- 70%
- INFECTIOUS GRANULOMA (histoplasmosis, coccidiomycosis, TB, atypical mycobacteria)
- OTHER INFECTIONS (Bacterial abscess, PCP, Aspergilloma)
- BENINGN NEOPLASM (hamartoma, lipoma, fibroma)
- VASCULAR (AVM, Pulmonary varix, PE)
- DEVELOPMENTAL (bronchogenic cyst)
- INFLAMMATORY (Wegener's granulomatosis, rheumatoid nodule, sarcoidosis)
- OTHER (hematoma, infarct, pseudotumor, rounded atelectasis, lymph nodes, amyloidoma) - Bronchogenic cancer (90% or primary lung cancers)
o SCLC vs NSCLC
o NSCLC (adenocarcinoma, squamous cell carcinoma, large cell, and bronchioalveolar cancer (BAC)
o Incidence of adenocarcinoma is increasing
- Lymphoma
- Secondary metastases: breast, colon, prostate, kidney, thyroid, stomach, cervix, rectum, testes, bone, melanoma 1) Lung, hilum, mediastinum, pleura: pleural effusion, atelectasis, wheezing
2) Pericardium: pericarditis, pericardial tamponade
3) Esophageal compression: dysphagia
4) Phrenic nerve: paralyzed diaphragm
5) Recurrent laryngeal nerve: hoarseness
6) Superior Vena Cava syndrome
a. Obstruction of SVC causing neck and facial swelling, as well as dyspnea and cough
b. Other symptoms: Hoarseness, tongue swelling, epistaxis, hemoptysis
c. Physical: dialted neck veins, increased number of collateral veins covering anterior chest wall, cyanosis, edema of the face, arms, chest. Pemberton's sign
d. Milder symptoms if obstruction is above azygois vein
7) Lung apex: Pancoast tumor = Horner's syndrome + Brachial plexus palsy (most commonly C8 and T1 nerve roots)...Horner's = MAP...Miosis, anydrosis, ptosis
8) Rib and vertebrae: erosion
9) Distant metastasis: to brain, bone liver and adrenals
10) Paraneoplastic syndromes
a. Group of disorders associated with malignant disease, not related to the physical effects of the tumour itself
b. Most often associated with SCLC - Initial diagnosis: CXR, CT chest + upper abdomen, PET scan, bone scan, sputum cytology, Bx (bronchoscopic, percutaneous, mediastinoscopic)
- Staging work-up: Blood work (electrolytes, LFT, calcium, ALP), Imaging (CXR, CT thorax and upper abdomen, bone scan, neuro imaging), Invasive: bronchoscopy, mediastinoscopy, mediastinotomy, thoracotomy
- EBUS or Bronchoscopy and Mediastinoscopy: for peripheral T1 2 cm or PET -ive scan - T1= < 3 cm
- T2= 3-7 cm, partial atelectasis, invasion of pleural, main bronchus but > 2cm from carina
o T2a= 3-5cm
o T2b= 5-7cm
- T3= > 7cm, whole lung atelectasis, invasion of phrenic nerve, diaphragm, chest wall, mediastinal pleura, main bronchus < 2cm from carina, parietal pericardium
- T4= Invasion of mediastinal organs, vertebral bodies, carina, tumor nodules in different ipsilateral lobe - IA: T1, N0, M0
- IB: T2a, NO, MO
- IIA:
o T2b, N0, M0
o T1, N1, M0
o T2a, N1, M0
- IIB:
o T2b, N1, M0
o T3, N0, M0
- IIIA:
o T4, N0, M0
o T3, N1, M0
o T4, N1, MO
o T1, N2, M0
o T2, N2, M0
o T3, N2, M0
- IIIB:
o T4, N2, M0
o T1, N3, M0
o T2, N3, M0
o T3, N3, M0
o T4, N3, M0
- IV: Tx, Nx, M1 - No role alone, only in combination with other treatments (surgery, radiotherapy)
- CISPLATIN and ETOPOSIDE
- Paclitaxel, vinorelbine and gemcitabine are newer NSCLC therapies
- New biologics: EGFinhibitor (Gefitinib)
- Complications:
o Acute: tumor lysis syndrome, infection, bleeding, myelosuppression, hemorrhagic cystitis (cyclophosphamide), cardiotoxicity (doxorubicin), renal toxicity (cisplatin), peripheral neuropathy (vincristine)
o Chronic: neurologic damage, leukemia, additional primary neoplasms 1) IATROGENIC: (most common) endoscopic, dilation, biopsy, intubation, operative, NG tube placement
2) BAROGENIC: repeated, forceful vomiting (Boerhaave's syndrome), trauma, other: convulcsions, defecation, labour (rare)
3) INGESTION INJURY: foreign body, corrosive substance
4) CARCINOMA - Definition: progressive, intermittent, location
- Risks: EtOH, Smoking, reflux, ethnicity
- Associated symptoms: Weight loss, melena, hematemesis, regurgitation
- DDx: Benign/malignant (VINDICATE)
- Physical exam: Virchow's node, ascites, hematemesis, regurgitation
- Work up: swallow, endoscopic, CT, PET
- Staging: Barrett's, metastatic
- Tx: benign, malignant, palliative, neoadjuvant treatment
- Cancer results
Benign conditions: stricture, motility, paraesophageal hernia - Outpouchings of one or more layers of the GI tract
- Presentation:
o Commonly associated with motility disorders
o Dysphagia, regurgitation, retrosternal pain, intermittent vomiting, may be asymptomatic
- Classification:
o According to location
o 1) PHARYNGOESOPHAGEAL (ZENKER'S) DIVERTICULUM
• Most frequent form
• Posterior pharyngeal outpouching most often on the left side, above cricopharyngeal muscle and below the inferior pharyngeal constrictor muscle
• SSx: dysphagia, regurgitation of undigested food, halitosis
• Tx: endoscopic or surgical myotomy of cricopharyngeal muscle +/- excision of sac
o 2) MID-ESOPHAGEAL DIVERTICULUM:
• secondary to mediastinal inflammation, motor disorders
• Usually asymptomatic, no tx required
o 3) Just proximal to LES (pulsatile type)
• Usually associated with motor disorders
• Usually asymptomatic, no tx required - TYPE I
- Herniation of both the stomach and the GE junction into thorax
- 90% of esophageal hernias
- RISK:
o Age
o Increased intra-abdominal pressure (obesity, pregnancy, coughing, heavy lifting, straining with constipation
o Smoking
- CLINICAL FEATURES:
o Majority are asymptomatic
o Larger hernias frequently associated with GERD due to disruption of competence of GE junction and prevention of acid clearance once reflux has occurred
- COMPLICATIONS:
o Most common complication is GERD
o Other complications are rare and are related to reflux: esophagitis (dysphagia, heartburn), consequences of esophagitis (peptic stricture, Barrett's esophagus, esophageal carcinoma)
o Extra-esophageal complications (aspiration pneumonia, asthma, cough, laryngitis)
- INVESTIGATIONS:
o Barium swallow, endoscopy, or esophageal manometry
o 24-hr esophageal pH monitoring quantifies reflux
o Gastroscopy with biopsy to document type and extent of tissue damage and to rile out Barrett's and cancer
o CXR: globular shadow with air-fluid level visible over cardiac shadow
- TREATMENT:
o Treat symtoms of GERD
• LIFESTYLE: stop smoking, weight loss, elevate head of bed, no meals < 3hrs prior to sleeping, smaller and more frequent meals, avoid alcohol, coffee, mint and fat
• MEDICAL: antacid, H2-antagonist, PPI, adjuvant prokinetic agent
• SURGICAL (<15%): if sever complications or if refractory. NISSEN FUNDOPLICATION (laparoscopic)- fundus of stomach is wrapped around the lower esophagus and sutured in place (90% success rate) - Frequently asymptomatic and present late in disease
- Progressive dysphagia (mechanical): first solids, then liquids
- Odynophagia, then constant pain
- Constitutional symptoms
- Regurgitation and aspiration (aspiration pneumonia)
- Hematemesis, anemia
- Tracheoesophageal or bronchoesophageal fistula
- Direct, hematogenous or lymphatic spread: trachea (cough), recurrent laryngeal nerves (hoarseness, vocal paralysis), aortic, liver, lung, bone, celiac, mediastinal nodes
- Weight loss - Impingement of subclavian vessels and brachial plexus nerve trunk
- Etx: congenital cervical rib, trauma, degenerative (osteoporosis, arthritis)
- Presentation:
o Neurogenic, ulnar and median nerve motor and sensory function
o Arterial, fatigue, weakness, coldness, ischemic pain, paresthesia
o Venous, edema, venous distention, collateral formation, cyanosis
- Tx: Conservative (50-90%), physio, posture, behavioural modification. Surgical, when conservative tx fails, removal or first of cervical ribs - DIRECT INVOLVEMENT or compression of normal mediastinal structures.
o Cough, stridor, hemoptysis, SOB, Pain, dysphagia, hoarseness, facial and or upper extremity swelling due to SVC syndrome, hypotension due to tamponade or cardiac compression, and Horner's syndrome
- SYSTEMIC SYMPTOMS
o Fever, night sweats, weight loss in lymphoma or may be due to a variety of paraneoplastic syndromes, such as myasthenia gravis with thymoma - Place patient in the supine position with ipsilateral arm abducted and elbow flexed to position hand over patients head
- Prepare skin with chlorhexidine and wear full barrier precautions (glove, gown, mask, eye protection)
- Using 1% lidocaine, anesthetize 2-3 cm of skin and sub q tissue one intercostal space below where tube will go in
- Make 2 cm incision in skin at site of the lidocaine injection parallel to the intercostal space, anesthetize the periosteum of the rib above and the rib below the planned insertion site
- Using Kelly Clamp, blunt dissect and create a short subcutaneous tunnel from the incision site, cephalad towards intercostal space where tube will penetrate
- Push clamp over superior margine of rib and through parietal pleura
- Insert finger through the tract into pleural space
- Clamp tube at insertion end with kelp clamp and with the aid of the clamp tip, insert tube into pleural space
- Observe condensation within the tube to confirm placement in thoracic cavity
- Advance tube until the last drainage hole is within thoracic cavity
- Place a suture to anchor the test tube, loosely tying over the tube and then firmly tying around the tube
- Following placement, obtain a CXR to confirm tube position and assess lung expansion - Assess for air leak daily
- Qualitatively, air leaks are classified with increasing severity
o Forced expiratory, occurs with cough or valsalva (FE1 to FE7)
o Expiratory, alveolar-pleural fistulas (E1 to E7)
o Inspiratory, ventilated, brnochopleural fistula, alverolar-pleural fistula (I1-I7)
o Continuous, ventilated, true bronchopleural fistula (C1-C7)
- The number of chambers that are bubbling in a wet, suction-controlled, closed drainage provides semi-quantitative measure of air leak - Malignancy, empyema, tuberculous pleurisy, fungal infection of pleural space, chylothorax, cholesterol effusion, urinothorax, esophageal rupture, hemothorax, peritoneal dialysis, extravascular migration of central venous catheter - PROTEIN:
o Most transudate < 3g/dL
o Tuberculous effusion protein > 4g/dL
o Protein 7 to 8 g/dL = Waldenstrom's macroglobulinemia and Multiple Myeloma considered
- LDH:
o Above 1000 IU/L = empyema, pleurisy, pleural paragonimiasis, and sometimes malignancy
o LDH ratio > 1 and Protein ratio <0.5 = PCP or urinothorax
- CHOLESTEROL:
o Increases likeliness of exudative and can define cholesterol effusion
- TRIGLYCERIDES:
o > 110 mg/dL supports chylothorax
- GLUCOSE:
o Low pleural glucose lowers DDx for exudative
o Rheumatoid pleurisy, Complicated parapneumonic effusion or empyema, malignant effusion, Tuberculous pleurisy, lupus pleuritis, esophageal rupture
- pH:
o below 7.3 is same DDx as low pleural glucose
o Rheumatoid pleurisy, Complicated parapneumonic effusion or empyema, malignant effusion, Tuberculous pleurisy, lupus pleuritis, esophageal rupture
o Normal is 7.6
- AMYLASE:
o Pancreatic or esophageal etiology
o Acute pancreatitis, chronic pancreatic pleural effusion, Esophageal rupture, malignancy - Most are asymptomatic for at least 20-30 years, however pleural disease presents earlier
- SSx: SOBOE. cough, sputum production, and wheeze are unusual
- Px: Dibasilar fine end-inspiratory crackles and clubbing. May progress to Cor Pulmonale in advanced cases and present with peripheral edema, jugular venous distension, hepatojugular reflux, and or Right ventricular heave/gallop
- Labs: Generally non-specific
- PFT: reduced lung volume, particularly VC and TLC, diminished single breath DLCO, decreased pulmonary compliance, absence of airflow obstruction (normal FEV/FVC
- Earliest abnormality detected is reduced DLCO and pulmonary compliance along with exertional hypoxemia 1) RESPIRATORY FAILURE: slowly progressive disease that culminates in respiratory failure in a minority of patients. Risk of respiratory failure: cumulative asbestos exposure, duration of exposure, fiber type, SSx of SOB, cigarette smoking, diffuse pleural thickening, Honeycombing on HRCT, high concentration of inflammatory cells
2) MALIGNANCY: Asbestos exposure associated with relative risk of lung cancer of 3.5
- Risk compounded by cigarette smoking. Asbestos = 6X, smoking = 11X and combined = 59X
- Also associated with cancers of larynx, oropharynx, kidney, esophagus, and biliary system
- Asbestos is the ONLY known risk factor for malignant mesothelioma - Generally less common, but more deadly than blunt chest trauma
- Occurs most often from gunshots and stabbings, which comprise ~ 10% each of all major trauma in US
- Other impaling objects from industrial accidents, falls, collisions, blast injuries and fragmenting military devices
- Most penetrating chest injuries do not require major operative intervention and many are manages with observation and serial evaluation. 15-20% requires surgery
- Chest wall, lungs, Major vascular injury, tracheobronchial wounds, esophagus, cardiac injury, diaphragm, spinal cord, thoracic vertebrae, thoracic duct - Appearance: Respiratory distress, diaphoresis, combativeness or an unwillingness to lie flat may signal active or imminent cardiopulmonary decompensation
- Rapid assessment and primary survey
o AIRWAY: patency, intubation?, treating pericardial effusion or pneumothorax before intubating
o BREATHING: inspection of chest wall, auscultation of breath sounds, palpation of chest wall for flail segments, step off and crepitus, palpation of trachea position. Oxygenation.
o Tension Pneumo: asymmetric breath sounds, hypoxia, hypotension common, tracheal deviation late
o Chest tube no smaller than 36 Fr used in trauma cases
o CIRCULATTION: Check for diminished pulses and hypotension. Look for tension pneumo or cardiac tamponade in any trauma patient with hypotension
o Hemorrhagic shock or SBP < 90 NS, LR, or blood products given as necessary
o FAST: FOCUSED ASSESSMENT WITH SONOGRAPHY IN TRAUMA: Detects hemopericardium, pneumothorax, hemothorax and peritoneal fluid
- Secondary survery
o Head-to-toe assessment
o Dyspnea, odynophagia, chest pain, back pain
o Hematemesis, stridor, chest wall crepitus, Hamman's sign, fever, hematoma, air leak - Follow ATLS when there is a possibility of underlying pulmonary, cardiac, or major extrathoracic injury
- Start with ABC's, rapid transport to trauma center.
- Basic interventions: High flow oxygen, spine immobilization, vital monitoring.
- If no evidence of respiratory difficulty, no intervention may be needed, however important features of the incident should be recorded to shared with clinicians at the trauma center (intrusion, deformed steering wheel, ejection of patient, fatality at scene, prehospital hypotension) - Initial resuscitation and management based on ATLS.
- First assess and stabilize ABC's, except in the incidence of tension pneumothorax when the pneumo should be treated before endotracheal intubation
- After ABC, comes initial evaluation of vital signs, initial presentation and mechanism of injury
- Rapid search with concurrent management of life-threatening injuries of head, spine, abdomen, chest and pelvis
o Aortic injury
o Tension pneumothorax
o Hemothorax with severe, active bleeding
o Pericardial tamponade from myocardial injury
o Tracheobronchial disruption
- Patients with respiratory distress, hemodynamic instability, or severe injury are intubated.
- Suspected tension pneumothorax is treated with chest tube (36 Fr) or needle decompression using large angiocatheter (14 Fr)
- Needle thoracostomy inserted in the 2nd or 3rd intercostal space midclavicular line or 5th interspace midaxillary line
- Once stabilized, CHEST CT +C performed to define extent of injury and exclude aortic rupture. If operative approach is required and patient cannot be CT'd, ECHO FAST assessment used in ED or OR to assess aorta and heart
- FAST will reveal pericardial tamponade, most likely from myocardial rupture, which should be treated with pericardiocentesis
- If hemodynamic compromise is severe and tamponade is note relieved or patient develops cardiac arrest during resuscitation, Emergency Department Thoracotomy (EDT) may be necessary - 1) CARINA: Trachea rings anterior, soft tissue posterior allows orientation to Left and Right mainstem bronchi
- 2) RIGHT MAINSTEM BRONCHUS: short, approximately 2.5cm, bifurcates into RUL bronchus to the right and Bronchus Intermedius to the right
- 3) RUL bronchus has a trifurcation. Apical, anterior and posterior segments
- 4) Bronchus intermedius leads to RML (left) and RLL (right). RML opening is 40:60 the RLL opening
- 5) RLL has superior segment to the right, and a basal trunk to the left with 4 basal segments (medial, anterior, lateral, posterior)
- 6) RML has medial and lateral bronchial segments
- 7) LEFT MAINSTEM BRONCHUS has longitudinal muscle fibers from the membraneous trachea posteriorly
- 8) Bifurcation in LUL (right) and LLL (left) is not sharp like the carina. This split happens at 8' and 2'
- 9) LUL divides into LUL PROPER which divides into 3 segments (fused apical-posterior, and anterior segment) and a lower division the LINGULA divides into superior and inferior segments
- 10) LLL BRONCHUS has significant variation from person to person. Typically divides into 4 segments (one superior to the left and courses superiorly, and 3-4 basal segments).
- 11) 4 basal segments are anterior, lateral, posterior, and medial. When there are three basal segments, the anterior and medial bronchi are fused. - 1) CONGENITAL vs ACQUIRED
o CONGENITAL
• Congenital Lobar Emphysema
• Congenital cystic adenomatoid malformation
o ACQUIRED
- 2) ACQUIRE → Traumatic vs Atraumatic
- 3) TRAUMATIC → Iatrogenic vs Trauma
o TRAUMA: MVA, Assault, Fall...
o IATROGENIC: Needle, biopsy, surgery
- 4) ATRAUMATIC → Primary vs Secondary
o PRIMARY: no associations
o SECONDARY: COPD, Lymphangioleimyomatosis (LAM), Esophageal perforation, Cystic Fibrosis, Severe Asthma, Infectious diseases (PCP, TB, necrotizing pneumonia), Marfan's syndrome, Neoplasm, Ehler Danlos Syndrome, Birt-Hogg-Dube syndrome (BHD)