ACD 8-14 Some lung issues
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ACD 08.14Sandra P. Susanibar Adaniya Chief Resident IM - UAMS
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What is the diagnosis?
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Thoracic complications of nasogastric tube: review of safe practice
0Traditionally, nasogastric tubes have been inserted blindly.0The X-ray remains the gold standard to verify the correct
placement.0Bedside ‘confirmatory’ signs of gastric placement may not be
reliable and should not be used as a substitute to the X-ray.0The check X-ray, detects a complication, but does not prevent
it.0Tracheobronchial complications are not uncommon with blind
nasogastric tube insertions.0Pneumothorax is the commonest pulmonary complication.
Pillai. Thoracic complications of nasogastric tube: review of safe practice. Interact CardioVasc Thorac Surg (2005) 4 (5): 429-433. doi: 10.1510/icvts.2005.109488
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2-step NGT insertion
0The 2-step insertion is the best way to prevent complications.
0 Initial 30 cm is the crucial damage limiting distance, as it is at the tracheoesophageal transition zone.
0The final nasogastric-position is ideally at 50–60 cm from the incisor teeth.
0 Insertion of excess tubing is to be avoided.0High risk patients include:
0 Intubated and sedated0 Elderly0 Mentally obtunded0 Repeated attempt after earlier pulmonary misadventure
Pillai. Thoracic complications of nasogastric tube: review of safe practice. Interact CardioVasc Thorac Surg (2005) 4 (5): 429-433. doi: 10.1510/icvts.2005.109488
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Learning pointsRadiation induced Lung Disease
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Radiation-induced lung disease (RILD)
0Common. Though incidence varies depending upon the particular regimen used and upon the radiation field. 0 In patients with breast cancer, clinical pneumonitis occurred in
0 to 10 percent, while radiographic abnormalities were present in 27 to 40 percent.
0 In patients with lung cancer, clinical pneumonitis occurred in 5 to 15 percent of patients, while radiographic abnormalities were present in 66 percent. It is unclear to what extent the latter were due to irradiation versus tumor.
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CLINICAL MANIFESTATIONS
Acute radiation
pneumonitis
• Timing: four to twelve weeks
late or fibrotic
radiation pneumonitis
• Timing: after six to twelve months.
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Symptoms
• Nonproductive cough• Dyspnea may only occur with
exertion• Inability to take a deep breath.• Fever is usually low grade, in the
acute phase• Chest pain (pleuritic or substernal)
- can represent pleuritis, esophageal pathology, or rib fracture.
• Malaise and weight loss.
Signs
• Crackles or a pleural rub may be heard; in some cases auscultation is normal.
• Dullness to percussion = a small pleural effusion; 10 % of patients.
• Effusions often cause no symptoms and may spontaneously remit.
• In contrast to malignant effusions, radiation-induced effusions do not increase in size after a period of observed stability.
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Radiologic manifestations
Acute radiation
pneumonitis
• Ground-glass attenuation within the area of irradiated lung
late or fibrotic
radiation pneumonitis
• Opacities may evolve into a fibrotic phase, characterized on CT by linear opacities (scarring) or an area of dense consolidation and volume loss.
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TREATMENT
0 No prospective controlled studies have evaluated the efficacy of therapies for radiation pneumonitis in humans.
0 Many experts recommend the use of glucocorticoids for symptomatic patients with a subacute onset of radiation lung injury.
0 Patients who have established fibrosis due to prior irradiation are unlikely to benefit from glucocorticoid therapy.
0 Prednisone (at least 60 mg/day) is generally given for two weeks, with a gradual taper over three to twelve weeks.
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