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Respiratory
Disorders
[More]
Pulmonary Embolism, Pleural Effusion, Spontaneous
Pneumothorax , Altitude Sickness & Tuberculosis
Pulmonary Embolism
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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
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17 mL pleural fluid created daily for lubrication
Absorbed by lymphatic system
Effusions form if increased exudative process
Causes (many!)
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4.
5.
6.
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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
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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
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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.org/article/thoracoscopicmanagement-spontaneous-pneumothorax
Spontaneous Pneumothorax
Spontaneous Pneumothorax
Altitude Sickness
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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/nonhealt
hcare_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
•Has no symptoms
•Does not feel sick
•Cannot 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
•Needs treatment for latent TB infection to
prevent TB disease
A Person with [active] TB Disease
•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
•Usually feels sick
•May spread TB bacteria to others
•Usually has a skin test or blood test result
indicating TB infection
•May have an abnormal chest x-ray, or positive
sputum smear or culture
•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