2. AIRWAY OBSTRUCTION
DEFINITION:
It occurs when you cant move air in or out of your longs.
it may be part or the whole airway blocked.
EPIDEMIOLOGY:
It is the commonest cause of emergence departmental visits and most
common cause in the adults is inflammation, infection and trauma .In
children its foreign bodies
3. CAUSES:
INTRALUMINAL:
Inhaled foregin bodies,neoplasm, abscess
INTRAMURAL:
Congenital stenosis, fibrous stricture
EXTRAMURAL:
Neoplasm{thyroid cancer} and aortic aneurysm
Other causes are allergy, trauma vocal cord issues, infections,
tracheomalasia and asthma
4. TYPES OF AIRWAY OBSTRUCTION:
Upper Airway obstruction from nose to larynx
Lower Airway obstruction from larynx to narrow passageways of lings
Partial and complete
Acute or chronic
9. MANAGEMENT:
A B C
Heimlich manouver
Back blow manouver
Epinephrine for allergic reactions, usually epipen 1 injections at the outer
thigh
Cardiopulmonary rescucitation{CPR}
In hospital, endotracheal or nasotracheal tube may be inserted
Tracheostomy and chricothyrotomy are openings made to by pass the
obstruction
Resection of up to 6cm of trachea is possible
10. SURGERY I : CHEST CONDITION.
GROUP 3-DCM MARCH 2021
ASSIGNMENT
1 Belinda
2 Beatrice
3 Peter
4 Victor
5 Felix
COMPILED BY ROJAR
5/29/2023 10
11. CONTENT TO BE COVERED
1 PNEUMOTHORAX
2 HAEMOTHORAX
3 EMPYEMA THORACIC
4 SURGICAL EMPHYSEMA
5 CARDIAC TAMPONADE
5/29/2023 11
13. 1 PNEUMOTHORAX
DEFINITION
• A pneumothorax is the presence of air or gas within the pleural
cavity i.e. the potential spaces between the visceral pleural &
parietal pleural of the lungs.
• This is usually from the defect on the lung surface e.g. rapture
bullae(Large blister ) or through the damage of the chest wall e.g.
following trauma.
• Air within the pleural cavity causes the physiological pleural seal to
be lost ,meaning the normal negative pressure in this space , that aid
the lung expanding within the chest wall movement is lost.
• This impedes(prevent) lung expansion & leads to partial or total lung
collapse.
5/29/2023 13
16. EPIDEMIOLOGY/INCIDENCE
• Annual incidence of pneumothorax is around 9% per 100,000
• Primary pneumothoraces occur most commonly in tall thin men aged
between 20-40
• They are less common in women- consider the possibility of
underlying lung disease e.g. LAM, Catamental pneumothorax
• Cigarette or cannabis smoking is a major risk factor for pneumothorax
increasing the risk by factor of 22 in men & 9 in women
5/29/2023 16
17. Cont..
• The mechanism is unclear ; a smoking induced influx of inflammatory
cells may both break down elastic lung fibers (causing bulla formation
) & cause small airway obstruction (increasing alveolar pressure & the
likelihood of interstitial air leak)
• More common in patient with Marfans syndrome & homocystinuria
• May rarely be farmilial
5/29/2023 17
18. PATHOPHYSIOLOGY
• As air enters the pleural space which normally have a negative
pressure , the elastic recoil in the lung tissue causing either a partial
or full lung collapse.
NORMAL PHYSIOLOGY
• Pleural space has a negative pressure
• Chest wall expand ►surface tension between parietal & visceral
pleural expands the lungs.
• Lung tissue has an elastic recoil► innate tendency to collapse inward.
5/29/2023 18
19. Traumatic pneumothorax
• Closed pneumothorax : blunt trauma →lung damage →air flow from
the lung into the pleural spaces.
• Open pneumothorax : penetrating trauma to the chest wall→
pathway for air directly into pleural spaces.
• Close & open pneumothorax : In closed pneumothorax air travel in &
out of the pleural spaces from the lungs .
• However in an open pneumothorax a defect in the chest wall allows
air to move in & out of the pleural spaces.
5/29/2023 19
21. Iatrogenic pneumothorax
• Induced in a patient by the treatment or comment of a physician
• Lung surgery
• Central venous catheter insertion
• Thoracentesis -removal of fluid around the lung
• Mechanical ventilation
• Esophageal procedure
5/29/2023 21
22. Spontaneous pneumothorax
• Ruptured bleb→ air flow from the lungs into the pleural spaces→ positive pleural
pressure→ compressed lung.
• Lung collapse until an equilibrium is achieved or the rupture seals
• Vital capacity & ↓ partial pressure of oxygen
• Primary/idiopathic
Rapture apical subpleural bleb or bullae
• Secondary
• Chronic obstruction-COPD account for 50%
5/29/2023 22
24. Tension pneumothorax
• Life threatening & can develop from any type of a pneumothorax.
• Air enters the pleural space through a one way mechanism →air
cannot escape.
• Air accumulate in the pleural space with each inspiratory phase→ ↑
pleural space pressure → shifting of mediastinum→ compression of
the contralateral lung → hypoxia.
• Eventually compress of the vena cava & atria →↓ venous return to
the heart & ↓ cardiac function .
• Leads to rapid cardiopulmonary collapse.
5/29/2023 24
26. Cont..
• Tension pneumothorax:
• Spontaneous & traumatic pneumothorax can develop into a tension
pneumothorax if the defect that allow air into the pleural space
becomes one way valve (air enters during inspiration but cannot
escape during exhalation which causes rising pressure in the pleural
cavity , shifting the mediastinum to the contralateral side
5/29/2023 26
27. Cont..
• Simple
• Mediastinum remains central
• Clinical condition stable
• Can wait for CXR to confirm diagnosis
• Tension
• Progressive build up of air in the pleural space, causing a shift of the heart and mediastinal structures
away from side of pneumothorax
• Clinical condition unstable
• Do not wait for CXR to confirm diagnosis
5/29/2023 27
30. RISK FACTORS/CAUSES
• Sex-men are at high risk
• Smoking
• Age
• Genetics
• Lung disease
• Mechanical ventilation
• History of pneumothorax
5/29/2023 30
31. CLINICAL PRESENTATION
• Shortness of breath of varying degree depending on the size of the
pneumothorax & patients factors e.g. lung disease.
• Sudden onset chest pain, often pleuritic in nature , small
spontaneous pneumothorax can be asymptomatic particularly in
younger patients.
• O/E there will be:
Hyperresonance on percussion
Reduced or absent breath sound on auscultation
Reduced chest expansion
Decrease in tactile fremitus
5/29/2023 31
32. Cont..
• In cases of tension pneumothorax:
Patients will be hypoxic
Tachycardiac
Hypotensive
Potential distended neck vein
Tracheal deviation away from the affected side
Cyanosis
Tachypnea-abnormal rapid breathing
• Cardiovascular-jugular venous distension
-Pulsus paradoxus-↓ stroke volume
5/29/2023 32
34. INVESTIGATION
• Initial investigation should run alongside this(expect for cases of
tension pneumothorax when urgent needle decompression is
required in 2 or 3rd ICS
• Tension pneumothorax is a clinical diagnosis & management should
not wait for imaging confirmation
1 Plain chest radiograph(CXR)
• The size of pneumothorax is determined by measuring interpleural
distance at the level of hilum.
• Should be performed in upright position (when possible)
5/29/2023 34
35. Cont..
General findings
• White visceral pleural lining defining lung & pleural air
• Bronchovascular markings are not visible beyond pleural edge
• Deep sulcus
• Ipsilateral hemidiaphragm elevation
Tension pneumothorax
• Potential mediastinum shift
• Trachea deviation
• Ipsilateral hemidiaphragm flattening
• Ribs are spread a part
5/29/2023 35
36. Cont..
2 Routine blood –FBC
-CPR
-U & Es & clotting
• Arterial blood gas (ABG)
• Electrocardiogram (ECG)
3 CT imaging
• determine underlying cause in context of trauma & concurrent injuries
• Findings –air in the space , can evaluate the location , pleural pathology &
lung disease
5/29/2023 36
38. Cont..
4 Ultrasound
• Presence of a lung point –boundary between the lung &
pneumothorax
• Lung sliding will be absent at the location of pneumothorax
5/29/2023 38
39. MANAGEMENT
• Management is determined by both size or type of the
pneumothorax & patient factor.
• As a minimal ensure all patient have sufficient analgesia & started on
oxygen if required.
• For patient with chest drain inserted ensure it is attached to
underwater seal.
INITIAL MANAGEMENT
• Primary spontaneous pneumothorax those that are small (<2) &
asymptomatic patients should be admitted for observation.
5/29/2023 39
40. Cont..
• Symptomatic or large primary pneumothoraces needle
decompression should be attempted placed in 2nd or 3rd intercostal
spaces at the midclavicular line if no improvement chest drain via
seldinger technique to be placed
• 5th ICS space in the anterior or midaxillary line in SAFTEY TRIAGE is
another option-followed by chest tube placement.
• Small spontaneous pneumothorax will required admission for
observation with a low threshold for attempting needle
decompression ,
• Those that are large & symptomatic required chest drain via
seldinger technique to be placed.
5/29/2023 40
41. Cont..
• Traumatic pneumothoraces will normally require surgical chest drain
insertion or otherwise admitting for observation if small &
asymptomatic.
• Importantly there is no role in needle decompression in traumatic
non-tensioning pneumothoraces.
• For traumatic tension pneumothoraces either needle decompression
(in 5th intercostal space mix-axillary line) or finger thoracostomy is
required prior to chest drain insertion.
5/29/2023 41
42. Cont..
FURTHER INVESTIGATION
• Considered in those with persistence air leak or failure of lung re-
expansion.
• Spontaneous cases medical pleurodesis is often trailed resulting in partial
obliteration of the pleural space through introducing irritant agent aiming
to prevent recurrences ,alternatively Heimlich valve can be trailed a one
way valve attached to a chest tube & enable evacuation of air that is not
under tension.
• Those failing these intervention or in traumatic cases should ne considered
surgical intervention which includes video assisted thoracoscopic surgery
(VATS) for pleurectomy +/- pleural abrasion or open thoracostomy&
pleurectomy .
5/29/2023 42
43. COMPLICATIONS
• Hypoxemic respiratory failure-low level of oxygen
• Respiratory or cardiac arrest-heart suddenly stop pumping blood
• Hemopneumothorax-combination of pneumothorax & hemothorax.
• Bronchopulmonary fistula-abnormal communication btwn bronchial tree &
pleural cavity
• Pulmonary edema –following lung re-expansion
• Empyema-collection of pus in the pleural cavity
• Pneumomediastinum-presence of air in mediastinum
• Pneumopericardium-presence of air in pericardium
• Pneumoperitoneum-presence of air in peritoneal cavity
• Pyopneumothorax-accumulation of gas & pus in pleural cavity
5/29/2023 43
44. Cont..
COMPLICATIONS OF SURGICAL PROCEDURE
• Failure to cure the problem
• Acute respiratory distress or failure
• Infection of the pleural spaces
• Cutaneous or systemic infection
• Persistent air leak
• Re-expansion pulmonary
• Pain at the site of chest tube insertion
• Prolonged tube drainage & hospital stay
5/29/2023 44
46. R
•Right lung more translucent than left
•Faint line just visible (zoomed view to follow)
5/29/2023 46
47. •Pencil-thin white line
running parallel to chest
wall
•No lung markings lateral
to the line
Blade of right scapula
Right pneumothorax
5/29/2023 47
49. Simple Left Pneumothorax
No mediastinal shift
Small pleural
effusion
(common
finding)
Visceral
pleural line
(zoomed
view on next
slide)
5/29/2023 49
54. HEMOTHORAX
• Hemothorax is the accumulation of blood in the intrapleural spaces.
• Bleeding is usually from intercostal artery in lacerated chest wall or
from underlying contused lung, heart or great vessel.
• Massive hemothorax is bleeding of more than 1500ml into pleural
cavity
5/29/2023 54
55. EPIDEMIOLOGY
• Hemothorax can be associated with a single rib fracture.
• Approximately 150,000 deaths occurs from trauma each year.
• Approximately 3times this number of individuals are permanently
disabled because of trauma.
• Chest injuries occurs in approximately 60% of multiple trauma cases.
5/29/2023 55
56. PATHOPHYSIOLOGY
• Accumulation of blood in the pleural space caused by bleeding from;
penetration or blunt lung injury, chest wall vessels or intercostal
vessels.
• Hemothorax is manifested by;
• >hemodynamic response-hypovolemic shock rapid bleeding.
• >respiratory response-slow bleeding.
• Blood that enters the pleural cavity is exposed to the motion of the
diaphragm, the lungs, and other intrathoracic structures.
5/29/2023 56
57. CLASSIFICATIONS
TRAUMATIC HEMOTHORAX
• Occurs due to penetration injury of the lungs, heart, great vessels, or chest wall
non Traumatic hemothorax
• Malignancy pleural diseases(sarcoma, angiosarcoma)
• Bleeding disorders(hemophilia, thrombocytopenia, rupture of thoracic aorta)
• Necrotizing infection
• Pulmonary embolism with infarction
Iatrogenic hemothorax
• Causes;
Central venous catheterization
5/29/2023 57
58. Cont..
• Injury during trans lumber aortography
• Thoracocentesis
• Pleural biopsy
• Trans brachial biopsy
5/29/2023 58
62. management
• ABC of resuscitation
• Large bow cannular &begin IV fluids-crystolliods
• Vital check up including SPO2
• Intercostal drainage tube thoracostomy
• Large bore tube in 5th spacing between mid and posterior axillary lines
• Can be done before x-ray
• Draining of blood from chest cavity
• Thoracostomy(indicated when total chest tube output exceeds 1500ml within
24hrs)
• Video assisted thoracoscopic surgery(VATS)
• Shock care due to blood loss
5/29/2023 62
66. SURGICAL EMPHYSEMA/
SUBCUTANEOUS
DEFINITION
• Infiltration of air in the subcutaneous layer of the skin
ETIOLOGY
• It can result from:
• surgical
• traumatic infection or spontaneous etiologies
• rapture esophagus
• lung injury
• tracheal injury
5/29/2023 66
67. EPIDEMIOLOGY
• Incidence is worldwide
• Woman in labor i.e. 2nd stage can experience subcutaneous
emphysema from pushing which can increase intrathoracic pressure
PATHOPHYSIOLOGY
• Injury to the parietal pleural that allows for the passage of air into the
parietal & subcutaneous tissue
• Air from the alveolus spreading into the endothelial sheath & lung
hilum into the endothelial fascia
• Air in the mediastinum spreading into the cervical visceral & other
connected tissue
5/29/2023 67
68. Cont..
• Air originating from external sources
• Gas generation locally by infection especially necrotizing infection
TYPES
• Localized –trauma
• Extensive -extensive in neck ,face ,eyelid & scrotum
CLINICAL FEATURES
• Pain
• Swelling of subcutaneous region
• Palpable crepitus
• Painless & small nodule feel bubble
5/29/2023 68
69. COMPLICATIONS
• Cardiac arrest
• Dysphagia
• Respiratory failure
• Tension pneumothorax
• N/B – It requires a breach of an air containing viscus in
communication with soft tissue & the generation of positive pressure
to push air a long tissue planes
• Is the hallmark of Fournier's gangrene
5/29/2023 69
70. CAUSES
• Trauma during surgery
• Injury to esophagus during insertion of feeding tube
• Infections –bacteria
• Bowel perforation
INVESTIGATION
• Radiography (x-ray) of chest & neck
• CT
• Both will show dark pocket in the subcutaneous layer indicating of
gas.
5/29/2023 70
71. TREATMENT & MANAGEMENT
• Treatment of the underlying cause of precipitating factor
• Mild cases –observation is appropriate
• Patient with discomfort –give high oxygen concertation
• Use of empiric broad spectrum antibiotic
• Extensive phase -2cm intravascular incision bilaterally can reduce
further subcutaneous expansion
• In severe cases ICT on one side or both sides placement
5/29/2023 71
76. 5 CARDIAC TEMPONADE
• Compression of the heart caused by fluid collecting in the
pericardium e.g. bleeding in the pericardial cavity.
• Cardiac tamponade puts pressure in the heart & keeps it from filling
properly with resulting dramatic drop in blood pressure that can be
fatal.
5/29/2023 76
77. PATHOPHYSIOLOGY
• The pericardium space normally contain 20-50ml of fluid
• Increase in this amount causes the accumulation of pericardial fluid
which impairs relaxation & filling of the ventricles, requiring a higher
filling pressure.
• With further fluid accumulation the pericardial pressure increases
above the ventricular filling pressure ,resulting in reduced cardiac
output.
• A further decrease in cardiac output occur which result to the
equilibration of pericardial & left ventricle filling pressure
5/29/2023 77
78. Cont..
• The underlying process for the development of tamponade is a
marked reduction in diastolic filling , which result when transmural
distending pressure becomes insufficient to overcome increased
intrapericardial pressure
• Tachycardia is the initial cardiac response to these changes to
maintain the cardiac output
• Because the heart is compressed throughout the cardiac cycle due to
increased intrapericardial pressure ,systemic return is impaired &
right atrial & right ventricle collapse occur
5/29/2023 78
82. CLINICAL FEATURES /SIGNS
• Hypotension/shock(rapid weak pulse)
• Grossly distended neck vein (raised JVP)
• Elevated central venous pressure
• Severe distress
• faint heart sound
• Penetrating injury in the proximity to the heart
• The classic findings /a hallmark signs of beck triad 1Hypotension
• 2 Distended neck vein
• 3 Faint heart sound
5/29/2023 82
83. BECKS TRAID
• Collection of three clinical signs associated with pericardial
tamponade which is due to excessive accumulation of fluid within
the pericardial sac
5/29/2023 83
84. SYMPTOMS
1 Sharp pain in the chest –pain may radiate to the nearby parts of the body
like abdomen ,arm ,neck & shoulder
2 trouble breathing /breathing rapidly
3 fainting ,dizziness/light headache
4 changes in skin color
5 heart palpitation
6 fast pulse
7 Altered mental status /confusion
8 decreased urine output
5/29/2023 84
86. MANAGEMENT
• Removal of the fluid around the heart
• Its done through pericardiocentesis –the procedure use a needle that
is inserted into the chest until in enters the pericardial sac & the fluid
is aspirated
• Surgery
5/29/2023 86
87. COMPLICATION
• Shock
• Heart failure
• Death
PERICARDIOCENTESIS & SURGERY COMPLICATION
• Bleeding
• Injury to the heart chambers
• Heart attack
• Infections
• Injury to nearby organs
5/29/2023 87
91. INTRODUCTION
• Chest injuries is defined as a form of injury to the chest including the ribs, heart, lung
and great vessels trachea and esophagus
• Chest injuries are potentially life threatening because of immediate disturbances of
cardiorespiratory physiology and hemorrhage and later development of infections,
damaged lung and thoracic cage
Traumatic injuries to the chest contribute to 75% of all traumatic deaths
• Thoracic injuries range from simple rib fractures to complex life threatening rapture
of organ
• The mechanism of injuries causing chest trauma are dived into two:
• Blunt trauma and penetrating trauma
INCIDENCE
• 25% of all death form traumatic injury
92. CAUSES OF CHEST INJURY
Blunt injury cause e.g. motor vehicle accident, pedestrian accident, fall,
sports injury, assault with blunt object or altercations, crush injury and
explosion injury
Penetrating injury causes: knife, gun short, stick, arrow and occupational
injury
94. RIB FRACTURE
• DEFINITION: a complete or incomplete fracture of any of the 12 ribs
on either side
• Most are accompanied by sprain or rupture of muscles, tendons or
ligaments between ribs
• Ribs 4-9 are most commonly broken due to blows because they are
less protected
95. PATHOPHYSIOLOGY
• This morbidity and mortality associated with rib fracture is caused by
three main problems:
• Hypoventilation due to pain
• Impaired gas exchange in damaged lung underlying the fractures
• Altered breathing mechanism
RISK FACTORS
1. Osteoporosis
2. Sport participation
3. Cancerous lesion in a rib
4. Poor nutrition
5. History of bone and joint disease
96. CAUSES RIB FRACTURE
1. Direct blow to the chest from blunt a object
2. Trauma to the chest
3. Hard coughing or sneezing
4. Compression to the chest
5. Repetitive trauma
6. CPR
7. A fall for elderly
97. CLINICAL PRESENTATION
• Severe pain at the fracture site
• Tenderness to the touch
• A feeling that the “ wind has being knocked out”
• Abdominal pain if the fractured side are below the diaphragm
• Severe chest pain when coughing, sneezing or breathing deeply
• A feeling of small air pockets under the skin of the chest or neck if
the lung has been injured and leaked air
• Swelling and bruising over the fracture site
• Shallow breathing
98.
99. DIAGNOSTIC EVALUATION
• History taking
• Physical examination; while doing physical examination assess for-
cyanosis, tenderness on the fracture site
INVESTIGATIONS
• Chest-x ray
• CT scan
• MRI
• ABGs
100. MANAGEMENT
• Give analgesic (usually non opioids) to assist ineffective coughing and
deep breathing
• To decrease pain when you cough hold a small pillow or folded towel
over the site and press firmly
• Avoid strenuous activities
• Do not where a rib belt or binder
• Eat normal well balanced high fiber diet
• Avoid constipation
• Take deep breaths several times a day
102. FLAIL CHEST
• The breaking of two or more ribs in two or more places resulting in
free floating rib segment
• When this occurs one portion of the chest has lost its bony
connection to the rest of rib cage
PATHOPHYSIOLOGY
• During respiration the detached part of the chest will be pulled in on
respiration and blown out on expiration (paradoxical movement)
leading to hypoventilation and hypoxemia
112. ANALGESIA
opioid analgesics(risk of respiratory depression)
NSAIDs
Thoracic or high lumbar Epidurals with or without opioid derivatives
INTUBATION & VENTILATION
Rarely indicated
indicated for hypoxia due to pulmonary contusions
Double lumen tracheal tube,Each lumen connected to a different
ventilator where each lung may require different pressures and flows to
adequately ventilate
113. CHEST TUBE INSERTION
To treat hemothorax
To treat pneumothorax
PHYSIOTHERAPY
To aid better drainage of secretions
To rebuild musculature
To reposition chest wall
Coughing exercises
Resistance exercises
Trunk exercises
114. REHABILITATION
12 week outpatient program for at least 3 days a week
Patient should be seen for 30-45 mins a day after a 5-10 minute warm
up session
After a discharge , patient should be given an exercise regimen to be
performed at home
118. DEFINITIONS
• also known as pyothorax or purulent pleuritis.
• it is the accumulations of pus in the pleural cavity.
• it is not a primary disease, it is secondary to other
underlying disease.
• it is complication to other diseases
5/29/2023 118
123. Risk factors
• alcoholism
• smoking
• HIV infections
• neoplasm
• pre existence pulmonary disease
5/29/2023 123
124. Pathopysiology
• presence of parapneumonic effusion
• release of inflammatory mediators
• increases permiability of the capilaries
• attracts WBCs to the site ,escape of albumin and other
protein from capillaries
• increase pleural fluid
• presences of free flowing protein rich pleural fluid
(stage 1)
• inflammation worsen
• attracts more wbcs to the site
5/29/2023 124
125. PATHOPHYSIOLOGY ….
• extensive purulent exudate production
• initiation of fibrinoblastic activity (stage 2)
• adherance of the two pleural membranes (stage 3)
• formation of the peel.
5/29/2023 125
126. Stages of empyema formation
• Development of empyema passes through 3 stage;
• stage 1 (exudatives stage)
• stage 2 Fibrino purulent stage
• Stage 3 organising stage
5/29/2023 126
127. • Stage 1; exudative (early) stage
• this is purely an inflammatory process in which there is increase in
permeability of small blood vessels leading to exudation of fluid in
the pleural cavity.
• The fluid is very thin with low cellular content and underlying lungs
that re-epands easily.
5/29/2023 127
128. • stage 2; fibrino purulent
• stage is characterized by;
• large number of polymorphonuclear leucocytosis.
• deposition of fibrin on both visceral and parietal surfaces of the
involved pleura.
• bacteria invasion of the pleural space.
• tendency towards loculation formation.
5/29/2023 128
129. Classifications
• Anatomical classifications
• total thoracic empyema-the whole pleural cavity is involved.
• Localised or encysted thoracic empyema- only part of the thoracic
cavity is involved.
5/29/2023 129
130. Clinical classifications
• acute- pt presents with high grade fever, cough with pleuritic chest
pain and shallow breath.
• sub acute thoracic empyema- this is less severe form in patient who
was on antibiotics for pneumonia.
• chronic thoracic empyema- this resuits from mismanagement of the
acute form.
5/29/2023 130
133. Investigations
• lab studies
• hb levels
• wbc count + ESR
• ELISA test for HIV
• bacteriological investigations
• sputum for AFB
• Sputum for c/s
• pus for c/s
5/29/2023 133
134. IMAGING INVESTIGATIONS
• Chest ray
• abdominal USS to rule out hepatic abcess
• CT scan –differentiates empyema ,lung abcess & subdiaphragmatic
fluids
• Diagnostic procedure –aspiration of pus to confirm empyema.
5/29/2023 134
136. MANAGEMENT AND TREATMENT OF
EMPYEMA
• Objectives of treatment;
to control primary infections bu appropriate medications
evacuations of purulent contents of empyema sac and eradications to
control chronicity.
to prevent complications
5/29/2023 136
137. Modalities of treatments
• Depends on the stage of empyema
• divided into;
• Non surgical therapy- Antibiotics cefuroime 150mg/kg/day-3 doses,
clindamycin 25-40 mg/kg/day (3 doses)
• Needle aspiration (Thoracocentesis)
5/29/2023 137
139. Needle aspiration(thoracocentesis)
• both diagnostic and therapeutic , adequate only in eudate stage
Closed Chest Drainage(UWSD) –this is done if the fluid (pus) in the pleural sac is thick to
be evacuated by simple needle aspiration
5/29/2023 139
141. Open chest drainage(rib resection)
• 2-3 ribs are resected to allow evacuation of pus ,
break up loculations , wash the cavity and pus
(UWSD) to prevent re-accumulations
• done if the pus is too thicker to be evacuated by
UWSD
Decortication- in this case thoracostomy is done and
peel out the cortival layer over the parietal & visceral
surfaces.
5/29/2023 141
142. THORACOPLASTY
• Ribs are taken away to compress the chest .
• NB-Due to high mortality and morbidity, the
procedure has been ABANDONED
5/29/2023 142
145. Definition
• Is the abnormal growth of cells which tend to proliferate in an
uncontrolled way and in some cases metastize (spread).
• Cancer is a group of more than 100 different and distinctive diseases.
5/29/2023 145
146. Epidemiology and incidence
• Overall, the chances that a man will develop lung cancer in his
lifetime is about 1 in 15;for a woman is 1 in 17.The numbers include
both people who smoke and who don’t.
• According to WHO data published in 2018,lung ca deaths in Kenya
reached 481or 0.19%of total deaths.
• The age adjust death rate is 2.67 per 100000 of population ranks
kenya#152 in the world.
5/29/2023 146
147. Classification
1 Benign tumors:
papilloma
fibroma
chondroma
2 Locally malignant tumors:
bronchial carcinoid.
3 Malignant tumors:
1. Primary: bronchogenic carcinoma, lymphoma, sarcoma.
2. Secondary: small cell lung cancer and non small lung cancer.
5/29/2023 147
148. Small cell lung cancer (sclc)20-25% of all lung
cancer
• It starts in the bronchi then affect the whole lung.
• They metastases to other body parts(brain, liver, bone marrow).
5/29/2023 148
149. Non-small cell lung cancer (NSCLC)
• Most common-80-85%
• Is any type of epithelial ca other than SCLC.
• Spreads more slowly than SCLC.
1. Squamous cell carcinoma:arise centrally in larger bronchi.
2. Adenocarcinoma:formed from mucus secreting glands in the
periphery of the lungs.
3. Large cell carcinoma:occur in any part of the lung and tend to grow
spread faster than squamous cell carcinoma and adenocarcinoma.
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150. Squamous cell carcinoma
• Moderate to poor differentiation.
• Makes up 30-40% of all lung
cancer.
• More common in males.
• Most occur centrally in the large
bronchi.
• Uncommon metastasis that is slow
affects the liver,adrenal glands and
lymph nodes.
• Associated with smoking.
• Not easily visualized on x-ray.
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151. Adenocarcinoma
• Increasing in frequency.Most
common type of lung cancer (40-
50% of all lung cancers)
• Clearly defined peripheral lesions.
• Glandular appearance under a
microscope.
• Easily seen on a CXR.
• Can occur in non-smokers.
• Slow metastatic in nature.
• Patients present with or develop
brain,liver,adrenal or bone
metastasis.
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152. Large cell carcinoma
• Makes up 15-20% of all lung cancers.
• Poorly differentiate cells.
• Tends to occur in the outer part(periphery) of lung,invading sub-
segmental bronchi or larger airways.
• Metastasis is slow but early metastasis occur to the kidney,liver and
adrenal glands.
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153. Causes and risk factors
• Gender
• Smoking: Active-85-87% and passive 3-5%.
• Older age.
• Presence of airflow obstruction.
• Genetic predisposition.
• Pollution and occupation exposure.
• Industry work due to asbestos (Heat resistant fibrous).
• Lung disease eg TB.
• Diet(low in fruits and vegetables).
• Exposure to asbestos
5/29/2023 153
154. Pathophysiology
• Carcinogens like smoke, occupation and environmental agents, genetics
• Binds with cell’s DNA and damage the cell
• Cellular changes and abnormal cell growth occur
• Malignant transformation of pulmonary epithelial cells
• Abnormal proliferation of lung cells.These cells grow slowly and covers the
segmental bronchi and lobes of the lung.
• Nonspecific inflammatory changes with hypersecretion of mucus,
desquamation of the cells.
• Lessions formation in the lung tissues involving the bronchi, bronchioles or
even alvoeli.
• Bronchogenic carcinoma.
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155. Signs and symptoms
1. Localized s/s-involving the lung.
2. Generalized s/s-involves other areas throughout the body where it
has spread.
• Early s/s
• Late s/s
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156. Localized S/S
• Cogh and fatigue
• Breathing problems,stridor
• Blood in phlegm
• Lung infection, haemoptysis
• Hoarseness, hiccups
• Weight loss
• Chest pain and tightness
• Pleural effusion
5/29/2023 156
157. Generalized-early/late s/s
Early s/s Late s/s
Cough/chronic cough
Dyspnoea
Hemoptysis
Chest/shoulder pain
Reccuring temperature
Reccuring resp. infections
Bone pain,spinal cord compression
Chest pain/tightness
Dysphagia
Head and neck edema
Blurred vision, headache
Weakness,anorexia,weight loss,cachexia
Pleural effusion
Liver metastasis/regional spread
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158. Diagnosis
• Hx of the patient
• CXR
• CT scan
• MRI
• Sputum cytology
• Bronchoscopy-view airway
• Thoracic fine needle aspiration
• Lab tests: blood tests-cbc,blood chemistry tests for liver and kidney
functions.
• Biopsy
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159. Cancer staging systems
• Most common staging system for lung cancer is the TNM system
developed by International Union Against Cancer(IUAC)
• Guides best course of treatment
• Estimates prognosis
• Only useful in staging NSCLC, when surgery is considered.
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160. TNM staging
• T-tumors: tumor size(local invasion)
• N-node: node involvement (size and type)
• M-Metastasis: general involvement in organs and tissue
Tumor size
Tx-tumor unknown or CA cells are only found in sputum
T0-present only in the cells lining the airway
T1-tumor size less than or equal to 3cm
T2-tumor size 4-7cm
T3-tumor size more than 7cm
T4-tumor that invade structures in the chest eg heart,major blood vessels near the heart, the trachea and
esophagus
n1
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161. Nodal involvement
N0-No nodes involved
N1-tumor has spread to the nearby nodes on the same side of the
body
N2-tumor has spread to the nodes farther away but on the same
side of chest.
N3-tumor has spread to the lymph nodes on the other side of the
chest from the original tumor or has spread to the nodes near the
collar bone or neck muscles.
Metastasis
Mo-tumor has not spread to distant regions.
M1-M1a:tumor has spread to the opposite lung, to the lung
linin
M1b:tumor has spread to distant regions of the body e.g., brain
or bones.
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162. Staging
• Stage 1-tumor is small and localized, no lymph node involvement
. A-tumor less than 3cm
B-tumor greater than 3cm and invading surrounding local area
• Stage2-A-tumor less than 3cm with invasion of lymph nodes
. B-tumor greater than 3cm involving the bronchus lymph nodes on
the same side of the chest and tissue of local organs
• Stage3-A-tumor spread to the nearby structure and regional lymph nodes
. B-tumor involving the heart,trachea, esophagus, mediastinum,and
lymph nodes.
• Stage4-distant metastasis.
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164. Surgical treatment
• Labectomy: single lobe of lung is removed
• Bilectomy:2 lobes of lung are removed (only on the right side)
• Sleeve resection: cancerous lobe is removed and segment of the main
main brochus is resected
• Pneumoectomy: removal of the entire lung
• Segmentectomy: segment of the lung is removed
• Wedge resection: removal of small,pie shaped area of the segment
• Chest wall resection with removal of the cancerous lung tissue.
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165. Radiation treatment and chemotherapy
Radiation
• Useful in controlling the neoplasm that cannot be surgically removed
• Used to reduce the size of the tumor
• May help to remove the symptoms like cough, chest pain, dyspnea and hemoptysis
Chemotherapy
Used to alter tumor growth and to treat the patient with metastasis
• NSCLC :2 drug regimen-cis/carbo playing + 1 other(taxol/taxotere/gemcitabine)
• SCLC:cisplatin/etoposide
Other drugs involved
Paclitaxel
Cyclophosphamide
Doxorubicin
vinblastin
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166. Side effects of treatments
Surgery Radiation Chemotherapy
Pain
Hemotomas
Hemorrhage
Altered resp.function
Risk of atelectasis,
pneumonia,hypoxia
Risk of DVT
Fatigue
Decreased nutritional intake
Radiodermatitis
Decreased hemopoeitic
functions
Risk of pneumonitis,
esophagitis,cough
Lung fibrosis
Grief
Anemia, thrombocytopenia
Fatigue
Alopecia
Cold pale skin
Tingling
Irritable
Dizziness, weakness
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167. Complimentary therapy
• Foods: green tea, garlic,fish oil, lactobacillus
• Mind-body:help to reduce anxiety, mood disturbance or chronic pain
in CA patients (audiotapes,videotapes, books, music, relaxation,yoga,
meditation)
• Acupuncture
• Hypnosis
• Massage therapy
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170. Breast carcinoma is the commonest cause of cancer death in
women.
It accounts for 6% of all female deaths
171.
172.
173.
174. Other risk factors
1)Early menarche
2)Family history of breast ca, GIT or Ovarian cancer.
3)Benign breast disease with hyperplasia and atypia,
benign breast disease with multiple papillomas.
4)Breast cancer in the contralateral breast
5)Oral combined contraceptives.
6)Hormonal replacement therapy.
7)Whether breastfed and length of breastfeeding.
8)Exposure to radiation, occupational or therapeutic.
>>Diet.
184. palpation
Start from the normal side.
Quadrant by quadrant.
Squeeze nipple for any discharge.
185. Lymph nodes exam
Examine the tail of the breast
Axillary lymph nodes; apical,lateral,posterior and
anterior, medial
Supraclavicular,infraclavicular, and axillary
lymphadenopathy can be suggestive of advanced
disease
Characteristics suggestive of malignancy include,
skin involvement, fixation to the chest wall, irregular
border, firmness, and enlargement.
186. Other systems to be examined
Respiratory
Abdominal
Musculoskeletal
187. Differential diagnosis
Giant fibroadenoma, fibrosarcoma
Deep breast mycosis
Chronic breast abscess e.g TB
Secondary malignancies to the breast; melanoma,
lungs
Cystsarcoma phylloides
198. Staging
TNM staging TUMOR SIZE
TX-Primary tumour cannot be assessed
T0 -No evidence of primary tumour
Tis- Carcinoma in situ
T1- Tumour <2 cm in greatest dimension
T2- Tumour > 2 cm but< 5 cm
T3- Tumour > 5 cm
T4- Tumour of any size with direct extension to chest
wall or skin(including inflammatory carcinoma)
199. LYMPH NODE INVOLVEMENT
Nx- Regional lymph nodes cannot be assessed.
N0- No regional node metastases.
N1- Metastases to ipsilateral axillary lymph nodes
withOUT fixation.
N2- Metastases to ipsilateral axillary lymph nodes
with fixation.
N3- Metastases to ipsilateral supraclavicular or
internal mammary lymph node.
200. METASTASIS
MX- Cannot be assessed.
M0- No metastases.
M1- Distant metastases including ipsilateral
supraclavicular lymph nodes.
201. Manchester staging
Stage 1- tumour confined to the breast.
Stage 2- tumour confined to breast, palpable, mobile
axillary nodes.
Stage 3- tumour extends beyond the breast tissue
because of skin fixation in an area greater than the
size of the tumour or because of ulceration.
Tumour fixed to underlying fascia.
Stage 4- Distant metastases.
213. Prevention of breast cancer
Breast self-examination.
Annual evaluation with mammography.
Removal of breast lumps.
Tamoxifen for those at high risk.
Lifestyle modification- alcohol, sedentary lifestyle.
Prophylactic mastectomy in those at higher risk.
214. Prognostic factors
Chronological prognostic factors include:
-Age; younger women have poorer prognosis.
-Tumour size; diameter of tumour correlates directly
with survival.
- Lymph node status; direct correlation between
number and level of nodes and survival.
-Metastases; distant metastases have worse prognosis.
215. Mastectomy
Indications:
1. Congenital supernumerary breast.
2. Extensive destruction of breast archtecture
due to chronic infections(TB,Fungi),
Sarcoidosis, severe trauma.
3. Tumours.
a) Early breast cancer(carcinoma in- situ).
b) Large tumours in relation to the size of the
breast.
c)Central tumours beneath the nipple.
216. Indications for mastectomy
d) Multifocal disease.
e) Local recurrence after breast conserving
surgery
f) Palliative( toilet mastectomy).
g) Prophylaxis where there is a strong family
history.
h) Patient preference.
Editor's Notes
Early menarche
Family history of breast ca, GIT or Ovarian cancer.
Benign breast disease with hyperplasia and atypia, benign breast disease with multiple papillomas.
Breast cancer in the contralateral breast
