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Joe B. (Bill) Putnam, Jr., MD, FACS Ingram Professor of Surgery and Chairman

Thoracic Surgery: A Pleural Problem Primer. Vanderbilt University Medical Center February 14, 2007. Joe B. (Bill) Putnam, Jr., MD, FACS Ingram Professor of Surgery and Chairman Department of Thoracic Surgery Professor, Department of Biomedical Informatics

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Joe B. (Bill) Putnam, Jr., MD, FACS Ingram Professor of Surgery and Chairman

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  1. Thoracic Surgery: A Pleural Problem Primer Vanderbilt University Medical Center February 14, 2007 Joe B. (Bill) Putnam, Jr., MD, FACS Ingram Professor of Surgery and Chairman Department of Thoracic Surgery Professor, Department of Biomedical Informatics Vanderbilt University Medical Center Nashville, Tennessee 37232-5734 bill.putnam@vanderbilt.edu

  2. STEP 1. Take your own pulse.

  3. STEP 2. Relax. Take a deep breath. If the patient is not arresting, think… Reflect on the situation Ask yourself the question ‘Why…..’ Save the patient’s life…..!

  4. The Pleural Space 2 thin semi-permeable membranes Visceral pleura: covers the lung Parietal pleura: lines the chest wall Parietal pleura has a rich nerve supply Visceral pleura does not

  5. The Pleural Space Physiology Small amount of fluid (like oil between two glass plates) Dynamic fluid processes From parietal pleura to visceral pleura Balanced by blood pressure, serum proteins / oncotic pressure , etc.

  6. Diseases of the pleura Air - Pneumothorax Blood - Hemothorax Infection - Empyema Air - Pneumothorax Chyle - Chylothorax Tumor - ‘Tumor-thorax’ or tumor tamponade Fluid - Pleurothorax

  7. Pneumothorax

  8. Spontaneous pneumothorax • No specific etiology • Probably rupture of a bleb or bulla • Tall lanky young (20 – 40 years of age) • Cigarette smoking and family history • complication of underlying pulmonary (lung) diease • COPD, asthma, cystic fibrosis, tuberculosis, etc.

  9. Traumatic pneumothorax • Penetrating • GSW / stab • Blunt trauma

  10. Tension pneumothorax • Progressive air pressure within chest impairing venous return. • Life threatening emergency

  11. Tension PneumothoraxRespiratory distressHyper-resonanceAbsent breath soundsTracheal deviation

  12. NOT AN X-RAY DIAGNOSISRx: Immediate needle decompression, chest tube

  13. Tension Pneumothorax • Tension pneumothorax is a clinical diagnosis and should not be made radiologically! • Confused with hemothorax • Hyperresonance is the key to diagnosis • If in doubt - insert needle!

  14. Tension Pneumothorax • Respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absence of breath sounds, neck vein distention, cyanosis • Hyperresonance!

  15. Spontaneous PTXMore common males ages 20-40, smokersMayoccur following a scream,valsalva, or coughSudden sharp pleuritic chest pain and dyspnea Tachypnea, tachycardia, subcutaneousemphysema

  16. Expiratory CXR may be needed to make diagnosisTreatment: Observation for PTX less than 15-20% and no symptomsOthers: needle/catheter decompression and/or chest tube

  17. Pneumomediastinumpneumopericardiumsubcutaneous emphysema Barotrauma

  18. Open Pneumothorax • Large defect (>2/3 size of trachea) • Removes normally negative intra-thoracic pressures - thus impedes respiration • Prompt closure - sterile, occlusive • Tape three sides - allowing a flap valve effect • Surgery usually required

  19. Massive Hemothorax • More than 1500 ml. blood in chest - surgery • Dullness to percussion, absent breath sounds, possible flat neck veins • Insert large bore chest tube • Be prepared for auto-transfusion • >200 ml/hr may indicate need for surgery • Most chest wounds do not require surgery

  20. Massive Hemothorax • Penetrating wounds medial to the nipple or scapula should alert the surgeon to heart, hilum or great vessel injury • Thoracotomy should be done by thoracic surgeon

  21. Massive Hemothorax • Massive pleural effusions can mimic hemothorax. • Trauma patients are unlikely to have a pleural effusion that is not blood

  22. Pleural Effusion • Fluid that accumulated in the pleural space • Trauma • Disease • Heart failure • Cancer • Pulmonary embolism • Inflammation

  23. Pleural Effusion • Fluid accoumulates by • increased production • Hypertension , Hypoalbuminemia , Ascites • Decreased absorption • Blocked lymphatic drainage (lymphoma) • Chylothorax • Malignant tumors • Pleural metastases , Primary pleural malignancies (e.g. mesothelioma) • Combinations

  24. Transudates and Exudates • Transudates: • Etiology: Imbalance between the venous-arterial pressure and pleural space pressure (oncotic pressure) • Characteristics • Clear, pale yellow color,few protein, cells, or other debris. • Setting: • Cardiac failure • Less commonly liver and kidney disease

  25. Transudates and Exudates • Exudates: • Etiology: Inflammation, infection, and cancer. • Characteristics: large amt protein, cells, debris; color varies ; usually cloudy. If infected -> empyema; and ususlly a foul order • Setting: Pneumonia, tuberculosis, pulmonary embolism, cancer, trauma

  26. It’s time we face reality, my friends….. We’re not exactly rocket scientists.”

  27. Malignant Pleural Effusions (MPE) • 25% of all pleural effusion in a general hospital setting are secondary to cancer • 30-70% of all exudative effusions are secondary to cancer • 50-60% of MPE are positive on first thoracentesis (70-80% after 3) • Thoracoscopy is diagnostic in 92%

  28. Median Life Expectancy(months) • Ovarian 9.4 • Breast 7.4 • Non-small cell lung 4.3 • Small cell lung 3.7 Sanchez-Armengol A, Rodriguez-Panadero F: Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases. Chest 1993;104:1482-1485.

  29. Malignant Pleural Effusions (MPE) Increased capillary permeability Disruption of capillary endothelium Impaired lymphatic drainage Direct invasion of pleural space by tumor Malnourishment and hypoalbuminemia

  30. Exudates Light’s criteria absolute fluid LDH > 200 pleural fluid LDH:serum LDH ratio > 0.6 pleural fluid protein:serum protein ratio >0.5 pleural cholesterol > 55 mg/dl

  31. Pleural Fluid Analysis • Cell Count • Cytology • Cultures • LDH • Protein • Glucose • pH

  32. Predicting Survival • Pleural fluid pH (p=n.s.) • Pleural fluid glucose (p=n.s.) • Extent of pleural carcinomatosis (p=n.s.) • Karnofsky Performance Score (<= 30 vs. >= 70, p<0.0001) 34 d median vs. 395 days Burrows CM, et al. Chest 117:73-78 (2000)

  33. Treatment Goals for MPE • Relieve or eliminate dyspnea • Optimize patient function • Minimize/eliminate hospitalization • Minimize cost

  34. Chest Tube Insertion (Tube Thoracostomy) 1 • 1.Sterile technique (scrub, gown, mask, glove?). • 2. Local anesthesia (Lidocaine 1%) – generous and liberal use. • 3.Site of Insertion: • Anterior axillary line (high – 4th ICS - and midaxillary; Low in 8th or 9th ICS • Avoid injury to HEART, liver, spleen, lung, etc.! • Avoid diaphragmatic injury (can occur with haste or inexperience) • Digital exploration for intrapleural adhesions. • Catheter size depends on treatment goals: • Air….smaller tube • Pus…bigger tube and DEPENDENT drainage in adult 36-40. • Posterior and mid axillary line at level of 10th rib.

  35. Drainage system • Pleuravac • Water • Air • Three chambers • Collection • Water seal • Suction • Pleur-Evac System: Suction Water Seal Drainage

  36. Treatment: Chest Tube Insertion (Tube Thoracostomy) 2 • Dissect and tunnel with a curved clamp over top of rib! • Neurovascular bundle runs along the inferior border of rib • In a controlled fashion, puncture into the pleural space • Insert a finger into the pleural space to identify potential space and guide chest tube. • With a clamp onto the end of the chest tube, and guided by the finger track, insert the drain into the chest directing it towards the apex and posterior. • ALL DRAIN HOLES to be within the pleural cavity • Special eye!

  37. Chest Tube Insertion (Tube Thoracostomy) 3 • Check for leaks in the system (persistent air drainage, or inability to re-expand the lung) • Persistent leak: ruptured bronchus, bronchopleural fistula, ruptured bleb. • Connect to underwater drainage system (Pleurovac). • Secure tube on skin. • Vaseline gauze not needed ! • Remove when air leak or fluid drainage ceases • A functionless tube is only a nidus for infection • Have patient take a deep breath in • As patient begins to exhale, remove the tube quikly • Patient involuntarily Valsalva’s, minimizing potential for sucking air into the pleural cavity • Chest X-ray after removal.

  38. Comments • Maintain fluid levels in chambers • Maintain hemostats and dressing at bedside • Keep extra drainage system on nursing unit • Do not clamp tubing -- unless getting ready for removal

  39. The last part of surgery, namely, operations, is a reflection on the healing art; it is a tacit acknowledgement of the insufficiency of surgery. It is like an armed savage who attempts to get that by force which a civilized man would get by strategem. John Hunter (1728-1793)

  40. Congratulations and Good Luck!

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