Reliable delivery of these vaccinations depends upon effective information management systems in general practice, and substantial efforts by patients, ca rers, district nurses, and GP nurses A common reason to have missed immunization is to have been a long-term inpatient (eg undergoing rehabilitation) during the autumn immunization period. H ospitals should ensure that these inpatients are immunized Vaccinating healthcare workers, especially those working in long-term care settings, reduce s the spread of infection and therefore death due to in \202 uenza among patients Pneumococcal vaccine \200 Pneumovax II, a multivalent pneumococcal polysaccharide vacc ine, is effective against 65 % of serotypes Immunity remains for at least \201 ve years, perhaps for life \200 Bacteraemia is reduc ed by at least 50 % . The effect on incidence of pneumonia itself is less clear In \202 uenza vaccine \200 The trivalent vaccine is prepared from currently prevalent se rotypes \200 Immunity develops in <2 weeks, and it is therefore useful during epidemics Immunity remains for up to 8 months \200 The risk of pneumonia, hospitalization, or death due to in \202 uenza is reduced by over half Postexposure antiviral prophylaxis \200 Pharmacological prophylaxis of in \202 uenza is currently recommended when an unimmunized, high-risk group adult (eg care home resident) ha s had close contact with a person with in \202 uenza-like illness during a period when \202 u is prevalent (NICE 2008) Treatment with neuraminidase inhibitors must be initiated within 24hr (for oseltamivir) or 24hr (for zanamivir) ( see b \200\230Upper respiratory tract infections \200\231, p.314) Consider why immunization was not performed. Is it too late to administer this year (this contact may not have \200\230 \202 u, but the next one might)? If not, then optimize the chances of immunization next year PULMONARY FIBROSIS 325 Pulmonary \201 brosis This common problem is much underdiagnosed in older people due to a combination of under-investigation and overlap of clinical signs with common pathologies s uch as heart failure. Consider when breathlessness coexists with profuse \201 ne chest crepitations, with or wi thout clubbing. On CXR, there may be bilateral pulmonary shadowing consistent with pulmonar y oedema, but with little supporting evidence (eg normal heart size, absent Kerley B lines) . Causes \200 Idiopathic. The most common type in older people, known as usual interstitial pneumonia Connective tissue disease, eg rheumatoid arthritis (most common), systemic lupus erythemato sus, sarcoidosis. Lung involvement is sometimes the \201 rst manifestation of the multisy stem disease Drugs, eg amiodarone, nitrofurantoin rarely \200 Occupational exposure, eg asbestos, sili ca \200 If localized, consider TB, bronchiectasis, and radiotherapy Tests \200 The diagnosis is usually con \201 rmed by high-resolution CT scanning, which can also help distinguish subgroups likely to respond to immunosuppressive treatment Respiratory function tests may be useful (a restrictive picture with decreased transfer fac tor is usual) but typically adds little in the frail older person Refer to a respiratory physician to con \201 rm diagnosis and guidance on management Prognosis This is very variable \200\224 about a third are clinically stable, a third impr ove and a third deteriorate at rates that vary greatly between individuals. Some can live w ith pulmonary \201 brosis for years without signi \201 cant functional impairment. Treatment \200 Treat or remove any underlying cause, eg drugs \200 A minority respond s lowly (over weeks) to immunosuppression (eg prednisolone and azathioprine). Monitor closely for side effects. In non-responders, ta il off and stop. In responders, reduce dose cautiously. Ensure bone protection with calcium , vitamin D, and bisphosphonates Home oxygen therapy is often useful \200 Give opiates for distressing dyspnoea \200 In those in whom dyspnoea progresses, consider end-of-life issues including treatment limitation, and a change of focus from life-extending measures t o a purely palliative approach 326 CHAPTER 11 Chest medicine Rib fractures Common in older people. \200 Often a result of falls or even minimal bony s tress such as coughing in a person with osteoporosis Consider the possible contribution of alcohol, which causes both falls and osteoporosis Diagnosis Rib fractures should be diagnosed clinically. \200 Point tenderness and crepitu s are often found \200 Pressure over the sternum may provoke the pain in a lateral rib \200 CXR, even with multiple projections, may miss the fracture, but is useful in excludin g early complications such as pneumo- or haemo- thorax Radioisotope bone scans are very sensitive but not speci \201 c (hot spots are often found without clinical fracture) so they are rarely indicated Management Rib fractures heal without speci \201 c treatment. The major problem is pain, w hich commonly leads to voluntary splinting of the injured area. There is hypoventilation an d a failure to clear secretions, and secondary pulmo- nary infection can occur. \200 The patient should be encouraged to breathe deeply and to cough. Supporting the injured area wh en coughing, using a small pillow, minimizes pain. Strapping of the affected area is no lon ger done, as it increases complication rates Regular analgesia should include paracetamol, plus a weak opiate in most cases. A short course of NSAIDs may be helpful Admit to hospital if pain is severe and the patient unable to cough, or if complications (usually infection) have occurred In cases of severe pain (eg multiple fractures), consider strong opiates or intercostal/paravertebral blocks. Involve the local pain team Reassure the patient that the injury itself is not severe, will heal without immobilization and that coughing will prevent complications, not cause further damage. This page intentionally left blank 328 CHAPTER 11 Chest medicine Pleural effusions A frequent (clinical or radiological) \201 nding, sometimes incidental. Common causes are heart failure, post-pneumonia, PE, and malignancy (especially lung prima ry, mesothelioma, leukemia, lymphoma, and meta- static adenocarcinoma (ovary, stomach)). The differential diagnosis is wide, but narrowed when the results of CXR and pleural \202 uid aspiration are known (Table 11.2 ). Table 11.2 Differentiating cause, by protein level Transudate (protein <25g/L) Exudate (protein > 35g/L) Heart failure Malignancy Hepatic cirrhosis Infection, including TB Hypoproteinaemia, Gastrointestinal causes, eg malabsorption, sepsis eg pancreatitis Nephrotic syndrome Multisystem disorders, eg rheumatoid (Exudative causes if low serum protein) (Heart failure after diuresis) Empyemas, malignancy, and TB produce exudates with low pH (<7.2), low glucose (<3.3mmol/L) but high lactate dehydrogenase (LDH) \200 Transudates are usually not due to focal lung p athology, and so usually affect both lungs. Unilateral effusions due to transudates occasio nally do occur, more commonly on the right side Effusions due to heart failure are typically small and bilateral, with cardiomegaly; they can be unilateral, but usually a tiny contralateral effusion is seen, ma nifesting as blunting of the costophrenic angle; if the angle remains sharp, other causes a re more likely A massive unilateral effusion is usually due to malignancy \200 A uniformly bloodstained effusion is usually due to infection, embolism, malignancy or trauma Chronic effusions \200 If bilateral transudates, should be treated as for heart failure \200 If the diagnosis is not clear after CXR and aspiration consider chest physician refer ral and tests including CT, pleural biopsy (CT-guided rather than blind), video-assisted th oracoscopy with biopsy (VATS), and echocardiogram For large, recurrent effusions, consider chest physician referral for continuous outpatient external \202 uid drainage via a semipermanent intrapleural ( \200\230Pleuryx \200\231) catheter Frail patients may not tolerate, or desire, the more invasive tests. In this case, consider: \200 Repeated aspiration, combining diagnostic with therapeutic taps and sending larger volumes of \202 uid for cytology and acid-fast bacillus culture \200\230Watching and waiting \200\231, with regular clinical review \200 A trial of diur etics, especially if the effusion is a transudate PLEURAL EFFUSIONS 329 HOW TO Aspirate a sample of pleural \202 uid Although aspiration is increasingly co nducted under ultrasound guid- ance it remains a safe procedure in selected patients (compl iant with good sized effusions) without ultrasound guidance. Simple aspiration in an outpat ient or community setting remains a useful tool for the geriatrician: 1. Sit the patient le aning forwards and resting comfortably. Make yourself comfortable 2. Clinically identify the effusion (review the CXR; percuss to \201 nd maximum dullness) 3. Using permanent ink, mark this point 4. Clean and disinfect the skin. Attach a green hub (21-gauge) needle to a 10mL syringe 5. Using aseptic technique, insert the needle close to the marked point, but above a rib in order to avoid the neurovascular bundle 6. Advance slowly, applying moderate suction to the syringe, until the pleural space is entered and \202 uid \202 ows If a larger volume of aspirate is needed, swap to a larger syringe, holding the needle quit e still. Ultrasound detects small effusions (50 \200\223100mL) and aids diagnostic aspiration in patients with a small effusion. Tests on the aspirate should usually include microscopy/culture, cytology, protein, LDH, gl ucose, and pH. If tuberculosis or cancer is suspected, then send larger volumes (eg 50mL) t o microbiology and cytology, respectively. 330 CHAPTER 11 Chest medicine Pulmonary embolism Pulmonary embolism (PE) is common, yet as \200\230the great pretender \200\231 (of other pathology), is underdiagnosed and underreported on death certi \201 - c ates. It commonly coexists with and is confused with other lung disease eg pneumonia, heart failure and COPD \200\224 and is a common cause of dete- rioration in such patients. Presentation The classic symptom triad of pain, dyspnoea and haemoptysis is seen less commo nly in older people. Common presentations include: Brief paroxysm(s) of breathlessness, or tachypnoea \200 Collapse, cardiac arrest, syncope , presyncope, or hypotension \200 Pulmonary hypertension and right heart failure, present ing as chronic unexplained breathlessness Puzzling signs eg fever, wheeze, resistant heart failure, arrhythmia, confusion, or functional decline Investigations Determining the likelihood of PE rests on combining clinical judgment (the p roduct of history, examination, and immediately available tests such as CXR) with appropria te imaging such as V/Q scan or CT pulmonary angiogram (CTPA). The common clinical features of PE \200\224 tachypnoea, tachycardia, and modest degrees of hypoxaemia \200\224 are com mon in ill older people, so clinical judgment alone is rarely enough. Moreover, a con \201 dent diagnosis is essential because in older people: The risk of anticoagulation is higher \200 The risk of a missed diagnosis is higher (less physiological reserve) Possible PE in older people should be investigated in the usual way , with the choice of tests guided by local facilities and expertise. The following issues a re especially relevant: \200 In a patient without known lung disease, the combination of breathlessness and a CXR showing clear lung \201 elds strongly suggests PE. Further test( s) (V/Q or CTPA) are indicated CXR abnormalities may be minor (atelectasis, raised hemidiaphragm, small effusions), or maj or (usually re \202 ecting comorbid conditions rather than PE itself). Classical wedge sha dows or unilateral oligaemia are rare PE in the absence of lower limb deep vein thrombosis is common (10 \200\22320 % of cases), so do not be put off by an absence of clinical signs of the leg , or a negative Doppler ultrasound D-dimer can be a useful screening test to rule out PE but because many older people have co existing conditions, eg infection false positives are very common (ie sensitivity high, spe ci \201 city low) Arterial blood gasses have some value in diagnosis, but the common abnormalities (low PaO 2 , low PaCO 2 , and increased alveolar-arterial (A-a) oxygen gradient) are neither sensitiv e nor speci \201 c \200 In healthy older people, an increased A-a gradient is common \200 In older people following PE, a normal A-a gradient is seen in > 10 % PULMONARY EMBOLISM 331 Echocardiogram may be normal following PE. However, in a patient with a high clinical probability, typical features of PE on echocardiogram usually provide suf \201 cient diagnostic con \201 dence to permit anticoagulation without further imagin g In the patient with unexplained right heart failure, consider PE: obtain an ECG and echocar diogram (ask for PA pressures) and request imaging that details the lung parenchyma (high-r esolution CT: pulmonary \201 brosis?) and the vasculature (CTPA: pulmonary embolism?) In the patient who does not respond to treatment for chest infection, heart failure or acut e exacerbation of COPD, consider whether PE may be responsible Treatment Anticoagulation Standard treatment is low molecular weight heparin (eg dalteparin , enox- aparin) followed by warfarin with goal INR 2 \200\2233. Once the possibility of PE is raised, it is essential to treat with low molecular weight heparin pending investigation results, unless there are particular treatment risks. To minimize bleeding risk: Anticoagulate with caution. Check baseline clotting. Give 5mg (not 10mg) warfarin dose on day 1 ( see b \200\230HOW TO Initiate warfarin \200\231, p.14 6) Beware the older patient with mild anemia or a low MCV \200\224 do they have occult blood loss? In the very frail, sick, unstable patient in whom anticoagulation with warfarin would present signi \201 cant risk, consider a period of anticoagulation wit h low molecular weight heparin. Start warfarin when clinical stability returns Thrombolysis Consider thrombolysing, balancing risks and bene \201 ts, where there is life -threatening PE, manifesting as acute right heart strain and systemic hypotension. Both ris k and bene \201 t increase with age, so age itself is not a contraindication. Inferior vena cava (IVC) \201 lter An IVC \201 lter ( \200\230Green \201 eld \201 lt er \200\231) can be inserted under local anesthesia by an interventional radiologist. Most cannot be removed once in situ but some of the newer ones are potentially retrievable . Indications include: Strong contraindication to anticoagulation, eg Active bleeding \200 A high risk of bleeding, eg newly diagnosed peptic ulcer or very recent haemorrhagic stroke Massive thromboembolism with contraindication to thrombolyis \200 Ongoing thromboembolism despite anticoagulation \200 Embolism from a septic focus 332 CHAPTER 11 Chest medicine Aspiration pneumonia/pneumonitis The involuntary entry of extrinsic material into the pulmo nary airways. This is a common problem, ranging from subclinical micro-aspiration of oropha ryngeal mucus to major inhalation of gastric contents. Risk factors \200 Swallowing problems \200 Gastro-oesophageal disorders leading to re \202 ux \200 Impaired conscious level including seizures \200 Sedative drugs \200 Pre vious aspiration or non-aspiration pneumonia \200 Clinically assisted nutrition \200\224 either NG or gastrostomy Diagnosis Commonly, the occurrence of pneumonia in a patient with risk factor(s) suggests t he diagnosis. CXR may show consolidation in dependent lung zones, eg R lower lobe, although any zone may be affected. Treatment \200 The role of antibiotics is debated. Much of the radiographic response may be a chemical pneumonitis, ie in \202 ammatory reaction to caustic gastric contents, rathe r than infective pneumonia The choice of antibiotics is also contentious. Many cases respond well to amoxicillin or co-amoxiclav, but consider broad spectrum iv antibiotics to cover Gr am-negatives and anaerobes in: \200 The unwell \200 The especially frail \200 High-de pendency settings \200 Where aspiration has been major If possible, treat the underlying cause. If risk factors persist (eg impaired swallow or co ntinual seizures), consider a \200\230nil by mouth \200\231 order until they are addressed . Where the swallow may be impaired, perform a formal swallowing assessment (see b \200\230H OW TO Manage swallow after stroke \200\231, p.189) and manage according to the result s In palliative care; Consider anticholinergics to dry secretions \200 In advanced dementia, it is often approp riate to accept the risk of aspiration. Insertion of a gastrostomy (commonly a PEG) risks medicalizing the \201 na l months while achieving nothing \200\224 aspiration is common in patients with a PEG It is often cruel and futile to deny a dying patient food that he or she may enjoy, even if the risk of aspiration and a life-shortening pneumonia exists. \200\230Nil by mouth \200 \231 orders are usually inappropriate in end-of-life situations. Instead consider using thi ckened \202 uids, pureed diet, supervised feeding, and avoiding eating in recumbent posit ion, with straws or feeder cups CHRONIC COUGH 333 Chronic cough A common problem, with causes ranging from the trivial to the sinister. Even where the underlying cause is benign, chronic cough can be both distressing and disabling. Causes \200 Asthma. Cough is a common presenting symptom in older people \200 Silent pu lmonary aspiration \200 GORD \200 Postnasal drip can be due to sinusitis or chronic rhi nitis. Frequently allergic in origin, but in older people, symptoms are often not seasonal Drugs, eg ACE inhibitors (may take weeks or months to develop), B -blockers (leading to bronchospasm) Persistent benign cough following upper respiratory tract infection. May persist for 2 \200\2233 months Chronic pulmonary pathology eg COPD, TB, bronchiectasis \200 Heart failure, with high pul monary pressures \200 Thoracic malignancy, either primary or secondary Investigation Consider both tests and trials of treatment. Their pace and extent depends on the differential diagnosis following careful history and exami- nation. Consider the follo wing tests: \200 CXR (mandatory) \200 Sinus X-ray \200 Spirometry, with assessment of response to bronchodilators \200 Regular monitoring of PEFR, looking for morning drops s uggesting asthma Sputum microscopy and culture is unlikely to be helpful Next, consider a trial of treatment for the most likely cause, eg: \200 Bronchodilators (and inhaled steroids) for possible asthma \200 A PPI for possible GORD \200 Assess the effect of treatment of possible chr onic rhinitis with: \200 Nasal corticosteroids. Probably the treatment of choice, eg beclometasone, budesonide Decongestants. Should be used in short courses only (since rebound phenomenon) Antihistamines. Most useful for obviously allergic rhinitis. Can be topical spray or tablet . Should be used with caution; select those with fewer anticholinergics properties, eg ceti rizine or loratadine In all cases, trials of treatment need to be prolonged ( (cid:116) 8 weeks). Treatment This is of the underlying cause. Where this cannot be treated effectively (eg adv anced malignancy), speci \201 c treatments aimed at reducing cough may be of bene \201 t. These include opiates such as codeine or morphine. Simple cough linctus may be useful for irritating dry cough following an upper respiratory tract infection. 334 CHAPTER 11 Chest medicine Lung cancers The commonest cause of cancer deaths, and largely a disease of older people. \200 Symptoms may be non-speci \201 c (eg fatigue, weight loss), or else pulmonary in origin but attributed to existing non-malignant pathology (eg dyspnoea in a pa tient with COPD) Have a high index of suspicion and a low threshold for further investigation. Have an even higher degree of suspicion in older smokers presenting with pne umonia Sinister features in those presenting with pneumonia include: \200 Haemoptysis, especiall y if signi \201 cant, eg with persistent blood clots \200 Regional or generalized sympto ms of cancer (eg hoarse voice, weight loss) Cough and consolidation without obvious infective symptoms (eg fever) Symptoms that continue to be troublesome despite antibiotics If sinister features are prese nt, it is unacceptable to wait (up to 6 weeks) before repeating a CXR to con \201 rm resol ution. Refer promptly for urgent specialist assessment and consider CT scanning, bronchosco py, or lung biopsy. Treatment \200 Treatment has improved and is now more effective, both in extending life a nd in palliating symptoms. Therefore, \200\230benign neglect \200\231, ie simply observing an older person with probable lung cancer, is now only rarely acceptable. It may be approp riate, for example, in cases of extreme frailty or severe cognitive impairment Older people with probable lung cancer remain under-investigated and under-treated: \200 Tests such as bronchoscopy and a histopathological diagnosis are less commonly obtained. This makes palliative treatment and prognostication dif \201 c ult Treatment such as surgery or chemotherapy are less commonly considered or administered. To an extent this re \202 ects appropriate decision making bas ed on functional status Treatment decisions should be made by expert MDTs that consider the patient \200\231s functional status, comorbidities, and cancer characteristics 2Refer a ll patients with suspected or con \201 rmed lung cancer for a specialist opinion. LUNG CANCERS 335 Non-small cell carcinoma (squamous cell, adeno-, and large cell carcinoma) \200 Surgery m ay lead to cure if: There is adequate pulmonary function (arbitrarily, FEV 1 (cid:116) 1.5L) \200 There is no distant spread (but > 50 % of cancers have spread at presentation) The patient is relatively well with good functional status and no serious comorbidity Surgical procedures are high risk (eg at 70 years, lobectomy has 10 % perioperative fatalit y, and pneumonectomy 20 % ). However, the condition is always fatal without treatment, so t he patient \200\231s view is critical Radiotherapy. When surgery is not feasible, either because of the nature of disease, or the \201 tness of the patient, then radiotherapy may be used either : \200 Palliatively, to control symptoms (see b \200\230Palliative interventions \200 \231, p. 335) Curatively, in high dose (CHART). Success rates are lower than for surgery Neoadjuvantly, to reduce tumor volume and sometimes to convert a non-operable tumor into an operable one \200 Chemotherapy. Oral agents can be u sed if EGFR mutation found Small cell carcinoma \200 Relatively more common in older people: > 20 % of cases \200 Most cases are advanced at presentation, and treatment is palliative \200 Most tumors are chemoresponsive. Frail patients are unlikely to tolerate aggressive treatment and it risks reducing the quality of the brief life that rema ins. Therefore, chemotherapy regimens are tailored to the patient, determined by structured assessment of performance status. In general, frail patients undergo fewer but similar che motherapy cycles compared to the more robust Surgery is the treatment of choice, but is seldom useful because tumors are rarely localized at presentation Palliative interventions \200 Radiotherapy for superior mediastinal obstruction, bronchia l obstruction, chest pain, haemoptysis, or painful bony metastases. This is generally well to lerated, although 710 % develop radiation pneumonitis weeks after treatment, and it is on a verage more severe in older people \200 Opiates for cough \200 Aspiration of pleural ef fusion for breathlessness \200 Endobronchial therapy (eg stenting, diathermy) 336 CHAPTER 11 Chest medicine Tuberculosis: presentation In older people, TB: \200 Incidence is much higher, especially in the very old \200 Outcomes, including mortality, are much less good \200 Is most co mmonly due to reactivation of previous disease, the primary infection having been asymptoma tic or unrecognized. In the early twentieth century, primary infection of young adults was common. By the mid-late twentieth century, primary infection in younger people had diminish ed. When this cohort reaches old age, TB reactivation will be much less common Reactivation (postprimary disease) occurs due to decreased immunity itself due to intrinsic ageing, disease (eg diabetes mellitus, renal failure), malnutrition (eg chronic alcohol ex cess) or drugs (eg steroids) \200 A few patients develop new infection from open cases. C are home residents are most vulnerable, infection passing from fellow residents or from care home st aff Consider HIV infection when TB diagnosed Presentation Pulmonary disease \200 Sometimes similar to that in younger people, ie cough , sputum, fatigue, weight loss and anorexia Night sweats, fevers and pulmonary symptoms may be less common \200 May present as pneumo nia that fails to resolve, or as an incidental \201 nding, suggested on CXR Extrapulmonary disease Most ( > 75 % ) presentations are pulmonary, but extrapulmonary case s are relatively more common in older people, eg: \200 Miliary . Diffuse, overwhelming in fection with fever, weight loss and hepatosplenomegaly. Pancytopenia can occur Urogenital and renal . May affect any part of the renal tract. Sterile pyuria, haematuria, abdominal or back pain, genital sinuses, or pelvic masses may occur, or disease may be asymptomatic Meningeal . Consider this in the very frail, malnourished or immunosuppressed patient with non-speci \201 c cerebral signs (eg confusion, dementia-like syndrome, headache, or reduce d conscious level). Meningism may be absent, and the CSF virtually acellular Skeletal . Bone infection most commonly affects the spine (usually thoracic or lumbar), presenting as pain and tenderness. TB arthritis usually affects large weight-bearing joints Other eg lymph nodes, intestine TUBERCULOSIS: PRESENTATION 337 Sequelae of previous treatment Lung collapse therapy was used widely in the treatment of pu lmonary TB in the 1930 \200\22350s. Procedures included therapeutic pneumothorax, tho- raco plasty, and plombage (expanding the extrapleural space with arti \201 cial materials). Seq uelae include empyema, sinus formation, bronchopleural \201 stulae, and ventilatory failu re. TB, pyogenic or fungal organisms may be isolated. Early specialist input is essential. 338 CHAPTER 11 Chest medicine Tuberculosis: investigation Chest X-ray Changes are more variable than in younger people, a nd may mimic other benign or malignant disease (eg bacterial pneumonia, cancer) \200 Usua lly upper zone in \201 ltrates with cavities, but more common features in older people include mid/lower zone in \201 ltrates, miliary (diffuse nodular) and bila teral change Healed old disease is usually seen, ie calci \201 ed hilar nodes, a peripheral primary com plex, pleural thickening, and diffuse apical \201 brosis and calci \201 cation Pleural effusions are common \200 Rare changes include mass lesions or isolated lymphaden opathy \200 Very rarely the CXR may be normal, eg occasionally in miliary or endobronchial disease Sputum for microscopy and culture The standard method of con \201 rming TB. \200 Convent ionally, three early morning sputum specimens are obtained and stained by acid fast stainin g (eg Ziehl-Neelsen). The quality and persistence of the microscopist is important, as the scanty organisms can be easily missed on cursory examination If a patient cannot expectorate, obtain \200\230induced sputum \200\231, through physiotherapy, or nebulized normal saline (rarely nebulized hypertonic saline). If this fai ls, or clinical suspicion is high despite negative smear and culture, consider bronchoscopy with washings Other tests \200 Raised ESR and CRP are usual \200 FBC . Mild (normocytic) anemia and r educed white cell count are more common in older people. Lymphocytosis or pancytopenia can occur Obtain three early morning urine specimens in case of possible genitourinary infection Tissue sampling . Where possible, sample tissue eg lymph node, pleura, bone marrow. Send sa mples to both microbiology (microscopy and culture) and to histology. Typical histological features, of caseous necrosis with granuloma formation (with or without acid fast bacilli) support strongly the diagnosis of TB Tuberculin skin testing is complex TUBERCULOSIS: INVESTIGATION 339 HOW TO Perform and interpret a tuberculin skin test In these diagnostic tests, tuberc ulin puri \201 ed protein derivative (PPD) is injected in a standardized manner, and the r eaction assessed quantitatively. Heaf \200\231s test has been used in screening larger numb ers of younger patients, often as pre-vaccination screening programs. Tiny droplets of high -concentration PPD are administered using a multiple tine (Heaf) apparatus. High-concentrat ion PPD is no longer manufactured, and the test is not further described here. Mantoux \200\231s test is most commonly performed where TB is suspected in an individual pa tient. Fixed volumes of less concentrated PPD are injected intradermally. \200 The standa rd dose is 5 tuberculin units (0.5mL of 1 in 10 000 dilution) \200 Examine the skin after 48 \200\22372hr and measure the diameter of induration, re \202 ecting the extent of the cell-mediated immune response A positive test indicates immunity, not necessarily infection. This may be a result of previous (probably asymptomatic) TB infection, or immunization (although reactivity to the bacille Calmette Gu rin (BCG) vaccine often disappears after 10 years) The degree of induration correlates approximately with the likelihood of infection. However, the post-test probability of infection is a product of bo th the pre-test probability and the test result. \200 (cid:116) 15mm indicates a signi \201 cant reaction and the probability of active infection 5 \200\22315mm may be signi \201 cant if pre-test probability is high eg close contacts, s uggestive CXR. Consider causes of a false negative reaction <5mm is negative, usually indicating a low probability of active infection. However, if the pre-test probability is very high, consider treatment The test may be falsely negative (or equivocal) with steroid use, lymphoma, malnutrition, sarcoid, overwhelming TB infection or when there is concurrent othe r infection Ageing itself impairs the immunological reaction to tuberculin, and may produce a false negative or equivocal test in patients previously infected with TB. Giv ing a second (booster) tuberculin dose within 20 weeks of the \201 rst often produces a p ositive test, de \201 ned as when induration > 10mm and augmentation of induration (test 1 \200\223test 2) exceeds 6mm 340 CHAPTER 11 Chest medicine Tuberculosis: treatment Given the complexities of treatment, specialist referral is mandato ry. This is a noti \201 able disease and public health local authorities will investigate contacts, especially in the care home setting. Respiratory isolation precau- tions are nece ssary for patients with pulmonary TB treated in hospital. Pulmonary disease is treated for a total of 6 months Usually 6 months of rifampicin and isoniazid, with pyrazinamide (and ethambutol) for the \201 rst 2 months only Ethambutol may be omitted if the risk of resistance to isoniazid is low \200 Longer treat ment periods may be needed for extrapulmonary disease In older people: Drug resistance is rare, as most infections are recurrences of primary disease, contracted decades ago Failures of treatment are usually due to poor concordance. Combination drug preparations may improve this (eg Rifater = rifampicin + isoniazid + py razinamide) Side effects are more common, including ocular toxicity from ethambutol (reduce dose in renal impairment) and hepatitis from isoniazid. Close monitoring is important Atypical mycobacteria, eg Mycobacterium avium intracellulare or kansasii can occur in those with structural lung disease such as bronchiectasis. This requires even broader and more p rolonged courses of antibiotics but isolation is not required as it does not spread from pe rson to person This page intentionally left blank 342 CHAPTER 11 Chest medicine Asthma and COPD: assessment Presentation Asthma and COPD (Table 11.3 ) in older people: \200 Are both diseases characterized by air \202 ow obstruction \200 Commonly coexist, eg in the childhood asthmatic who has smoked \200 May both be mimicked by other common di seases eg cancer, pulmonary embolism, heart failure May present late: older people are less aware of hypoxaemia, breathlessness or bronchoconstriction Are underdiagnosed and undertreated, especially in older people Asthma \200 May present i n old age as true \200\230late onset asthma \200\231. There are also increasing numbers of people who have grown old with their asthma \200 In older people, c ough may dominate, symptoms \202 uctuate less, triggers (eg cold, smoke, allergens) are l ess frequent and the association with hay fever or eczema is less strong Nocturnal cough or dyspnoea, including paroxysmal nocturnal dyspnoea, may be caused by asthma NSAIDs and B -blockers (oral or ocular) may worsen bronchoconstriction COPD \200 Is much more common in older age, the consequence of intrinsic ageing and progressive disease Is caused by environmental exposure, usually to tobacco smoke, in genetically susceptible people. Signi \201 cant disease can develop in those who have not smoked for years, as acquired lung damage depends more on \200\230total pack years \200 \231 smoked rather than duration alone Symptoms are usually more chronic and slowly progressive, without signi \201 cant variability If bronchitis is signi \201 cant, there is a productive cough (most days of at least 3 mon ths of 2 consecutive years). Fatigue and sleep disturbance are common. Daytime somnolence s uggests ventilatory failure \200 There may be associated anemia of chronic disease, osteo porosis, malnutrition, and depression Investigations \200 Oximetry will determine the presence and degree of hypoxaemia. In moderately or severely hypoxaemic patients (O 2 saturation <92 % ), consider ABGs to det ermine whether long-term oxygen therapy may be of bene \201 t ( see b \200\230Oxygen ther apy \200\231, p.348) and, in the acutely unwell, to guide oxygen administration CXR , ECG , and FBC will help to exclude other pathology, eg anemia, dysrhythmia ASTHMA AND COPD: ASSESSMENT 343 PEFR , measured regularly (bd \200\224 qds) for up to 2 weeks, helps determine whether var iable airways obstruction (asthma) exists. Variability (cid:116) 20 % is signi \201 cant. Older people may \201 nd using PEFR meters and charting the results dif \201 cult. Ask t hem to demonstrate technique, reading the device, and charting in clinic Spirometry . Obtain at least FEV 1 and forced vital capacity (FVC). An FEV 1 : FVC ratio of <70 % suggests obstruction \200 Older people often have dif \201 cu lty performing pulmonary function tests; an experienced technician in a respiratory laboratory will help provide accurate res ults Assessments for bronchodilator responsiveness using inhaled bronchodilators are now considered less helpful, as they are poorly predictive of the respo nse to treatment, and do not distinguish reliably between asthma and COPD. However, air \202 ow obstruction that completely and repeatedly resolves after bronchodilator administra tion does exclude COPD Assessments for steroid responsiveness can be helpful in distinguishing between asthma and COPD (response is greater in asthma than COPD, although t here is overlap). Perform spirometry before and after steroids (either 2 weeks of prednisol one 30mg od, or 6 weeks of inhaled beclometasone 400micrograms bd) \200 Some patients sho w improvement in FVC or functional status (walking distance or speed) despite no signi \201 cant change in FEV 1 Table 11.3 Distinguishing Asthma from COPD Asthma COPD Modest degree of \201 xed airways obstruction (this is uncommon in younger people) Greater degree of airways obstruction Signi \201 cant or full reversibility No, or only minimal, reversibility (cid:116) 20 % variability in PEFR <20 % variability in PEFR Greater age Signi \201 cant smoking history 344 CHAPTER 11 Chest medicine Asthma and COPD: drug treatment In general, treatment principles are similar to those in yo unger people, and are described in detail in British Thoracic Society guidelines. However s ome differences and some similarities bene \201 t from emphasis. Bronchodilators \200 Older people perceive symptoms less reliably, so where there is evidence of variable airways obstruction, give bronchodilators regularly rather than as req uired In older age, response to anticholinergics, eg ipratropium, tiotropium, may be better than to B -agonists, eg salbutamol High dose B -agonists, eg from nebulizers, may cause tremor, tachycardia or rate-related an gina. Nebulizers may not be required \200\224 try higher inhaled doses via a spacer (eg sa lbutamol 400 \200\223800micrograms (4 \200\2238 puffs of a standard metered dose inhaler)), or long-acting B -agonists, eg salmeterol Anticholinergic bronchodilators uncommonly cause side effects such as dry mouth or blurred vision, more often with higher (nebulized) doses and with long-acting preparations. Acute g laucoma is a rare but important complication \200\224 reduce ocular exposure by nebulizing via a mouthpiece rather than a face mask Corticosteroids \200 Long-term oral steroids are rarely bene \201 cial \200 In those r eceiving regular courses of oral steroids for acute exacerbations, give osteoporosis prophylactic treatment. Inhaled steroids alone probably do not cause osteoporosis Theophylline \200 Toxicity is common in older people. Plasma levels are increased by febr ile illness, heart failure and drugs, eg erythromycin/cipro \202 oxacin. Serious side effe cts, eg convulsions may be the \201 rst sign of toxicity \200 Check levels when titrati ng dose. Most of the therapeutic effect is seen by the lower end of the therapeutic range, so target this \201 rst Before introducing oral theophylline, optimize inhaled bronchodilator and steroid therapy, including the use of long-acting and higher dose preparations if necessary Other \200 In \202 uenza and pneumococcal vaccine should be given \200 Exercise extrem e caution in the use of respiratory depressants , eg benzodiazepines or opiates. In general: \200 In acutely unwell patients with CO 2 rete ntion, stop them, reintroducing only if withdrawal effects occur In stable patients with or without CO 2 retention, withdraw or reduce them where possible In severe, end-stage COPD, if dyspnoea or cough are distressing and cannot be otherwise rel ieved, consider giving opiates. Give small doses initially, but increase as needed to relie ve distress, even if respiratory function deteriorates. Explain the rationale to staff, rel atives and the patient if appropriate ASTHMA AND COPD: DRUG TREATMENT 345