Pulmonology #5 (Atelectasis, Post-Op Fever, Pleural Diseases)

Question 1

What exactly is atelectasis?

Explain some patients who are at risk for this condition?

Answer 1

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

Question 2

There are three types of atelectasis. Describe them:

Obstructive
Post-Operative
Non-Obstructive

Answer 2

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

Question 3

Symptoms of atelectasis

Answer 3

-Dyspnea, SOB
-Wheezing, coughing
-Tachypnea, shallow breathing
-Diminished breath sounds in affected area
-Low-grade fever

Question 4

What is seen on a CXR in a patient with atelectasis?

Answer 4

Shifting of mediastinum TOWARD the collapsed lobe

Question 5

What is the treatment for atelectasis?

Answer 5

-Coughing, deep breathing
-Pain control
-Ambulation
-Incentive Spirometer

Question 6

Regarding Post-Operative Fever, what conditions MC occur on the following days. What is the phrase to remember them?

Answer 6

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.

Question 7

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:

Answer 7

Parapneumonic: noninflected pleural effusion due to bacterial PNA

Empyema: direct infection of the pleural space

Hemothorax: gross blood (malignancy, trauma)

Chylothorax: increased lymph

Question 8

There are two main etiologies of a pleural effusion. Name and describe them.

Answer 8

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.

Question 9

Symptoms of a pleural effusion

Answer 9

-Dyspnea, Cough, Pleuritic chest pain
-Dullness to percussion
-Decreased fremitus
-Decreased breath sounds
-Egophony
-Pleural Friction Rub

Question 10

What is seen on CXR for a pleural effusion? is this the initial test done?

What is the best position to take the CXR?

Answer 10

Yes, it is the initial test

-Blunting of costophrenic angles (meniscus sign)
-Have patient lay in left lateral decubitus position

Question 11

What is the GOLD STANDARD diagnostic for pleural effusion?

Answer 11

Thoracentesis
-remove a small sample of fluid from the pleural space

Question 12

What is Light’s Criteria and what does it mean?

Answer 12

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

Question 13

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

Answer 13

Thoracentesis

Pleurodesis (Talc, Doxycycline)

Question 14

What treatment is done for an empyema and how do you know this is the cause of the pleural effusion?

Answer 14

Chest tube drainage

pH < 7.2, glucose <40, or positive gram stain

Question 15

What is a pneumothorax and what are some symptoms?

Answer 15

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

Question 16

What are the five types of pneumothorax?

Answer 16

-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)

Question 17

What view of CXR do you get for a pneumothorax and what do you see?

Answer 17

Expiratory upright view

Decreased peripheral markings, companion lines, contralateral mediastinal shift

Question 18

Treatment for the following pneumothorax:

1) Small PSP < 3cm
2) Large PSP > 3cm
3) Stable SSP
4) Tension

Answer 18

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

Question 19

Tuberculosis, infection of respiratory system by Mycobacterium tuberculosis, infects how?

What are risk factors for TB?

Answer 19

-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*****

Question 20

Explain what chronic (latent) TB is

Answer 20

-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)

Question 21

What three things does a patient need to be not contagious with chronic (latent) TB?

Answer 21

+ PDD, no symptoms, no imaging findings of active infection of TB

Question 22

What is progressive/primary TB?

What part of the lung does this MC occur in?

Answer 22

-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

Question 23

What is secondary (reactivation) TB?

Where does this MC occur in the lungs?

Answer 23

-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

Question 24

Symptoms of TB

-There are two SPECIFIC exam findings of this

Answer 24

-Cough, hemoptysis, fever, night sweats, chills, weight loss
-Pott’s Disease: TB of vertebrae
-Scrofula: TV of Cervical lymph nodes

Question 25

Initially, for TB, you get a CXR. What is seen with the following conditions:

Primary:
Reactivation/Secondary:
Miliary:
Ghon Complex:

Answer 25

Primary: middle/lower lobe consolidation

Secondary: apical upper lobe consolidation

Miliary: small, millet-seed nodular lesions

Ghon Complex: residual evidence of healed primary TB

Question 26

What other diagnostics can you get for TB?

Answer 26

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

Question 27

What does a PPD test for TB do?

What needs to be done if you get a positive PPD?

Answer 27

Measure area of induration within 48-72 hours

Any positive test needs a CXR to rule out active disease

Question 28

What can give a false positive PPD?

Answer 28

BCG vaccine

Question 29

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.

Answer 29

-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

Question 30

What are some positives of the Interferon Gamma Release Assay test for TB?

Answer 30

-Improved specificity, but expensive
-One time test
-Not affected by prior BCG vaccine

Question 31

What is the treatment regimen for active TB

Answer 31

RIPE or RIPS for 6 months
–RIPE for 2, then RI for 4 months
-Rifampin + Isoniazid + Pyrazinamide + Ethambutol
-Can substitute Streptomycin for Ethambutol though

Question 32

What are the side effects you should know about the following medications:

Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin

Answer 32

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

Question 33

What is the treatment for Latent (Chronic) TB? There are three options…

Answer 33

INH + B6 (Pyridoxine) x 9 months

INH + Rifapentine

RIF x 4 months