Lung and Pleural Cavity

Dr Rainbow WH Lau
Division of Cardiothoracic Surgery
Department of Surgery
Prince of Wales Hospital
 Lung cancer
Chronic airway disease
Pneumothorax
Pleural effusion
Chest drain insertion
 Lung cancer
Chronic airway disease
Pneumothorax
Pleural effusion
Chest drain insertion
 Lung cancer
Chronic airway disease
Pneumothorax
Pleural effusion
Chest drain insertion
 Lung cancer
Chronic airway disease
Pneumothorax
Pleural effusion
Chest drain insertion
 Lung cancer
Chronic airway disease
Pneumothorax
Pleural effusion
Chest drain insertion
 How would you manage this patient?
HPI; Past medical/ surgical history, Drug History
Hx Family / social/ occupational etc

Organ/ system specific

P/E Systematic related to the current illness

Differential diagnoses
?

Non invasive: blood test/ imaging etc

Ix Invasive: endoscopy/ surgery etc

Differential diagnosis
? Definitive diagnosis

Evidence based
Rx Personalized
Lung Cancer
 History
Smoking/ occupation
Family history
Exercise capacity Systemic
Symptoms Symptoms due to
metastatic disease
Regional
Past Hx of other Major airway
Bone met
Brain met
obstruction with
malignancy shortness of breath/
Pleural/ pericardial
effusion
Local stridor/ dysphagia
Symptoms due to
Lymphadenopathy
Cough ectopic hormonal
leading to SVCO
secretion
Haemoptysis
SIADH
Chest pain
Ectopic ACTH
Chest infection
Constitutional
Asymptomatic Nerve palsy
symptoms
Phrenic
Poor appetite
Brachial plexus
Weight loss
Sympathectic trunk
 Physical examination

Systemic
Symptoms due to
Regional metastatic disease
Bone met
Major airway
Brain met
obstruction with
shortness of breath/ Pleural/
Local stridor/ dysphagia pericardial
effusion
Cough Lymphadenopathy
leading to SVCO Constitutional
Haemoptysis symptoms
Cervical
Chest pain lymphadenopathy Poor appetite
Chest infection Weight loss
Asymptomatic Nerve palsy
No signs Phrenic
Brachial plexus
Sympathectic trunk
 Investigation
To confirm diagnosis
Treatment plan decision
Stage: TNM staging
Fitness for various treatment options
 Investigation
To confirm diagnosis
Non invasive vs invasive
Non invasive
Imaging
CXR
CT thorax with contrast
Delineate anatomy of the tumour
assessment of resectability
Guide choice of biopsy option
PET/ CT
Staging
Look for distant metastasis
Look for concomitant malignant pathology
The suspected lung cancer maybe metastatic in nature
 Investigation
To confirm diagnosis
Non invasive
Blood test
Tumour markers eg CEA, PSA etc
Non diagnostic but will aid direction of Investigation
Monitoring of treatment progress
Sputum
Bacterial culture, TB culture, cytology
Lung mass secondary to infection can mimic malignancy
Chest infection superimposed on malignancy
 Investigation
To confirm diagnosis and staging of CA lung
Invasive
To obtain tissue from the tumour/ lymphadenopathy/
effusion to confirm tissue diagnosis
Varies cell type
Genetic mutation analysis
Unnecessary invasive Ix should be minimized
Modality of biopsy should be guided by the tumour
anatomy and highest possible stage
 Investigation: Bronchoscopy
Suitable for centrally located tumour
Can also assess bronchial resection margin
Biopsy, bronchial aspirate, Bronchoalveolar lavage, bronchial
brushing
 Investigation: Image guided
percutaneous biopsy/ FNA
CT/ USG guided, depending on tumour
anatomy and expertise
Risk
Pneumothorax
Haemothorax
Pulmonary
haemorrahge
 Lymph adenopathy on CT or PET/CT
Mediastinal
Endoscopic bronchoscopic ultrasound (EBUS)
guided Needle aspiration
Mediastionscopy
Cervical
USG guided FNAC
 Pleural effusion/ pericardial effusion
Drainage of the effusion can be diagnostic and
therapeutic
In case confirmed malignant effusion, it will be
stage IV disease
 Investigations
To assess the fitness for curative surgical
resection
Lung function test
FEV1
DLCO
Calculation of predicted post-operative percentage
Cardiopulmonary Exercise Tolerance Test (CPET)
6 minute walk test, Shuttle walk test
Other pre-operative work up will be guided by
patients history and physical signs
 Dx / DDx
? Confirmed lung cancer
? Stage
? Fitness for operation
Treatment plan for lung cancer

Surgical resection Chemotherapy

Lung cancer
treatment

Radiotherapy Targeted therapy

 Treatment plan for lung cancer
Palliative/ curative
Stage of the disease
Principles
Surgical resection for early stage disease with localized
tumour +/- regional lymphadenopathy if the patient can
tolerate lung resection
Radiotherapy for early stage tumour in patient medically
not fit for surgery, localized metastatic disease in brain/
bone etc
Systemic treatment with chemotherapy/ targeted therapy
for wide-spread metastatic disease
There are multiple exceptions for the above principles
 Treatment plan for lung cancer
Multi-disciplinary approach
Individualized treatment programme for each
patient
Chronic airway disease
 History
COAD/ COPD/ COLD
Chronic obstructive airway disease
Combination chronic airway inflammation and emphysematous
lung disease
Exposure to tobacco
Chronicity, progression
Shortness of breath, reduced exercise tolerance
Chronic sputum production
Oxygen dependence
Complication related to chronic airway disease
Chest infection
Pneumothorax
Respiratory failure
 Physical examination
Signs suggestive of chronic tobacco use
Clubbing
Cyanosis
Nasal flaring/ pursed lips
Agitation/ delirium due to hypoxia / CO2 retetion
Tachypnoea
Use of accessory respiratory muscles
Hyper- inflated chest
Prolonged expiratory phase
Wheeze due to small airway obstruction
Crepitation due to presence of sputum/ chest infection
Hyperresonance due to pneumothorax
Dull to percussion due to chest infection with lung collapse/ effusion
Heart failure due to cor pulmonale
 Investigation
Lung function test
Reduced FEV1/ FVC ratio to <70%
A

C
 Investigation
Lung function test
Reduced FEV1/ FVC ratio to <70%
 Investigation
CXR:
Hyperinflated lung
Lung bulla may mimic pneumothorax, may
become infected with fluid level
Pneumothorax, maybe loculated
Pulmonary inflitrates/ consolidation during time
of infective exacerbation
Pneumonia may complicated with pleural effusion
Concomitant lung cancer in patient with long
history of smoking
Hyperinflation
Emphysematous lungs
Infected bulla
Loculated pneumothorax
pneumonia
 Investigation
CT thorax
Without contrast:
Can be useful to differentiate emphysematous lung/
bulla from pneumothorax
Better localization of pneumothorax for chest drain
insertion
Assessment of heterogeneity of emphysema for
consideration of lung volume reduction surgery(LVRS)
with contrast:
In case of infective complications or lung neoplasm is
considered
 Investigation
ABG:
Useful when assessing patients is suffering from
acute exacerbation to determine if there is any
respiratory failure requiring mechanical ventilation
For titration of ventilatory support
Familiarize yourself with the definition of type I
and type II respiratory failure, with or without
compensation
Also useful to determine if a patient is suitable for
surgical treatment of COAD
 Investigation
Echocardiography/ ECG
To look for signs of cor pulmonale
To look for underlying heart disease which may
induce symptoms and signs mimicking COAD
To look for heart disease which share similar risk
factors with COAD eg coronary artery disease
 Investigation
Ventilation perfusion scan
When bronchoscopic / surgical lung volume
reduction is considered
 Dx / DDx
? Confirmed COAD
?Stage
any complication
 Treatment plan for COAD
Life style modification
Smoking caseation Medical therapy
Pulmonary rehabilitation Bronchodilator
Long term home O2 Corticosteroid
vaccination

COAD

Treatment of complications Invasive intervention

Exacerbation Bronchoscopic / surgical lung volume
Infection reduction
Secondary pnemothorax Transplant
Pneumothorax
 History
Symptoms
Age/ gender
Precipitating factors
Chest infection
Trauma
Menstruation
Recent invasive procedure/ surgery, eg central line insertion, CT
guided lung biopsy
Underlying lung disease/ connective tissue disease
Tobacco exposure
Previous history of pneumothorax
Occupation
 Physical examination
Hamemodynamcic stability
? Tension pneumothorax
Concomitant haemothorax with blood loss in the pleural
cavity
SaO2 monitoring
Position of trachea
Trauma related
any open wound
Previous surgical/ chest drain scars, reduced chest
expansion, absence breath sound and hyper resonance
Subcutaneous emphysema
 Investigation
CXR
In case of suspect tension pneumothorax ,
attempt emergency thoracocentesis while waiting
for CXR
Classically an expiratory CXR should make a small
pneumothorax more easily identified
Pneumothorax with blebs

small lung bullae that has not ruptured

Quantification of pneumothorax

Percentage of lung volume

loss in pneumothorax
= c3 -(c b) 3 /c3
c A 2cm radiographic
pneumothorax approximates
to a 50% pneumothorax by
volume
lung collapses towards hilar
 Haemopneumothorax
whilst lung is collapsing, vascular adhesion is torn > bleeding can be profuse
tension component, physiological change of mismatch, obstructive + hypovolemia due to blood loss
can make it a life threatening condition
do chest drain to relieve pneumothorax and allow lung to re-expand, sometimes when lung touches chest wall again,
torn vascular adhesion will heal by itself and resolve healing, use larger bore chest drain than usual since
fresh blood clot easily in drain

Immediate large bore chest drain

insertion and Emergency Operation
 Investigation
CT thorax
When uncertain about the nature of radiolucency
on CXR; chest drain inserted to emphysemtous
lung can be difficult to manage and lead to
complications
To look for causes of secondary pneumothorax
before further definitive intervention
 Secondary pneumothorax
Lymphangiomyomatosis (LAM)
 Secondary pneumothorax
Catamenial

Fenestration of diaphragm

Endometriosis on visceral pleura

 Investigation
Blood test:
Look for underlying connective tissue disease
 Dx / DDx
Primary vs secondary
? Spontaneous
? Recurrent
? Complications
Treatment plan for pneumothorax
Initial management of pneumothorax
Emergency thoracocentesis
Chest drain insertion Subsequent in-hospital management
Observation
Emergency VATS

Pneumothorax

Prevention of recurrence
Treatment of underlying pathology and
Chemical pleurodesis
complication
Surgical pleurodesis
British Thoracic Society Guideline
 Surgery for pneumothorax
Indication of surgical intervention for primary
spontaneous pneumothorax
Second ipsilateral pneumothorax.
First contralateral pneumothorax.
Synchronous bilateral spontaneous pneumothorax.
Persistent air leak (despite 57days of chest tube
drainage) or failure of lung re-expansion.
Spontaneous haemothorax.
Professions at risk (eg, pilots, divers).
Pregnancy.
 Chemical pleurodesis
In patient not fit for surgical pleurdoesis
Instillation of various agents via chest drain
into pleural space induce pleural synthesis
Talc >> associated with ovarian malignancy, and some myloma??? Johnsons and
Johnsons

Autologous blood
Tetracycline/ minocycline
Povidone-iodine
Pleural effusion
 History
Smoking/ occupation
Recent trauma
Past Hx
Medical illness eg. Heart failure, liver failure, renal failure(? Use of peritoneal dialysis)
Malignancy
Recent surgery
Severity of symptoms depend on
Underlying pulmonary reserve
Rate of accumulation of pleural effusion
SOB, cough, sputum production, chest pain, fever
Constitutional symptoms
 Physical exam
Any respiratory distress
Respiratory rate
Use of accessory muscles
Signs of massive pleural effusion
Unstable haemodyanmic
Tracheal/ mediastinal shift
Signs suggesting underlying cause of pleural
effusion
 Investigation: Imaging
CXR
Useful for initial diagnosis and monitoring
Decubitus CXR can confirm present of free flowing fluid
Unilateral pleural effusion: more suggestive of thoracic
pathology
Bilateral pleural effusion: more suggestive of systemic illness
related pleural effusion
USG
Useful bedside imaging for localization of fluid and differentiate
fluid from collapsed lung/ tumour mass
CT thorax
Valuable in assessing underlying intra-thoracic pathology and
the anatomy of complex pleural effusion
 Investigation: blood tests
For evaluation of general medical condition
and circumferential evidence of underlying
cases
Hypoalbuminaemia
Renal failure
Tumour markers if malignancy is suspected
 Investigations: pleural fluid
To differentiate the causes of pleural effusion
Appearance
Clear straw colour
Blood stained
Milky >> chylothroax >> leakage of lymphatic fluid into
chest cavity
Pus >> infection
 Investigations: pleural fluid
Biochemistry:
Modified Lights criteria
Transudate vs exudate
 Investigations: pleural fluid
Adenosine Deaminase (ADA)
Concentration > 30IU/L suggestive of TB empyema
Triglyceride/ cholesterol/ chylomicrons
 Investigation: pleural effusion
Microscopy and culture
AFB stain and TB culture
Cytology examination
 Investigation: pleural biopsy
If investigation of the pleural fluid is not
revealing and malignant disease/ TB is
considered
Treatment plan for pleural effusion

Drainage for symptom Medical treatment of

relief and further underlying systemic
investigation disease

Pleural
effusion

Prevention of recurrence Surgical management for

Chemical pleurodesis specific pathology
 Choice of drainage procedures
Thoracocentesis
One off drainage at bedside
For diagnosis purpose without leaving any drainage
catheter
Image guided pleural catheter(pigtail) insertion
Insertion of a indwelling catheter for a prolonged
drainage (days to weeks)
Suitable for thin pleural fluid
Large bore chest drain insertion
For haemothorax/ empyema (pus in chest)
Expected need of chemical pleurodesis
Chest drain insertion
 Chest drain insertion
One of the most commonly performed beside
procedure
A technique that you are expected to be able to
describe in final examination
A procedure that you are suppose to be able to
perform under supervision as intern and
independently perform as a medical officer, no
matter what specialty you are working in
Yet deadly complication can occur
Its not a one off procedure, continuous
monitoring is very important
http://www.nejm.org/doi/full/10.1056/NEJMvcm071974
 Chest drain insertion

What is your indication Where? How? What

of chest drain insertion? size of chest drain?

Chest drain

Post CD insertion When can we take off

management? the chest drain?
Indication of chest drain insertion
Before you perform the procedure
Check
Patient, side, indication
Look at the latest CXR/ CT
Consent
Get all the equipment you need
Prepare your working environment
Adequate space and privacy
Patient positing
Patient monitoring
Pulse Oximetry
Briefing
To your assistant
To the patient
 Consenting
Explain the indication and expected outcome
Risk of procedure
Alternative choice of treatment
 Equipement
Bedside USG
Needles, syringes and local anaesthetic
Antiseptic solution
Drapes for a sterile operating field
Blade
Dissecting instruments
Drain
Size, ? Trocar
Anchoring stitches
Drainage system/ bottle
Dressing
Make sure you have everything ready so that your assistant do not
need to leave you to get what you need
 Choice of drain
Size
? Pneumothorax/ haemothorax/ empyema
? Need of subsequent chemical pleurodesis
Patients factor
 Patient positioning
Supine and pop up ~45 deg
Abducted arm to expose safety triangle
Safety triangle for chest drain insertion
Lateral border of pectoris major muscle
5th Rib
Mid Axillary line
Why safety triangle?
Intercostal muscles
Three layers
Intercostal vessels
and nerves beneath
costal groove
Anchoring chest drain
 Drainage bottle / system
Make sure you know how to draw a 3-bottle
system and explain how it works
Modern chest drain system
Pressure change during breathing
1mmHg = 1.36cm H2O = 0.133kPa
6mmHg = 8cm H2O
 Post Chest drain insertion
Documentation
LA used
Where, what size, depth
What is drained
Any difficulty/ complication
Arrange immediate CXR
How much suction
 Subsequent management
Make sure the chest drain is functioning
Make sure that it doesnt slip out
Regular CXR monitoring
Known when to take out the chest drain
Questions