Spontaneous pneumothorax

• The spontaneous presence of air in the thoracic space

• primary. The only abnormality is superficial blebs at the apex of one or

more lobes, typically the upper lobes, which either leak spontaneously or
are triggered by an otherwise unremarkable event such as exertion. It is
more common in males, occurs predominantly in the ‘teens or twenties,
thin &long individual, may be bilateral and may be familial.

• secondary. Any lung disease that breaches the pleura may cause a
pneumothorax so probably every possible lung disease will, at one time or
another, cause a pneumothorax. The most common causes are
obstructive airways disease in any form like asthma and bullous
emphysema,TB
• Symptoms include chest pain, cough, and dyspnea and range from mild to
severe.
• Diagnosis is made by physical examination and chest radiograph.
• Treatment
– chest tube drainage of the pleural space
– Bedside pleurodesis. Doxycycline, bleomycin, and talc have all been
described..
– Indications for surgery i.e thoracotomy
• Recurrent pneumothorax (ipsilateral or contralateral)
• Persistent air leak for 3-5 days
• Incomplete lung expansion
• Hemopneumothorax
• Procedure is stapling of apical blebs and pleural abrasion. This is
an excellent indication for videothoracoscopy and repair.
SUPPURATIVE LUNG INFECTION
 EMPYEMA THORASIS
Defn. Collection of pus in the pleural cavity.
Aetiology
 2/3 From spread of infection in contagious organs.
 Lung ( pneumonia, lung abscess )
 Esophagus (perforation, post-oesophagectomy)
 Spine & ribs ( osteomyelities )
 Sub diaphragmatic vesera (subphrenic & paracolic abscess
 1/3 Result from direct inoculation of
pleural space by penetrating injury
-Iatrogenic infections ( chest drain)
-Percutanous biopsies.
-Thoracic surgery (post op. infection)
 Infecting organism reflect the aetiology.
 Following pulmonary infection often grow staph. Aureus or streptoccus
millari.
 From oesophageal perforation or subdiaphragmatic infection
Anaerobes & gm –ve bacilli.
 ~50% of empyema  polymicrobial.
 Children < 2 yrs S.pneumoniae & S. aureus.
 Pts with DM At risk of K. Pneumoniae.
 Parpneumonic empyema Is the presence grossely purulent effusion or in
which-Gram stain is +ve.
-WBC > 15,000 cells/mm3
-Protein levels > 3g/dl
-PH <7.0
-Pleural fluid glucose < 50mg/dL
-LDH >1000 Iu/L
Can be presented in association with lung abscess & bonchiectasis.
 Clinical Feature
• Empyema from aerobic organisms
-Chest pain, fever, cough, tightness in the chest & occasionally SOB.
• In pt with anaerobic infections
Course  more insidious & chronic
Wt loss & anemia may be more common
Failure of response or even worsening.
Sudden expectoration of a large amount of purulent sputum Bronchopleural fistula
Physical finding
 Decreased breath sounds.
 Restricted respiratory excursion.
 Dullness over the involved area.
 Limited movement of affected hemithorax.
 Clubbing of finger.
A chest wall abscess An empyema necessitants.
Late in the course of the disease
-Pericarditis, mediastinal abscess, disseminated infection & multi organ failure.
 I.LABORATORY
–Leukocytosis
--Elevation of ESR & C – reactive proteins.
II. Radiology – pleural based opacity
-PA & Lateral CXR reveal most empyema
-Multiple air fluid level bronchopleural fistula.
III. CT scan
Define the extent.
Differentiate b/n a pleural fluid containing air & lung abscess.
Demonstrate loculated pockets.
IV.U/S
Image early adhesion
Linear irregular honeycomb-like adhesions.
• Principles of management
Management
Objective Options
Treatment of underlying -Antibiotics
cause
Complete drainage of -Thoracocentesis
empyema -Ribe resection
-Intercostal drain -Thoracoscopy

Obliteration of pleural -Intercostal drain

space -Thoracoscopy/ Decorticatin
-Thoracotomy/ Decorticatin
-Thoracoplasty -Pedicle muscle flap
 Bronchiectasis
Defn.
- Abnormal & permanent dilation of bronchi.
Aetiology
1.Mechnical obstruction -Intrinsic (FB, Tumor, mucus impaction)
-Extrinsic LN compression.
2.Post infection/inflammatory: Bacterial pneumonia, TB, Aspiration, inhalation of
irritant.
3. Allergic -Bronchopulmonary aspergilosis, lung transplantation.
4.Mucociliary abnormality -Cystic fibrosis, primary ciliary dyskinesia.
5. Immune deficiency -Panhypogammaglobinemia, selective Ig deficiency
(Ig A, Ig M )
6 . Miscellaneous ( sarcoidesis, RA, & UC )
• Pathophysiology
An infectious insult, impairment of drainage & air way
obstruction
-Thickening of mucosa followed by ulceration, inflammation
&fibrosisBronchiolitis oblitrans  Atlectasis
damage to the muscle & elastic component Br. Wall
diffuse peribronchial fibrosis
 abnormal Br. Wall Dilatation
 Impaired clearance of secretion
 colonization &infection of Br. Tree further bronchial
damage
Normal Resp. epithelium squamous metaplasia.
• The classic manifestation
Cough with daily production sputum of
mucopurulent or tenacious sputum lasting for
months to yrs.(3/4 of pts )
• Less specific SMS
-Dysnea, wheezing, & pleuritic chest pain.
-Recurrent “bronchitis” requiring antibiotics.
-Past Hx of repeated RTI (1/3 )
-Hemoptysis  usu. minor
P/E  Audible rals over the involved lung .
marked clubbing & cyanosis
A. Laboratory Tests.
-CBC
-Immunoglobulin quantitative- IgG,IgM,IgA
-Sputum culture & smear for bacteria, mycobacterium & fungi.
B. CXR Mild case Normal.
-Abnormal but non diagnostic in 90%
Common finding
-Increased lung marking
- linear atlectasis
-Dilated & thickened airways (tram or parallel line)
-Air fluid level or cystic spaces
-Pleural Rxn & displaced fissure advanced disease
C. CT
D. Bronchogram using contrast
E. Bronchoscopy
F. Pulmonary function test.
 Treatment
Medical -Main stay of Rx & adequate for most pts.
-Rx . of infection (acute exacerbation & prevent recurrent infection)
-Frequently isolated bacteria H. influenza, P.aruginosa, s.pneumonie)
-Expectorant & bronchodilator
-Physiotherapy & postural drainage.

Surgical treatment.
Indication -Pts who have
-Significant symptoms despite prolonged medical treatment.
- Recurring episode of major pneumonitis.
-Recurrent major hemoptysis
 Lobectomy / pneumonectomy
Rigid bronchoscopy –Tamponad Using fogarty catheter.
-suction & lavage .
 LUNG ABCSESS

Defn. Is a localized area of suppuration & cavitation in

the lung (>2cm.)
-Abscess stays > 6 months Chronic.
 In community acquired pneumonia
-predominant organism  gm +ve
 In hospital acquired pneumonia
- 60- 70% are gm –ve
 In immunosuppressed pts
The usual pathogen + less virulent & opportunistic organism
-salmonella spp. -PCP
-Legionella spp. -Atypical mycobacterium .
 In aspiration pneumonia
 Typically polymicrobial
50% purely anaerobic
25% Mixed
25%  aerobic organism.
 Diagnosis
The typical presentation
-Productive cough, fever ( >38.9o)
-Chills, Wt loss, fatigue, pleuritic chest pain, dyspnea &
leukocytosos ( >15,000 cell/mm3)
Pt may present with indolent course (wks-months)
-cough, malaise, wt loss, low grade fever, night sweats,
leukocytosis & anemia
After aspiration pneumonia
-40 - 75% of pts produce putrid, foully-smelling sputum
Sever complication
-Massive hemoptysis
-Septic shock
-Endobronchial spread
-“empyema necessistants”
-Pyopneumothorax
 Diagnosis
A. Sputum examination
-Gram stain & culture for gm +ve & gm -ve
-Special staining for AFB & fungi
. Helpful exclude aerobic bacteria & TB
B. Empyema fluid examination.
C. Blood culture  may be +ve ( in metastatic lung abscess )
D. CXR 1o tool for diagnosis
-Air-fluid level within the cavity.
- The typical abscess has equal air –fluid width both on PA & lateral
CXR.
E. CT scan -Clarify the diagnosis
F. Bronchoscopy & Biopsy -R/o endobroinchial obstruction &
Bronchoalveolar lavage.
G. Thoracotomy  for peripheral lesion
 Treatment
Medical
For community acquired infection
-Penicillin G, Ampicillin or Amoxacillin + beta- lactamasae inhibitor or metronidzol.
For anaerobic lung abscess
Standard Px  clindmycin(600mg iv tid followed by 150-300mg po QID)
Metronidzol alone  Not effective, so use with penicillin.
 Duration of therapy  3-12 weeks
 Bronchoscopy Establish the dx. & bronchial drainage.
Should be done weekly.

General supportive measures

Nutritional support.
cessation of smoking & alcohols
postural drainage.
 transfusion.
Correction of serious dental disease
 Weekly CXR
Surgical Drainage
Indication
 Failure of medical therapy
 An abscess under tension
 Abscess increasing in size during antibiotics
 Giant abscess > 6cm
 Massive hemoptysis.
 Abscess rupture or Pyopneumothorax.
 Inability to exclude cavitary Ca
External drainage
1. Tube thoracostomy Tension pyopneumothorax
2. Percutanouse catheter drainage
3. Resection of lung abscess
Lobectomy
Rib resection & drainage
 Tuberculosis
• Treatment
– Chemotherapeutic agents
• Indications for surgery
• Bronchopleural fistula with empyema
• Destroyed lobe or lung
• Persistent open cavities with positive sputum
• Post-tubercular bronchial stenosis
• Pulmonary hemorrhage
• Suspected carcinoma
• Aspergilloma
• Bronchiectasis
 Bronchogenic Carcinoma
• The leading cause of cancer death in the United States.
• About 95% of lung cancers occur in patients who are older than 40 years of age.
Etiology
– Smoking; a history of smoking one or more packs of cigarettes daily for 20
years.
– Chronic exposure to various substances may play a role; nickel, asbestos,
arsenic, radioactive materials, and petroleum products have all been
implicated.
Pathology
• Squamous cell carcinoma (SCC) over 60 % of lung cancers. Tends to be centrally
placed. There is a tendency to cavitate and metastasise outside the thoracic cavity.
• Adenocarcinoma15%. It is more common in females and nonsmokers, and tends
to be sited in the periphery of the lung. Adenocarcinoma often metastasise widely
to the liver, brain and adrenals.
• Small cell carcinoma metastasises widely early in its. These tumours are often
associated with ectopic hormone production and paraneoplastic syndromes.
• Alveolar cell carcinoma arises in the distal airways..
 Clinical features
• Depend on: the site of the lesion; invasion of neighbouring
structures; the extent of metastases.

Common symptoms:
Persistent cough, weight loss, dyspnoea and nonspecific
chest pain ,fever, sputum production, and wheezing.
Uncommon symptoms
Patients may be asymptomatic.
Haemoptysis occurs in less than 50% of patients presenting for the first time.
Severe localised pain suggests chest wall invasion with the infiltration of an
intercostal nerve.
Pancoast’s syndrome(Invasion of the apical area may involve the brachial plexus).
Clubbing and hypertrophic pul­monary osteoarthropathy are sometimes seen,
particularly with squamous cell lesions.
Hemorragic pleural effusion
Invasion of the mediastinum may result in hoarseness (due to recurrent laryngeal
nerve involvement), dysphagia (due to involvement of, or extrinsic pressure on,
the oesophagus) and superior vena caval obstruction, Horner's syndrome (i.e.,
ptosis, miosis, enophthalmos, and anhidrosis)..
Hormonal secretion by a tumour results in Cushing's syndrome, hypercalcemia,
myasthenic neuropathies, hypertrophic osteoarthropathies, and gynecomastia
• Metastatic extrapulmonary manifestations include weight loss, malaise,
symptoms referable to the central nervous system, and bone pain.
 Diagnosis

• Chest radiograph
– The tumor may present as a nodule, an infiltrate, or as atelectasis.
– Consider Ca esp. if age is > 40
• CT scan reveals the extent of the tumor and the possibility of mediastinal
lymph node metastasis.
• Bronchoscopy assesses for bronchial involvement and resectability in
central lesions, and tissue is obtained for cytologic examination.
• Mediastinoscopy or mediastinotomy obtains mediastinal lymph nodes for
pathologic examination and aids in the staging of the disease
• Percutaneous needle biopsy may be used for peripheral lesions to obtain
tissue for cytologic examination.
TNM Definitions
• T1 A tumor that is 3 cm or less
• T2 A tumor more than 3 cm in greatest dimension
• T3 A tumor of any size with direct extension into the chest wall, diaphragm, or the mediastinal pleura
or pericardium, or a tumor in the main bronchus within 2 cm of the carina without involving the carina
• T4 A tumor of any size with invasion of the mediastinum or involving heart, great vessels, trachea,
esophagus, vertebral body, or carina or presence of malignant pleural or pericardial effusion, [†] or with
satellite tumor nodules within the ipsilateral

• N0 No demonstrable metastasis to regional lymph nodes

• N1 Metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region, or both
• N2 Metastasis to ipsilateral mediastinal lymph nodes and subcarinal lymph nodes
• N3 Metastasis to contralateral mediastinal lymph nodes, contralateral hilar lymph nodes, or ipsilateral
or contralateral scalene or supraclavicular lymph nodes

• M0 No (known) distant metastasis

• M1 Distant metastasis present.
Group Stages  
• Stage 0 Carcinoma in situ
• Stage 1A T1 N0 M0
• Stage 1B T2 N0 M0
• Stage IIA T1 N1 M0
• Stage IIB T2N1 M0 , T3 N0 M0
• Stage IIIA T3 N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0
• Stage IIIB T4 N0 M0, T4 N1 M0, T4 N2 M0, T1 N3 M0, T2 N3 M0, T3 N3 M0,
T4 N3 M0
• Stage IV Any T, any N, M1
Treatment
• Surgical treatment
– Pulmonary resection (i.e., lobectomy, extended lobectomy, or
pneumonectomy, Wedge resections or bronchial segmentectomy ) is the only
potential cure for bronchogenic carcinoma
– Contraindications for thoracotomy..
• Extensive ipsilateral mediastinal lymph node involvement (N2 disease),
particularly high paratracheal and subcarinal
• Any contralateral mediastinal lymph node involvement (N3 disease)
• Distant metastases
• Malignant pleural effusion
• Superior vena cava syndrome
• Recurrent laryngeal nerve involvement
• Phrenic nerve paralysis
• Poor pulmonary function (relative contraindication)
• Adjuvant therapy. Further treatment using radiotherapy, chemotherapy, or both is
indicated for some advanced-stage tumors.