Thoracic Surgery
Back to Basic
FM Shamji
2008
Esophagus
 Adult
- hollow muscular tube 25 cm long
 1 cm in neck, 19 - 22 cm in the
mediastinum, 3 cm in the abdomen
 Specialized sphincters at each end
 LES – physiological sphincter, prevents
gastroesophageal reflux
 UES – anatomical sphincter, prevents air
entry during breathing and regurgitation
from esophagus into pharynx
Esophagus
 Three



Heart burn
Dysphagia
Chest pain
 Three



symptoms
operations
Antireflux repair
Esophagectomy
Esophageal myotomy
Dysphagia






Difficulty in swallowing is a WORRYING
symptom; precise symptom that must never be
ignored
Clinical history is most important
Progressive dysphagia with progressive weight
loss are suggestive of malignancy
Intermittent dysphagia implies motility
disturbance
Investigations must be thorough and quick
First comes diagnosis, then comes treatment
Investigations for Dysphagia







Focused clinical history, present and past
Physical examination is of secondary importance
– begin with mouth, examine neck for
supraclavicular lymph nodes, goitre, abdomen
for hepatomegaly, ascites
CXR
Barium swallow and UGI study
Upper GI endoscopy and mucosal biopsy
Esophageal function assessment – manometry
study if motility disorder is suspected
CT scan chest and abdomen
Implications of Delayed Diagnosis

Failure to thrive and weight loss
 Recurrent aspiration pneumonia




Bronchiectasis
Lung abscess
Lung fibrosis
Empyema

Retention esophagitis
 Local extension of cancer


Aortic-esophageal fistula
Tracheal-esophageal fistula
Dysphagia – Case 1

1.
2.
3.
A barium swallow was
performed on this
elderly 80-year-old man
who had difficulty in
swallowing.
What is the diagnosis?
What are the two
important reasons for
treatment?
What treatments are
possible?
Zenker’s Diverticulum




Pharyngoesophageal Diverticulum in the Neck
Dysphagia and Recurrent Pulmonary Aspiration
Treatment is always Surgical
Cricopharyngeal Myotomy






Myotomy alone (if small)
Myotomy plus diverticulectomy (if large)
Acquired condition – 80% of patients are >50 years age
Pulsion diverticulum
Dysfunction of the UES – cricopharyngeus muscle
Other symptoms are: regurgitation of undigested food,
choking and foul breath
Dehiscence of Killian
Dysphagia – Case 2

The barium study shown
was obtained in a 55 year
old man with a 10 year
history of mild vague
postprandial “indigestion”
and heartburn. Within the
past 6 weeks he has
developed dysphagia for
solid food and 10 lb
weight loss. What is the
next step in his
management?
Mid-Esophageal Stricture


Cancer until proven otherwise
Assessment of patient



Complete history and physical
examination
Heart, Lung, Liver and kidney
function
Assessment of stricture





Esophagoscopy and mucosal
biopsy
Rigid and flexible
bronchoscopy
CT scan chest and abdomen
PET scan
Esophageal U/S
Causes of Esophageal Cancer

Adenocarcinoma


Barrett’s epithelium complicating chronic gastroesophageal
reflux disorder
Squamous cell carcinoma









Excess alcohol and tobacco
Nitrosamines in pickled vegetables and cured meats
Silica in wheat
Fungus
Caustic ingestion
Achalasia
Chronic iron deficiency
Tylosis palmaris et plantaris
Remote radiation therapy to the mediastinum
Gastro-Esophageal Reflux Disorder




Backward flow of gastric juice into the esophagus
Physiological and Pathological
Lower esophageal sphincter is incompetent
Causes

Most common is idiopathic
• Normal LES pressure 15 to 30 mmHg
• <6 mmHg pathognomic reflux disorder
• <10 mmHg reflux often present

After treatment for Achalasia
• Pneumatic dilatation or distal esophagomyotomy




Scleroderma
Esophagogastrectomy
Truncal vagotomy and pyloroplasty
Prolonged Naso-gastric tube insertion
Symptoms of Gastroesophageal
Reflux Disorder

Typical symptoms
 Intermittent, substernal discomfort or burning
sensation
 Within 1 hour of eating, with exercise or recumbent
 Postural regurgitation is most consistent symptom
 Water brash

Atypical symptoms
 Cough, laryngitis, wheezing, pulmonary due to
aspiration
 Dental caries due to loss of enamel
Complications of Pathological
GERD

Esophagus







Proximal airway



Laryngitis
Asthma
Lung


Reflux esophagitis
Chronic blood loss – iron deficiency anemia
Peptic stricture
Epiphrenic diverticulum
Barrett’s epithelium – risk for adenocarcinoma
True Barrett’s ulcer – perforate into mediastinum, thoracic aorta,
pericardium, and airway, penetrate, bleed massively
Recurrent aspiration pneumonia – fibrosis, bronchiectasis, lung
abscess, empyema
Mouth – loss of tooth enamel
Esophagus

Which of the following tests is the most sensitive for the
detection of pathologic gastroesophageal reflux?
a.
b.
c.
d.
e.
acid perfusion (Bernstein) test
barium swallow
24 hr pH monitoring
esophagoscopy
manometric testing
discussion

24 hour pH monitoring is now the gold standard and
the most precise measurement of acid reflux. Normal pH
range 4.1 and 7.0 Reflux episode is present when pH <
4.0
 Endoscopic examination to assess acid-related
esophageal mucosal damage – esophagitis, stricture,
columnar metaplasia
 Barium swallow is for anatomical examination of
esophagus, stomach and duodenum – demonstrate
diverticula, hiatus hernia, esophageal stricture – a road
map for safer endoscopic examination
 Manometric testing of esophagus is done for suspected
motility disorder as a cause of dysphagia and chest pain
 Acid perfusion test will only confirm that esophagus is
sensitive to acid – an attempt to reproduce symptoms
Investigations for GERD

CXR



Barium study




Hiatus hernia
Stricture
Zenker’s diverticulum
Flexible esophagogastroscopy and mucosal biopsy




Fixed hiatus hernia
Pulmonary parenchymal changes from recurrent aspiration
Hiatus hernia
Esophagitis
Columnar lined esophagus – look for Barrett’s epithelium from biopsy
Esophageal function assessment



Manometry
Impedance-pH study
24 hr pH monitoring
Complication of GERD




A 45-year-old man presents
with a history of recurrent
heartburn with occasional
central chest pain, and
frequent episodes of postural
regurgitation of gastric juice
into his mouth. UGI endoscopy
finding is shown.
What is the diagnosis?
Was it necessary to take
mucosal biopsy?
How will the diagnosis
influence future treatment?
Columnar Lined Esophagus





Acquired condition due to
chronic gastroesophageal
reflux
Barrett’s Epithelium – intestinal
metaplasia recognized by
presence of goblet cells
Malignant transformation to
adenocarcinoma
Surveillance is important once
dysplasia is present
High grade dysplasia is
serious; within 2 years
adenocarcinoma develops
Esophagus




A 40-year-old man has
progressive dysphagia and 20
lb weight loss for 6 months. He
had taken antacids regularly
for many years for heartburn
and indigestion.
Esophagoscopy performed for
assessment is shown.
Can you describe the findings?
Are any other tests necessary
for assessment of this lesion?
What is the best treatment?
Adenocarcinoma of Esophagus



Columnar lined esophagus
and distal malignant stricture
Esophageal mucosal biopsy,
CT scan chest and abdomen
or PET scan, esophageal
ultrasound, complete blood
count and serum biochemistry
Esophagectomy and
reconstruction if patient is
operable and cancer
resectable
Esophagectomy
Esophageal Cancer
Incidence of adenocarcinoma is rising – an
explosion
 Gastroesophageal reflux related – not
necessarily acid reflux
 Develops in metaplastic Barrett’s epithelium or
heterotopic gastric mucosa in esophagus
 Always do mucosal biopsy of gastric cardia and
distal esophagus – establish diagnosis of reflux
and columnar transformation

Esophagus

A 50-year-old woman complains of nocturnal
regurgitation and cough, a sour taste in her
mouth, postural regurgitation, and heart burn
for 5 years. She wants to consider an operation
now. Which of the following is/are helpful in
deciding whether to perform antireflux surgery?
1.
2.
3.
4.
5.
failure of medical therapy to control symptoms
incompetent lower esophageal sphincter
presence of reflux related esophageal mucosal
injury
increased esophageal exposure to gastric juice.
all of the above
Emergency in Esophagus




A 67-year-old man has had
intermittent dysphagia, burning
epigastric pain and retrosternal
chest pain after meals for 2
years. For the past 24 hours,
he has been unable to tolerate
anything by mouth. CXR was
done in the ER.
What is the diagnosis?
Does this condition constitute
an emergency?
Can you describe treatment
that is most appropriate?
Emergency in Esophagus

82-year-old woman
 Retrosternal chest
pain, vomiting and
retching for 48 hours
 Similar episodes in
the past 4 years
Emergency in Hiatus Hernia

Risk of Volvulus and Strangulation in incarcerated Type
III or IV hernia
 Early operation is mandatory to preserve stomach and
prevent death from ischemic gastric necrosis and
perforation
 Emergency Room
 Insert naso-gastric tube to decompress of stomach
 Intravenous fluid resuscitation with Ringer’s Lactate
 UGI Endoscopy to evaluate gastric mucosa
• Stomach non-viable ---- urgent gastrectomy
• Stomach viable ---- semi-urgent hiatus hernia repair and
concomitant antireflux repair
Type I
Type II
Type III
Type IV Hernia
Treatment for Hiatal Herniation




Type I
• Most common 85 to 90%
• Operate for severe reflux disorder refractory to optimal
medical therapy for minimum of 6 months
Type II
• Pure type II is rare < 1%. Operate to prevent mortality from
strangulation and ischemic perforation
Type III
• Mixed Type I and II
• More common than Type II 6%
• Needs operation for symptoms of reflux and incarceration
Type IV
• Least common. Entire stomach in the chest with volvulus
• Needs operation
Management of GERD

Medical Therapy is for life





Diet must be modified eating small meals and avoid
late night meals
Antacids
Combination of histamine receptor blocker PM dose
and proton pump inhibitor AM dose
Postural therapy by elevating head of bed 15 cm
Surgical Therapy is for failure of medical therapy

Anti reflux fundoplication
Thoracic Surgical Emergency


A 45 year old man, after a large meal and alcohol,
arrives in the ER complaining of severe retrosternal
and left pleuritic chest pain for 6 hours after a bout of
vomiting and retching. Respiration 28, Pulse 130, BP
90/60, T 38.5
The most likely cause of his illness is
1.
Aortic dissection
2.
Acute pericarditis
3.
Myocardial infarction
4.
Pulmonary embolism
5.
Esophageal perforation
Barium Swallow
Esophageal Perforation

Very serious; high mortality is directly related to
delay in treatment
 Acute septic mediastinitis and sepsis syndrome
 Iatrogenic is more common than post-emetic
perforation
 Operation within 1 hour - resuscitation, drainage
of sepsis in the mediastinum and pleural space,
adequate repair of perforation, broad spectrum
antibiotic for both aerobes and anaerobes, and
nutritional support
Dysphagia




This barium swallow was
performed on a 33-year-old
woman complaining of difficulty
in swallowing both solids and
liquids for 4 years with gradual
worsening over time and 10
lbs weight loss. Regurgitation
of undigested food has
occurred.
What is demonstrated in this xray?
How is this diagnosis
confirmed?
What is the treatment?
Esophageal Motility Disorder





Achalasia with Epiphrenic
Diverticulum
Esophagoscopy is necessary
to assess gastroesophageal
junction – rule out peptic
stricture, leiomyoma, cancer
Esophageal manometry
confirms diagnosis
Preferred treatment - Distal
esophagomyotomy and partial
fundoplication
Pneumatic dilatation carries a
risk of esophageal perforation
of 4%
Achalasia
Achalasia is Greek for “without relaxation” in
which the lower esophageal sphincter fails to
relax before the oncoming bolus of food
 Failure of the sphincter to open is due to lack of
the necessary stimulus of the peristaltic wave
 Motility disorder, neurogenic in origin, related to
changes in the ganglion cells of the Auerbach’s
plexus – degeneration, impaired function, query
autoimmune in origin
 Chronic condition in which treatment is for
palliation of obstruction to swallowing

Manometric Features
Achalasia: Manometric Features
Definitive Diagnosis
Achalasia
LES
Elevated baseline
>45 mm Hg
Incomplete Relaxation*
RP>8 mm Hg
Normal
UES and Upper 1/3 striated
segment of esophagus
ESOPHAGEAL BODY
Absent peristalsis*
Elevated baseline
Complications of Achalasia

Esophageal







Trachea


Obstruction from compression due to mega-esophagus
Pulmonary


Progressive dilatation
Retention esophagitis
Perforation
Epiphrenic diverticulum
Malnutrition
Squamous cell cancer pretreatment and adenocarcinoma posttreatment due to reflux
Recurrent aspiration pneumonia, lung abscess, bronchiectasis, fibrosis
Social

Withdrawn, eats alone
Pseudo-Achalasia due to Cancer in
Gastric Cardia
Mediastinum





This specimen was removed
from anterior-superior
mediastinum in a 45-year-old
woman complaining of
fluctuating weakness in arms
and legs, slurring of speech,
chewing difficulty, drooping of
eyelids.
What is it?
How could it have been
predicted?
Why was it removed?
What condition does the
patient have?
Chest Radiograph
Thymus Gland
 Thymus
gland with a thymoma
 CT scan chest
 Presence of tumour and for treatment of
muscle weakness
 Myasthenia Gravis
Myasthenia Gravis

Autoimmune disorder
 Auto-antibodies against acetylcholine receptors
 Reduced number of receptors destruction>synthesis
 Relationship to Thymus gland
• Atrophic 10%
• Thymoma 8% to 15%
• Hyperplasia 70% to 80%
Mediastinum

The syndrome most commonly
associated with a thymoma is
a.
b.
c.
d.
e.
Myasthenia gravis
Red blood cell aplasia
Aplastic anemia
Hypogammaglobulinemia
Cushing’s syndrome
Parathymic Syndromes

Myasthenia gravis



Myositis dystrophica

Myocarditis

Dilated cardiomyopathy
12%

Mucocutaneous candidiasis

Non-thymic malignancies
Red cell aplasia



Hypogammaglobulinemia


30-45%
Favourable prognostic factor
5%
Autoimmune hemolytic anemia
Hemoptysis
 Coughing
up blood
 Differentiate between hemoptysis,
hematemesis, epistaxis, bleeding from
gums
 Clinical assessment
 CXR
 Bronchoscopy
 Chest CT scan
Massive or Life-Threatening
Hemoptysis
The Ottawa Experience
90 Patients
F. M. Shamji MBBS, FRCSC, FACS
Division of Thoracic Surgery
Ottawa Hospital
University of Ottawa, Canada
Airway Hemorrhage
Definition
MASSIVE HEMOPTYSIS
Cause of Death
Asphyxiation
> 600 mL blood loss in 24 hours
EXSANGUINATING HEMOPTYSIS
> 1000 mL blood loss in 24 hours
> 150 mL blood loss per hour
Hypotension and
Asphyxiation
Asphyxiation
It takes only 150 mL of blood in
the bronchial tree to produce lifethreatening hypoxemia, if it is
brisk
DEAD SPACE VOLUME
The Outcome of Significant Airway
Hemorrhage
Rate of Bleeding and Underlying Lung Function
versus
Timely Specific Treatment
Airway Hemorrhage - Etiology I
Cause of Bleeding
Number of
Cases (42)
Lung Cancer
20
Lymphoma
2
Bronchiectasis
10
Retained aspirated foreign body
2
Acute pulmonary tuberculosis
1
Tracheo-innominate artery fistula
1
Lung abscess
3
Mycetoma
3
Airway Hemorrhage - Etiology II
Cause of Bleeding
Vascular
Number of
Cases (48)
22
Catheter related pulmonary artery rupture
10
Erosion of subclavian artery – mucormycosis
1
Aortobronchial fistula – thoracic aortic aneurysm
1
Erosion of prosthetic aortic graft
4
AV Malformation – bronchial, pulmonary
1,5
Post FNA – thrombocytopenia
1
Post bronchoscopic biopsy
1
Unknown
2
Airway Hemorrhage - Etiology

Third World Population

N=123 cases of Life-Threatening Hemoptysis

Inflammatory Lung Disease N=101
 Active pulmonary tuberculosis 47
 Bronchiectasis 23
 Chronic necrotizing pneumonia 11
Source of Bleeding in Significant
Airway Hemorrhage

Bronchial arterial circulation

Non-bronchial arterial circulation

Pulmonary arterial circulation

Thoracic aorta

Innominate artery
Lung Cancer in USA - 2004
New
Cases
Rank
Deaths
Rank
Male
93,110
2
91,930
1
Female
80,660
2
68,510
1
Total
173,770
3
160,440
1
Cell Types
 Small
cell 25%
 Non-small cell 75%
50% adenocarcinoma
30% squamous cell
15% large cell undifferentiated
5% bronchiolaveolar, mixed
adenosquamous
Risk factors







Tobacco smoking - greatest risk factor
Prior surgery for lung cancer
Occupational exposure to asbestos, uranium
and nickel mining
Prolonged exposure to high-level of radon –
ubiquitous radioactive gas
A history of other previous head and neck
cancer
High dose ionizing radiation
Molecular Genetics
Carcinogens in Tobacco Smoke



Polycyclic aromatic hydrocarbons -benzopyrene
Polonium 210
Phenol derivatives
• 87% of lung cancers occur in active smokers
• Amount of daily smoking
• Tendency to inhale
• Duration of smoking habit
• 10-fold to 60-fold greater risk in smokers compared
to non-smokers
Diagnosis
 CT
scan chest
 Bronchoscopy for central mass,
atelectasis
 Fine needle aspiration biopsy for
peripheral lung lesion
 Sputum cytology
Cavitating lung mass




A 55-year-old man is
complaining of persistent
cough and mild
hemoptysis for 2 months.
CXR is shown
What is the differential
diagnosis?
What tests will be helpful
in establishing diagnosis?
Solitary Pulmonary Nodule



A 39
year old man with
recent onset of severe
headaches and
depression is found to
have a 3 cm nodule in the
RUL. He has been a 1
pack per day smoker for
24 years.
What are the causes of
SPN?
How will you establish the
diagnosis?
CT scan Brain




Lung FNA biopsy
confirmed
adenocarcinoma
What additional tests are
necessary?
How much delay in
management is
acceptable?
Which services need to
be consulted?
Right Arm Pain




A 55-year-old man has
pain in the right arm,
anterior chest and axilla
for 6 months. He has
smoked for 25 years.
Treated for shoulder
bursitis, cervical spine
disease, muscle strain
What do you think he
has?
What tests will you order?
Pancoast Tumour






FNA biopsy lung lesion
CT scan chest, abdomen,
head
MRI chest and head
Nuclear bone scan
PET scan
Bronchoscopy and
cervical mediastinoscopy
to complete staging
Pancoast Tumor

Mass at the extreme apex of the lung within
thoracic inlet area
 Pain



Intercostal nerves
Lower Brachial plexus C8 and T1
Bone invasion – ribs, vertebral body
Horner’s syndrome
 Advanced local tumour-invasion through
intervertebral foramen into spinal canal, higher
brachial plexus, subclavian vessels

Staging of Lung Cancer
 Why
stage cancer?
• Staging determines treatment
• Staging determines prognosis
• Staging allows assessment of efficacy of treatment
for each stage of the disease
• Staging allows comparison of treatment for
different stages of disease between different
centres
Staging of Cancer

Pre-operative
•
•
•
•
•
•
Clinical assessment
CXR
CT scan chest, upper abdomen, and head
Nuclear bone scan
FNA – lung, neck lymph node if palpable, new skin nodule, soft tissue mass
Mediastinal lymph node biopsy – cervical mediastinoscopy and left anterior
mediastinotomy
• Bronchoscopy – lobar obstruction, tracheal carina involvement

Intra-operative
• Lung mass – location, size, relationship to fissures and visceral pleura
• Pleural space
• Lymph nodes

Post-operative
• Surgical pathology – tumour cell type, differentiation and size, resection
margins, visceral pleura invasion, lymph node status, local invasion parietal
pleura and/or ribs
• Follow-up for minimum 5 years
Non-Small Cell Lung Cancer
Staging
Treatment for NSCLC
Stage
Localized
IAB + IIAB
Intention
Treatment
Cure
Surgery + CT;
add CT to
increase by 10 –
15% for IB and II
Loco-Regional
IIIA + IIIB
Depends
Induction +
Surgery
Concurrent CT +
RT
CT alone
Metastatic
IIIB Pleural + IV
Palliative
BSC +/- CT
Treatment for Non-small cell lung
cancer

Surgical and it must be Complete Resection
 Stage Ia and Ib –Surgery
 Stage IIa and IIb – Surgery
 Stage IIIa – potentially surgical, needs induction therapy
 Stage IIIb – potentially not surgical
 Stage IV – not surgical but one exception when it is
stage IV only in the brain, the brain metastasis is solitary
and resectable, and the primary tumour in the lung is
localized and mediastinum is normal
Small Cell Lung Cancer





20-25% of cell types
<1% occur in non-smokers
Most common cause of paraneoplastic
syndromes – SIADH (water intoxication), ectopic
ACTH (biochemical cushing’s syndrome),
neuropathies, Eaton-Lambert syndrome
Aggressive cancer, often advanced disease at
presentation – stage IV
Most chemo-sensitive and radio-sensitive
Small Cell Lung Cancer Staging

Very Limited Disease
 Confined only to one lung
 Mediastinum is normal
 Limited Disease
 Confined only to one lung and nearby lymph nodes,
broncho-pulmonary and/or mediastinal
 Extensive Disease
 Intra-thoracic spread beyond one lung and lymph
nodes or extra-thoracic spread
 Recurrent Disease
 Tumor has recurred in the same lung and/or another
part of the body
Small Cell Carcinoma

Chemotherapy and/or radiotherapy
 Very limited disease
• induction chemotherapy and then surgery
 Limited disease
• confined to the ipsilateral chest – lung and
mediastinum within field of radiotherapy
• Without treatment fatal within 4 to 6 months
• With treatment median survival 22 months and/or
cured
 Extensive disease – systemic
• Without treatment fatal within 12 to 14 weeks
• With treatment median survival 10 to 12 months
Para-neoplastic manifestations
TRAUMA: A KILLER
ON THE LOOSE
“The public feels that if they go into any
emergency room, they are in the hands
of Jesus. They don’t realize how true
that is.”
Trauma takes its toll
“ They often arrive in the middle of the
night – when the streets are angry
and the dark city terrors stalk innocent
prey. Or mangled in highway accidents. Or
badly injured in accidents at home or work.
They are trauma victims. And
most of them won’t live to see the
coming of dawn.
Thoracic Trauma
 Chest
injuries account for 50% of civilian
deaths due to trauma
• 25% direct cause of fatality
• 25% contributing factor
 <15%
of patients with chest injury need
urgent chest operation
 >85% are adequately treated by
resuscitative measures, assisted
ventilation, and inter-costal chest drainage
Thoracic Trauma
Loss of function is the abnormality
 Normal function of the Thorax
 Protection of internal viscera
 Preservation of vital function


Lung ventilation, perfusion, and gas exchange,
Cardiac pump, tissue perfusion, and oxygen transport
Damaged organs  loss of normal function
 Thorax is the vital pump

Thorax the Vital Pump
Requirements for Normal Respiration
 Normal respiratory centre and neuromuscular
mechanism
 Chest wall that is both intact and mobile
 Intact ribs, sternum and diaphragm
 Pleural cavity that is not encroached upon
 Lungs that are both mobile and resilient
 Unobstructed air passages
 Normal alveolar-capillary membranes
Thorax the Vital Pump
Requirements for Normal Circulation
 Normal myocardium
 Intact cardiac valves and septa
 Normal intrinsic cardiac rhythm
 Normal pericardial space
 Adequate blood volume
 Normal sympathetic response
 Adequate oxygenation and normal acid-base
and electrolyte balance
Why is Thorax the Vital Pump?

All life depends on oxygen-a constant supply
that is needed at a rate of 250ml/min at rest and
more in illness
 For every 1 ml of oxygen used up, 0.8ml of
carbon dioxide is produced – a waste for the
human body that must be regulated
 Constantly fighting acidosis –to maintain pH 7.4
requires integrated function: circulation,
respiration, buffer system, and renal function
Thoracic Trauma
Pathophysiology – Disturbance of function
Acute chest wall pain
Changes in chest wall compliance and mechanics
Unstable chest wall
Chest wall defect
Altered pleural pressures
Increased work of breathing
Lung parenchymal damage
Retained bronchial secretions
Acute cardiovascular alterations
Airway injury
Rib Fracture





A single rib fracture in patient with pre-existing
compromised lung function may precipitate
respiratory failure
Severe emphysema
Paralyzed hemi diaphragm
Previous extended pulmonary resection
Acute chest wall pain




Impaired cough
Retention of secretions
Atelectasis and V/Q mismatch
Respiratory failure
Consider Thoracic Trauma on
Anatomical Basis
Familiar with anatomy of the thorax
 Chest wall
•
•
•
•

Soft tissues
Ribs, single or multiple
Pleura
Sternum and Thoracic Spine
Internal structures
•
•
•
•
•
Lungs
Heart
Major vessels
Esophagus
Diaphragm
Consider Thoracic Trauma on
Anatomical Basis
Cannot dissociate a specific chest injury from one
or more injuries of neighbouring structures
 Diaphragm rupture
• Pelvic bone fracture
• Lower rib fractures
• Abdominal visceral injury: Liver on right, Spleen on left

Fracture of sternum
• Thoracic aortic rupture
• Myocardial contusion
• Thoracic spine fracture at T4 – T5

Flail chest injury
• Multiple rib fractures
• Hemothorax and/or pneumothorax
• Lung contusion
Thoracic Trauma
 Important


Direct cause in 25%
Contributing cause in 25%
 Early



mortality is related to
Hypoxia
Hypotension
 Late

cause of death
mortality is related to
Sepsis
Multiple organ failure
Priorities in Thoracic Trauma
 Establish
patent airway
 Restore circulation and oxygen transport
 Occlude sucking chest wound
 Drain pleural space
 Re-expand lungs
 Stop bleeding
 Stabilize chest wall
 Evaluate ventilation – arterial blood gases
Seven Immediately LifeThreatening Chest Injuries
 Proximal Airway
Obstruction
 Open Pneumothorax
 Flail Chest
 Massive Hemothorax
 Tension Pneumothorax
 Cardiac Tamponade
 Air Embolism
Six relatively Life-Threatening
Chest Injuries
 Tracheal-Bronchial
rupture
 Pulmonary Contusion
 Diaphragmatic rupture
 Major vascular injury
 Esophageal Perforation
 Myocardial Contusion
Chest Trauma

A 55 year old man involved in a car accident has been placed on
assisted ventilation because of severe head injury. He was noted to
have bruising and surgical emphysema on the right lateral chest wall
but no pneumothorax. The ventilator setting is rate 16/min, tidal
volume 500 mls, FIO2 of 40%, and PEEP of 10 cm of water
pressure. He develops sudden tachycardia, hypotension, increase in
airway pressure, and hypoxia. The most likely cause is
a.
b.
c.
d.
e.
open pneumothorax
systemic air embolism
cardiac tamponade
tension pneumothorax
myocardial contusion
Chest Trauma

The most common physiologically significant injury
resulting from blunt chest trauma is
a.
b.
c.
d.
e.
flail chest
pulmonary hematoma
subcutaneous emphysema
pulmonary contusion
diaphragm rupture
Chest Trauma

A 24-year-old man is brought into the ER after a fall from
a ladder. His breathing is laboured, and he is cyanotic.
He is complaining of right chest pain. There is
subcutaneous emphysema on the right side. No breath
sounds can be heard in the right lung field, which is
hyper-resonant to percussion. Among the following
choices, the most appropriate next step in his
management is:
a. obtaining a stat chest X-ray
b. insertion of an endotracheal tube
c. cricothyroidotomy
d. stat arterial blood gas analysis
e. immediate needle decompression followed
with chest tube insertion
Indications of Severity in Chest
Trauma
 Multiple
rib fractures
 Sternal fracture
 1st rib fracture
 Diaphragm rupture
 Flail chest injury
 Open pneumothorax
 Massive hemothorax
 Laryngeal fracture
Open Pneumothorax

Penetrating wound of the chest wall



Ipsilateral lung collapse
Inability to generate negative intra-thoracic pressure
Often concomitant lung parenchymal injury
 Acute ventilatory failure
 Treatment: in the ER apply occlusive dressing
over the chest wall wound or endotracheal
intubation and assisted ventilation
Penetrating Chest Wall Wound
Open Pneumothorax
Pathophysiology
Open Pneumothorax






Sucking chest wound
Chest wall is breached and pleural space has
become real.
Open pneumothorax  acute ventilatory failure
Acute life-threatening state; act fast in the ER
Cover defect with sterile occlusive dressing
immediately followed by chest tube insertion
Immediate endotracheal intubation and assisted
ventilation
Open Pneumothorax - Disturbance
of Respiration
Breach in Chest Wall
 If breach in chest wall is large these effects 
death occurs rapidly
 I f breach in chest wall is small, effects are
less serious and outcome will depend on vital
capacity
 Adhesions in pleural space will prevent lung
collapse and so minimize these effects.
Airway Obstruction
A
A
AIRWAY
A
A
Acute airway obstruction kills
in
5 minutes
Airway Obstruction

Foreign body, vomitus or blood in the
oropharynx
 Severe maxillofacial trauma
 Fracture of the larynx
 Treatment




Remove foreign body from mouth
Suction out blood or vomitus
Establish airway by controlled intubation
Cricothyroidotomy in selected cases
Blunt Laryngeal Injury
Chest Trauma: Emergency Airway
Options

Oro-tracheal or naso-tracheal intubation
(stabilize C-spine)
 Fibre-optic Intubation
 Cricothyroidotomy
Flail Chest Injury

Damaged painful unstable chest wall




Impaired cough
Impaired breathing
Retained secretions  retention atelectasis  V/Q
mismatch  hypoxia
Inefficient ventilation
Lung contusion  Hemorrhagic, edematous,
non compliant lung  increased capillary
permeability  V/Q mismatch  hypoxia
 Abnormal pleural space with pneumothorax
and/or hemothorax  compressive atelectasis
 V/Q mismatch

Flail Chest
Management of Flail Chest Injury

Isolated injury or component of multiple injuries
 Severe chest injury
 Fractures of multiple ribs at two or more sites
 Recognized by paradoxical respiration
 Treatment: multiple injuries



Control ventilation and correct hypoxia
Pain control, relieve hemo-pneumothorax, restrict fluids
Treatment: isolated injury


Admit to a monitored location trauma unit or intensive care unit
Optimum pain control, physiotherapy, bronchodilators, relieve
hemo-pneumothorax
Treatment of Flail Chest Injury


Do not underestimate its seriousness
Isolated injury with correctible hypoxia


Isolated injury with respiratory failure


Manage in ICU with good pain control, restrict fluids,
bronchodilators, monitor for ventilation and gas
exchange, chest physiotherapy, supplemental oxygen
Manage in ICU with endotracheal intubation and
assisted ventilation
Multiple injuries

Manage in ICU with endotracheal intubation and
assisted ventilation
Chest Wall Injury
Fractures and Soft Tissue Injury
Acute chest wall pain
 Chest wall and Lung expansion impaired
Effects: poor ventilation and unstable alveoli
leads to progressive alveolar collapse
 Impaired cough and mucociliary system
Effects: inability to clear air passages of
mucoid bronchial secretions with resultant
progressive retention segmental or lobar
collapse
Chest Wall Injury
Fractures and Soft Tissue Injury
Acute chest wall pain
 Cannot breathe deeply
 Cannot cough well



Retention of bronchial secretions
Increased work of breathing
Retention atelectasis  V/Q mismatch 
hypoxia and fatigue
Acute Chest Wall Pain
 Demands
immediate control
 Must restore ability to breathe well and
cough well to protect the lungs against
retention atelectasis
 Oral opiods and NSAIDS
 Intercostal nerve blocks
 Epidural analgesia – most effective
 Watch out for respiratory depression
Underlying Lung Parenchymal Injury
Lung contusion – “lung bruising” - intra-alveolar
bleeding and increased capillary permeability
Effects: impaired diffusion  hypoxia
 Surface lung laceration – leakage of air and
blood into pleural space
Effects: impaired lung expansion  hypoxia
 Deep lung explosive tears – bleeding into
cavities, pulmonary hematoma
Effects: obstruction of peripheral air
passages due to blood clots causing segmental
or lobar collapse  hypoxia and hemoptysis

Increased work of breathing

Adverse changes in lung and chest wall
compliance
reason: injury to the lung and chest wall
 Impaired inter dependency of lung and chest
wall
reason: altered pleural pressures
 Increased airway resistance
reason: reduced lung volume, contraction of
bronchial smooth muscle, retained
secretions and blood clots in the air
passages
Increased work of breathing





Increased metabolic demand
Hypoxia
Chest wall muscle spasm for splinting rib
fractures
Respiratory muscle fatigue and oxygen debt
Respiratory failure
Hemothorax
Intra-thoracic Bleeding
Low pressure
Pulmonary parenchyma
Stops with lung expansion
Self-limiting
High pressure
Systemic vessels
Arteries – ICA, IMA, Aorta,
IA, LSA, LCA
Veins – AV, SVC
Persistent
Hemothorax






Radiologic diagnosis
CXR and CT scan
Insert large bore chest
tube – 28F or 32F
Measure initial blood loss
Monitor drainage for next
3 hours
Repeat CXR after tube
insertion
Hemothorax

Bleeding into the pleural space is of two types
 Low Pressure versus High Pressure


Low Pressure Bleeding is from torn lung
parenchyma and it stops spontaneously with lung
expansion. Self Limiting
High Pressure Bleeding is from systemic arteries
and veins and it is continuous. Not Self Limiting
Massive Hemothorax
 When
is urgent thoracotomy necessary?
 Initial blood loss is > 1500 mls

8% of body weight is blood volume
 Persistent
bleeding at 300 mls/hour for 3
consecutive hours
 Large amount of retained blood clots on
CXR inspite of adequate chest tube
drainage
Hemothorax

Pleural space can accommodate large amount
of free and clotted blood >1.5L
 Hypotension from loss of circulating volume and
tension effect
 Hypoxia from compressive atelectasis
 High pressure bleeding


Systemic, persistent
Low pressure bleeding

Pulmonary parenchymal, self-limiting
Hemothorax








Insert a large bore chest tube # 32F
Measure initial blood loss
CXR lung expanded, unevacuated clotted
blood
Monitor for on-going bleeding and recognize lifethreatening situation
> 500 ml in 1 hr
> 400 ml/hr for 2 hrs
> 300 ml/hr for 3 hrs
Action: Urgent Thoracotomy to stop bleeding
Thoracic Trauma





The CXR was taken in
the ER of a patient
involved in a MVA. He is
complaining of severe
pain in the right chest and
unable to breathe.
What does it show?
What did it arise from?
Why is it life-threatening?
What treatment is
required?
Tension pneumothorax

Any closed pneumothorax has the potential to
become tension type under the right
circumstances – persistent coughing, positive
pressure ventilation in ICU, under GA
 Life-threatening due to combination of


Hypoxia – collapsed ipsilateral lung and compressed
contralateral lung
Hypotension – impaired venous return, low stroke
volume, low cardiac output
Immediate Treatment is Necessary
Pneumothorax
TENSION
SIMPLE
Tension Pneumothorax

Treat immediately and do not wait for CXR
confirmation
 Decompress affected pleural space with large
gauge needle followed by insertion of
intercostal chest tube
 Tension Pneumothorax is a clinical diagnosis
 CXR is not needed
 Remember – in chest injury can get bilateral
tension pneumothoraces and tell-tale
mediastinal shift will be absent
Tension
Pneumothorax

Pressure in pl. space
exceeds ambient press.
Causing a net positive intra
thoracic pressure.
 Most commonly caused by
PP ventilation
 May occur in spontaneously
breathing patient.
 Characterized by
mediastinal shift,
compression of functional
lung and decrease in
venous return.
Question

A young 18-year-old man is brought to the ER
with closed head injury and blunt chest trauma.
He has multiple rib fractures on right side with
surgical emphysema, and small traumatic
pneumothorax. He is hypoxic and O2 saturation
is 82% on supplemental oxygen. Assisted
ventilation with positive end-expiratory pressure
is initiated and soon thereafter there is sudden
occurrence of hypotension.
 What is the most likely cause of hypotension?
Tension Pneumothorax
Acute Cardio-Pulmonary Collapse





Tension Pneumothorax
Air continues to leak from lacerated lung or ruptured
bronchus into the pleural space because of high airway
pressure – result of coughing or positive pressure
ventilation
Life-threatening due to combination of
 Hypotension
 Hypoxia
Treat immediately and do not wait for CXR confirmation
 First insert large gauge needle and then intercostal
chest tube
Tension Pneumothorax is a clinical diagnosis
Tension Pneumothorax
Tension Pneumothorax
 Combination
of hypoxia and hypotension
is life-threatening
 Need immediate decompression by
insertion of large bore needle followed by
insertion of intercostal chest tube
Blunt Thoracic Trauma





A young man was involved in a
high speed head-on accident
with another car. The
aortogram performed after
CXR indicates a dangerous
situation, as arrowed.
What is it?
What causes it?
What treatment is required?
What are the clinical and the
chest radiographic signs that
suggest presence of this
injury?
Thoracic Aortic Injury
Thoracic Aortic Injury

Clinical indicators of
severe chest injury
are



Sudden deceleration
force
Fractures of multiple
ribs, scapula, sternum,
first rib
Suspicious CXR
findings
Who should be screened for Thoracic Aortic
Injury?

1.
2.
3.
4.
5.
6.

1.
2.
3.
4.

1.
2.
3.
4.
Patient with an abnormal mediastinal silhouette on CXR:
loss or irregularity of aortic knob contour
widened superior mediastinum (> 8 cm)
depression of left main stem bronchus (> 140 degrees from trachea)
lateral tracheal deviation
rightward deviation of nasogastric tube
Apical cap and/or hemothorax
Patient with a significant mechanism of injury (irrespective of CXR
appearance)
crushed steering wheel
ejection from vehicle
fall > 5 meters
major lateral chest impact
Any patient with associated injuries including
sternal fracture
multiple rib fractures
scapular fracture
first or second rib fracture(s)
Thoracic Aortic Injury

Transection of the aorta at the junction of mobile
aortic arch and fixed descending aorta
 Deceleration injury
 Emergency operation to repair ruptured aorta
 Rule of 85: 85% of victims die at the site of
accident from bleeding, 15% reach hospital alive
and if missed 85% will die in the first week, and
in 85% the site of injury is just distal to left
subclavian artery
Thoracic Aortic Injury





Can you name 6 radiological features of
Thoracic Aortic Injury on plain chest x-ray?
Do you know the clinical signs of this injury?
Why do 85% die at the site of accident?
What percentage of the 15% who reach the
hospital alive will die in the next 7 days if
missed?
What is the site of 85% of this injury and why?
Thoracic Aortic Injury

20% of all MVA
fatalities
 85% dead at the site
of accident
 85% dead with 1
week
 85% of tear at the
ligamentum
arteriosum
Trauma takes its toll
“ They often arrive in the middle of the
night – when the streets are angry
and the dark city terrors stalk innocent
prey. Or mangled in highway accidents. Or
badly injured in accidents at home or work.
They are trauma victims. And
most of them won’t live to see the
coming of dawn.
Chest Trauma: Indications for O.R.

Hemothorax




1500 ml
Ongoing bleed
Persistent shock
despite
resuscitation
Documented or
suspected injury
to airway or
esophagus
 Impalement
Massive Hemothorax
Circulation

Massive bleeding: loss of >20% circulating blood
volume
effect: hypotension, impaired oxygen transport,
metabolic acidosis and impaired cardiac function
 Severe cardiac injury: myocardial contusion,
valve rupture, septum rupture
effect: arrhythmias, acute heart failure
 Cardiac Tamponade: as little as 150-200 ml
bleeding into pericardial space is serious
effect: acute hypotension due to impaired
venous return
Cardiac Tamponade

Life-threatening state
 Beck’s triad




Hypotension
Raised JVP
Small quiet heart
Rapid accumulation of 150 to 200 ml of blood in
the pericardium can be fatal
 CXR not diagnostic
 Urgent pericardiocentesis is necessary
Intrapericardial
Pressure (mm Hg)
Cardiac Tamponade and
Chronic Pericardial Effusion
Rx-Cardiac Tamponade

If pt. stable: subxiphoid
pericardial window under G.A.
 Extraperitoneal via midline
incision or transperitoneal at
laparatomy.
 Be prepared for immediate
med.sternotomy.


If unstable: Lt. Anterolateral
Thoracotomy.
Minor-pledgeted sutures
 Major-CP bypass.
 Survival for simple injury
>60%
Traumatic Pneumothorax




Insert 28F or 32F chest tube and expect lung to expand
immediately
If you find massive air leak from chest tube  question
What is the reason?
 Fault with chest tube insertion
 Fault with connections or drainage system
 Large lung laceration
 Rupture of tracheal-bronchial tree or esophagus
 Unrecognized penetrating chest wound
Action: stop suction, examine chest tube insertion site,
examine all connections and drainage bottle, immediate
CXR, urgent bronchoscopy for airway injury and if
present, urgent operation
Thoracic Trauma
Clinical shock
Neck veins flat
Massive Bleeding
Neck veins distended
Tension pneumothorax
Cardiac tamponade
Cardiac valve rupture
Cardiac septum rupture
Systemic air embolism
Chest Trauma
Pitfalls for the unwary

Is there a chest injury
which is associated with
pelvic fracture?
Diaphragmatic
Rupture
Air - Closed Pneumothorax
 Encroachment




on pleural cavity by air
Introduced from outside by injury or operation
Following injury to the lung or trachealbronchial tree
Spontaneous either primary in the absence of
underlying lung disease or secondary to a
recognized lung disease
Perforation of esophagus
Pneumothorax


Classification
Spontaneous





Traumatic



Primary
Secondary
Catamenial
Neonatal
Chest injury: blunt and penetrating
Iatrogenic: FNA, thoracentesis, faulty chest tube removal,
perforation of esophagus, CVP line insertion, pacemaker
insertion, barotrauma from positive pressure ventilation
Diagnostic
Dangerous situation

If clinical examination confirms presence of
pneumothorax and patient has


Severe shortness of breath, low BP, tachycardia, and dilated
neck veins  Tension Pneumothorax. Clinical diagnosis. CXR is
not necessary for confirmation. Immediate decompression in ER
is necessary
Low volume state – low BP, pallor, low hemoglobin, tachycardia
 Hemo-pneumothorax and immediate resuscitation. CXR is
necessary, chest tube insertion in ER, and prepare for
thoracotomy.
Pneumothorax – Disturbed
Physiology and Lung Function



Limitation of lung expansion  inadequate ventilation,
the severity of which will vary with the extent of
encroachment and vital capacity of the patient
Failure to expand lung fully early  will result in
formation of fibrinous exudate in the pleural cavity and
on lung surface  fibrosis which may fix the lung in
compressed position and impair function
Tension effect - impaired ventilation and venous return to
the heart  hypoxia and hypotension, a life-threatening
state
Primary Spontaneous
Pneumothorax





Tall, thin body habitus
Young < 40 yrs
5M:1F
Rupture of apical bleb (<1cm) or bulla (>1cm)
Bleb forms from rupture of apical sub-pleural
distended alveolus  collection of air bubble
within layers of visceral pleura
 Bulla forms from tractional emphysema due to
apical scarring
Secondary Spontaneous
Pneumothorax

Underlying lung pathology








COPD -Emphysema
Infections - necrotizing pneumonia, abscess,
tuberculosis, pneumocystis carinii pneumonia
Lung metastases – subpleural
Histiocytosis X
Cystic fibrosis
Sarcoidosis
Collagen disorders – scleroderma, rheumatoid
arthritis
Lymphangioleiomyomatosis - LAM
Clinical Presentation
 Absence
of precipitating factors
 Emergency Room
 Sudden onset of pleuritic chest pain
 Shortness of breath
 O/E hyperinflated chest, tympanitic chest,
absent air entry
Clinical Presentation symptoms
 Acute
pleuritic type chest pain
 Dyspnea – worse particularly if underlying
lung disease
 Hypotension and severe dyspnea
indicating life-threatening tension
pneumothorax
Clinical Presentation - signs
 Affected



hemithorax
Hyperinflated
Tympanitic
Reduced air entry
 Low
blood pressure, cyanosis, mediastinal
shift, and dilated neck veins indicating lifethreatening tension quality
Radiology
 Chest
X-ray – inspiration and expiration
films
 Size estimation
 Presence of underlying lung disease
 Associated hemothorax
 CT scan chest in recurrent
pneumothoraces
Management

Observation




Mild symptoms
No progression
Size is small: <20%, <4cm from apex, <1cm from chest wall 
expect spontaneous resolution at rate of 1.25%/day
Intercostal chest tube drainage





Size is large: >20%, >4cm from apex, >1cm from chest wall
Tension quality
Progression noted
Undergoing general anesthesia
Goal is to relieve symptoms and permit early full re-expansion of
lung
Results
 Early

5-10% will require surgical intervention
because of prolonged air leak beyond 3 days
 Long

term
with conservative treatment recurrence after
1st episode 15-20%*, after 2nd episode 40 50%, after 3rd episode 80%
* usually within 2 years, 75% ipsilateral
Indications for chest tube
insertion in Pneumothorax








Large size at initial presentation
Increasing size
Symptomatic
Associated hemothorax
Undergoing general anesthesia
Bilateral
Tension quality
Contralateral
Indication for Surgery










First episode with prolonged air leak > 3 days
2nd or 3rd recurrence on same side
1st occurrence on contra-lateral side
Associated hemothorax >1000mls
Associated pleural sepsis
Incomplete re-expansion
Occupational risks
Synchronous bilateral
Life-threatening episode
Patient living in remote areas
Therapeutic Options
 Apical
bullectomy and parietal
pleurectomy


Video-assisted thoracoscopic approach
Limited thoracotomy
 Chemical


pleurodesis - elderly
Talc
Tetracycline
Traumatic Pneumothorax
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




Barotrauma from positive pressure ventilation
Insertion of central venous lines, pacemaker
leads
Cervical lymph node biopsy
Percutaneous and transbronchial lung biopsy
Perforated esophagus – post-emetic or
instrumental
Chest injury with rib fracture causing lung
laceration or tracheal-bronchial tear