Chest Lectures Pr. Dr.Waleed Mustafa Consultant Thoracic & Vascular Surgeon
Pulmonary Echinococcosis (Hydatid Cyst)Hydatid disease of the lung is caused by the small tape worm (Taenia Echinococcus ) or (Echinococcus Granulosis) .Hydatid cyst means cyst full of water .It has a life cycle between dogs & sheep .Parasites in the elementary tract of the dog shed ova that excreted in the dog faeces , contaminated the food of the sheep in which hydatid cyst will develops in the viscera . Including the lung .Infected sheep when slaughtered and its entrails are eaten by dogs , the life cycle is completed .When a human being hands or food become contaminated with canine fecal material containing ova which will be ingested .The parasitic larva burrow through the gastric mucosa and are carried to the liver in the portal venous circulation where most of them filtered out to form hydatid cyst of the liver , some escape the liver & lodge in the lung to form one or more hydatid cyst which grows slowly or rapidly over years .
The cyst consists of a germinal layer & cyst fluid containing broad capsule & scoleses . A cellular white hyaline layers are laid down outside the cyst so that the cyst is enclosed by a laminated cyst membrane .As the cyst enlarged , it usually reaches the pleural surface . Compression of the lung tissues produces a thin fibrous layer of atelectatic lung tissue around the cyst (capsule , pericyst or adventia)
Clinical Manifestation A-Asymptomatic Any smooth homogenous opacity of uniform density with clear cut border and little or no reaction around it on a chest X-Ray is a hydatid cyst unless proved the other wise .B-Cough & haemoptysis due to rupture of the cyst , or it can lead to severe dyspnea , or asphyxia ,or a hyper sensitivity reaction ,If the cyst get infected ,it will lead to formation of lung abscess or bronchiectatic changes .
Radiological Findings 1-Smooth homogenous opacity (Intact H.C).2-Partial rupture (per vesicular pneumocyst).3-Complete rupture (Water –lilly sign) .4-Formation of lung abscess(Air –fluid level) .5-Completely coughed out cyst(empty cavity )6-Rupture into the pleura (hydropneumothorax)
Treatment Surgical A-Inoculation means to remove it intact.B-Aspiration &evacuation technique C-Wedge resection or excision of the cyst with adjacent lung tissue.D-Segmentectomy ,Lobectomy or Pneumonectomy (rare ).
Bronchiectasis Is a persistent abnormal dilatation of the bronchi generally beyond the sub segmental level , generally classified as three types cylindrical , varicose & saccular . The left lower lobe is more commonly involved then the right lower lobe .Aetiology :-1-Congenital causes (25%) 2-Acquired causes (75%) The acquired causes include air way infection (bact. Or viral) bronchial obstruction (F.B., neoplasm.,LN)It present in 40% of patients with chronic middle lobe infection (middle lobe syndrome) which involved impaired clearance of secretion mostly due to a pressure of enlarged LN.
Congenital Bronchiectasis (Kartagner’s syndrome) It includes (Bronchiectasis , situs inversus ,sinusitis ,sperms hypo motility ) .It represents genetic disorder with abnormal ciliary motility so impaired clearance of sputum with the resultant bronchiectasis .
Clinical manifestation :-The onset is mostly in childhood whereas symptoms generally appear in the second or third decade of life .The disease is more common in females .Major symptom cough with the production of purulent sputum with fetor oris .50% of the patients presented with haemoptysis .Others present with repeated RT infection .,others develop osteo arthropathy & finger clubbing which will resolve with treatment . Diagnosis :-1-History chronic cough with purulent sputum.2-Plain CXR may shows prominent vascular marking .3-Bronchoscopy to diagnose obstructive lesion & to obtain bronchial wash for C&S test .4-Bronchography through giving radio opaque dye through the bronchoscope & into bronchial tree ,now replaced completely by CT.5-Chest CT is the single non invasive tool for both diagnosing &assessing the severity of the disease .6-X-Ray paranasl sinuses to treat any excisting infection .7-Pulmonary function tests very important specially in pre operative assessment .
Treatment :-Medical treatment is the main stay of treatment ,it includes antibiotics , chest physiotherapy &postural drainage .Surgical treatment in cases of failure of medical treatment and it includes segmentectomy , lobectomy & pneumonectomy
Lung Abscess It is a localized area of suppuration and cavitations in the lung.It includes TB , mycotic or parasitic cavitations ,bronchiectasis ,ruptured infected hydatid cyst , even pulmonary infarction with abscess formation & cavitating tumors Simple lung abscess (pyogenic) can occurs as a result of aspiration of a septic debris from the oropharynx into the lung or following dental or tonsillar operations .Esophageal diseases that lead to regurgitation &subsequent aspiration of esophageal content into the lung is another cause.Usually the aspiration is into the RMB leading to severe pnemonitis and liquefaction may occurs .As the liquefied necrotic material empties through the bronchus , a necrotic cavity containing pus and air is formed .The organism responsible may be streptococcus , staphylococus &eschrescia coli .
Clinically cough & foul smelling sputum fever , pleuritic chest pain night sweat & weight loss in severe cases dyspnea & cyanosis Chest X-Ray Can shows the characteristic air fluid level ,may associated with pleural thickening , pneumothorax CT chest is helpful in demonstrating the abscess .
Treatment 1- Primary treatment is Medical Prolonged antibiotics treatment Bronchoscopy useful to remove a FB or drainage of abscess2-Surgery indicated in Failure of medical treatment Massive haemoptysis persistent of a thick wall cavity when malignancy is suspected when empyaema developsComplications :-Empyaema , septicaemia ,metastatic brain abscess ,bronchogenic spread &development of chronicity
The Mediastinum
Mediastinum :-It is part of the chest , which is bounded above by the thoracic inlet , below by the diaphragm , anteriorly by the sternum , posteriorly by the dorsal vertebrae , and laterally by mediastinal pleura .It is divided by a transvere plane between the angle of Lewis anteriorly and the lower border of the 4th. Dorsal vertebra posteriorly into superior and inferior medistinum ,and the inferior medistinum is further subdivided by the presence of the pericardial sac into anterior , middle and posterior mediastinum Mediastinal tumors or cysts occur in a chracterstic location so a mass in the superior medistinum is mostly thymoma or lymphoma ,while a neurogenic tumor occur mostly in the posterior mediastinum .Pericardial cyst or bronchogenic cysts occur in the middle mediastinum .Mediastinitis Causes :-1-Perforation of the esophagus or leakage from anastomosis .2-Extension from a nearby infection (lung , vertebra ,pleura ).3-Following median sternotomy for cardiac surgery .Clinical manifestations :- Fever , tachycardia , chest pain Barium swallow is useful to demonstrate esophageal perforation.Esophagoscopy will confirms the perforation .Chest X-ray & CT –scan of great value in the diagnosis .Treatment :-1-Treatment of the cause .2-Antibiotics according to culture and sensitivity .3-Tube thoracostomy to drain any pleural collection .4-Supportive therapy .
Surgical Treatment of Pulmonary Tuberculosis Indications :-1-Massive or recurrent haemoptysis . Surgery is indicated to remove the source of bleeding .2-Broncho pleural fistula 3-Open cavity with positive sputum resistant to 3-6 months of treatment .4-TB bronchiectasis .5-When malignancy is suspected as TB and malignancy can co exist .Carcinoma can arise in TB scar (Scar carcinoma ) .5-Patients with (Trapped lung syndrome ) after chronic empyaema .It includes segmetectomy ., lobectomy ., or pneumonectomy ., or to remove thickened adherent parietal and visceral pleura( decortication ) alone or in combination with pulmonary resection .
Superior Vena Cava Obstruction A number of benign and malignant lesions involving the mediastinum may lead to obstruction of SVC with the production of the classical syndromeWhich characterizes by elevation of the venous pressure and edema of the face , neck and upper extremity with the appearance of the dilated venous chandelles in the chest wall and cyanosis .It may be caused by the carcinoma of the lung and in (25%) of the cases ,it may be caused by a benign lesion such as idiopathic mediastinal fibrosis .
Congenital Deformities of the Chest Wall Pectus Excavatum in which the costal cartilages developed in a concave position and thus depress the sternum towards the vertebral column. Few patients may have cardio- respiratory problems . The best time of correction obtained at the age of 2-3 years .
Pectus carinatum ( Pigeon Breast ) Less common , consists of protrusion of the sternum ,caused by an upward curve in the lower costal cartilages , generally 4th. To 8th. Cartilages pushing the sternum forward .Surgery is the treatment of choice in symptomatic patients . Severe case of Pectus Carinatum
Thoracoscopy It is the examination of the pleural cavity with an endoscope .Hans Jacobaeus was the originator of the thoracoscopy in 1910 .It is done under general anesthesia with double lumen intubation ,
Indications 1-Diagnostic 1-Diagnosis of pleural diseases 2-Evaluation of carcinoma of the bronchus . 3- Biopsy of a discrete pulmonary nodules . 4-Evaluation of mediastinal mass .Therapeutics :- 1-Treatment of pleural effusion . 2-Treatment of recurrent pneumothorax . 3-Removal of intra- pleural FB . 4-Debridement of empyaema space . 5-Dorsal sympathectomy .There is no absolute contra indications for thoracoscopy .
Mediastinoscopy
Is a surgical procedure that enables visualization of the contents of the mediastinum, usually for the purpose of obtaining a biopsy . Mediastinoscopy is often used for staging of lymph node of lung cancer or for diagnosing other conditions effecting structures in the mediastinum such as sarcoidosis or lymphoma .It involves making an incision approximately 1 cm above the suprasternal notch of the sternum , or breast bone. Dissection is carried out down to the pretracheal space and down to the carina . A scope (mediastinoscope) is then advanced into the created tunnel which provides a view of the mediastinum. The scope may provide direct visualization or may be attached to a video monitor.Mediastinoscopy provides access to mediastinal lymph nodeMediastinoscopy is used to explore the superior and middle part of the mediastinum. a. Superior mediastinum. b. Anterior mediastinum. c. Middle mediastinum. d. Posterior mediastinum
Mediastinoscopy is usually performed in a hospital under general anesthesia.. Once the patient is under general anesthesia, a small incision is made, usually just below the neck or at the notch at the top of the sternum. The surgeon may clear a path and feel the person's lymph nodes first to evaluate any abnormalities within the nodes. Next, the physician inserts the mediastinoscope through the incision. The scope is a narrow, hollow tube with an attached light that allows the surgeon to see inside the area. The surgeon can insert tools through the hollow tube to help perform biopsies. A tissue sample from the lymph nodes or a mass can be removed and sent for study under a microscope, or to a laboratory for further testing. The person will remain in the surgerical recovery area until the effects of anesthesia have lessened and it is safe to leave the area. The entire procedure should require about an hour, not counting preparation and recovery time. Studies have shown that mediastinoscopy is a safe, thorough, and cost-effective diagnostic tool with less risk than some other procedures.
Aftercare Following mediastinoscopy, patients will be carefully monitored and watched for changes in vital sign , or symptoms of complications from the procedure or anesthesia. The patient may have a sore throat from the endotracheal tube, experience temporary chest pain, and have soreness or tenderness at the incision site.
Risks Complications from the actual mediastinoscopy procedure are relatively rare. The overall complication rates in various studies have been reported in the range of 1.3–3%. However, the following complications, in decreasing order of frequency, have been reported: hemorrhage pneumothorax (air in the pleural space) recurrent laryngeal nerve injury, causing hoarseness infection tumor implantation in the wound phrenic nerve injury (injury to a thoracic nerve) esophageal injury chylothorax (chyle is milky lymphatic fluid in the pleural space) air embolism (air bubble) )
Causes :- 1-Blunt Trauma 2-Pentrating & perforating injuries 3-Blast injuries 1-Chest wall injury Superficial chest wall injury affecting the skin and muscles of the chest wall without affecting the ribs or the underlying pleura as proved by normal chest x-ray .Management is to arrest any bleeding and wound debridement with primary closure if possible . Classification Chest Trauma
2-Ribs & Sternal injuries May lead to Single rib fracture the important thing is to relief pain by . analgesic , chest wall strapping or intercostal nerve block or Multiple ribs fractures , flail chest in that case four or more ribs are fractured anteriorly and posteriorly which lead to paradoxical respiratory movement with the resultant hypoxia and severe dyspnea that nictitates emergency intubation and assisted ventilation and if the patient needs prolonged intubation for more than one week then tracheostomy is indicated .
Flail chest End tracheal tube Costo chondral disruption Chest wall haematoma
3-Pleurl injuries Can lead toA-Pneumothorax which can be partial or complete closed or open sucking or tension pnemothorax . B-Haemothorax may be mild or severe and may be with pneumothorax Pneumothorax Collapsed lungTraumatic haemothorax Fractures
4-Pulmonary injuriesTrauma can lead to pulmonary contusion with interstitial edema which may lead to consolidation of the lung tissues and can be manage by antibiotics administration and clearing of secretion5-Tracheo-bronchial injuries It may lead to crushing or complete tracheal separation which needs immediate air way management and repair of the trachea.Bronchial injuries can be so severe that it lead to complete separation of the bronchus which lead to pneumothorax with severe air leak, haemoptysis &haemothorax .Bronchoscopy will establish the diagnosis and surgery is mandatory to reanastomosed the bronchus .
6-Great vessels injuriesInjuries to the thoracic aorta and its branches can occur mainly with deceleration injury . Most patients with ruptured aorta die immediately but in 10% of patients the per aortic tissues and pleura are able to maintain the intravascular pressure producing false aneurysms ,which can be diagnose by CT angiography and needs immediate surgery . Traumatic aortic disruption is a time-sensitive injury requiring rapid and accurate diagnosis to prevent death.
Widen mediasinum Descending aortic injury Endo vascular stent control
7-Diaphragmatic injuries Trauma can lead to rupture of the diaphragm ,most commonly the left side affected ,leading to herniation of the viscera .Stomach is the most frequent organ to herniated followed by the transverse colon , spleen leading to collapse of the lung and mediastinal shift which can be seen on chest X-ray .Barium study is of great help in the diagnosis .Treatment surgery through abdominal , thoracic ,combined approach or by laparoscopy .8-Esophageal injuriesThoracic esophagus rarely injured but mostly the cervical esophagus due to penetrating injury to the cervical region .Pain and dysphagia ,sometime fever .Diagnosis can be established by contrast study which will visualized the site of perforation.Treatment may be conservative by intravenous fluid , heavy antibiotics & NBM for 5-7 days which may be enough to seal the perforation , otherwise surgery is indicated to close the perforation .
9-Cardic injuries May vary from superficial laceration to transmural damage which lead to atrial or ventricular septal defect or coronary artery injury .The patient may present with dyspnea ,hypotension & tachycardia .Diagnosis can be accomplished by Echocardiography .Management includes resuscitation & immediate thoracotomy or sternotomy to treat the injury . Stab to the pericardium - Resuscitative thoracotomy "The surgeon who should attempt to suture a wound of the heart would lose the respect of his surgical colleagues" - Theodore Bilroth, 1882
Thoracotomy in chest trauma90% of chest injuries can be treated by chest tube (tube thoracostomy or intercostal drain (ICD) ).Thoracotomy may be …immediate (resuscitative thoracotomy ) ……emergency .. … elective Emergency Department ThoracotomyResuscitative thoracotomy Penetrating thoracic injury - Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital) - Unresponsive hypotension (BP < 70mmHg) Blunt thoracic injury - Unresponsive hypotension (BP < 70mmHg) - Rapid exsanguinations from chest tube (>1500ml)
Immediate(urgent) thoracotomy 1-Massive haemoptysis 2-Massive haemothorax/ initial dain1500 ml. or more than 200 ml /hr. for few hrs. 3-Ruptured bronchus with massive air leak 4-when great vessels injury is suspected 5- In diaphragmatic injury 6-Some cases with esophageal injury .7-In cardiac injury 8-In some cases of flail chest . Elective thoracotomy1-Clotted haemothorax2-Trapped lung syndrome 3-Big foreign body
Complications of chest injuries 1-ARDS: Syndrome of acute RF with the formation of a non –cardiogenic pulmonary edema leading to reduced lung compliance and hypoxaemia which is refractory to oxygen therapy characterized by bilateral diffuse pulmonary infiltrate on chest X-ray (white lung) .A less severe case (ALI=acute lung injury ) which consists of a non specific pathological changes in the lung in response to a specific insult . 2-Atelectasis3-Infection4-Pulmonary embolism5-Air embolism6-Traecheal complications7-Cardiac arrhythmias
Poly trauma Team Members Team leaderAnesthetist + assistantGeneral surgeonOrthopedic surgeonsA/E physicianTwo (2) nursesRadiographerScribe (nurse or doctor)