APPROACH TO THORACIC
AND CARDIAC DISEASESURGEONS POINT OF VIEW
Emmanuel C. San Pedro, M.D.
Fellow, PCS
Fellow, PATACSI
Anatomic considerations
 Sternal Angle of Louis
 2nd rib attachment, a point from which to count
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the ribs
end of the ascending aorta and the beginning of
the aortic arch.
end of the aortic arch and the beginning of the
descending thoracic aorta.
bifurcation of the pulmonary artery into right and
left pulmonary arteries
bifurcation of the trachea
level between t4 and t5 vertebral bodies
Midclavicular line
Midsternal line
Parasternal line
Anterior axillary line
Vertebral line
Tip of the scpula
Midscapular line
 a triangle of
auscultation
 lateral border of
the trapezius
 upper border of
the latissimus
dorsi
 medial border of
the scapula.
 Save for lower
fibers of the
rhomboid
muscles, this
area is free of an
intervening mass
of muscle tissue.
Anatomic considerations
 Vessels/nerves run
underneath the ribs
 Perform surgery above
the rib
Anatomic considerations
 Right lung
 Upper lobe
 3 segments
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Middle lobe
 2 segments
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Lower lobe
 5 segments
 Left lung
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Upper lobe
 4 segments
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Lower lobe
 4 segments
 Lingular division= right
middle lobe
 No medial basal segmentleft
Thorax Anatomy/Physiology
 Primary muscles of respiration
 Diapragm- 75 to 80 % of pulmonary ventilation in quiet
breathing
 Intercostal muscles (external intercostals and anterior
portion of the inner intercostals)- 20 – 25 % of
ventilation in quiet breathing
 Respiratory movement
 Diaphragm can rise up to 4th ICS during expiration-
penetrating injuries up and below this level consider
abdominal injury
Physiologic considerations
 Intrathoracic pressure
 Negative pressure (5 cm H2O lower than that of
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the surrounding atmosphere)
Elastic recoil of the lung encased in a rigid/bony
thorax
Integrity of the thoracic wall is necessary to
maintain negative pressure,
any break (lung, chest wall)- air is sucked in and
lungs collapse
Loss of rigidity- lungs collapse
Physiologic considerations
 Intrathoracic pressure
 End of maximal inspiration- most negative
 Valsalva- most positive, bear down, positive
ressure of abdomen transmiteed to thoracic cavity
preventing pneumothorax
AIR IN THE PEURAL SPACE
 Collection of air
between the chest wall
and lung parenchymapneumothorax
 Upright patient- air
collects in the upper
regions of the thoracic
cavity
AIR IN THE PLEURAL SPACE
 Spontaneous Primary
 Subpleural bleb rupture- most common
 Secondary
 Bullous disease, including chronic obstructive
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pulmonary disease
TB
Metastatic cancer, especially sarcoma
Pneumonia with lung abscess
Catamenial
Asthma, secondary to mucous plugging
Lung cancer
AIR IN THE PLEURAL CAVITY
 Acquired
 Iatrogenic
 Transthoracic needle
biopsy
 Subclavian (percutaneous)
catheterization
 Central lines
 Pacemaker insertion
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Transbronchial lung biopsy
Thoracocentesis
Chest tube malfunction
After laparoscopic surgery
 Barotrauma
 Traumatic
 Blunt trauma
 Motor vehicle accidents
 Falls
 Sports-related
 Penetrating trauma
 Gunshot wounds
 Stab wounds
AIR IN THE PLEURAL CAVITY
 Symptoms
 Dyspnea
 -DEGREE DIRECTLY
PROPORATIONAL TO
SEVERITY OF
PNEUMOTHORAX…
 Cough-NON-
PRODUCTIVE
 Chest pain
 -PLEURITIC
(AGGRAVATED BY
INSPIRATION)
AIR IN THE PLEURAL CAVITY
 PE findings
 Vital signs
 Tachypnea
 Tachycardia
 Hypotension (tension pneumothorax)
 Inspection
 Lag
 Shifting of mediastinal structures (tension pneumothorax)
 Tracheal shift
 Apex beat displacement
 Neck vein distention ( tension pneumothorax)
 Palpation
 Decreased transmission of VOCAL fremiti
AIR IN THE PLEURAL CAVITY
 Percussion
 Hyper resonance
 Ascultatation
 Diminished transmission of spoken words
 Decreased breath sounds
FLUID IN THE THORACIC CAVITY
 Collection of fluid between the chest wall and
lung parenchyma
 Normally- no fluid can be detected by
imaging
 Upright patient
 Fluid collects in the most dependent region of the
thoracic cavity- costophrenic sulci
FLUID IN THE THORACIC CAVITY
 Transudative pleural effusions
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Infection (pneumonia, tb)
Congestive heart failure
Pericardial disease
Cirrhosis
Nephrotic syndrome
Peritoneal dialysis
Fontan procedure
Myxedema
Cerebrospinal fluid leaks to pleura
Sarcoidosis
Urinothorax
FLUID IN THE THORACIC CAVITY
 Exudative pleural effusions
 Neoplastic diseases
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Metastatic disease
Mesothelioma
Primary effusion lymphoma
Pyothorax associated
lymphoma
 Infectious diseases
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Bacterial infections
Tuberculosis
Fungal infections
Viral infections
Parasitic infections
 Pulmonary embolization
 Gastrointestinal disease
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Esophageal perforation
Pancreatic disease
Intraabdominal abscesses
Diaphragmatic hernia
 Collagen vascular diseases
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Rheumatoid pleuritis
Systemic lupus erythematosus
Drug-induced lupus
Immunoblastic
lymphadenopathy
 Sjogren's syndrome
 Wegener's granulomatosis
 Churg-Strauss syndrome
FLUID IN THE THORACIC CAVITY
 Exudative effusion
 After surgical procedures
 Post coronary artery bypass
surgery
 Post cardiac injury syndrome
 Post lung transplantation
 Post liver transplantation
 Post abdominal surgery
 Post endoscopic variceal
sclerotherapy
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Asbestos exposure
Sarcoidosis
Uremia
Meigs' syndrome
Yellow nail syndrome
Drug-induced pleural disease
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Trapped lung
Radiation therapy
Electrical burns
Urinary tract obstruction
Iatrogenic injury
Ovarian hyperstimulation
syndrome
 Chylothorax
 Hemothorax
FLUID IN THE THORACIC CAVITY
 Symptoms
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Dyspnea
Cough
Chest pain
Fever
 PE
 Inspection
 Lag
 Percussion
 Dullness
 Palpation
 Diminished transmission of spoken
words
 Ausculatation
 Decreased breath sounds
 Diminished transmission of spoken
words
Solid in the thoracic cavity
 Non aerated entity occupies the pleural cavity
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Atelectatic lung
Fibrotic lung
Organized pyothorax
Clotted blood
Tumor
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Primary lung malignancy
Metastatic disease
Mesothelioma
Large mediastinal masses
Solid in the thoracic cavity
 Symptom
 Dyspnea
 Cough
 Chest pain
 Fever
 hemoptysis
Solid in the thoracic cavity
 PE
 Inspection
 Loss of lung volume
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Asymmetric chest
Scoliosis
Narrowed intercostal space
Shoulder drop
 Non expanding lung
 Lag or no expansion at all
Solid in the thoracic cavity
 Percussion
 Dullness to flat
 Ascultation
 Non-obstructed bronchus
 Egophony
 Increased transmission of spoken words
 Decreased breath sounds
 Obstructed bronchus
 Stridor , wheezing
 Decreased breath sounds
 Diminished transmission of spoken words
Solid in the thoracic cavity
 Palpation
 Non-obstructed bronchus
 Increased transmission of spoken words
 Obstructed bronchus
 Diminished transmission of spoken words
Fluid in the pericardium
 Pericardial effusion
 Normally- fluid present in the pericardial
space, undetectable by imaging
 Etiology
 Trauma
 Infection (tuberculous)
 Malignancy
 Uremia
 Congestive heart failure
Fluid in the pericardium
 Symptoms- possible findings
 Dyspnea, orthopnea
 Chest pain
 Substernal
 Worsened by supine position
 Relieved by leaning forward
 Edema
 Ascites
Fluid in the pericardium
 PE
 Vital signs
 Tachycardia
 Tachypnea
 Hypotension (tamponade)
 Inspection
 Neck vein distention (tamponade)
 Edema
 Ascites
Fluid in the pericardium
 Auscultation
 Distant/ muffled heart sounds
Congenital heart disease
 Acyanotic
 Cyanotic
 Atrial septal defect
 Tetralogy of fallot (TOF)
(ASD)
 Ventricular septal defect
(VSD)
 Patent ductus arteriosus
(PDA)
 Coarctation
 Transposition of the
great arteries (TGA)
 Tricuspid stenosis (TS)
 Total anomalous
pulmonary venous
return (TAPVR)
 Pulmonic valve stenosis
(PS)
Acyanotic heart disease
 Pathology
 Connection between pulmonary and venous
system (overload of blood in pulmonary system)
 Obstruction in aortic outflow
 Symptom
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Failure to thrive
Poor weight gain
Easy fatigability
Recurrent pulmonary infection
Hypertension (coarctation)
Acyanotic heart disease
 PE
 Vital signs
 Tachypnea
 Tachycardia
 >20 mm hg difference in BP of upper extremity and
lower extremity (post ductal coarcatation)
 Inspection
 Funny looking kid????
 Pigeon breast deformity ( ventricular septal defect)
 Dynamic precordium
 Displacement of apex beat
Acyanotic heart disease
 Palpation
 Heave (forceful ventricular contraction in VSD)
 Thrill
 Auscultation
 Machinery type mumur (Patent ductus arteriosus)
 Systolic Pansystolic, Lower left sternal border
(Ventricular septal defect)
 Bilateral crackles (pulmonary congestion)
Cyanotic heart disease
 Pathology
 diminished blood flow to the lungs (TOF, PS, TS)
 Discordant connection between pulmonic and
systemic circulation (TGA, TAPVR)
 Symptom
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Cyanosis during crying
Failure to thrive
Dyspnea
Easy fatigability
Squatting (tetralogy of fallot)
Cyanotic heart disease
 PE
 Vital signs
 Tachypnea
 Tachycardia
 Inspection
 Cyanosis- circumoral, nailbeds
 Clubbing of fingernails
 Malnourished
 Dynamic precordium
Cyanotic heart disease
 Palpation
 RV heave (TOF)
 Ascultation
 Systolic murmur heard best at left upper sternal
border
 Murmur across the pulmonic valve (TOF, PS)
Valvular heart disease
ACQUIRED HEART DISEASE
Mitral stenosis
 Diseased mitral
valve prevents
normal emptying of
the blood form the
left atrium to the
ventricle during
diastole
 Pressure overload
of left atrium
VALVULAR HEART DISEASE
 MITRAL STENOSIS
 Only known etiology- rheumatic heart disease
 Symptoms
 Cough, hemoptysis
 Orthopnea, PND, dyspnea on exertion
 PE:
 Atrial fibrillation (Irregular heart rate)
 Normal LV dimension
 Auscultatory triad- increased first heart sound, opening snap,
apical diastolic rumble
Mitral Regurgitation
 Leak of blood from the
left ventricle to
through the diseased
mitral vavle back to the
left atrium during
systole
 Volume overload of
left atrium and left
ventricle= LAE, LVE
Mitral Regurgitation
 symptoms
 Acute MR- sudden onset of congestive heart
failure
 Dyspnea, orthopnea
 edema
 chronic MR -symptoms do not develop until later
in the course of the disease when the ventricle
eventually fails, resulting in:
 exertional dyspnea
 decreased exercise capacity
 orthopnea.
Mitral Regurgitation
 PE findings
 Systolic apical murmur transmitted to axilla
 Forceful apical impulse
Aortic stenosis
 Obstruction to
the flow of blood
form the left
ventricle to the
aorta (narrowed
aortic orifice)
 Pressure
overload of the
left ventricle
 Effect: LV
hypertrophy
Aortic stenosis
 Symptoms
 PE
 Exertional dyspnea-
 Systolic ejection
most common symptom
 Angina- develops in 3040 % of patients,
myocardial ischemia
associated with silent
muscle necrosis
 Syncope- 10 % of
patients
murmur- 2nd ICS right
sternal border with
radiation to carotid
artery
 Pulsus parvus at
tardus- pulses pressure
is narrow and sustained
Aortic Insufficiency
 Back flow of blood
from the aorta to the
left ventricle due to
weakened aortic valve
 Volume overload of left
ventricle
 Effect: left ventricular
enlargement (cor
bovinum)
Aortic Insufficiency
 Symptoms
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Dyspnea on exertion- most common symptom
Palpitations
Biventricular failure symptoms
Angina
Aortic Insufficiency
• Auscultatation- systolic ejection murmur, S3 gallop of
heart failure, mid-diastolic rumble in mitral valve area
(Austin Flint murmur)
 Inspection/palapation- widened pulse pressure
 Watson's water hammer pulse - pulse that is bounding
and forceful, as if it were the hitting of a water hammer
that was causing the pulse.
 Corrigan pulse- carotid pulsations seen in aortic
regurgitation, named after Dominic Corrigan . (rapid
upstroke and collapse of the carotid artery pulse)
 Demuset’s sign- head bobbing