Wk 3: Day 2: Pulmonology by Heidi Pang

Today we rotated with Dr Yu all day. We started the day with a morning meeting on a presentation of Colistin and clinical approach to treat CRAB (Acinetobacter baumannii as 2^nd MC nosocomial pathogen at ICU in Taiwan). Mortality rate caused by CRAB can be up to 50% according to TNIS data in 2013. Dr Shen from National Taiwan University explained that standard lab testing cannot identify the subspecies of Acinetobacter (they refer the group of subspecies as AB complex) so sometimes patient may be able to recover by treating with standard antibiotics. Dr Shen suggested traditional antibiotic duration 10-14 days of Colistin or combo of Colistin + Tigecycline for CRAB. Inhalation Colistin can be considered for 7-10days for decolonization when systemic antibiotic fails after 48-72 hours. For Tigecycline treatment: check if MIC ≤2μg/ml

After the presentation, we went on patient rounds. Some of the things I have learnt include:

Trachial malacia – softening of the trachea. Dx by either full inspiration vs full expiration CT scan or Tracheal bronchoscopy (high risk procedure).

BiPAP is indicated for patients with COPD/asthma w/ AE, pleural edema. It is contraindicated for patients w/ facial trauma and deep coma. As I have mentioned before, it may cause some abdominal distention. Dr Yu mentioned that BiPAP is now overused in hospitals in Taiwan since families of elderly patients often refuse intubation.

Nursing home facilities here in Taiwan are actually privately run but are on contract with the government.

We also encountered a few cases of aspiration pneumonia caused by patient families insisting on feeding patient liquid food/oral feeding instead of feeding through a NG tube.

In the afternoon, we observed 3 thoracentesis procedure at the ultrasonography room. Below is a summary of 1 of the 3 cases:

61 y/o female previously w/ 1 episode of hemoptysis 1 wk ago, pleuritic chest pain and exertional dyspnea. CXR at clinic showed >1/2 of L lung w/ opacity w/ suspected pleural effusion. Results: anechoic and non-septated pleural fluid, (-) solid lesion. Left thoracentesis was performed; 1400ml yellow and mild turbid fluid was drained.

Primary suspect on differential is primary pulmonary tuberculosis. Dr Yu explained that Tb is the most likely possibility because of the patient’s presentation w/ hx hemoptysis w/ fever 1 wk ago and (-) chronic cough. General course of Tb is rather indolent. If patient has empyema (a common cause of pleural effusion), patient should be presenting w/ more persistent cough. Additionally, Tb culture may take up to 2 months to grow and commonly with negative results. Dr Yu stated that Tb can only be identified by exclusion. Lymphocyte should be predominant cells, and since Taiwan has a pretty high incidence of Tb, patient will often be put on standard Tb treatment and observe for improvement. Although pleural biopsy is available, Taipei hospitals rarely perform the procedure due to its high risk.

General steps for thoracentesis:

1.       Ultrasonography to determine location of pleural effusion and identify possible masses

2.       Mark ideal location of insertion. Palpate rib notch: ideal location for insertion will be right above the rib notch and not below due to VAN

3.       Disinfect w/ iodine, then possible local anesthesia depending on whether patient has a lot of adipose tissue. Dr Yu does not recommend anesthesia since often times it will cause local swelling

4.       Insert needle that is connected w/ a syringe, once syringe is filled, switch to IV draining unit (unit has switch). IV drainage is only necessary if the patient also requires drainage due to high volume of pleural effusion.

5.       IV unit will drain to collection bottle (sterilized, negative pressure bottle, usually ~1L volume)

* it is important to adjust the drainage flow rate if patient is starting to cough as it is an indication of fluid being mostly drained *

Example of patient with pleural effusion and atelectasis of LLL. Pleural effusion usually appears as a homogenous black shade.

http://radiopaedia.org/cases/cardiomegaly-with-bilateral-pleural-effusion

Picture below shows generally how the patient is set up: 

Standard pleural effusion studies include:

Gram Stain

Culture

CEA

Pleural fluid cell count

Total Protein

LDH

Glucose

Cell count, total protein, LDH level to distinguish exudate vs transudate

Glucose level for narrowing down differentials; if  <50, there are 3 possibilities: severe infectious empyema, malignant cell, Rheumatoid arthritis (chronic inflammatory process)