Thoracic Tutorial

Sept 9 2010
Dr. Alan Sihoe

CTS syllabus in MBBS

- Definite question in OSCE during CCT
- Finals:
 will submit questions for written papers and MCQs
 clinical exam will definitely include patients with CTS background

Cardiac: 3 main categories

 IHD
 Specific to surg: know the indications for surgery/ PCA
 In general all surgeries are done for
• presence of SYMPTOMS (sometimes despite medical treatment)
• SURVIVAL (sometimes asymptomatic)
 E.g. in IHD, indications for CABG instead of PCI
- Symptoms despite medical treatment/ PCI
- Triple vessel disease/ left main branch occlusion (survival)
 Valvular heart disease
 Know how to interpret ECHO/ classify the patient into surg vs. medical
management
 Know types of valves, advantages of each etc.
 Thoracic aortic disease e.g. TAA, dissection

Thoracic:
• CA Lung
• Pleural disease e.g. pleurisy, mesothelioma, pneumothorax
• Mediastinal—be able to give 4-5 differentials for presence of mass in
EACH COMPARTMENT and know appropriate investigations for each
differential
- Anterior mediastinal mass:
 4Ts: thymus, thyroid, teratoma, terrible lymphoma
- Middle
 Pericardial sac and contents, tracheal bifurcation and bronchi,
aortic arch and pulmonary trunk, phrenic nerves, LNs, SVC
lower half
 - Posterior mediastinum
 Structures- DATES: descending aorta, azygous vein, thoracic
duct, esophagus, sympathetic trunk,
• Chest trauma—rib fracture, flail chest, ruptured aorta etc.
25-30% of deaths with multiple trauma are accounted for by chest
trauma
• Chest drains—draw 3-bottle chest drain. Know how to check for air
leaks (SWINGING and BUBBLING); a VERY COMMON QUESTION (esp a
PASS/FAIL moment. The pass/fail moment in medicine is when they
ask you on CPR)
Pneumothorax
Combined from
- Thoracic Tutorial
- Washington Manual of Surgery

WILL DEFINITELY BE ASKED

REASONABLY GOOD PERFORMANCE IS EXPECTED
Definition: ANY collection of air within the pleural cavity

Classification:
- spontaneous vs. traumatic OR
- primary vs. secondary

- Cause of primary spontaneous pneumothorax:

• idiopathic (accepted in all specialties)
• rupture of blebs (accepted in surg)
• Predilection in young (post-pubertal) thin tall males
 M:F ratio=9:1 locally
 Theory: growth spurt stretches the lungs and lead to uneven lung
growth formation of blebs!

- Causes of traumatic pneumothorax:

• Most commonly iatrogenic:
 CENTRAL VENOUS CATHETER INSERTION (therefore always do CXR after
insertion)
 MECHANICAL VENTILATION
• Unlikely to recur therefore usually drainage per se is sufficient

- Causes of secondary pneumothorax

• COPD
• Asthma
• Connective tissue disease e.g. Marfan’s syndrome
• Likely to recur due to underlying pathology. Therefore Mx is pleuradesis
(preferably surgical, but often unfit for surg medical)

- Tension pneumothorax
• P/E:
 TACHYCARDIA IS THE EARLIEST SIGN
 • b/c pain ANXIETY
 JVP elevation (LATE)
 Signs of midline shift (LATE)
 hyptotension (LATE)

Ix: Sizing is by % VOLUME (3D). Area on CXR is an underestimation b/c 2D.

Mx:
- ANY pneumothorax of ANY size should be hospitalized to
• look out for tension pneumothorax
• do serial SaO2, BP/P
• give oxygen (theoretically increases PO2 in blood so generates a pressure
gradient of PN2 for nitrogen to diffuse back into the atmosphere, but should
only work for CPAP 100% O2 and not nasal cannulas like what we see in wards)
• +/- pain relief

Acute mx:
conservative vs. needle thoracostomy vs. pleuracentesis/tapping ( gold
standard)
• Contraindication to conservative management
 Large pneumothorax (larger than 10-20%, no consensus): because if left
alone without complete resolution:
Short term  very symptomatic (because lungs do not expand due to air
filling out the change in volume within the pleural space
Long term entrapped lung due to the proteinaceous coating by pleural
fluid “cortex” formation will need decortication to restore elasticity
• needle thoracostomy is effective and convenient to the patient, for low
suspicion of continuous leak
• Advantage of tapping over needle thoracostomy:
 continuous drainage
 monitor air leak bubbling and swinging
 route for chemical pleuradesis if needed
• If no air leak for more than 24 hours the chest drain can be removed!
• Recurrence rate after first episode: 20-30%
• After first recurrence: 60-70%

Operative Mx: Pleuradesis

- Chemical pleuradesis
 • 10-30% recurrence of pneumothorax, because the blebs are not removed
• Procedure:
 Always administered with LA. Therefore actually not that painful
 50mL of sclerosant administered through chest tube
• 1st line: antibiotics (usu. tetracycline cheaper)
• 2nd line: chemotherapeutic agent (e.g. belomycin) if ABx allergy+
• 3rd line: talc (=滑石粉＝爽身粉 minus fragrance)
- adsorbant
- more effective compared to the other agents and less painful
- ?ARDS due to excessive inflammation (controversial)
- “carcinogenic”, causing mesothelioma according to U.S.
textbooks mainly because U.S. mines are contaminated by
asbestos
• Roll in different positions q 15 min for 2 hours

- Surgical pleuradesis
 VATS or thoractomy
 More effective because
• Resection of blebs
• Rub pleurae until bleed+ more inflammation (and hence hurt much
more)
 2-3% recurrence
 Indications:
• 1st recurrence
• patient preference
• prolonged air leak (3-5 days)
- risks of respiratory infection & drain wound infection
• In selected cases of first episode primary spontaneous pneumothorax
if:
- Bilateral (not necessarily simultaneous)
- Tension pneumothorax
- High-risk occupation (e.g. pilots, divers)