Diagnosis and Treatment of Thoracic Conditions: A Comprehensive Review
I- Dx and T of Spontaneous Pnthorax:
^DX :
I- Dyspnea, pleuritic chest
Pain / ↓ Breath Sounds/Hyperesonance!
Pain / ↓ Breath Sounds/Hyperesonance!
II-XRay on Inspiration:
-Radiolucent air & absence of MAaking between
a shrunken lobe or lung
&the parietal pleura are diagnositc of Pneumothorax!
-Tracheal deviation ,
III- Pnthroax Defined:% of empty hemithorax
^^Tension Pn thorax :
if there is suden & unexplained :
-hypotension
-Dyspnea
-+ve Pressure ventilation
^^Tx:
I-”TENSION Pn TRX=Needle Decompresion
– ER —-> cannot wait for XRay
– Needle —–> 2nd IC space at mid-clavicular level!
II-‘1o Spont Pnthorax”=Catheter Aspiration
-Small bore IV —-> 2nd IC space ,mid lcaviular
-Air is withdawn from pleural space
-Process is repeated until Lung Re-expands or 4 L of air remvoed
III-”2nd & Traumatic Pnthorax”=Tube thoraccostomy:
-1/2 HEmotact/ Kelly Clamps
-Inserted Tube—-> 4th IC space , midaxillary line
-Using advanging Hemosat or kelly lamp the Pleura is dissected,
pleura is then pergorated
-clamp is inseeed through the tract and directly apical to Pnthoax
IV- Thoracosoy:
-Rigid telescope & insturment inserted into the pleiral space ,
through the trocar under local anasthesia
-1/2 tubes are left in the pleural space
V- VATS (Video assisted thoracic surgery):
-Under general ansthesia
– operated side should be isolated & its bronchial tree exposed
to outside atmopsere
-VATS beigns with insertion of a trocar camera and exploraton fo hemithrax later
-Principles of Surgery is :Resecting blebs, nbullae,
Obliteration of pleural space
(2)*** Surgical Approach in Tx of pleural empysema : irrigatie -aspirativ drainage ….:
Blood in pleura Sac
Primary Pleural empyema |
| – bacterial contamination of pleural space due to chest Trauma |
| Secondary pleural empyema |
-Direct contamination from organs adjacent to pleural surface -direct bacteria spread across the visceral or parietal pleura 90 |
^^Bacterial Classication:
-non speicif/pyogenic
-Specific
-Mixed
Complicated, Lined with bronchopleual/alvoelar fistula
Non complicated
^^Surgical proceudre foe empyema:
| I-Irrigation & Drainage:– Acute & chronic Non compicated Pleural empyema to facilitation elimation of peural content-Caution is adviced in presence of Bronchopleural Fistula de to possible aspiration with washing Fluid |
| II-Decortication and pleuretony -In Case of chronic pleural empyema! -Decortication:-—–>removal of constricting Peel from the Lung -Pleurectomy—->excision of thickened parietal pleura -Goal: of these procedure is Lungreexpansion |
| III-Pleurostoma:-in patient whose lung can re-expand and his condition is stable-Pulmonary Decortication alternative-Involves resecting 6-20 cm of 2-4 ribs —–>creating large defect in patient chest |
(3) *** Classification of Chest Trauma :
Penetrating ChT(Isolated /Polytrauma) |
-Superficial Wound (Chest Wall) -Involving the parietal pleura & intrathoracic viscera |
Blunt ChT(Isolated/Polytrauma) |
-Non complicated chest wall injury ( Contusion / hematoma/ Chest bone fracture) -Complicated Facture of chest Bone -Blunt Injuries of intrathoracic viscera (Pleruopulmonary/CVS.Rupture of esophagus/Diaphragm rupture) |
(4) *** Syndrome of Chest Trauma :
| ^^Gaseous Syndrome (air —-> into soft tissue of Chest Wall ,mediastinum & Pleural Space) I-Subcutaneous EmphysemaII-Pneumothorax-Air in pleural cavity -minimal= no lung compression -Moderate=Lung collapse -Total= compression and displacement of Mediastinum III-Pneumomediastinum-Maybe due to esophageal perforation -Degree caries with location -Air reaches Visceral pleura IV- Intersitial Pulmonary emphysema-Air penetrates into pulmonary parenchyma dissecting into along the vessel and small bronchi -blebs occur when air reaches Pleura |
^^Open Pneumothorax:-Penetrating Wound /Defect in chest wall -Result : intrapleural = atm |
^^Flail chest:-2 pint fracture of Several Ribs or sternum -paradoxical movement of segment of chest -Alters ventilation and result in hypoxemia or Hypercapnia |
^^Traumatic Asphyxia-Cause: Crush injury or sidden compression -Rise n intrathoacic pressre,intrathoracic Venous Pressure , stopping or reversing venous Drainage(head and neck) |
| ^^Pulmonary contusion & hematoma: |
^^Hemothroax (Blood accumilation in pleural cavity ) |
(5)***Dx & Tx of Penetrating Thoracic Trauma :
^^Dx:
I-
-EvaluateVital sign( Temp/ HR/ BP/ Resp Rate)
-Conciousness
-Airway compentency
-Vascular integrity
-Cardiac function
II-
—> if patient isStable & No surgery
-XRay
-CT
-Aortography
-esophagoscopy
-Bronchoscopy
-US
^^Tx :
I-establish ABC
II-Emeregency endotracheal intubation indicatedif :
( Apnea, Profound shock , Inadequate ventilation)
III-Damage Control Operation:
correction Acidocis/ Coagulopathy/ Hypothermia
IV-Volume replenishment^^scenarios :
1- chest Wall Injury :
-Thoracostomy
-pain control , Aggressive pulmonary and physical therpay—>intubation & ventilation
-Large open chest wall—–>Reconstruction
-Rarely Chest Wall require Operative control
2- Lung Injuries:
-Pn thorax / Hemothorax Rx—> thoracostomy
-Pulmonary parenchymal laceration——> treated with Tube thoracostomy
3- Tracheobronchial injuries:
-Urgent operative Treatment , Debridements, release Tension
, End to end Anastomosis ,While preserving Blood supply!
4- Esophageal Injury:
-Operative Repair with adequate tissue buttressing & draiange
-Sometimes needs Esophageal replacement
5- Diaphragmatic Injury :
-Laparscopy & thoracoscopy can be used in Dx & Tx
-injuries require Heavy , non absorbable sutures, mesh closure
6- thoracic Great Vessel Injury :
-emergency thoracotomy in case of hemodynamic deterioration !
7- Cardiac injury :
-Patient with significant Hemodynamic compromise
& cardiac tamponade can be managed with peeridcadiocentesis
-Aggresive resuscitation in bleeding PAtients
(6) : Dx & Tx of blunt thoracic Trauma:
DX : |
-Hisotry -CBC -ABG -Serum -Troponin -XRay/XT/Aortogram /US |
| Tx |
-Stop Bleeding -analgesics -Bronchodilator -Broad spectrum Ax -prevent obstruction (Airway hydration /postural Draine( -emegency operation |
(7) *** Indication for urgent thoracotomy!!
Chronic & Acute Cases( Below) :
-Cardiac tampone
-acute hemodnyanic Deteriotaton
-Cardiac Arrest
-penetrating Trunk Trauma
-Ai leak
-Traumatic thoractomy
-Esopgageal injury
-Great Vessels Injury
(8)***Aspirative Punture of pleural cavity :Indication , technique, possible complication
| ^^Thoracentesis:—-> puncture through chest wall to aspirate pleural Fluid |
| ^^Indication :-determination of pleural effusion etiology(Dx)-relieve dyapnea caused by pleural effusion(Tx)-Pleurodesis |
| ^^Technique:-Find the location of Fluid using physical exam , or imaging-Patient is sitting upright-leaning slightly forward with arms supported-In sterile condition 1-2% lidocain is injected with 25-gauge needle-then larger needle with anasethetic is inserted at upper border of the rib one intercostal space below the Fluid level-needle is advanced with periodic aspiration-Anathetic is progressively injected deeper -Needle is advanced beyond parietal pleura until pleural fluid is aspirated!-thoracentses needle is passed thrugh skin & Subcutanous tissue Along the upper border of the Rib into effusion -the catheter is inserted through the needle, the needle is withdrawn to decrease the Risk on Pn thorax |
| ^^ Complication :Pnthorax-Heoptysis-Hemothorax -Vasovagal syncope |
(9) ***Methods of Pleural Cavity Drainage, indication ,
| ‘Tube Thoractomy:-Tube Into Pleural Sapce-Promote air or Fluid evacuation-Lung Re-exanapsion-Restoration of intrapleural -ve pressure |
| ^^ Indication :-Pnthorax-hemithrax-empyema-Chylothorax -Pleural effusion |
| ^^ Technique:1-2 sites for closing pleural drainage:-2nd IC space in midclavicular line-safetly traingle( 3-5 IC space from anterior—->posterior axillary line)2-Skin is cleaned with antiseptic 3-Give Local anasthesia is applied3- parietal pleura should be infiltrated & aspiration of air or fluid through a needle and syringe4-a 1-2 cm incision is then made through the skin & subcutaneous tissue5- chest tube is inserted via blunt dissection technique6-holding of tube by skin suture7-Chest Xray can be performed to asses lung re-expansion |
| ^^ possible complication :-Misplacement of thoracostomy tubes-injury of intrathroacic organs-diaphramgatic & intrabdominal injury-hemmorhage -subcutaneous emphysema |
(10) Acute mediastinitis, Main causes…
| ^^Def:Acute Mediastinitis is fulminant infectious process that spreads along fascia of mediastinum |
| ^^ Classification is Compartmental:Infection :– superior mediastinum<—-Direct extension fron neck infection – Anterior mediastinal infectiont<—surgery /penetrating wounds,anterior thorax – Posterior mediastinal abscesses<—Tb/pyogenic inf |
| ^^ Causes:-Esophageal perforations– Sternal infections– Oropharyngeal or neck infections– Infections of the lung and pleura – Metastatic abscess |
| ^^ CF:– Chest pain– Dysphagia– Respiratory distress– Cervical and upper thoracic subcutaneous crepitus -Fever |
| ^^Imaging :-CT |
| ^^Tx:True Surgical Emergency & Tx must be to correct underlying condition-Debridement-Draiange-Ax Adm-Fluid Resuscitation -Surgical correction |
(11)***Cicatricial Tracheal Stenosis:
| ^Gx:-caused due to placement of a tracheostomy Tube-injury of trachea-Chronic inflammation |
| Px: inspiratory stridor & dyspnea |
| ^^Dx: -CT -CT-3D image to ID the location of Stricture& determine size -Bronchoscopy |
| Tx:-”Resection of stenosedtracheal part” is the Procedure of choice -we use tracheostomy to bypass intubation |
(12) ***Mediastinal Disease^^^Mediastinal Tumours
| Dx:1-CXR- to ID abnormality2-CT :Can asses the mediastinal widening , Diff Cystic & Solid MassesLocalize Masses wrt other structures3-Biopsy & distopathology :-Tisse confirmation prior to therpy -Fine needle percutanous biopsy to excisional biopsy |
| ^^TX :-depends on location h& histological Type of Tumor-All Tumours & Mases should be surgically removed-Non resectable malignant tumours should undergo Chemo therapy & or Radiotherapy! |
^^ Bacterial Medistinitis:
| ^^Dx: -CF : chest pain ,dyaphgia , Cervical & mediastinum emphysema-CXR : normal ( early) —–> Widnd mediatinal tumour (Later) -Contrast Esophagogtraphy—–> esiphageal perforation is suspected |
| ^^ Surgical Tx:-early & aggressively-In case of Esopahgeal Perforation do Surgery directly! ( closure of esophageal wall defect / Debridment irrigation & drainage) -Ax therpay after Surgery |
(13)***Esophageal Diverticulo : classification , diagnsotics, Surgical Techniqus^^ Esophageal Diverticulim :
outpatching of mucosa through msuclar laer of esophagues
^^ Classficiation :
| Zenker diverticulo -Posterior outpouching of mucosa & submcosa through the cricopharyngeal muscle |
| Midesophageal diverticula: Traction from mediatinal inflammatory lesions |
| Epiphrenic deverticula: Occur aboe the diaphragm & accompany mobility disorder |
^^ Dx
Zenker Diverticula: -Sx vary with Stage –dysphagia Food regurgitation Dx by Videotaped Barium Swallow |
Diverticula of Esophageal body Sx: dysphagia, esopahgeal reteion Regurtitationn Dx: esophagoscopy |
^^Tx:
| I-Zenker Diverticula: Devertticulostomy: ”inscion along anteriomediastinal border right to SCM muslce” cut of omohyoid and prethyroid muslle exposing juulanr vein and carotid artery & thyroid gland -Diverticula sac dissected |
| Traction diverticula : Not surgical indicationNot surgical indication |
| pulsion diverticula: -Diverticlomy + -Stopping the barrier of blowout |
***Esopageal Cancer:Dx & Tx:
-start Asx
-Sx appear when Lumen <14mm
-Dysphrafia
-Cehst pain the the pain
-Vocal problems( largyngeal compression)
-Horners (sx) .
-paralysis of diaphragm
-intraluminal Tumour : Vommit/ odynophaia . E Def anemia
I-CT/Xray:
Hilar mass / Tracheal coprsssion . Deviation
III-Barium Studies
-mucosal irregularies and lenfth of tumours
IV-Esophagoscopy :
extent of tumour , secimen for histological confirmaton by biopst
V-Bronchoscopy:
To Asses the Bronchial Tree Involvement !!
^^Indication for surgery:
Depends on stage .Health status
-Surgery—–>0/1//IIA with preoperative chemotherapy & radiation
-IIB andIII poor suvivie —-> NEoadjuvant radiation and chemoitherapy to decrease size
^^Radical operation :
-remove of gastic cardia and esophagua and reconstruction
-”esophgeal eratication _ esiohagastroplasty
***Esophageal injury :
^^DX:I-structural abnormalities: -RAdiographic -Endocopic II-Functional abnormalities-Manometry -Esophageal impeance -esophagealTranist Scitongraphuy -Video andcineratiography III-Increase Esophageal exposure to Gastric acid:ph mnitoring 24 hours -Rdiographic GERD IV-Dudengastic function-G emptying -Gastric acid test |
^^Surgerical Technique:-Partial esophagus resection -Reconstrction after sophagotomy -composte reconstrcution -vagal sparing esophagectomy +colon interpositon |
*** Esophageal ruptire:
^^Dx:CF : -Substernal epigastric pain -Radiation to left chest/shoulder/ back Xray :Wide mediastinum / Cervical and mediastinal air/ LEft pleural effusion/ H@Opn thorax esophagrpht +H2O solutble contrast: Best |
^^Surgery Tx:-as soon as Dx established -LEft Posterolateral Thoracotom -ecucuate Pleural cavity from debris -was with antispectics, Close the esophageal defect by sutures -2 tubes in cavity to provice feeding via jejnunum~ |
***Lung cancer Dx:
I-Bronchoscope:
-is a Must for all LC
– to collecte secretion by lavage ,Biopsy of Peripheral , MEdiastinal LN
II-Mediastinoscopy: Most helpful
III-Needle percutanous biopsu
Of peripheral tumours — >obtain material for histological exmination
IV- Dx thoractomy
If we susepct but other methods to do work
***LC Indication surgery:
NSLC——>surgical resecton is Tx o choice ( Stage I + II+ some III)
SCLC—–>C +R Surgery is small and not metastases
| NSCLC | SCLC |
I: Segementomy/Wedge resection -Lobectomy -Bronchiopastic Loboctomy | I: -Segmental /WEdge Resection |
II: -lobectomy (biocstomy) -broncoplastic lobectomy -Pneumoctomy | II: 1+2 sme |
IIIA: -Lobectomy(blioctomy) broncoplastic lobectomy -Pneumoctomy( medistinal LN) | -Palliative Pul resetion! |
IIIB: -Lobesctomy(blioctomy) -/Pnemctomy with mediastinal LN dissection -….+rescition of chest wall/diaphragm | Not indicated |
IV: Pallaitve Pul resection | Not indicated |
**Palliative +radical Op LC :
GRAPH
^^Oncologcail Surgery
-Remove tumour and intrapulmonary collectors completely
-Care to avoid tumour spilling
-Resection of adacent invaded structure is prefered to disocnion resection
-Asses Resection margins
-remove Accesible Mediadstinal LN
^^Pallaitve Procedure:
-Throacentesis& pleurodises, Reccuring effusion
-Pleural drainge catheter
-Stent to prevent airway obstruction
-Spinal stabilization to prevent SC compression
***Purulent Lung disease :monaldi^^Mnaldo:
-pecutnaous cathetizaton of lung absecess cavity
-For acute abcess that has no contact to bronchial tree
-Imageing is done
-anasheia
-incion
-usingTrasnparitral Trocar intorcduce drainge tube
-cather for Local Ax application
-close would by sutur
^^Minirachstomy:
-Tx and prevention sputum retesion after thoractomy/lacropctomy
1-Make vertical inscion in skin of thyroid cartilae
-Insert Tuophy needle through skin at 90 Degree to anterior wall of trachea
-inseet guide wire through needle into trachea
-Pass the dilator and minitrache over the wire into tachea
-remove the introucer
Lung resection:
chronic inflammatory provess and Conservative Tx fail
-Cancer suspeciton(CF and Radio)
-Massive reoccruign hemmorhag!T