Thoracic Infections and Hemoptysis Flashcards
Indications for surgery for M. tuberculosis infection
- Massive hemoptysis
- BPF
- Broncial stenosis
- Entrapped lung
- Failure of medical therapy
- Persistent cavitary diease
- Destroyed lung of lobe
- Rule out malignancy
Prior to sugery for M. tuberculosis, patients should have what profile
- Combination drug therapy for 3 months
- Sputum cultures ideally should be negative
First line medical therapy for M. tuberculosis
- INH and Rifampin (6 total months)
- INH+Rifampin+Pyrazinamide+Ethambutol (first 2 months)
Increases need for surgery for those with M. tuberculosis
Multi-drug resistant TB (MDR-TB)
Pericardial complication of TB
Pericardial effusion or constrictive pericarditis
(pericardial bx diagnostic, high level of adenosine deaminase (ADA) test in pericardial fluid suggestive)
The adenosine deaminase (ADA) test is not a diagnostic test, but it may be used along with other tests such as pleural fluid analysis, acid-fast bacillus (AFB) smear and culture, and/or tuberculosis molecular testing to help determine whether a person has a Mycobacterium tuberculosis infection (tuberculosis or TB) of the lining of the lungs (pleurae).
Tx of TB related pericardial effusion
Antibiotics
Pericardial drainage
Tx of TB related constrictive pericarditis
Antibiotics
Pericardectomy
Pleural TB associated with _
Lymphocyte-rich pleural effusion
Dx of pleural TB
Pleural biopsy (fluid culture may result in no growth)
Tx of pleural TB
- Tube thoracostomy (large effusion)
- Decortication (trapped lung or empyema)
May form in cavitary lung lesions after TB infection
Aspergillomas
Uncommon endobronchial compication that may result from TB infecton
Endobroncial stenosis (scarring) or obstruction (extrinsic compression from lymph nodes)
Tx (endobronchial stenosis): inhaled corticosteroids (I&D of lymph nodes if steroids unsuccessful, not lymph node excision)
Most common (organisms) of Non-tuberculous mycobacterial infection (NTM)
Mycobacterium avium and intracellulare (M avium complex)
Other organisms:
M. chelonae
M. abscessus
M. fortuitum
Non-tuberculous mycobacterial infection (NTM) infections most common in what patient populations
Disease lungs
Women
Caucasians
T/F
Non-tuberculous mycobacterial infection (NTM) are more resistentant to drug therpy than MTB infecitons
True
The surgical treatment approach to Nontuberculous Mycobacteria (NTM) Infections
- Pts with localized disease more amenable to surgical therapy
- Consider surgery in course of treatment
- Extrapleural dissection preferential
- d/t dense adhesions between parietal and visceral pleura
- All grossly infected tissue should be removed
- Tissue flaps used to reduce bronchial stump complications
- Continue anti-tubercular medications x 12-24 hrs postoperatively
Complications associated with surgical resections for mycobacterial infections
High rate of BPF
Overall classification scheme of lung abscesses
Primary vs. secondary lung abscess
Most common overall etiology of lung abscesses
Aspiration
Atypical bacterium that classically causes multiple abscesses throughout the body, including the lungs
Actinomyces
(PCN sensitive)
Most accurate diagnostic modality for lung abscesses
High resolution CT
(cavity with air-fluid level)
First line treatment for lung abscesses
Prolonged antibiotic therapy (directed by cultures)
Lack of response to antibiotic therapy is bronchoscopy (r/o obstructive process)
Sampling of lung abscess most accurately performed by what technique
CT-guided or bronchoscopic FNA
Indications for external drainage of lung abscesses (as an adjunct to Abx)
- Failure of medical managment
* symptoms lasts more than 12 weeks with appropriate therapy - Giant abscess (>8 cm in diameter)
- Contralateral contamination
- Rupture
Indications for surgery for lung abscesses
- Empyema
- BPF
- Major hemoptysis
- Suspicion of cancer
- Failure of non-operative therapy
7 major mycotic lung infections
- Histoplasmosis
- Coccidiomycosis
- Blastomycosis
- Cryptococcus
- Mucormycosis
- Aspergillosis
- Pneumocystis
Mycotic infection associated with bat and/or bird feces** and **Mississippi Valley
Histoplasmosis
Presentation of Histoplasmosis
- Self-limited, flu-like illness (often do not require treatment)
- Disseminated histoplasmosis (immunocompromised)
- Tx: amphotericin
- Granulomas (non-caseating, sometimes calcified)
- can compress or erode into trachobronchial tree
- Obstruction or hemoptysis
- can compress or erode into trachobronchial tree
Rare complication of histoplasmosis resulting in progressive compression of mediastinal structures (SVC, esophagus, etc)
Fibrosing mediastinitis
Can mimic TB
Chronic cavitary histoplasmosis
(Dx: isolation of organisms in culture)
Mycotic infection associated wtih dimorphic fungus found in soil in the Southwest US, Mexico, Central America
Coccidiomycosis (“Valley fever”)
Characteristics of Coccidiomycosis
- Self resolved infecton in immunocompetent patient
- Erythema nodosum (positive prognostic sign of cell-mediated immunity)
- Chronic infection = cavitary lesion
- Cavitations located peripherally, may rupture into pleural space
- Effusion
- Ptx
- BPF
- Empyema
Surgical indications for coccidiomycosis
- Treatment of complications
- Effusion
- Ptx
- BPF
- Empyema
- Differentiate Coccidioides nodules from cancer
Mycotic infection found in Southeastern and Central US
Blastomycosis
- Types:
- Pulmonary blastomycosis
- Cutaneous blastomycosis
- Multiple ulcerated skin nodules
- Disseminated blastomycosis
Dx:
wide-based budding yeast with double refractile walls
Blastomycosis
Treatment of Blastomycosis
-
Antifungals
- Although spontaneous remission can occur, it is recommended that all patients with mild or moderate disease be treated to avoid dissemination and recurrence.
- _Itraconazole i_s the treatment of choice for all forms of the disease, except in severe, life-threatening cases.
- Amphotericin B is used in severe and life-threatening diseases at a high dose of 0.7 to 1 mg/kg/day to a total dose of 1.5 to 2 grams. Liposomal amphotericin B at a dose of 3 to 5 mg/kg per day can alternatively be used for severe infection and is preferred for CNS blastomycosis and treatment in pregnant women.
- Surgery: rule out malignancy
Mycotic infection characterized by encapsulated yeast round in soil
Cryptococcus
Mycotic infection with tendency to invade meninges (especially in immunocomprimised)
Cryptococcus
Microscopic appearance:
capsule with narrow budding
Cryptococcus
Next step in diagnosis and treatment after pathology demonstrates Cryptococcus in lung mass
CSF analysis (r/o meningitis)
Amphotericin
Omnipresent yeast found in soil that thrives in acidic, hyperglycemic enviornments
Mucormycosis
(DKA patients susceptible)
Risk factors for Mucormycosis
- Diabetic ketoacidosis (uncontrolled hyperglycemia)
- Corticosteroid use (immunosuppressed)
- Neutropenia
Mycotic infection that causes infarction of tissue and is associated with PA rupture and hemoptysis, and invasion of chest wall and mediastinal structures
Mucormycosis
Typical presentation of Mucormycosis
PNA refractory to antibacterial therapy
Microscopic appearance:
broad aseptate hyphae with right-angled, finger-like projections)
Mucormycosis
Treatment principles of Mucormycosis
- Correction of DKA
- Reversal of immunosuppression
- GM-CSF (if neutropenia)
- Amphotericin
- Rapid and aggressive surgical resection
Mycotic infection that typically affects immunocompromised patients or those with structural lung disease
Aspergillosis
Types of aspergillus infection
- Aspergilloma
- Invasive pulmonary aspergillosis
- Allergic bronchopulmonary aspergillosis (asthma, cystic fibrosis)
- Esosinophilia and IgE elevation
Cross-sectional imaging charactistics of aspergillosis
Fungus ball within thick-walled cavity sometimes surrounded by a crescent of air (Monod’s sign)
Monod’s sign
The Monod sign simply describes gas that surrounds a mycetoma (most commonly an aspergilloma) in a pre-existing pulmonary cavity.
It should not be confused with the air crescent sign which is seen in recovering angioinvasive aspergillosis. The air crescent sign heralds improvement in the condition.
Diagnostic stains used to visualize Aspergillosis
- Gomori methenamine silver stain
- Calcofluor White Stain
Can be visualized in sputum with polarizing light microscopy to diagnose Aspergillosis
Birefringent calcium oxalate crystals
Component of Aspergillosis cell wall that can be measured in serum or BAL fluid
Galactomannan
Most common symptoms of aspergillosis
Hemoptysis
Tx: bronchial artery embolization (recurrence of bleeding 50%)
Rebleeding = surgical resection
True of False
Antifungal therapy is helpful for treatment of aspergilloma
False:
Antifungal therpy is not helpful for treatment of aspergilloma
- Asymptomatic aspergilloma: should not be treated (most resolve)
- Symptomatic aspergilloma (i.e. hemoptysis): bronchial artery embolization/resection
Complication of invasive pulmonary aspergilosis
Necrotizing bronchopneumonia refractory to antibacterial therapy
(Immunocompromised patients)
Treatment of invasive pulmonary aspergilosis
- Antifungal therapy (high mortality rate)
- Surgery reserved when diagnosis questionable or for patient with resectable disease
Opportunistic mycotic infection limited to immunocompromised patients (commonly found in lungs of healthy individuals)
Pneumocystis
(i.e. Pneumocystis PNA [PCP])
Treatment of choice for PCP
Bactrim
- Most common cause of massive hemoptysis
- Most common cause of death d/t massive hemoptysis
- MCC
- bronchiectasis
- cancer
- TB
- Mycetoma
- MCC death: asphyxiation
Initial treatment priorities for massive hemoptysis
- Stabilization of airway (mainstem intubate non-bleeding side)
- Resuscitation
- Position in lateral decubitus position (bleeding side down)
- Anti-tussive
- Avoid bronchodilators
- Bronchoscopy (evacuate blood, selective intubation)
- Balloon occlusion if possible
Bronchoscopic measures to control bleeding with massive hemoptysis
- Ice-cold saline lavage
- Epinepherine lavage
- Directed cautery
- Application of pro-coagulants (fibrin, thrombin)
- Balloon tamponade
Most common source of hemoptysis
Bronchial arteries (~ 95%)
Justification for bronchial artery embolizaiton (BAE)
Embolizaiton techniques utilized for hemoptysis
- Bronchial Artery Embolization (BAE)
- ~ 95% of hemoptysis due to broncial artery bleeding
- PA angiography with vaso-occlsion or endovascular stenting
- if PA bleeding
Risk of early re-bleeding after Bronchial Artery Embolization (BAE)
~30%
Thus, semi-elective surgical resection usually desired after Bronchial Artery Embolization (BAE)
Treatment of choice for massive hemoptysis if Bronchial Artery Embolization (BAE) fails or patient too unstable
Emergent surgical resection (lobectomy)
Signs of pneumonia on auscultation of the chest?
On physical examination, most patients have audible crackles on auscultation. Signs of consolidation include decreased or bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony.
if clinical presentation is classic for pneumonia, but chest x-ray is normal. What should you do next?
On the other-hand if clinical presentation is classic for pneumonia, but chest x-ray is normal, clarification with chest CT should be done as the chest x-ray may be a false negative. Chest CT has a higher sensitivity and specificity than chest x-ray for detecting pneumonia
Important risk factors in The Pneumonia Severity Index (PSI)
- Age > 50 years
- Co-existing conditions: Cancer, Heart Failure, Cerbrovascular disease, Renal Disease, Liver Disease
- Physical examination abnormalities:
- Altered mental status
- pulse ≥ 125/minute
- respiratory rate ≥ 30/minute
- Systolic blood pressure < 90 mm Hg
- Temperature < 350C or ≥400C
Indications for intervention for lung abscesses include:
Indications for intervention for lung abscesses include:
* failure of medical therapy
* size larger than 4 to 6 cm in diameter
* necrotizing infection with multiple abscesses
* complications (hemoptysis and rupture into pleural space)
* high degree of suspicion for cancer
Surgical intervention in such cases is usually a lobectomy or pneumonectomy.
Interventions for lung abscess in those that are poor surgical candidates?
- For those who are poor operative candidates, percutaneous and endoscopic drainage have been described.
2. Care has to be taken in percutaneous procedures to avoid soilage of the pleural space. - Endoscopic drainage is achieved under bronchoscopic visualization with a catheter placed into the abscess.
4. The catheter is then left in place until the cavity has drained.
Empyema Management
- Early
- Fibrinopurulent stage
- Organized stage
Patients with early empyema should be treated with drainage, patients in the fibrinopurulent stage can be treated with VATS or possibly fibrinolytics, and patients in the organized stage need a decortication to remove the rind and fully re-expand the lung.
Treatment of CAP
The vast majority of CAP is treated on an outpatient basis for five days, and empiric antibiotics (a macrolide or fluoroquinolone) are effective in >95% cases
Empiric antibiotic choice for Hospital acquired pneumonia:
- No risk factors for MDR: Piperacillin-tazobactam 4.5 g IV every six hours, or Cefepime 2 g IV every 8 hours, or Levofloxacin 750 mg IV daily
- For MDR suspicion:
- One of the following – Piperacillin-tazobactam 4.5 g IV every six hours, cefepime 2 g IV every 8 hours, Ceftazidime 2 g IV every 8 hours, Imipenem 500 mg IV every 6 hours, Meropenem 1 g IV every 8 hours, Aztreonam 2 g IV every 8 hours\
- Plus an aminoglycoside (amikacin, gentamicin or tobramycin IV)
- Plus one of the following – Linezolid, Vancomycin or Telavancin
Prevention of Ventillator associated pneumonia (VAP)
- Avoidance of intubation and mechanical ventilation with the use of non-invasive positive pressure ventilation for able patients:
* especially in immunocompromised patients
* those with acute exacerbations of chronic obstructive pulmonary disease (COPD)
* those with pulmonary edema - Elevation of head of bed (300 to 450)
- Daily sedation interruption and assessment of readiness to extubate
- Use of subglottic secretion drainage
- Avoidance of scheduled ventilator circuit changes
The most common organisms causing aspiration pneumonia and lung abscesses are:
The most common organisms causing aspiration pneumonia and lung abscesses are oral anaerobes
Simple parapneumonic effusions have characteristic features:
- pH >7.2
- LDH < 1000 iu/L,
- Glucose >2.2 mmol/L
- no organisms in culture or gram stain.
characteristic biochemical and microbiological features of complicated pleural effusions:
pH< 7.2, glucose < 2.2 mmol/L, LDH >1000 iu/L and possible positive gram stain and/or bacterial culture.
