Collapse / pneumonectomy / lobectomy
Terms in this set (12)
- tracheal deviation towards the side of the collapse
- unilateral decreased expansion
- ipsilateral dullness to percussion
- ipsilateral diminished breath sounds
- ipsilateral increased vocal fremitus
- evidence of bronchogenic malignancy: tar staining, clubbing, cachexia
The differential for dullness to percussion includes:
- pleural effusion
Commonly lung collapse is found:
- complication of pneumonia
- mass lesion
Mass lesions include:
- External compression: enlarged lymph nodes (TB, malignancy)
- Within the airway wall: malignant endobronchial lesion
- Within the airway lumen: inhaled foreign body, mucous plugs.
Refers to a specific radiological finding in left lower lobe collapse where the collapsed lobe causes the appearance of a double left heart border.
Indications for lobectomy / pneumonectomy
1. Lung malignancy (common) and pulmonary metastasis (rare)
2. Bronchiectasis with uncontrolled symptoms (e.g. recurrent haemoptysis)
3. Old TB (prior to anti-tuberculous therapy)
4. Fungal infections (e.g. aspergilloma)
5. Traumatic lung injury
6. Large emphysematous bullae (bullectomy)
Differential diagnosis for indications for lung transplantations
1. Diffuse parenchymal lung disease
2. Cystic fibrosis
4. alpha1-antitrypsin deficiency (the strong candidate will examine for a liver edge in a young patient)
5. Pulmonary vascular disease - idiopathic pulmonary hypertension
6. Rare diseases - Langerhans cell granulomatosis.
Clinical findings lobectomy / pneumonectomy
- Tracheal deviation. Towards the lesion in pnemonectomy and
lobe lobectomy; trachea may be central in other lobectomies.
- Displaced apex beat (towards lesion)
- Reduced chest expansion
- Dull percussion note.
- Decreased / absent breath sounds. However, in pneumonectomy, there may be transmitted bronchial breathing from deviated trachea appreciated in the upper zones.
Chest radiographic features in a pneumonectomy / lobectomy
On PA CXR the following features will be seen:
- 'White out'
- In lobectomy there may be volume loss in the ipsilateral hemithorax, increased transradiancy of the ipsilateral lung due to compensatory hyperinflation, the presence of surgical clips and evidence of rib resection.
- Deviated trachea or mediastinum towards the lesion.
- Compensatory hyperinflation (of opposite lung in pneumonectomy or other ipsilateral lobes in lobectomy)
Preoperative evaluation in pneumonectomy
Preoperative evaluation is vital because of the significant loss of lung function that follows.
Additionally, because such interventions are usually performed on patients with underlying lung disease, must assess functional reserve and predicted pulmonary function following surgery.
If preoperative FEV1 >2L -> low risk
Subtypes of pneumonectomy
There are 2 main types of pneumonectomy:
- Simple: removal of affected lung.
- Extrapleural: removal of affected lung plus part of the diaphragm, parietal pleural and pericardium on the ipsilateral side. These linings are then replaced by surgical Gore-Tex.
The primary use of extrapleural pneumonectomy is in the treatment of malignant mesothelioma because this particularly technique has been shown to have the best survival rates.
If this paitent had a lobectmoy secondary to lung malignancy, can you suggest a likely subtype of lung cancer.
Surgery has a greater roll in the management of 'NSCLC' rather than small-cell carcinoma' which has poorer prognosis and is almost always unsuitable for surgical intervention by the time of presentation.
Approximately 25% of NSCLC will be suitable for surgical resection.
Operative mortality of lobectomy and pneumonectomy
Operative mortality for lobectomy is approximately 2-4% and for pneumonectomy this rises to 6%.
There is a marked difference in mortality risks between the right and left sides following a pneumonectomy.
A right sided pneumonectomy is associated with higher overall mortality (10-12%) as compared left sided (1-3.5%). Reasons are uncertain for this difference but are most likely due to life-threatening complications that are encountered at higher frequency following right-sided procedures such as post-pneumonectomy space empyema, pulmonary oedema and bronchopleural fistula.
This syndrome results from the extrinsic compression of the distal trachea and main-stem bronchus due to mediastinal shifting and compensatory hyperinflation that occurs in the remaining lung.
Post-penumonectomy syndrome occurs almost exclusively in patients with right-sided pneumonectomy, approximately 6 months post-surgery but can occur years after the procedure.
The syndrome is characterised by progressive dyspnoea, cough, inspiratory stridor and pneumonia. Treatment includes surgical re-positioning of mediastinum and filling of post-pneumonectomy space with non-absorbable material +- possible stenting of bronchi.
This condition can be fatal if left untreated.