Pneumonia, bacterial

BASICS
DESCRIPTION:
An acute, bacterial infection of the lung parenchyma. Infection may be communityacquired or nosocomial (hospital acquired by an inpatient for at least 48 hours or
inpatient in the previous 1-3 weeks). Most commonly, community-acquired disease is
caused by Streptococcus pneumoniae or Mycoplasma pneumoniae. Hospital-acquired
pneumonia is usually due to gram negative rods (60%) such as Pseudomonas; 14.5%
from Staphylococcus.
System(s) affected: Pulmonary
Genetics: No known genetic pattern
Incidence/Prevalence in USA:
Incidence - community-acquired: 1200 cases/100,000 population per year
Incidence - nosocomial: 800 cases/100,000 admissions per year
Predominant age: Age extremes
Predominant sex: Male > Female
SIGNS AND SYMPTOMS:
Cardinal signs and symptoms
Cough and fever
Chest pain (pleuritic)
Chill, with sudden onset
Dark, thick or bloody (rusty) sputum
Respiratory
Signs of consolidation
Rales
Egophony
Signs of pleural involvement
Decreased breath sounds
Dullness to percussion
Friction rub
Signs of respiratory distress
Tachypnea/tachycardia (or bradycardia)
Cyanosis
Central nervous system
Mentation changes to include anxiety, confusion and restlessness
Gastrointestinal
Abdominal pain
Anorexia
CAUSES:
Sources
Aspiration from the oropharynx
Inhalation

Hematogenous spread
Bacterial pathogens
Streptococcus pneumoniae (pneumococcus)
Haemophilus influenzae
Mycoplasma pneumoniae
Staphylococcus aureus
Legionella pneumophila
Chlamydia pneumoniae, C. psittaci
Moraxella catarrhalis (Branhamella catarrhalis)
Pseudomonas aeruginosa
Klebsiella pneumoniae (and other gram-negative rods)
Anaerobes
RISK FACTORS:
Recent/concurrent viral infections
Hospitalization to include mechanical ventilation, antecedent antibiotics, NG tubes
Age extremes
Alcoholism
AIDS or other immunosuppression
Tobacco smoking
Renal failure
Cardiovascular disease
Functional asplenia
Chronic obstructive pulmonary disease
Diabetes mellitus
Malnutrition
Malignancy
Altered level of consciousness or gag (e.g., seizures, stroke, neuromuscular disease,
etc.)
Occupational exposure
Poorly implemented infection control practices
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Other causes of infectious pneumonitis: Viruses (respiratory syncytial, adenovirus, CMV,
parainfluenza, influenzae A and B, varicella, measles, rubella, hantavirus); Nocardia;
Fungi (Blastomyces, Cryptococcus, Aspergillus, Histoplasma, Coccidioides,
Pneumocystis carinii); Protozoans (Toxoplasma); Rickettsia (Coxiella burnetii - Q fever).
Also tuberculosis, pulmonary embolism with infarction, bronchiolitis obliterans with
organizing pneumonia (BOOP), pulmonary contusion, pulmonary vasculitis, acute
sarcoid, hypersensitivity pneumonitis, ARDS, pneumothorax, and other causes.
LABORATORY:
Leukocytosis with an immature shift on differential
Hyponatremia (SIADH)
Hypoxemia

Hypocapnia initially, then hypercapnia

Blood culture - positive in 10-20% of patients with community-acquired pneumonia, 820% nosocomial pneumonia
Drugs that may alter lab results: Antecedent antibiotics
Disorders that may alter lab results: Refer to lab test reference
PATHOLOGICAL FINDINGS:
Lung:
Segmental, lobar, or multifocal peribronchial consolidation
Positive gram stain for bacteria
SPECIAL TESTS:
Decubitus chest roentgenograms to investigate for empyema or parapneumonic
effusion
Gram stain and culture of pleural fluid
pH of pleural fluid (iced, airless sample sent to blood gas laboratory)

IMAGING:
Chest roentgenogram (with lateral decubitus views if pleural
effusion present)
Lobar or segmental consolidation (air bronchogram)
Bronchopneumonia
Interstitial infiltrate
Pleural effusion (free-flowing or loculated)
DIAGNOSTIC PROCEDURES:
Gram stain and culture of sputum (induced, if necessary)
Nasotracheal suctioning for culture
Transtracheal aspirate for culture
Bronchoscopy with bronchoalveolar lavage or protected telescoping catheter brushing
for culture
Thoracentesis for pleural fluid studies
Blood culture, especially if hospitalized - prior to antibiotics
TREATMENT
APPROPRIATE HEALTH CARE:
Community-acquired - outpatient for mild case, inpatient for moderate to severe case
such as hypoxemia, altered mental status, hypotension, significant co-morbid illness, and
age extremes.
Nosocomial - patients already hospitalized
GENERAL MEASURES:
Empiric antimicrobial therapy for most likely pathogen(s)

Consider oxygen for patients with cyanosis, hypoxia, dyspnea, circulatory disturbances
or delirium
Mechanical ventilation for respiratory failure
Chest physiotherapy
Hydration
Nasotracheal suction
Analgesia for pain
Electrolyte correction
Respiratory isolation if TB is a possibility
SURGICAL MEASURES:
N/A
ACTIVITY:
Bedrest and/or reduced activity during acute phase
DIET:
Nothing by mouth if there is incipient respiratory failure
Consider soft, easy-to-eat foods
PATIENT EDUCATION:
Printed patient information available from: American Lung Association, 1740 Broadway,
New York, NY 100019 (212)315-8700; web site http://www.lungusa.org
MEDICATIONS
DRUG(S) OF CHOICE:
Initial therapy
Usually empiric for most likely pathogens given clinical scenario (if specific etiology
is identified, adjust antimicrobial therapy)
Otherwise healthy young adult with mild community-acquired pneumonia:
erythromycin 500 po q6h (the new macrolides should be considered in those intolerant of
erythromycin or doxycycline and in smokers [to treat H. influenzae])
Older patients or patients with preexistent illnesses, with mild community-acquired
pneumonia: pneumococcal-active fluoroquinolone or amoxicillin-clavulanate with or
without erythromycin or other macrolide
Patients with community-acquired pneumonia requiring hospitalization: third
generation cephalosporin (cefotaxime or ceftriaxone) or ampicillin-sulbactam plus
macrolide or a pneumococcal-active fluoroquinolone
For nosocomial pneumonia: either ceftazidime or an antipseudomonal penicillin
(piperacillin, mezlocillin, or ticarcillin) plus an aminoglycoside. Vancomycin should be
considered if strong suspicion of Staphylococcus aureus.
Therapy for specific organisms
S. pneumoniae: penicillin G or oral amoxicillin/penicillin V. If high incidence of
penicillin resistant S. pneumoniae in the area, consider either vancomycin or
pneumococcal-active fluoroquinolone
H. influenzae: trimethoprim-sulfamethoxazole. For severe infections - cefotaxime,

ceftriaxone, or carbapenems
S. aureus: nafcillin; vancomycin (if high incidence of methicillin resistant S. aureus)
Klebsiella species: carbapenems, 3rd generation cephalosporin
Pseudomonas: aminoglycoside plus antipseudomonal penicillin or ceftazidime
Moraxella catarrhalis: 2nd generation cephalosporin (cefuroxime axetil), -lactam/lactamase inhibitors
Chlamydia pneumoniae: doxycycline, fluoroquinolone
Mycoplasma pneumoniae: erythromycin, fluoroquinolone
Legionella pneumophila: erythromycin (add rifampin for documented disease),
fluoroquinolone
Anaerobes: clindamycin, -lactam/-lactamase inhibitors
Contraindications: Allergy or likely cross-allergy to the prescribed antibiotic
Precautions: Possible significant sodium overload with antipseudomonal penicillins
Significant possible interactions: Refer to manufacturer's literature
ALTERNATIVE DRUGS:
S. pneumoniae: macrolide, doxycycline; cephalosporin
H. influenzae: cefuroxime; fluoroquinolones; extended macrolides; beta-lactam/betalactamase inhibitor
S. aureus: a first generation cephalosporin; clindamycin
Klebsiella: fluoroquinolone
Pseudomonas: carbapenems, aztreonam
Moraxella catarrhalis: trimethoprim- sulfamethoxazole; fluoroquinolone; cefixime,
extended macrolide
Chlamydia pneumoniae: clarithromycin; azithromycin
Mycoplasma pneumoniae: clarithromycin; doxycycline; azithromycin
Legionella pneumophila: clarithromycin; azithromycin; doxycycline
FOLLOW UP
PATIENT MONITORING:
If outpatient therapy, daily assessment of the patient's progress, and reassessment of
therapy if clinical worsening or no improvement in 48-72 hours
Chest roentgenograms take time to clear and may not show clearing, even though
patient is improving. Repeat study about 9 weeks after recovery to verify the pneumonia
was not caused by an obstructing endobronchial lesion in selected patients.
Repeating the cultures after treatment has been started is unnecessary unless there has
been treatment failure or if treating TB
PREVENTION/AVOIDANCE:
Reduce risk factors where possible
Bedridden and postoperative patients - deep breathing and coughing exercises; prevent
aspiration during nasogastric tube feedings
Avoid indiscriminate use of antibiotics during minor viral infections
Annual influenza vaccine for high risk individuals
Polyvalent pneumococcal vaccine

POSSIBLE COMPLICATIONS:
Empyema
Pulmonary abscess
Superinfections
Multiple organ dysfunction syndrome (MODS)
Adult respiratory distress syndrome (ARDS)
EXPECTED COURSE AND PROGNOSIS:
Usual course - acute. In otherwise healthy individual, improvement seen and fever
resolved in 1-3 days; sometimes up to 1 week
Overall mortality is about 5% in community acquired; (~15% if hospitalized and < 1%
if not hospitalized) 30-50% in nosocomial
Poorest prognosis - age extremes, positive blood cultures, low WBC, presence of
associated disease, immunosuppression respiratory failure, inappropriate antecedent
antibiotics, delayed treatment >8 hours
MISCELLANEOUS
ASSOCIATED CONDITIONS:
Alcoholism
Tobacco smoking
Upper respiratory infection
AGE-RELATED FACTORS:
Pediatric: Morbidity and mortality high in children under age 1
Geriatric: Morbidity and mortality high if > 70, especially if associated disease or risk
factor
Others: N/A
PREGNANCY:
N/A
SYNONYMS:
Lobar pneumonia
Classic pneumococcal pneumonia
ICD-9-CM:
481 Pneumococcal pneumonia
SEE ALSO:
Pneumonia, viral
Pneumonia, mycoplasma
Rhodococcus infections
OTHER NOTES:
Pneumococcal vaccine for all adults over age 65 and children over 2 years (and adults)

with risk (cardio, pulmonary or metabolic disorders)

ABBREVIATIONS:
N/A
REFERENCES
Bartlett JD, Mundy LM: Community-acquired pneumonia. N Engl J Med
1995;333:1618-1624
Laforce FM: Antibacterial therapy for lower respiratory tract infections in adults - A
review. Clin Infect Dis 1992;14(S2):S233-237
American Thoracic Society: Guidelines for the initial management of adults with
community-acquired pneumonia. Am Rev Respir Dis 1993;148:1418-1426
American Thoracic Society: Hospital acquired pneumonia in adults: diagnosis,
assessment of severity, initial antimicrobial therapy, and preventive strategies. Am J Res
Crit Care 1996;153:1711-1725
Bartlett JD, et al: Community acquired pneumonia in adults: guidelines for
management. Clin Infect Dis 1998;26:811-838
Web citations:
N/A
Author(s):
James K. Radike, MD
Ronald A. Greenfield, MD
IMAGES
Illustrations:
N/A
Copyright 2001 by Lippincott Williams & Wilkins

Pneumothorax
BASICS
DESCRIPTION:
Accumulation of air or gas between the parietal and visceral pleurae.
Spontaneous pneumothorax - may be primary or secondary
Primary in young and otherwise healthy patients
Secondary - as a complication of an underlying lung disease
Traumatic pneumothorax - may coexist with hemothorax
Tension pneumothorax - the air in the pleural space is under higher pressure than air in
adjacent lung and vascular structures

System(s) affected: Pulmonary, Cardiovascular

Genetics: No known genetic pattern, possible congenital predisposition in thin, tall young
men
Incidence/Prevalence in USA: 9/100,000
Predominant age: Adults 20-40 years
Predominant sex: Male > Female
SIGNS AND SYMPTOMS:
Chest pain, sudden, sharp, made worse by breathing, coughing or moving the chest
Chest movements - asymmetrical
Dyspnea
Cyanosis (sometimes)
Moderate to severe - profound respiratory distress
Tension pneumothorax - weak, rapid pulse, pallor, neck vein distension, anxiety,
tracheal deviation
Shock
Circulatory collapse
Diminished breath sounds and voice sounds
CAUSES:
Perforation of the visceral pleura and entry of gas from the lung
Gas generated by microorganisms in an empyema
Penetration of the chest wall, diaphragm, mediastinum, or esophagus
Blunt trauma to thorax
RISK FACTORS:
Trauma (broken rib, ruptured bronchus, perforated esophagus)
Rupture of superficial lung bulla following cough or blowing a musical instrument
Vigorous or stretching exercises
Flying (high altitude) after loss of pressurization
Diving (at ascension or rapid decompression)
Pneumoconioses
Tuberculosis
Pneumonia due to TB, Klebsiella, Staph aureus
Subpleural Pneumocystis carinii pneumonia (PCP) (in AIDS patients on PCP
prophylaxis via pentamidine aerosol)
Bronchial obstruction
COPD (particularly emphysema)
Asthma
Neoplasms
Endometriosis (during menstruation)
Rare diseases (Marfan's, Ehlers-Danlos)
Rupture of an infected abscess
Lymphangioleiomyomatosis

Cystic fibrosis
Cigarette smoking
Intubation ventilation
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Pleurisy
Pericarditis
Myocardial infarction
Pulmonary embolism
Diaphragmatic hernia
Stomach herniation through diaphragm
Dissecting aneurysm
LABORATORY:
Arterial blood gases in significant pneumothorax
pH < 7.35
pO2 < 80 mm Hg (10.6 kPa)
pCO2 > 45 mm Hg (6.0 kPa)
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS:
N/A
SPECIAL TESTS:
N/A

IMAGING:
Chest x-ray:
Air without lung markings peripherally, mediastinal shift
to contralateral side
Small pneumothorax may be evident only with expiratory
or lateral decubitus film
DIAGNOSTIC PROCEDURES:
Careful history and physical. The physical findings depend on size of pneumothorax.
TREATMENT
APPROPRIATE HEALTH CARE:
Outpatient - lung collapse less than 30%, no dyspnea, no signs of tension
pneumothorax, no underlying lung disease
Inpatient - if more than 30% collapse, tension or underlying lung disease

GENERAL MEASURES:
Outpatient
Bed rest
Monitoring blood pressure, pulse rate, respirations
Oxygen at high concentration will accelerate rate of absorption by 4 times
Treatment of any underlying condition
SURGICAL MEASURES:
Inpatient
Simple aspiration - insert 16 gauge cannula into 2nd anterior intercostal space at
midclavicular line and attach a 3-way stopcock and 60 mL syringe. Withdraw air
manually until no more can be aspirated.
Thoracotomy tube - inserted in 4th, 5th or 6th intercostal space at midaxillary line
and connect underwater seal
Tension pneumothorax - insert 19 gauge or larger needle into the chest and attach a
3-way stopcock. Use a large syringe to withdraw air. Follow with tube insertion
Pulmonary edema can be a complication of re-expansion
Recurrent pneumothorax (more often occurs with larger pneumothoraces)
Can cause severe disability
Consider thoracoscopy or thoracotomy following 2 or more spontaneous
pneumothoraces, if lungs not expanded after 7 days therapy or persistent bronchopleural
fistula
Consider pleurodesis with talc or other agents
ACTIVITY:
Bed rest until re-expanded
No air travel until x-ray normal
DIET:
No special diet
PATIENT EDUCATION:
Stop smoking
MEDICATIONS
DRUG(S) OF CHOICE:
Pleurodesis for recurrent pneumothorax:
Intrapleural doxycycline, 5 mg/kg in a total volume of 50 mL. Intrapleural
doxycycline is painful so premedicate with short-acting benzodiazepine and give 4 mg/kg
lidocaine in a total volume of 50 mL intrapleurally before doxycycline is injected.
Intrapleural talc, 5g in 250 mL isotonic saline
Contraindications: If patient a possible candidate for future lung transplant, do not do
sclerosing pleurodesis (sclerosing agents increase risk of bleeding at surgery so patients
are not eligible for transplant)

Precautions:
Talc procedure precipitated respiratory distress syndrome in 2 reports
Pain at time of intrapleural instillation and post-procedure are most common side
effects
Significant possible interactions: Refer to manufacturer's literature
ALTERNATIVE DRUGS:
None
FOLLOW UP
PATIENT MONITORING:
Blood pressure, respiratory rate, arterial blood gases, for hospitalized patients
After simple aspiration - clamp chest tube for 24 hours, then remove if no recurrence
on x-ray. If lung not fully re-expanded after 7 days, consider persistent air
leak/bronchopleural fistula.
PREVENTION/AVOIDANCE:
No preventive measures known, but patients may avoid some risk factors, e.g., exposure
to high altitudes, flying in unpressurized aircraft, scuba diving, smoking
POSSIBLE COMPLICATIONS:
Re-expansion pulmonary edema following suction
Bronchopleural fistulae requiring surgical repair
Surgery indicated following 2 spontaneous pneumothoraces on the same side
EXPECTED COURSE AND PROGNOSIS:
Air reabsorbed from small spontaneous pneumothorax in a few days
Air reabsorbed from larger air space in 2-4 weeks
Risk of recurrence is 30-50%
MISCELLANEOUS
ASSOCIATED CONDITIONS:
Listed with Causes
AGE-RELATED FACTORS:
Pediatric: Unusual in this age group except following trauma
Geriatric: Higher morbidity and mortality
Others: N/A
PREGNANCY:
A known, but unusual complication of labor and delivery. It should be suspected in the
pregnant patient with dyspnea and chest pain.
SYNONYMS:
N/A

ICD-9-CM:
512.0 Spontaneous tension pneumothorax
512.1 Iatrogenic pneumothorax
512.8 Other spontaneous pneumothorax
SEE ALSO:
N/A
OTHER NOTES:
Chest pain may simulate an acute MI or acute abdomen
ABBREVIATIONS:
MI = myocardial infarction
REFERENCES
Massad G, Thomas P, Wihlm JM: Minimally invasive management for first and
recurrent pneumothorax. Ann Thorac Surg 1998;66:592-9
Tschopp JM, Brutsche M, Frey JG: Treatment of complicated spontaneous
pneumothorax by simple talc pleurodesis. Thorax 1997;52:329-32
Sadikot RT, Greene T, Meadows K, Arnold AG: Recurrence of primary spontaneous
pneumothorax. Thorax 1997;52:805-9
Light RW: Management of spontaneous pneumothorax. Ann rev Respir Dis
1993;148:245
Miller AC, Harvey JE: Guidelines for the management of spontaneous pneumothorax.
Br Med J 1993;307:114
Baumann MH: The clinician's perspective on pneumothorax management. Chest
1997;112:822-28
Web citations:
Chestnet - Pneumothorax
Virtual Hospital - Pneumothorax
Author(s):
Kenneth Lee, MD, MPH, MBA
Benito B. Perez, MD
IMAGES
Illustrations:
N/A
Copyright 2001 by Lippincott Williams & Wilkins

Tuberculosis
BASICS
DESCRIPTION:
A common disease transmitted by inhaling airborne bacilli from a person with active
tuberculosis (TB). The bacilli multiply in the alveolus and are carried by macrophages,
lymphatics and blood to distant sites (eg. lung pleura, brain, kidney and bone). Tissue
hypersensitivity usually halts infection within 10 weeks.
Infected persons: are asymptomatic, are not infectious, and usually have a positive
tuberculin skin test
TB: active disease - occurs in 10% of infected individuals without preventive
therapy. Chance of disease increases with immunosuppression and is highest for all
individuals within 2 years after infection - 85% of cases are pulmonary which is
infectious.
Primary TB: disease resulting from the initial pulmonary infection which the immune
system is unable to control
Recrudescent TB: active disease occurring after a period of latent asymptomatic
infection
Miliary TB: disseminated disease
System(s) affected: Pulmonary, Hemic/Lymphatic/Immunologic, Renal/Urologic,
Gastrointestinal, Nervous, Endocrine/Metabolic, Musculoskeletal
Genetics: N/A
Incidence/Prevalence in USA:
Decreasing overall incidence of TB: 6.8/100,0000, but greater among high risk
15 million have latent infection
Predominant age:
Primary infection - any age, especially pediatric
Recrudescent disease - adults and elderly
Predominant sex: Male > Female
SIGNS AND SYMPTOMS:
Cough
Hemoptysis
Fever and night sweats
Weight loss
Malaise
Adenopathy
Pleuritic chest pain
Hepatosplenomegaly
Renal, bone or CNS disease are late findings
CAUSES:

Mycobacterium tuberculosis, Mycobacterium bovis, and Mycobacterium africanum

RISK FACTORS:
For infection: Urban, homeless, minority, migrant workers; institutional (eg, prison,
nursing home); close contact with infected individual; foreign born (Asia, Africa, Latin
America); healthcare workers
For disease: HIV; recent infection; IV drug abuse; lymphoma; diabetes mellitus;
chronic renal failure; malnutrition; steroids, immunosuppressive drugs; silicosis
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Other pneumonias
Lymphomas
Fungal infections, especially other atypical Mycobacteria or Nocardia
LABORATORY:
Tine test: not recommended for screening
PPD [5 units (.1cc) intermediate strength, 0.1 cc volar forearm; measure induration at
72 hrs]
> 5 mm - positive if HIV infection (or suspected), immunosuppressed, exposed
household contact, clinical evidence of active or old disease on chest x-ray
> 10 mm - positive if other risk factor or < 4 years old
> 15 mm - positive if older than 4 years and no risk factors
Two step testing if: no recent PPD, age > 55 years, nursing home, prison or
healthcare worker
Nonspecific laboratory includes anemia, monocytosis, thrombocytosis,
hypergammaglobulinemia, SIADH and sterile pyuria
Drugs that may alter lab results:
BCG: false-positive skin test but unreliable
Steroids: false-negative skin test
Disorders that may alter lab results: Recent viral infections, new (<10 weeks) infection,
severe malnutrition, HIV, anergy, age < 6 months. Overwhelming TB: false-negative skin
test
PATHOLOGICAL FINDINGS:
Granulomas with foci of caseating necrosis surrounded by epithelioid histiocytes and
giant cells, in turn surrounded by lymphocytes
AFB stains positive
SPECIAL TESTS:
Persons with TB should be tested for HIV
If extrapulmonary suspected, urine, CSF, bone marrow and liver biopsy for culture
Direct nucleic acid amplification approved if AFB stain positive and < 7 days of antiTB
treatment, provides rapid accurate detection, but expensive

IMAGING:
CXR with primary disease: may show infiltrate with or
without effusion atelectasis or adenopathy
With recrudescent TB: cavitary lesions and upper lobe
disease with hilar adenopathy common. Diffuse miliary pattern
possible with appearance of "millet seeds".
HIV: atypical findings with primary infection - right upper
lobe atelectasis
CXR useful to rule out TB in asymptomatic infected persons
CT chest - good sensitivity
DIAGNOSTIC PROCEDURES:
AFB stain can give a presumptive diagnosis
Culture confirms diagnosis; 4-6 weeks on solid media or 2 weeks on BATEK broth
system
For suspected pulmonary TB, obtain at least 3 morning sputum samples for AFB stain
and culture - use aerosol induction, gastric aspirate (children) or bronchoalveolar lavage
if needed
Other specimens: bone marrow, urine, tissue, CSF, peritoneal/pleural fluids
Culture and sensitivity guide treatment
TREATMENT
APPROPRIATE HEALTH CARE:
Prophylaxis for positive PPD at any age if: HIV, close contact, recent converter (< 2
years), IV drug use, abnormal CXR, high risk medical condition or if age < 35 in other
high risk group. Use INH (or rifampin if resistant) in usual daily dose for minimum 6
months. Consider twice a week DOT if adherence not assured.
For inactive pulmonary TB on chest x-ray, use INH for 12 months
For active disease, use minimum of 3 drugs for 2 months, then 2 drugs to complete 6
months - start with 4 drugs if resistance possible. Several regimen options available using
DOT.
If HIV infected:
Active TB, treat at least 6 months after culture negative
Prophylaxis, use isoniazid (INH) daily for 9 months or INH twice a week with DOT
or rifampin (RIF) + pyrazinamide (PZA) daily for two months (if patient taking
antiretroviral drugs, substitute rifapentine [RFP] for RIF)
GENERAL MEASURES:
Careful reevaluation required. Only change to twice weekly dosing if using DOT.
SURGICAL MEASURES:
For extra pulmonary complications (spinal cord compression, constrictive pericarditis)

ACTIVITY:
As tolerated - respiratory isolation for infectious pulmonary TB
Children without cough and negative sputum smears: no isolation required after
treatment started
DIET:
Regular. Consider pyridoxine (10-50 mg/day) supplement.
PATIENT EDUCATION:
Teach pathogenesis, emphasize importance of drug therapy, warn of effects and/or
interactions, and find contacts
Inform local health department
MEDICATIONS
DRUG(S) OF CHOICE:
Isoniazid (INH) - scored tabs 100 mg, 300 mg or syrup 10 mg/mL
Daily dose - adult 300 mg; pediatric 10-15 mg/kg (maximum 300 mg)
Twice weekly - adult 15 mg/kg; pediatric 20-30 mg/kg (maximum 900 mg)
Consider pyridoxine
Rifampin (RIF) capsules (150/300 or syrup 10 mg/mL)
Daily dose - adult 600 mg; pediatric dose 10-20 mg/kg (maximum 600 mg)
Twice weekly - adult 600 mg; pediatric 10-20 mg/kg (maximum 600 mg)
Pyrazinamide (PZA), scored 500 mg
Daily dose - adult 20-35 mg/kg (maximum 1-3 gm); pediatric 20-40 mg/kg
(maximum 2 gm)
Twice weekly - adult 50-70 mg/kg; pediatric 50 mg/kg (maximum 4 gm)
Rifapentine (RFP) 150 mg tablet
Twice weekly 600 mg for 2 months, then weekly 600 mg
Streptomycin (SM) IM only, vials 1,4 gm
Daily dose - 20-40 mg/kg (maximum 1 gm); pediatric 20-40 mg/kg (maximum 1 gm)
Twice weekly - 25 mg/kg; pediatric 20-40 mg/kg (maximum 1.5 gm)
Ethambutol (EMB) - tablets 100/400 mg bacteriostatic
Daily dose 15-25 mg/kg, with maximum of 2.5 gm a week or twice weekly dose 50
mg/kg, with maximum of 2.5 gm
Contraindications:
RIF and RFP: avoid if patient taking antiretrovirals
Streptomycin: avoid use longer than 12 weeks secondary to ototoxicity
Ethambutol: because of optic neuritis, never use ethambutol unless patient old enough
to cooperate for visual acuity and color testing.
Precautions:
INH, RIF, RFP or PZA may cause hepatitis
Follow liver function if the patient has history of liver dysfunction or new signs
develop
RIF and RFP - colors urine, tears and secretions orange. Can permanently stain contact
lenses.

INH - peripheral neuritis and hypersensitivity possible. Consider pyridoxine.

PZA and RFP - may increase uric acid
EMB - may cause optic neuritis; follow monthly vision and color tests
SM - ototoxicity and nephrotoxic
Significant possible interactions: RIF alters the level of Dilantin and other drugs
metabolized by the liver and may inactivate birth control pills (recommend a barrier
method)
ALTERNATIVE DRUGS:
Rifabutin substituted for RIF or RFP if patient taking antiretrovirals
Steroids - use only with concurrent anti-TB therapy. Consider for meningitis, effusions,
severe miliary disease or endobronchial disease.
Other antituberculous drugs may be useful for multidrug resistant TB (MDRTB)
Combination tablets to enhance adherence
FOLLOW UP
PATIENT MONITORING:
During preventive therapy - monthly visits to assess adherence to regimen and monitor
for hepatitis and neuropathy
If age > 35 or symptoms, check liver enzymes, modify drugs if needed
During TB therapy - obtain sputum culture monthly until negative and at completion of
therapy
If culture positive after 2 months of therapy, reassess drug sensitivity and initiate DOT
CXR at 3 months and at completion of therapy
PREVENTION/AVOIDANCE:
PPD screening
Identify and treat contagious persons. Notify public health department and hospital
infection control if admitted
Inpatient - use personal sealed respirators, negative pressure ventilation, ultraviolet
Ambulatory patients use mask and tissues
Not infectious if: favorable clinical response after 2-3 weeks of therapy and 3 AFB
smears are negative.
POSSIBLE COMPLICATIONS:
Cavitary lesions can be secondarily infected
Spread to susceptible persons of all ages
Drug resistance - suspect if immigrant, drug resistant source or noncompliant
EXPECTED COURSE AND PROGNOSIS:
Generally few complications and full resolution if drugs taken for full course as
prescribed
MISCELLANEOUS
ASSOCIATED CONDITIONS:
HIV infection (see special protocols)

AGE-RELATED FACTORS:
Pediatric:
Caution with ethambutol
Children on medication may attend school
Disseminated TB more common in infants; prompt treatment with 4 drugs if TB
suspected
Congenital infection may occur with miliary TB of maternal bacillemia, endometritis or
amniotic aspiration. If suspected, get PPD, CXR, LP, culture placenta and infant, then
start treatment promptly
Protocol for newborn with mother/household member with infection or disease
Member with positive PPD, but no disease: no special evaluation or treatment. Skin
test all household members; prophylaxis if infected.
Member has abnormal CXR: separate infant until infectious status known; if not
contagious, monitor infant PPD
Member with disease and possibly contagious: evaluate infant for congenital TB and
test for HIV; separate newborn until member is noninfectious
If congenital TB suspected, treat as above
If no congenital disease, INH for 3-4 months, then repeat PPD: if positive, reassess
for infant disease. If negative, finish 6 months INH. If repeat PPD negative and source
not infectious, stop INH and monitor infant.
Consider BCG
Geriatric:
Symptoms may be more subtle and may be attributed to associated conditions or to
aging
Should have a PPD prior to entering a chronic-care facility using two step protocols
Side effects of INH more pronounced
Others: N/A
PREGNANCY:
o Treat pregnant woman with INH, rifampin (and ethambutol, if resistance suspected);
add pyridoxine
o Avoid streptomycin and pyrazinamide
o Prophylaxis - postpone INH until postpartum unless recent contact
o Breast feeding okay while taking TB drugs
SYNONYMS:
o Consumption
ICD-9-CM:
011.9 Pulmonary tuberculosis, unspecified
SEE ALSO:
N/A

OTHER NOTES:
BCG vaccine, live attenuated Mycobacterium bovis
50% efficacy for pediatric pulmonary TB
In USA, consider BCG for children with negative PPD and HIV tests with
unavoidable high risk and for health care workers at high risk for drug resistant infection
Abscess, ulceration and regional lymphadenitis occur in 1-2%, osteitis and fatal
infection can occur in immunosuppressed
Used more commonly in developing countries to prevent complications of TB
ABBREVIATIONS:
PPD = purified protein derivative
BCG = Bacillus Calmette-Gurin
DOT = directly observed treatment
REFERENCES
Centers for Disease Control: Screening for tuberculosis and tuberculosis infection in
high-risk populations. MMWR, 39:1-12, 1990
American Thoracic Society: Treatment of tuberculosis and tuberculosis infections in
adults and children. Am J Respir Crit Care Med 1994;149:1359-1374
Report of the Committee on Infectious Diseases (Red Book). Elk Grove Village, Ill,
American Academy of Pediatrics, 1997
Centers for Disease Control: Core curriculum on tuberculosis - what the clinician
should know, 1994
Dutt AK: Tuberculosis. Part 1 and 2. Disease-A-Month 1997;43(3 & 4)
CDC Prevention and treatment of tuberculosis among patients infected with human
immunodeficiency virus: principles and revised recommendations. MMWR 1998;47(No.
RR-20)
Web citations:
American Social Health Association
External Tuberculosis Resources
Columbia University - Tuberculosis Resources
National Jewish Medical and Research Center
Author(s):
Gregory Snyder, MD
IMAGES
Illustrations:
N/A
Copyright 2001 by Lippincott Williams & Wilkins

Bronchiectasis
BASICS
DESCRIPTION:
Chronic irreversible, abnormal dilatation of the bronchi, usually accompanied by
infection and productive cough
System(s) affected: Pulmonary
Genetics: Associated with many conditions including some that are congenital or
hereditary
Incidence/Prevalence in USA:
No reliable figures available
Less common than it once was, probably due to more effective treatment of childhood
respiratory infections
Predominant age: Begins most often in early childhood, but symptoms may not appear
until later in life
Predominant sex: Male = Female
SIGNS AND SYMPTOMS:
Cough
Sputum - copious and purulent
Hemoptysis
Wheezing
Coarse or moist crackles
Cyanosis
Digital clubbing
Dyspnea
Barrel chest
Emaciation
Fatigue
Fever
Recurrent pneumonia
Tachycardia
Tachypnea
CAUSES:
Alpha-1-antitrypsin deficiency
Allergic bronchopulmonary aspergillosis
Bronchial obstruction
Cystic fibrosis

Dyskinetic cilia syndromes

Hypogammaglobulinemia
Inhaling noxious chemicals
Kartagener's syndrome (situs inversus, sinusitis, immotile spermatozoa, bronchiectasis)
Necrotizing pulmonary infections
Pulmonary abscess
Severe lung infection in childhood (measles, adenovirus, influenza, pertussis, or
bronchiolitis)
Tuberculosis
Congenital immunodeficiency syndromes
Chronic aspiration
Rheumatic diseases
Transplant graft rejection
RISK FACTORS:
Repeated bouts of pneumonia
Any chronic respiratory illness
Retained foreign body
Immunodeficiency
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Chronic bronchitis
Chronic obstructive pulmonary disease
Cystic fibrosis
Pulmonary tuberculosis
Allergic bronchopulmonary aspergillosis
LABORATORY:
Positive sputum culture (yields H. influenzae, Streptococcus pneumoniae,
staphylococcal, klebsiella, pseudomonas, or anaerobes)
Hypoxemia
Leukocytosis, usually
Serum immunoglobulins - check for hypogammaglobulinemia, IgE level helpful
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS:
Bronchial dilation
Inflamed bronchi
Purulent bronchorrhea
Necrosis of bronchial mucosa
Peribronchial scarring
SPECIAL TESTS:

Sweat test
Skin test for aspergillus
Bronchoscopy useful in locating bleeding site and to exclude adenoma or foreign body
Ciliary biopsy with electron microscopy (EM)
Pulmonary function tests show variable obstruction and restriction
Sputum culture/sensitivity, AFB, fungus

IMAGING:
Bronchography
For definitive diagnosis, to help determine extent, and if
surgery contemplated
Bronchial dilation, truncated
Chest x-ray
Can be normal
Coarse lung markings - honeycomb/tram tracks
Air-fluid level
Cystic lesions
Atelectasis
CT scan
Shows dilation of airways with signet rings
High resolution CT is best to establish diagnosis and extent
of disease
Spiral CT helpful for questionable findings
DIAGNOSTIC PROCEDURES:
Fiberoptic bronchoscopy
Recommended when disease is of recent onset or is unilateral
May be combined with bronchography
Obtain culture
TREATMENT
APPROPRIATE HEALTH CARE:
Outpatient except for possible surgery
GENERAL MEASURES:
Airway clearance techniques
Chest physical therapy
Percussion
Postural drainage
Hydration
Pulmonary rehabilitation to improve functional status

Noninvasive positive pressure ventilation, nocturnal or chronic

Bronchial artery embolization may be lifesaving for massive pulmonary hemorrhage
Avoid cigarette smoking
Bronchoscopy may be required for extraction of mucus or mycelial plugs, or if
physiotherapy has failed
SURGICAL MEASURES:
Segmental pulmonary resection for localized disease or refractory hemoptysis
ACTIVITY:
As fully active as possible
DIET:
No restrictions
PATIENT EDUCATION:
Printed patient information available from: American Lung Association, 1740 Broadway,
New York, NY 10019, (212)315-8700
MEDICATIONS
DRUG(S) OF CHOICE:
Bronchodilators
Dependent on pulmonary function tests
May be helpful for patients with associated asthma or aspergillosis
Beta-adrenergic agonists (e.g., albuterol) given by metered dose inhaler with use of a
spacer (reservoir device)
Antibiotics
Dependent on culture results, use at exacerbations
Ampicillin: 250-500 mg orally q 6 hours (50 mg/kg/day in divided doses q 6-8 hours
in children less than 20 kg)
or
Trimethoprim-sulfamethoxazole: DS q12h
Tetracycline: 250-500 mg orally q 6 hours
Aminoglycosides via nebulizer
Steroids
Consider for patients with bronchopulmonary aspergillosis. IgE level guides steroid
dosing.
Contraindications:
Tetracycline: not for use in pregnancy or children < 8 years.
Precautions:
Tetracycline: may cause photosensitivity; sunscreen recommended.
Significant possible interactions:
Tetracycline: avoid concurrent administration with antacids, dairy products, or iron.
Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; barrier
method recommended.

ALTERNATIVE DRUGS:
For chronic persistent infection, long-term high dose of amoxicillin 3 g every 12 hours
may be useful. It does not provide relief for everyone and has more side effects.
Other broad-spectrum antimicrobials including anti-pseudomonals if required. Choice
would depend on pathogen and susceptibility.
Inhaled corticosteroids if reversible obstruction present
Oxygen - if PO2 < 60 mm Hg
Nicotine replacement, consider to aid smoking cessation
FOLLOW UP
PATIENT MONITORING:
Frequent followup for progress of illness, prevention of infection, smoking cessation,
and to check on physiotherapy
At some point in followup, need to discuss with patient the possibility of mechanical
ventilation and cardiopulmonary resuscitation in the future. The patient, family and
provider should determine if this type of treatment is appropriate.
PREVENTION/AVOIDANCE:
Treat all pneumonias adequately
Immunizations for viral illnesses (i.e., influenza)
Immunization for pneumococcal pneumonia
Routine childhood immunizations, e.g., pertussis, measles, Hib
Genetic counseling if inherited etiology
POSSIBLE COMPLICATIONS:
Recurrent pulmonary infections
Pulmonary hypertension
Secondary amyloidosis
Cor pulmonale
Brain abscess
Massive hemoptysis
Atelectasis
Lung abscess
EXPECTED COURSE AND PROGNOSIS:
Chronic. Surgery may be curative if disease localized.
Average life expectancy - 55 years
MISCELLANEOUS
ASSOCIATED CONDITIONS:
Sinusitis
Cor pulmonale
Kartagener syndrome
Cystic fibrosis

AGE-RELATED FACTORS:
Pediatric: Cystic fibrosis and other congenital disorders
Geriatric: Elderly more likely to need hospitalization for treatment
Others: N/A
PREGNANCY:
N/A
SYNONYMS:
N/A
ICD-9-CM:
494 bronchiectasis
SEE ALSO:
Aspergillosis
Bronchiolitis obliterans & organizing pneumonia
Cystic fibrosis
Lung abscess
Kartagener's syndrome
OTHER NOTES:
Conditions that may lead to bronchiectasis include severe pneumonia (especially measles,
pertussis, adenoviral infections in children), necrotizing infections due to Klebsiella,
staphylococci, influenza virus, fungi, mycobacteria, mycoplasma, bronchial obstruction
from any cause (foreign body, carcinoma, enlarged mediastinal lymph nodes
ABBREVIATIONS:
N/A
REFERENCES
Hardy KA: A review of airway clearance: New techniques, indications and
recommendations. Respir Care 1994;39(5):440-445
Lewiston NJ: Bronchiectasis in childhood. Pediatr Clin North Am 1984;31(4):865-878
Marwah OS: Bronchiectasis: How to identify, treat and prevent. Postgrad Med
1995;97:149-159
Web citations:
The Chronic Lung Disease Forum
Author(s):
Gregory Snyder, MD
IMAGES
Illustrations:

N/A
Copyright 2001 by Lippincott Williams & Wilkins

Bronchitis, acute
BASICS
DESCRIPTION:
Inflammation of trachea, bronchi and bronchioles resulting from a respiratory tract
infection. Generally self-limited with complete healing and full return of function.
System(s) affected: Pulmonary
Genetics: No known genetic pattern
Incidence/Prevalence in USA: Common
Predominant age: All ages
Predominant sex: Male = Female
SIGNS AND SYMPTOMS:
Preceding respiratory tract infection, such as a common cold with coryza, malaise,
chills, slight fever, sore throat, back and muscle pain
Cough, initially dry and unproductive, then productive. Later, mucopurulent sputum.
Fever
Fatigue, aching
Hemoptysis
Chest burning
Dyspnea (sometimes)
Rales, rhonchi, wheezing
No evidence of pulmonary consolidation
Pharynx injected
CAUSES:
Adenovirus
Influenza
Parainfluenza
Chlamydia pneumoniae (TWAR agent)
Bordetella pertussis
Respiratory syncytial virus
Coxsackievirus
Herpes simplex
Haemophilus influenzae
Possibly fungi
Mycoplasma
Secondary bacterial infection as part of an acute upper respiratory infection

Streptococcus pneumoniae
Moraxella catarrhalis
Mycobacterium tuberculosis
Rhinovirus
RISK FACTORS:
Chronic bronchopulmonary diseases
Chronic sinusitis
Bronchopulmonary allergy
Hypertrophied tonsils and adenoids in children
Immunosuppression
Air pollutants
Elderly
Infants
Smoking
Second-hand smoke
Alcoholism
Gastroesophageal reflux disease (GERD)
Tracheostomy
Environmental changes
Immunoglobulin deficiency
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Asthma
Influenza
Bronchopneumonia
Bronchiectasis
Acute sinusitis
Aspiration
Cystic fibrosis
Reactive airways disease
Bacterial tracheitis
Retained foreign body
Inhalation injury
LABORATORY:
Arterial blood gases - hypoxemia (rarely)
Leukocytosis
Sputum culture/gram stain
Viral titers
Mycoplasma titers
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:
Mucosal hyperemia and inflammation
Desquamation of columnar epithelium
Mucopurulent exudate
SPECIAL TESTS:
Pulmonary function tests (seldom needed during acute stages) - increased residual
volume, decreased maximal expiratory rate

IMAGING:
Chest x-ray - lungs normal if uncomplicated. Helps rule out
other diseases or complications.
DIAGNOSTIC PROCEDURES:
Symptoms and signs
TREATMENT
APPROPRIATE HEALTH CARE:
Outpatient unless elderly or complicated by severe underlying disease
GENERAL MEASURES:
Rest
Steam inhalations
Vaporizers
Antibiotics if bacterial etiology suspected
Adequate hydration
Stop smoking
Treat associated illnesses (e.g., GERD)
SURGICAL MEASURES:
N/A
ACTIVITY:
Rest until fever subsides
DIET:
Increased fluids (up to 3-4 L/day) while febrile
PATIENT EDUCATION:
For patient education materials favorably reviewed on this topic, contact: American Lung
Association, 1740 Broadway, New York, NY 10019, (212)315-8700
MEDICATIONS
DRUG(S) OF CHOICE:
Amantadine therapy if influenza A suspected; most effective if started within 24-48

hours of development of symptoms

Decongestants if accompanied by sinus condition
Antipyretic analgesic such as aspirin, in adults, 650 mg q 4-6 hours
Antibiotics - for more severe symptoms (high fever persists, concomitant COPD,
purulent discharge).
amoxicillin 500 mg q8hrs or trimethoprim-sulfamethoxazole DS q12hrs for routine
infection
Macrolide - clarithromycin (Biaxin) 500 mg q12hr or azithromycin (Zithromax) Zpack for PCN or sulfa allergy or mycoplasma infection
Doxycycline 100 mg qd for 10 days if Moraxella, Chlamydia or Mycoplasma
suspected
Quinolone - levofloxacin (Levaquin) 500 mg qd for more serious infection or other
antibiotic failure
Cough suppressant for troublesome cough (not with COPD)
Bronchodilators (aerosols/steroids)
Consider steroids for bronchospasm
Contraindications:
Doxycycline should not be used during pregnancy
Precautions: Refer to manufacturer's literature. Watch for theophylline toxicity with
macrolides and quinolones.
Significant possible interactions: Refer to manufacturer's literature
ALTERNATIVE DRUGS:
Other antibiotics if indicated by sputum culture (Moraxella needs different set of
antibiotics)
Antivirals
Other macrolides or quinolones according to pathogen and sensitivity
FOLLOW UP
PATIENT MONITORING:
Oximetry until no longer hypoxemic
Recheck for chronicity
PREVENTION/AVOIDANCE:
Avoid smoking
Control underlying risk factors (asthma, sinusitis, reflux)
Avoid exposure
Vaccinations
POSSIBLE COMPLICATIONS:
Bronchopneumonia
Acute respiratory failure
Bronchiectasis
EXPECTED COURSE AND PROGNOSIS:

Usual - complete healing with good return of function

Can be serious in elderly or debilitated patients
Cough may persist for several weeks after initial improvement
Post-bronchitic reactive airways disease (rare)
Bronchiolitis obliterans and organizing pneumonia (BOOP) (rare)
MISCELLANEOUS
ASSOCIATED CONDITIONS:
Asthma
Epiglottitis
Coryza
Pharyngitis
Croup
Influenza
Smoking
Pneumonia
Emphysema
Sinusitis
Bronchial obstruction
Gastroesophageal reflux disease
AGE-RELATED FACTORS:
Pediatric:
Occurrence in this age group usually is in association with other conditions of upper
and lower respiratory tract (trachea usually involved)
Some children seem to be more susceptible than others (if repeated attacks, child
should be evaluated for anomalies of the respiratory tract including immune deficiencies)
If acute bronchitis is caused by respiratory syncytial virus, may be fatal
Geriatric: Can be a serious illness in this age group, particularly if part of influenza
Others: N/A
PREGNANCY:
N/A
SYNONYMS:
Tracheobronshitis
ICD-9-CM:
466.0 acute bronchitis
SEE ALSO:
Asthma
Chronic obstructive pulmonary disease & emphysema
OTHER NOTES:
N/A

ABBREVIATIONS:
GERD = gastroesophageal reflux disease
REFERENCES
Baum GL, Wolinsky E, editors. Textbook of Pulmonary Diseases. 4th ed. Boston:
Little, Brown & Co.; 1989
Murray JF, Nadel JA, editors. Textbook of Respiratory Medicine. Philadelphia: W.B.
Saunders Co.; 1988
Seaton A, Seaton D, Leitch AG: Crofton and Douglas's Respiratory Diseases. Boston,
Blackwell Scientific Publications, 1989
Heuston WJ, Mainous AG III. Acute bronchitis. Am Fam Phys 1998;57(6):1270-76
Web citations:
N/A
Author(s):
Alan J. Cropp, MD, FCCP
IMAGES
Illustrations:
N/A
Copyright 2001 by Lippincott Williams & Wilkins

Atelectasis
BASICS
DESCRIPTION:
Atelectasis (lung collapse) is a portion of lung which is non-aerated, but otherwise
normal. May be an asymptomatic finding on chest roentgenogram or associated with
symptoms. Pulmonary blood flow to area of atelectasis is usually reduced, thereby
limiting shunting and hypoxia. Diagnosis and therapy are directed at basic cause.
System(s) affected: Pulmonary, Cardiovascular
Genetics: Depends on basic condition e.g., cystic fibrosis, asthma, congenital heart
disease, etc.
Incidence/Prevalence in USA: Common in general anesthesia and in intensive care with
high inspired oxygen concentrations
Predominant age: All ages
Predominant sex: Male = Female

SIGNS AND SYMPTOMS:

Small atelectasis
Commonly asymptomatic
Produces no change in the overall clinical presentation
Large atelectasis:
Tachypnea
Cough
Hypoxia which resolves in some cases over 24-48 hours
Dullness to percussion
Absent breath sounds if airway is occluded
Bronchial breathing if airway is patent
Diminished chest expansion
Tracheal or precordial impulse displacement
Wheezing may be heard with focal obstruction
CAUSES:
Increased alveolar surface tension due to cardiogenic or non-cardiogenic pulmonary
edema, primary surfactant deficiency, or infection
Resorptive atelectasis due to airway obstruction from lumenal blockage (mucus, tumor,
foreign body), airway wall abnormality (edema, tumor, bronchomalacia, deformation), or
extrinsic airway compression (cardiac, vascular, tumor, adenopathy)
Compression of the lung (lobar emphysema, cardiomegaly, tumor)
Increased pleural pressure due to fluid or air in the pleural space (pneumothorax,
effusion, empyema, hemothorax, chylothorax)
Chest wall restriction due to skeletal deformity and/or muscular weakness (scoliosis,
neuromuscular disease, phrenic nerve paralysis, anesthesia)
RISK FACTORS:
Varies with condition producing atelectasis
Atelectasis following anesthesia is increased in smokers, obese individuals, and
individuals with short, wide thoraces
Asthma
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Atelectasis is not a specific diagnosis, but rather a result of disease or distorted
anatomy. The differential is thus found under Causes.
The roentgenographic differential includes pneumonia, fluid accumulation, lung
hypoplasia, or tumor
LABORATORY:
N/A
Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:
Pathology varies with cause
Obstructive atelectasis - non-aerated lung without inflammation or infiltration
SPECIAL TESTS:
N/A

IMAGING:
Chest roentgenography
May demonstrate linear, round, or wedge shaped densities
Right middle lobe and lingular atelectasis will obscure the
ipsilateral heart border
Lower lobe atelectasis will obscure the diaphragm
Air bronchograms are usually absent in obstructive
atelectasis
Evidence of possible airway compression, pleural fluid or
air should be sought
Diffuse microatelectasis in surfactant deficiency may lead
to a ground-glass appearance with striking air bronchograms
Mediastinal structures and the diaphragm move toward
the atelectatic region
Adjacent lung may show compensatory hyperinflation
DIAGNOSTIC PROCEDURES:
Bronchoscopy to assess airway patency. (Bronchoscopy as therapy is controversial with
the exception of foreign body or other structural causes).
Echocardiography to assess cardiac status in cardiomegaly
Chest CT or MRI to visualize airway and mediastinal structures
Barium swallow to assess mediastinal vascular compression
Other procedures vary with potential cause
TREATMENT
APPROPRIATE HEALTH CARE:
Varies with severity
GENERAL MEASURES:
Varies with severity and cause of atelectasis
Ensure adequate oxygenation and humidification
Chest physiotherapy with percussion and postural drainage. Consider adding treatments

using new airway clearance techniques such as Positive Expiratory Pressure (PEP) mask.
Incentive spirometry
Positive pressure ventilation or continuous positive airway pressure in subjects with
neuromuscular weakness
SURGICAL MEASURES:
N/A
ACTIVITY:
Encourage activity, mobilization as tolerated
DIET:
No special diet
PATIENT EDUCATION:
Encourage activity as appropriate. Instruct in basic cause and its therapy.
MEDICATIONS
DRUG(S) OF CHOICE:
Bronchodilator therapy (beta-agonist aerosol)
Other therapies directed at basic cause - antibiotics, foreign body removal, tumor
therapy, cardiac medication, steroids in asthma
Contraindications: Refer to manufacturer's literature
Precautions: Refer to manufacturer's literature
Significant possible interactions: Refer to manufacturer's literature
ALTERNATIVE DRUGS:
N/A
FOLLOW UP
PATIENT MONITORING:
Varies with cause and patient status
In simple atelectasis associated with asthma or infection, monthly visits are adequate
PREVENTION/AVOIDANCE:
Avoidance of 100% inspired oxygen (which can rapidly absorb causing atelectasis)
Foreign body/aspiration precautions
Postoperative mobilization and/or rotation
Institute therapies such as chest physiotherapy and incentive spirometry as preventive
maneuvers in at-risk patients
POSSIBLE COMPLICATIONS:
Infection with chronic lung damage is an unlikely, but unfortunate complication
Atelectasis is rarely life-threatening and usually spontaneously resolves

EXPECTED COURSE AND PROGNOSIS:

Resolution with medical therapy
Surgical therapy needed only for certain causes, or if chronic infection and
bronchiectasis supervene
MISCELLANEOUS
ASSOCIATED CONDITIONS:
N/A
AGE-RELATED FACTORS:
Very young and very old patients with limited mobility at greater risk
Pediatric: Congenital airway obstruction due to mediastinal cysts, tumor, or vascular
rings; foreign body aspiration
Geriatric: Primary and secondary lung tumors sometimes associated
Others: Asthma
PREGNANCY:
Management is similar to non-pregnant and varies with cause
SYNONYMS:
Lung collapse
ICD-9-CM:
518.0 Pulmonary collapse (atelectasis)
SEE ALSO:
Asthma
Pneumonia, viral
Pneumonia, bacterial
Pneumonia, mycoplasma
OTHER NOTES:
Round atelectasis:
A pleural based round density on chest roentgenogram with a comet tail of vessel
and airway
More common in patients with asbestos exposure
May mimic tumor, but can usually be definitively diagnosed with imaging studies
thereby avoiding surgery
ABBREVIATIONS:
N/A
REFERENCES
Hazinski TH: Atelectasis. In: Chernick V, ed. Kendig's Disorders of the Respiratory
Tract in Children. 5th Ed. Philadelphia, W.B. Saunders Co., 1990

Marini JJ, Pierson DJ, Hudson LD: Acute lobar atelectasis: a prospective comparison of
fiberoptic bronchoscopy and respiratory therapy. Am Rev Respir Dis 1971;119:971
Rickstenste, Sventrik, et al: Effects of periodic positive airway pressure by mask on
postoperative pulmonary function. Chest 1986;6:774-781
Web citations:
N/A
Author(s):
Nancy N. Dambro, MD
IMAGES
Illustrations:
N/A
Copyright 2001 by Lippincott Williams & Wilkins

Pleural effusion
BASICS
DESCRIPTION:
A pleural effusion occurs when there is excessive fluid released into the pleural space or
if there is lymphatic obstruction precluding normal drainage. Under normal conditions
there is a small volume of pleural fluid in the pleural space which functions as a lubricant.
Under pathological conditions, effusions develop and are classified as either transudates
or exudates. Transudates are due to an imbalance between hydrostatic and oncotic
pressures (as in hepatic cirrhosis, congestive heart failure, nephrotic syndrome, and
obstruction of the superior vena cava). Exudates are secondary to a disturbance of the
systems regulating pleural fluid formation and absorption/drainage (as in bacterial, viral,
or fungal infection, rheumatologic disease, or malignancy). Distinguishing between these
types of effusions, when etiology is uncertain or if there is inadequate response to
therapy, can be helpful.
System(s) affected: Pulmonary, Cardiovascular
Genetics: N/A
Incidence/Prevalence in USA: Not known
Predominant age: Can occur at any age
Predominant sex: Male = Female
SIGNS AND SYMPTOMS:
None in small volume effusion

Pleuritic chest pain and referred abdominal or shoulder pain

Cough, may be productive or nonproductive, depending on etiology
Chest wall splinting
Dyspnea
Tachypnea, particularly with lung compression or more severe infections
Diminished chest wall excursion
Decreased tactile fremitus
Dullness to percussion over effusion
Diminished or absent breath sounds
Friction rub
Chills
Mediastinal shift (on chest radiograph)
Weight loss
Night sweats
Hemoptysis
Anorexia
General malaise
CAUSES:
Congestive heart failure, effusion usually bilateral, but if unilateral R > L.
Hypoalbuminemic states (cirrhosis, nephrotic syndrome)
Constrictive pericarditis
Dressler's syndrome with pericardial effusion
Infection: parapneumonic effusion or empyema. Etiologic agents include bacteria,
viruses, fungi, Mycoplasma, parasites, and tuberculosis. Empyema usually caused by
polymicrobial anaerobic infection, Pseudomonas, Staphylococcus aureus, Escherichia
coli, and occasionally Streptococcus pneumoniae.
Pulmonary embolism/infarction
Neoplastic processes: mesothelioma from asbestos exposure, bronchogenic carcinoma,
breast carcinoma, lymphoma, leukemia, metastatic disease
Rheumatologic disease (systemic lupus erythematosus, rheumatoid arthritis)
Pancreatitis (left-sided exudate with high amylase concentration)
Esophageal rupture
Drug reaction, possibly accompanied by eosinophilia
Uremia
Atelectasis
Meig's syndrome
Subdiaphragmatic abscess
Cirrhosis with ascites
Chylous or pseudochylous effusion (thoracic duct injury)
Trauma leading to intrapleural hemorrhage
Idiopathic
RISK FACTORS:
N/A

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
See causes
LABORATORY:
Leukocytosis with bandemia
Anemia
Hypoalbuminemia
ANA titer
Rheumatoid factor
Pancreatic enzymes
CA-125
CA-19-9
Creatinine/BUN
Aerobic/anaerobic blood cultures
Microbial cultures of pleural effusion fluid
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS:
See causes
SPECIAL TESTS:
Evaluation of pleural fluid withdrawn by thoracentesis. Transudates and exudates must
be distinguished. A transudate has none of the following characteristics; however, an
exudate must meet one:
Pleural fluid protein/serum protein
Pleural fluid LDH/serum LDH > 0.6
Pleural fluid LDH > 2/3 upper limit of that in serum
All exudates must be evaluated for:
Differential cell count
Amylase level
Glucose level
Comprehensive microbiologic culturing and Gram staining
Cytology for tumor cells
Additional studies: pH, RBC count (hemorrhagic effusion if > 100,000/cc, consider
trauma as etiology for effusion)
In the absence of a known primary tumor and/or there is a high index of suspicion for
malignancy, the cells harvested from an effusion can be evaluated for a variety of tumor
markers (VIM, CD-15, CA19-9, CA-125, CEA, HBME-l, etc)

IMAGING:
Chest radiography: AP and lateral decubitus views
Thoracic ultrasound

CT scan
DIAGNOSTIC PROCEDURES:
Pleural biopsy if suspicion of tuberculosis or neoplasm
Thoracentesis
Thoracoscopy (provides direct view of both parietal and visceral aspects of pleura)
TREATMENT
APPROPRIATE HEALTH CARE:
Inpatient
GENERAL MEASURES:
Supportive care
Supplemental oxygen
IV fluid hydration
Chest physiotherapy
Therapeutic/diagnostic thoracentesis
Antibiotics
Empirically by age/social circumstances and modified by blood and pleural effusion
fluid culture results
Empyema
Consider antibiotics alone with close monitoring in children
Antibiotics with chest tube drainage in adults
Pleurectomy in cases of trapped lung
Pleural fluid loculation
May inject 250,000 units of streptokinase or 100,000 units of urokinase
intrapleurally to dissolve fibrin meshes creating loculation. If unsuccessful, then either
thoracoscopic adhesiolysis or decortication via thoracotomy are indicated.
Malignancy
Consider treatment of primary source. However, most malignancies accompanied by
malignant pleural effusions are advanced and cure is unlikely with chemotherapeutic
intervention.
If effusion is causing dyspnea, perform therapeutic thoracentesis and, if fluid
reaccumulates rapidly, then place chest tube for continuous drainage.
Other therapeutic interventions include placement of a pleuroperitoneal shunt and
chemical pleurodesis
Chylothorax - radiation therapy if from malignant cause or surgical repair of thoracic
duct trauma.
Hemothorax - diagnosed if hematocrit of pleural fluid > 50% that seen in blood.
Usually caused by trauma or rupture of a tumor. Drainage via tube thoracostomy
indicated. If bleeding persists or is of high volume then emergent thoracotomy is
indicated
SURGICAL MEASURES:
See General Measures

ACTIVITY:
As tolerated
DIET:
Depends on clinical circumstances
PATIENT EDUCATION:
American Lung Association, 1740 Broadway, New York, New York 10038
MEDICATIONS
DRUG(S) OF CHOICE:
Antimicrobial therapy according to pathogens and associated sensitivities
Chemical pleurodesis with doxycycline 500 mg, bleomycin 60 units, or talc in a slurry,
as indicated
Chemotherapy according to current oncologic protocols
Steroids and nonsteroidal anti-inflammatory drugs for rheumatologic and inflammatory
etiologies
Diuresis as appropriate for effusions secondary to congestive heart failure and ascites
Contraindications: Refer to manufacturer's drug profiles
Precautions: Refer to manufacturer's drug profiles
Significant possible interactions: Refer to manufacturer's drug profiles
ALTERNATIVE DRUGS:
N/A
FOLLOW UP
PATIENT MONITORING:
Serial chest radiographs, with frequency/interval determined by patient status/diagnosis
Pulmonary function testing as indicated
Serum studies, echocardiography, renal/hepatic function tests as indicated to monitor
for stability/progression of nonmalignant/noninfectious factors precipitating effusions
PREVENTION/AVOIDANCE:
N/A
POSSIBLE COMPLICATIONS:
Chronic empyema
Drainage through chest wall - pleurocutaneous fistula
Bronchopleural fistula
Toxic shock syndrome
EXPECTED COURSE AND PROGNOSIS:
Mortality rate around 20% for exudative effusions; worse for elderly patients or those
with serious underlying conditions

MISCELLANEOUS
ASSOCIATED CONDITIONS:
N/A
AGE-RELATED FACTORS:
N/A
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY:
N/A
SYNONYMS:
N/A
ICD-9-CM:
511.9 Unspecified pleural effusion
511.1 Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis
197.2 Secondary malignant neoplasm of respiratory and digestive system, pleura
SEE ALSO:
N/A
OTHER NOTES:
N/A
ABBREVIATIONS:
N/A
REFERENCES
Dowdeswell I. Pleural Diseases. In Internal Medicine (Stein J et al., eds). 5th Ed. St.
Louis, Mosby, 1998
Kendig R, Chernick V. Disorders of the Respiratory Tract in Children 5th Ed.
Philadelphia, WB Saunders Co., 1990
Light RW: Disorders of the pleura, mediastinum and diaphragm. In: Fauci AS, et al,
eds: Harrison's Textbook of Internal Medicine. New York, McGraw Hill, 1998
Web citations:
N/A
Author(s):
Peter P. Toth, MD, PhD

IMAGES
Illustrations:
N/A
Copyright 2001 by Lippincott Williams & Wilkins