Respiratory Disorders, TB, Chest Trauma & Pulmonary Emergencies – Comprehensive Notes

TB Skin Test (Mantoux/PPD)

Procedure & Anatomy
- Wheel of solution placed intradermally on volar forearm; site often circled in ink so next reader can locate it.
- Read exactly $48–72$ h later by palpating/visualising the firm bump (induration) from a side view.
- Ignore surrounding erythema; only the diameter of the palpable hardness counts.
Interpretation by Risk Category
- General public, no RFs → positive if induration $\ge 15\,\text{mm}$ .
- Moderate-risk (health-care workers, IV drug users, LTC residents) → positive if $\ge 10\,\text{mm}$ .
- High-risk (HIV⁺, recent TB exposure, immunosuppressed) → positive if $\ge 5\,\text{mm}$ .
- $0\,\text{mm}$ = completely flat → negative.
Numerical memorisation tip: “ $5$ – $10$ – $15$ rule” — be able to assign the correct patient group to each cut-off.

Isolation & Infection-Control for Active TB

Hospital
- Airborne isolation (negative-pressure room, door closed).
- Staff must wear fit-tested N-95 or PAPR; students without fit test are not allowed in the room per policy example.
- Patient wears surgical mask when transported.
- Usually kept ≈ $3$ days to obtain serial AFB sputum cultures before discharge.
Home
- Must sleep alone, preferably separate room & bathroom.
- Dedicated personal utensils (fork, knife, etc.).
- Continue surgical mask when leaving room/home.
- Emphasise strict hand hygiene + isolation to family.

Pharmacology – "RIPE" Regimen

Rifampin, Isoniazid, Pyrazinamide, Ethambutol (often ≥ $6$ mo).
Key side-effects previously reviewed (hepatotoxicity, orange secretions, optic neuritis, gout).

Directly Observed Therapy (DOT)

Public-health nurses watch patient swallow each dose; mouth & tongue inspect.
Cook County model: homeless clients placed in hotel & visited daily.
Ethic: individual autonomy < public-health necessity when treating TB.

TB Case-Study Pearls

57-y-o Chinese male in homeless shelter, HIV⁺, IV drug use → multiple RFs (ethnicity alone is not an RF unless travel mentioned).
Priority: airborne isolation even before full ABCs because every breath exposes ED.
Diagnostic: sputum AFB is definitive for active TB.

Chest Trauma Fundamentals

Blunt (e.g.
- Baseball bat to chest → pneumothorax, rib fx).
Penetrating (e.g. ice-pick by spouse).
- Foreign object left in place, covered with bulky dressing until OR.
Trauma primary survey: ABC → fix airway first, then breathing, then circulation.

Common Complications

Rib fractures → pain-limited respirations → atelectasis → pneumonia (illustrated progression in 78-y-o stair-fall case).
Flail chest = ≥2 adjacent ribs fractured in ≥2 places → paradoxical chest wall movement; requires positive-pressure ventilation.
Pleurisy = inflamed pleural lining; sharp pleuritic pain, splinting.

Chest Surgery Types & Expected Lung Sounds

Wedge resection / Segmentectomy (portion)
Lobectomy (one lobe) → diminished sounds over resected area
Pneumonectomy (entire lung) → absent sounds on operative side (expected, not alarming)

Lung Cancer

Smoking = $80–90\%$ of cases; no safe alternative forms (vaping, hookah, dip).
Definitive diagnosis: lung biopsy (imaging only presumptive).
Treatment triad: chemo + radiation + surgery; biologics/targeted (e.g. Keytruda $\Rightarrow$ dramatic survival in some pts).

Chest Tubes – Principles & Trouble-Shooting

Hardware Orientation

Insertion: 2nd–3rd ICS, mid-axillary → tube secured with sutures + Vaseline gauze occlusive dressing, 4×4s & ABD, wide tape.
Drainage system kept at or below chest; portable units OK at mattress level.

Water-Seal Chamber

Initial insertion: brisk bubbling.
After initial phase: intermittent bubbling only.
Continuous bubbling $\Rightarrow$ air leak.
- Clamp tube briefly, moving distal → proximal; bubbling stops between last two clamps → replace faulty segment.

Drainage Monitoring

Mark level each shift with date-time-initials.
Report >100\,\text{mL·h}^{-1} sudden output.
Sudden stop (still in pt): consider occlusion/kink; notify provider → possible removal.

“Never clamp…ish” Rule

Acceptable brief clamp scenarios:
1. Changing the whole drainage box
2. Locating air leak
Always unclamp ASAP to prevent tension pneumothorax.

Disasters & Actions (stories)

System knocked over
- Contents mix; treat box as contaminated → clamp-change-unclamp.
Patient pulls tube out of box (open system)
- Submerge loose tube in sterile saline bottle to recreate water seal until new box attached.
Tube completely dislodged from chest wall
- Apply 4×4 dressing taped on three sides (vent flap) to prevent tension PTX.
- THEN call provider / rapid.

Chest-Tube Removal

Criteria: fully re-expanded lung, minimal drainage.
Provider at bedside; patient performs Valsalva; occlusive dressing/Band-Aid; CXR post-removal.

Mini Devices

Flutter/Heimlich valve for $\le 40\%$ pneumothorax → credit-card size, patient can go home.

Thoracentesis & Pleural Effusion

Needle into pleural space (bedside, IR, or ICU) to drain fluid.
Post-procedure monitoring
- Small serosanguinous site drainage = expected.
- Complications: infection (fever, redness), pneumothorax (pain, dyspnoea, ↓SpO₂), bleeding → tachycardia earliest sign.
Immediate-action question example: tachycardia $\rightarrow$ investigate for complication vs. normal pain/drainage.

Pulmonary Edema

Fluid inside alveoli; usually due to left-sided CHF ("L for Lung").
S/S: dyspnoea, crackles, ↑RR, ↑HR, ↓SpO₂, pink frothy sputum.
Dx: chest X-ray, elevated $\text{BNP}$ .
Tx: high-flow O₂ or BiPAP, IV diuretics (furosemide), upright positioning, strict I&O.

Pulmonary Embolism (PE)

Patho: DVT embolises, lodges in pulmonary vasculature.
Classic presentation: sudden chest pain & SOB, clear lung sounds.
Vitals: ↑RR, ↑HR, ↓SpO₂.
Screening lab: D-dimer (elevated ⇒ search for clot; normal virtually rules out PE).
Definitive imaging: CT angiography with contrast (requires 20 G AC IV, check renal function, iodine allergy, hold metformin $24–48$ h).
Alternative when contrast contraindicated: V/Q scan (reports low/moderate/high probability).
Treatment ladder
1. Anticoagulation (heparin → warfarin/DOAC); prevents propagation.
2. O₂ support; maybe BiPAP or intubation.
3. Massive/central PE: thrombolysis with TPA or surgical embolectomy.
4. Recurrence prevention: IVC filter (umbrella device catching future clots).
Monitor closely for bleeding when thrombolytics used (e.g. uncovered GI ulcer anecdote).

Cor Pulmonale

Right-sided heart failure secondary to chronic lung disease (e.g. COPD, pulmonary HTN).
Leads to systemic congestion: JVD, peripheral oedema, hepatomegaly.

Asthma

Common triggers: exercise, allergens, cockroaches, air pollution, emotional laughter/tickling, beta-blockers ( $\text{–lol}$ ).
Triple Pathophysiology
1. Bronchoconstriction
2. Mucosal inflammation
3. Excess mucus production
Pharmacologic management
- Short-acting β₂-agonist (SABA): albuterol → first.
- Long-acting β₂-agonist (LABA): salmeterol/formoterol → second.
- Inhaled corticosteroid: prednisone/prednisolone (systemic for severe attacks) → reduce inflammation.
- Inhaled anticholinergic: ipratropium; often given with albuterol as “DuoNeb.”
- Hydration (IV fluids) to thin secretions.
Teaching
- Spacer use, trigger avoidance, peak-flow monitoring, early SABA use.

Exam & Clinical Pearls

"Immediate action" in NCLEX items = life-threatening complication needing now, not merely abnormal finding.
Do not assume anxiety; rule out hypoxia & life threats first.
Tachycardia is an early compensatory sign for most pulmonary complications.
Never strip/"milk" chest-tube tubing (risk of high negative pressure damage).
Pain management: uncontrolled pain inhibits deep breathing ⇒ atelectasis ⇒ pneumonia (case of 78-y-o refusing morphine).
Three-sided dressing mnemonic: “open sucking chest wound or dislodged chest tube.”
Public-health vs patient autonomy tension illustrated by mandatory DOT.

Quick Reference Equations & Numbers

PPD positive: general $\ge 15\,\text{mm}$ , HCW $\ge 10\,\text{mm}$ , HIV/Exposure $\ge 5\,\text{mm}$ .
Chest-tube concerning output: > 100\,\text{mL·h}^{-1}.
Thoracentesis/Chest-tube water-seal: continuous bubbling → air leak.
Flutter valve indication: $\le 40\%$ lung collapse.
Post-thoracentesis hold metformin $24–48$ h if contrast subsequently used.

Keep rehearsing the clinical stories (ice-pick, baseball bat, grandpa with wandering chest tube) — they encode the why behind each rule and improve recall on exams.