic rash
Ethambutol: optic neuritis, red/green vision problems, peripheral neuropathy
Streptomycin: ototoxicity, nephrotoxicity
What is the treatment for Latent (Chronic) TB? There are three options…
INH + B6 (Pyridoxine) x 9 months
INH + Rifapentine
RIF x 4 months
