Chest Lectures

Objectives

-:The students should know the followings

. Surgical anatomy of the chest wall , lung ,pleura and mediastinum-1
. Diseases affecting pleura (From surgical point of view )-2
. Indications , contraindications and complications of bronchoscopy-3
Chest trauma -----indications for surgery-4
. Indications , contraindications , technique and complications of chest tube thoracostomy-5
. Hydatid disease in Iraq-6
.Surgery in bronchiectasis , lung abscess and TB-7
Carcinoma of the bronchus aetiology , presentation , investigations and modalities of treatment-8
. Chest wall deformities-9
. Thoracoscopy indications and complications-10
First Lecture
 Anatomy

: The respiratory system consists of the

Nose , Nasal passage , Nasopharynx , larynx ,Trachea ,Bronchi & lungs . The
both chest wall is covered by Pectoralis muscle anteriorly while posteriorly
. (Latissmus dorsi and serratus muscle) are encountered
, There are (12) pairs of ribs
Seven of which are termed (True Ribs) as the cartilages articulate with the
.sternum
The lower five ribs are termed (False Ribs) which are not connected directly to
.the sternum
The eleventh and the twelfth ribs are termed (Floating Ribs )
. Because they are not attached anteriorly
The sternum is divided into the
Manubrium .Body and xiphoid .
The clavicle articulates with the sternum
and Ist.costal cartilage .
Muscles associated with the intercostals
space are , The external intercostals
,internal intercostals and transversus
thoracic(inner most intercostal) muscles
.There are (11) intercostals spaces
containing a vein ,an artery and a nerve
which course along the lower edge of each
. rib
Pleura is a fibro elastic membrane lines by squamous epithelial cells .
It consists of two portions:-
1-Parietal pleura which lines the thoracic cavity and it is divided into four parts
a- Costal pleura which lies against the ribs &intercostal muscles
b-Diaphragmatic pleura which covers the upper surface of the diaphragm.
C-Mediastinal pleura which lies against the mediastinum .
D-Cervical pleura which covers the dome of the thoracic space

. 2-Visceral pleura which intimately invests the lung

.Costo –phrenic angle is the angle between the costal &diaphragmatic pleura
Cardio –phrenic angle is the angle between the heart &diaphragmatic pleura
Inferior pulmonary ligament is the anterior & posterior reflection of the
pleura between the root of the lung & the diaphragmatic surface

The function of the pleura is to maintain the environment of the pleural

.space in which the lung is function
The bronchial arteries originate from the aorta or
the intercostals arteries .
Pulmonary veins drain into the left atrium .No
bronchial veins.

The Lymph nodes found along the lobar branches

are termed(hilar LN).There are also Tracheal and
tracheo-bronchial LN.
Phrenic nerve located anteriorly while the vagus
. nerve located posteriorly in the thoracic cavity
The Trachea
is a fibro muscular tube (10-12 cm) in length
and (13-22 mm) in width. Supported laterally
and ventrally by (16-22) U-shaped hyaline
cartilages . The trachea originates at the level
of the cricoid cartilage down to its bifurcation
at the level of the sternal angle where it
divided into right and left main bronchi .The
spur at the bifurcation is termed the (Carina) .
The right main bronchus is (12-16 mm) in
diameter ,the left is ( 10-16 mm) in diameter
.The right main bronchus deviates less from
the axis of trachea than the left ,this explains
why foreign body is more common in the right
main bronchus .The main bronchi are divided
into the segmental bronchi which end into the
terminal bronchiole which divided into the
respiratory bronchiole which terminate into
. the alveoli
 Clinical manifestations of respiratory dieases

Cough-1
Dyspnea or breathlessness , it is an unpleasant subjective awareness of-2
. the sensation of breathing
. Chest pain in diseases with pleural or chest wall involvement-3
. Haemoptysis-4

-: Investigations
Chest X-Ray-1
CT chest-2
MRI mediastinum-3
. US chest to detect any effusion-4
. Pleural aspiration-5
. Bronchoscopy flexible or rigid-6
 Pulmonary Function Tests
Tidal Volume (TV)-1
Is the amount of air inspired or expired per single
. breath

Functional residual Capacity (FRC)-2

The amount of gas contained in the lung at the end
. of quiet expiration

-;Inspiratory reserve volume-3

Is reached when the patient makes a maximum
inspiration and increased the lung volume
tidal ,compared with that contained at the peak
.volume

-: Vital capacity-4
The volume expired from maximal inspiration to
.maximal expiration

-: residual volume-5
Is the amount of air remaining in the lung after
.maximal expiration
FEV1—8
. Is the volume of air expired in one second
 Diseases of the pleura

Spontaneous pneumothorax-1

Is the accumulation of air inside the pleural cavity , occurring without any known
etiology .More in males ,more on the right side .It can be bilateral
Causes
1- Ruptured pulmonary bleb.
2-Ruptured of a cystic defect in the pleura.
3-Teared visceral pleura
4-No cause can be demonstrated in (15-20%).
Complications:-
1-pleural effusion
2-empyema
3-tension pneumothorax which leads to mediastinal shift &circulatory collapse.
. 4-Respiratory failure in elderly patient with COAD (COPD)

-: Treatment
.Bed rest ,O2 administration &observation in limited pneumothorax-1
Aspiration-2
Chest tube (thoracostomy tube or ICD intercostal drain in a safety triangle which is-3
bounded by pectoralis muscle anteriorly &lattismus muscle posteriorly and the
superior border of the nipple.in the fifth intercostal space just anterior to the mid
. axillary line to avoid the long thoracic nerve
bronchoscopy is indicated if the lung fail to expand-4
Chemical pleurodesis.by injecting sclerosing agent as Tetra cycline-5
Surgery pleurectomy by thoracotomy or thoracoscopically if the lung fail to re-6
expand
 Spontaneous haemothorax-2

Is the presence of blood inside the pleural cavity

-:Causes
pulmonary causes ----------TB , AV malformation-1
pleural causes -----------torn vascular adhesion-2
pulmonary malignancy ….primary or metastatic-3
blood dyscrasia ……………..hemophilia-4
abdomina; pathology haemo peritoneum-5
thoracic causes ………ruptured great vessels-6
Clinical features
dyspnea , chest pain ,syncope
signs of hypovolaemic shock
blood inside the pleural cavity may leads to deposition of fibrin on the pleural
. surface leading to fibrosis (trapped lung syndrome)

Treatment
Resuscitation-1
Tube thoracostomy-2
May needs thoracotomy if excessive bleeding-3
initial bleeding more than 1.5 liter
Or continuous bleeding more than 200 ml/hour for more than 4 hours
•
 Chylo –thorax-3

Is the presence of lymph in the pleural space

Causes
A-Congenital atresia of the thoracic duct , birth trauma
B-Traumatic
C-Neoplastic malignancy
D-Infection TB
, Diagnosis milky pleural effusion that does not clot and
contains fat , fat soluble vitamins & antibodies, diagnosed by high content of
. chylomicrons or triglycerides
Treatment
Conservative consists of insertion of tube thoracostomy to drain the effusion ,-1
.correction of the fluid and electrolytes with nutritional supplement
Surgery consists of ligation of the thoracic duct if the effusion continues for more than-2
. two weeks
 Pleural effusion-4

Is the accumulation of fluid in the pleural space excessive transudation or exudation of the
. interstitial fluid from the pleural surface. It is signify pleural or systemic disease
Its effect depends on its size (mild , moderate or massive ) & the state of the underlying lung .It is
classified as transudate when the protein content is less than 3g% or exudates when protein
content is more than 3 gm % .Clinically patients will present with dyspnea & pleuritic chest pain
Radio logically (concave meniscus sign)
Transudate as in CHF
Exudate as in malignancy
Treatment :-1-aspiration (thoracentesis) 2-tube thoracostomy
.chemical pleurodesis 4-pleuectomy to remove the pleura to stop the effusion-3
 Empyaema-5

Is the accumulation of pus in the pleural space , it passes into three stages
. Acute phase with the clinical manifestation of fever & toxicity-1
Transitional phase with the increased turbidity of the fluid & decrease the size-2
. of the lung
the Chronic phase with the pleural thickening ,decrease amount of the fluid &-3
. development of the trapped lung syndrome
 Tube Thoracostomy
Tube thoracostomy or Chest Tube or ICD(Intercostal drain)
Is a flexible hollow plastic tube that is inserted through the chest wall into
the pleural space and connected to a bedside drainage container

-:Indications
Pnemothorax-1
Pleural Effusion-2
This effusion may be

A-Empyema
Hemothorax-2
Traumatic or Malignant Effusion
Hydro thorax-3
4-Chylothorax
5-Thoracic Operation (Tube Thoracostomy without trocar ) .
On the lung or Mediastinum Or The esophagus
6-Postoperative (Collection or Infected space ).
.7-malignant Effusion drainage and giving medication through it
Contra-Indications:-
Refractory coagulopathy
Lack of cooperation by the patient
Diaphragmatic Hernia
Lobar Emphysema
Surgical Emphysema without underlying pneumothorax

-:Technique
LA or GA
Surgical Set
The tube may be inserted in the Emergency Dept. , ICU ,Operating Room or
General Hospital Room
Size infantile , pediatric ,adult (8 FG ------ 40 FG)
Roughly ---- the size of adult index finger
---- Sites
Safe zone
The free end of the tube ------underwater seal below the level of the chest
Chest radiograph to be taken to check the location of the drain
The tube stays in for as long as there is air or fluid
Chest tube with trocar a banded in most countries due to its complications ,mainly
injury to the underlying structures , so the recent trained in chest tube insertion will be
illustrated in the next slides

Chest tube set

How long is a chest tube used ?
The tube remains in place until the lung is re-expand or the fluid is drained.
Occasionally the patient require more than one chest tube
Indications for Removal
Clinical
Mechanical
Radiological
Complications:-

1-Minor Complications:-
Severe pain during placement
Subcutaneous hematoma or seroma
Anxiety
Shortness of breath (Dyspnea)
Cough ( Rapid drainage of fluid )
Major Complications-2
Hemorrhage ---haemothorax or haemoptysis
Infection
Reexpansion pulmonary edema
Injury to the liver , spleen , diaphragm .
Injury to the Thoracic aorta & the heart
Second Lecture
 Bronchoscopy
Bronchoscopy
Looking into the living lungs (Chevalier Jackson 1928)

Today with the major advance in technology

View the fine details of the end bronchial anatomy
Diagnosis of the disease
Treating diseases
It is the visualization of the air way using either rigid Bronchoscope (GA) or the flexible (Fiber optic
Bronchoscope ) (LA) or both simultaneously .Through which we can remove FB , take BAL , brushing
. lesions &Trans bronchial Biopsy
 HISTORY
Gustav Killian (The father of bronchoscopy ) , was appointed professor
. of ENT at the university of Freiburg in 1892

Gustav Killian in 1897 succeeded in removing aspirated pork

bone from the bronchus of a 63 –year-old farmer under
cocaine anesthesia .He used external light source , a head
. mirror , esophagoscope and forceps to remove the bone
He became famous & his clinic attracted patients from far and
wide for his expertise in removing different kind of (FB) such
. as bones ,beans ,buttons ,coins & tin whistle

Gustav Killian Bronchoscope , external light source

 Bronchoscopy rapidly developed into a
science (with the creation of a better
instruments and techniques )

Chevalier Jackson
Founded philadelphia school of
bronchoesophalogology

Jackson‘s monograph first published in 1950

Chevalier Jackson’s Bronchoscope with a small distal bulb & built –in suction tube
Early in the 1960s Shigeto Ikeda devised a means to replace the small electric bulb with glass fibers
capable of transmitting brighter light from an outside source. He presented the first flexible
.bronchoscope at the 1966 International Congress on Diseases of the Chest in Copenhagen

could H.H.Hopkins English physicist developed the rod-lens optical telescopes which
be used with the rigid bronchoscope
At the end of the 1980s, Asahi Pentax replaced the fiberoptic bundle with a charge-coupled sensor at
the tip of the scope. This videobronchoscope allowed the bronchoscopist to look at a monitor screen
instead of through the eyepiece of the scope
 Rigid Bronchoscopes

Hollow metal tubes , of variables sizes down to ( 3mm -9.5 mm) and variable
length (20-40 cm) .These instruments usually have illumination at their tips
as well as side holes near the tip to facilitate ventilation .They are always
inserted trans orally .General anesthesia is recommended for its
. introduction
Indications for Rigid Bronchoscopy
Hemoptysis-1
.Tracheal stenosis-2
. Foreign body removal-3
All bronchological interventions such as bougienage , removal of threads &-4
.post intervention hemoptysis
Confirmation of cell type in case of previous , non diagnostic fiberoptic-5
. bronchoscopy
Laser treatment-6 •
Removal of tumor-7 •
. Removal of excess fibrin , mucous plug-8
. Bronchography-9
. Autofluorescence and photodynamic diagnosis-10

i.e. Diagnostic and Therapeutic

Bronchoscopy ( Adult Set )
Bronchoscopy (Pediatric Set )
Some of the inhaled F.B removed bronchoscopically
 F.B. Obstructing right lower lobe ,removed
bronchoscopically and the right lower lobe re expand
Foreign Body Pin (LMB)
 Flexible Bronchoscopy

It consists of Control section , a flexible insertion tube & a bending tip .The control
section contains the eye piece ,control lever and a channel for aspiration or for
.introduction of solution and instruments
 These flexible bronchoscopes have variable outside diameter (1.8 -6 mm) with
inner channel ranging from (1.8 -2.6 mm) . Highly maneuverable and can reach
areas in the endo bronchial tree not accessible to the rigid bronchoscopes .
Can be inserted either transorally or transnasally or through the rigid
bronchoscope.
We have the Infantile , Pediatric , adult types and the Video –Bronchoscopes
 Indications for flexible Bronchoscopy
. For routine examinations-1
.Treatment of acute respiratory problems in the ICU-2
. Suction under visual control-3
.Use of catheter and brushes for cytology-4
.For obtaining secretions for bacteriological tests-5
.Localization of the bleeding site in case of hemoptysis-6
. Theraputic suction & irrigation-7
. Transbronchial lung biopsy-8
. Selective bronchography-9
. Autofluorescence & photodynamic diagnosis-10

not Major disadvantage of the flexible Bronchoscope is that it is a closed system that does
provide an airway , and the relatively small inner channel is considered to be
incapable of allowing adequate suction when confronted with copious secretions or
. massive haemoptysis
. It is not so much effective in the removal of foreign bodies
Tracheo-Bronchial Trainer
Suction Lever Saline for irrigation Sample collection (BAL)

Lecture scope
 Contra indications

Rigid Bronchoscopy

Is best avoided in the presence of Cervical spine injury thoracic

to prevent hyperextension of the neck & in patient with Aneurysm of the
aorta

Flexible Bronchoscopy
Best avoided in patient with Massive Haemoptysis & patients with air way
problems

In cases of doubt as to whether bronchoscopy should be done or not , bronchoscopy

. should always be done ( Jackson’s 1915 statement )
In suspected cases of F.B inhalation it is better to have a negative bronchoscopy rather
. than to miss a F.B inside with all its pathological consequences
Normal Bronchoscopic Findings
Abnormal Bronchoscopic Findings
 COMPLICATIONS

When bronchoscopy performed by properly trained individuals

It is a safe procedure .However a variety of other problems have been reported
including
Pneumothorax , bronchospasm , Bronchial perforation (Surgical emphysema
, & tension pneumothorax )
Subglottic edema , Uncontrolled bleeding , Infections
Arrhythmias rarely ( Cardiopulmonary arrest )
Hypoventilation (Hypoxia& hypercapnia)
Majority related to a biopsy procedure So explorative thoracotomy may be safer than
(injudicious biopsy )

Some minor complications

Damage of teeth , Injuries to lips or mouth
 Post bronchoscopy care

Close monitoring for 2-4 hours after the procedure-1

. Eating and drinking is not allowed until the effect of anesthesia have worn off-2
Some may advise routine CXR after performing a biopsy to check for signs of-3
. pneumothorax
Those patients develop complications may need to stay in the hospital for-3
. additional time
. The patients may have sore throat , hoarseness ,cough or muscle ache-4
Fever up to temperature 38 “ c is common after bronchoscopy but usually for
. only 24 hours
 Advances in Bronchoscopy

Brochoscopic Ultra-sound -1
Bronchoscopic stenting (Air way prosthesis )-2
. PDD & AF Bronchoscopy-3
. Bronchoscopic Laser therapy-4
Bronchoscopic Electro Cautery-5
Cryo therapy-6
Brachy therapy-7
Photo therapy-8
 Bronchoscopy need cooperation and mutual understanding Between

A well trained endoscopist-1

a qualified staff-2
Expert and well trained anesthetist-3

Bronchoscopy
.is now an integral part of respiratory medicine
Diagnostic indications include tissue diagnosis, detection and staging of lung
malignancy, evaluation of diffuse lung diseases like sarcoidosis and idiopathic interstitial
pneumonias, pulmonary inspection of burn patients, identification of organisms infecting
.the respiratory tract and lungs

As a therapeutic modality, bronchoscopy is used to place stents to protect

airways vulnerable to collapse or occlusion, to remove foreign bodies or masses, to treat
.early stage endobronchial malignancy
 Pleural Tumors

. Classified as primary and secondary tumors

Primary Pleural tumors are Mesotheiloma which may be
Localized benign 2- Diffuse Malignant-1
Malignant Mesothelioma causes chest pain , bloody pleural effusion and chest X-Ray
findings of diffused pleural thickening with nodularity and limited pleural effusion
. .There is a possible relationship with asbestos exposure
to Metastases are uncommon .Death usually occurs within 1-2 years .It has a poor response
. surgery , radiotherapy and chemotherapy
Pleural involvement by metastatic diseases is more common than primary tumor and
. usually comes from lung , breast and stomach
 Benign Tumors of Trachea and Bronchi

Are rare ,more in males .They are slowly growing .Their presentation is is as a result of luminal
obstruction or mucosal irritation .Patients may present with dyspnea , cough and haemoptysis
.A sub glottic tumor presents with stridor ,The diagnosis is by bronchoscopy and treatment is
surgical excision .E.g Papilloma , Haemangioma ,Chondroma and Fibroma
 Bronchial Adenomas

Bronchial Carcinod-1
Muco epidermoid Tumors-2
Adenoid Cystic Carcinomas (Cylindromas )-3
Mucous Gland Adenomas-4
The first three are potentially malignant ,the 4th. Is benign
. The first three are slowly growing , invade locally and surgical excision is the treatment of choice

Bronchial Carcinoid Tumors

Resemble intestinal carcinoid as the cytoplasm as the cytoplasm of their cells contains neurosecretory
granules .In the bronchus these tumors arise from the neuro endocrine argentafin cells of bronchial mucosa
. (Kultchitsky ‘s cells ) .They are grouped among APUD tumors (Amine Percursor Uptake Decaboxylation)
They are capable of producing a number of hormones like Serotonin , histamine and gastrin .They are
slowly growing tumors , but sometime they are aggresaive termed (atypical carcinoid ) .They present with
. ( cough , haemoptysis and dyspnea
Carcinoid Syndrome is a rare ,presents with episodes of flushing , diarrhea and in addition to the systemic
manifestations ,there may be cardiac manifestations .Elavated 5-HIAA may be detected in the urine ,which
.Surgical may be diagnostic .Bronchoscopic appearance is diagnostic and severe bleeding may follow a biopsy
. excision is the treatment of choice
Third Lecture
Carcinoma of the lung
Affects both sexes , It is however commoner in men
. It has poor prognosis

The incidence has shown a marked rise during recent years partly because
of improved methods of diagnosis and partly due to
1-Ecessive cigarette smoking ,both active & passive smoking are implicated
2-Inhalation of irritants , such as silica ,cobalt dust .
Pathology :-
A-Central type is the commonest (75%).It arises in one of the main bronchi
or their primary division leading to bronchial obstruction with secondary
changes in the lung such as atelectasis .
B-Peripheral type (25%) arises from the smaller bronchi and remains
. symptom less for long time
Histologically

Squamous cell Ca (SCC) 60% , smoker , centrally located

,metastasizes to mediastinal & supraclavicular LN .
Adenocarcinoma (15% ) , located peripherally , more in
women .Tends to metastasizes to the liver , brain ,bone &
adrenals in addition to the LN
Undifferentiated carcinoma (oat) cell carcinoma and large
cell carcino(20-30%) which includes small cell ca.
Alveolar cell carcinoma , located peripherally ,metastasizes
to the liver and adrenals

Recent classification..Non small & small cell carcinoma

Superior sulcus tumor of Pancoast
It is a low grade epidermoid carcinoma that grows slowly and
metastasize late, infiltrates and involves lower root of Brachial
plexus, intercostal nerves , Cervical sympathetic nerves & eroding
the upper ribs ,producing pain in the shoulder & Horner's syndrome
.
Clinical features :-
1- cough dry or productive
2-Haemoptysis
3-Chest pain
4-Dyspnea
5-Pleural effusion
6-Anorexia & loss of weight
7-Clubbing of the fingers
8-Hoarseness of the voice (recurrent LN)
9-Dysphagia involvement of the esophagus
10-Hormonal syndromes ..ectopic ACTH , ADH, hypercalcaemia ,carcinoid
syndrome

Diagnosis
Clinical , sputum cytology
.. Chest X-ray ,CT chest
Bronchoscopy ,BAL ,bronchial brush &biopsy
FNAC….or Trucut biopsy , pleural fluid aspiration & cytology
Diagnostic Thoracoscopy & mediastinoscopy
TNM classification for staging
Signs of inoperability :-
1-Bloody pleural effusion .positive for
malignant cells
2-Horner’s syndrome .
3-Vocal cord paralysis
4-Phrenic nerve palsy(elevated hemi
diaphragm)
5-SVC obstruction
6-Distant metastasis
7-If during surgery ,the tumor locally
spreading or cannot be remover
technically or fixed to the PA or to the
heart ,it is technically irresectable
Treatment
1-Surgery more than 50%of the patients have distant metastases
at the time of diagnosis .
50% Iresectable per operatively
15-20 % resectability rate
Surgery ..segmentecomy , lobectomy . pneumectomy

Radiotherapy-2
Pre operative or post operative

Chemo therapy vincristine or adriamycin

Bleomycin for malignant effusion
Differential diagnosis of a solitary lung lesion (COIN LESION)
Hydatid cyst 4- Primary benign lesion-1
Tuberculoma 5-primary malignancy of the lung-2
Angiomatous malformation (AV fistula) 6-metastatic tumors-3
Pulmonary Echinococcosis (Hydatid Cyst)
small Hydatid disease of the lung is caused by the
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

.Smooth homogenous opacity (Intact H.C)-1

.Partial rupture (per vesicular pneumocyst)-2
. Complete rupture (Water –lilly sign)-3
. Formation of lung abscess(Air –fluid level)-4
Completely coughed out cyst(empty cavity )-5
Rupture into the pleura (hydropneumothorax)-6 •
 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
Congenital causes (25%) 2-Acquired causes (75%)-1
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
.History chronic cough with purulent sputum-1
. Plain CXR may shows prominent vascular marking-2
. Bronchoscopy to diagnose obstructive lesion & to obtain bronchial wash for C&S test-3
Bronchography through giving radio opaque dye through the bronchoscope & into-4
.bronchial tree ,now replaced completely by CT
Chest CT is the single non invasive tool for both diagnosing &assessing the severity of-5
. the disease
. X-Ray paranasl sinuses to treat any excisting infection-6
. Pulmonary function tests very important specially in pre operative assessment-7
-: 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

Primary treatment is Medical -1

Prolonged antibiotics treatment
Bronchoscopy useful to remove a FB or drainage of abscess
Surgery indicated in-2
Failure of medical treatment
Massive haemoptysis
persistent of a thick wall cavity
when malignancy is suspected
when empyaema develops
-: Complications •
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
. Perforation of the esophagus or leakage from anastomosis-1
.Extension from a nearby infection (lung , vertebra ,pleura )-2
. Following median sternotomy for cardiac surgery-3
-: 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
. Treatment of the cause-1
. Antibiotics according to culture and sensitivity-2
. Tube thoracostomy to drain any pleural collection-3
. Supportive therapy-4
 Surgical Treatment of Pulmonary Tuberculosis

-: Indications
Massive or recurrent haemoptysis . Surgery is indicated to-1
. remove the source of bleeding
Broncho pleural fistula-2
Open cavity with positive sputum resistant to 3-6 months-3
. of treatment
. TB bronchiectasis-4
When malignancy is suspected as TB and malignancy can-5
co exist .Carcinoma can arise in TB scar (Scar carcinoma )
.
Patients with (Trapped lung syndrome ) after chronic-6
. 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 syndrome
Which characterizes by elevation of the venous pressure and edema of the face ,
neck and upper extremity with the appearance of the dilated venous chandelles
and in the chest wall and cyanosis .It may be caused by the carcinoma of the lung
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
Fourth Lecture
 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

Diagnostic-1
Diagnosis of pleural diseases-1
. Evaluation of carcinoma of the bronchus-2
. Biopsy of a discrete pulmonary nodules -3
. Evaluation of mediastinal mass-4
-: Therapeutics
. Treatment of pleural effusion-1
. Treatment of recurrent pneumothorax-2
. Removal of intra- pleural FB-3
. Debridement of empyaema space-4
. Dorsal sympathectomy-5
. 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 node
Mediastinoscopy 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
Studies should require about an hour, not counting preparation and recovery time.
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)
(
 Chest Trauma
Causes :-
1-Blunt Trauma
2-Pentrating & perforating injuries
3-Blast injuries

Classification
Chest wall injury-1
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
Ribs & Sternal injuries-2
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
End tracheal tube

Flail chest
Pleurl injuries-3
Can lead to
A-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 lung
Fractures

haemothorax Traumatic
Pulmonary injuries-4
Trauma 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 secretion
Tracheo-bronchial injuries-5
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
 Great vessels injuries-6
Injuries 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

Diaphragmatic injuries-7
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
Esophageal injuries-8
Thoracic 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
Cardic injuries-9
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

The surgeon who should attempt to suture a wound of the heart would lose"
the respect of his surgical colleagues" - Theodore Bilroth, 1882

Stab to the pericardium - Resuscitative thoracotomy

Thoracotomy in chest trauma
90% 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 Thoracotomy

Resuscitative 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 thoracotomy
Clotted haemothorax-1
Trapped lung syndrome-2
Big foreign body-3
Complications of chest injuries
1-ARDS: Syndrome of acute RF with the
pulmonary formation of a non –cardiogenic
compliance edema leading to reduced lung
and hypoxemia 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-Atelectasis
3-Infection
4-Pulmonary embolism
5-Air embolism
6-Traecheal complications
7-Cardiac arrhythmias
 Poly trauma Team Members

Team leader∙
∙Anesthetist + assistant
∙General surgeon
∙Orthopedic surgeons
∙A/E physician
∙Two (2) nurses
∙Radiographer
∙Scribe (nurse or doctor)
Thank you