CHEST

Begashaw M (MD)

Introduction

Acute upper airway obstruction is a surgical emergency

Infants are vulnerable more than adults

Upper Airway Obstruction

is an obstruction at or above the vocal cord characterized by inspiratory stridor

Etiology Acquired_Inhaled foreign body_Infection_Laryngeal spasm_Trauma to the neck_Vocal cord paralysis _External compression_Malignancy - laryngeal

carcinoma

Congenital_ Laryngomalacia_ Laryngeal or tracheal

web and stenosis_Subglottic tumour_ Aberrant vessels_ Adenoids

CLINICAL FEATURES

stridor (noisy breathing)suprasternal retractiontachycardia cyanosis

TREATMENT

Tracheostomy Intubation Emergency cricothyroidotomy

CHEST INJURIES

25% of all trauma deaths are a result of chest injuries alone

CLASSIFICATION

1. Blunt trauma - 85% of all chest injuries2. Penetrating trauma -accounts for 15% -Stab & gunshot -results in hemothorax & pneumothorax

Chest trauma

PATHOPHYSIOLOGY

Inadequate delivery of oxygen:1. Ventilation-perfusion mismatch 2. Decreased tidal volume due to pain3. Hypovolemia from bleeding4. Mechanical obstruction due to tension

pneumothorax & cardiac tamponade

INITIAL ASSESSMENT AND MANAGEMENT

Ensuring adequate airwayEnsuring adequate ventilationControl extreme hemorrhage & restore

circulation

Chest wall injuries

Simple rib fracture -Most common injury -less than three rib fractures other than first

and second rib -pain, reduced motion during breathing and

point tenderness -Confirm by Chest x-ray -Pain relief & chest physiotherapy

Major chest wall injuries Flail chest -paradoxical movement of a segment of chest wall -Fracture of four or more ribs at two points Diagnosis: paradoxical chest motion -Chest x-ray-multiple segmental fracture Treatment: Chest physiotherapy, Analgesia, Oxygen

supplement Administer fluid only to restore hemodynamic stability Intubation for PPV

Flail chest

Fracture of 1st , 2nd rib & sternum

considered to be major injuries causes associated injury to underlying

structures like vessels or nerves

Lung contusion

presents with bloody sputum upon coughingDiagnosis: Chest x-ray (parenchymal

opacity immediately after injury & increasing in the next 24-48 hours

Treatment: Pulmonary physiotherapy prevention of fluid load

Diaphragmatic rupture

Mostly occurs on the left side diagnosis needs high index of suspicionDiagnosis: Insert NG tube Auscultate chest Chest x-ray - tube, loop of bowel or fluid level

in the thoraxTreatment: Immediate repair

PNEUMOTHORAX

presence of air in pleural cavityTYPE: Open-chest wall wound communicate with

external envt Tension-is a surgical emergency pressure compromises breathing/circulation Simple-not associated with compromised

breathing/no breach of chest wall

CAUSE -Blunt & penetrating injuriesMECHANISM -Fractured rib penetrating lung -Deceleration & crush disrupting alveoli -Sucking effect of negative intrapleural

pressure

CLINICAL FEATURE

decreased chest expansiontracheal shifthyper resonant percussion note decreased air entryIf patient’s condition is stable, confirm by

erect chest x-ray

Tension pneumothorax

TREATMENT

remove trapped air through tube thoracostomy (chest tube)

Incase of tension pneumothorax, insertion of needle at second intercostal space over the mid clavicular line of the same side relives the tension until chest tube insertion

Chest tube

HEMOTHORAX

is collection of blood in the pleural cavityusually occurs from intercostal or internal

mammary arteriesBleeding from parenchymal injury is nearly

always self-limitingMassive Hemothorax is a bleeding of more

than 1500ml in to pleural cavity

CLINICAL FEATURE

history of trauma to chestDecreased air entry, dull percussion noteChest x-ray: costophrenic angle obliteration

if more than 500 ml blood existsUltrasonography can reveal a small amount

of fluid in the pleural recess

Hemopneumothorax

TREATMENTChest tube insertion if sign of collection is

visible on erect chest x-ray

EMPYEMA THORACIS

is a collection of purulent fluid in the pleural space

ETIOLOGY Pulmonary Infection_pnuemonia Trauma Aspiration of pleural effusion Extra pulmonary spread

CLASSIFICATION- Early (acute/exudative) phase Thin fluid , with PH less than 7, Glucose < 40 mg/dl &

LDH >1000 IU/L - sub acute/fibro-purulent phase thicker pus with fibrin deposition loculation of pleural exudates- Chronic/organization phase fibroblast proliferation scar formation causing lung entrapment

Empyema

Factors contributing to chronicity

Delay in antibiotic treatmentInappropriate choice of antibioticsFailure of early interventionPresence of foreign bodyFailure to detect underlying lung pathology

MICROBIAL PATHOGENS

In adults: Staphylococcus aureus Streptococcus pneumonia Streptococcus pyogensImmunocompromised Aerobic gram negative bacilli Fungal infection

Children: less than 6 month of age: Staphylococcus

aureus 6 month-2 years of age: Staphylococcus

aureus, Streptococci pneumonia and H.influenza

2 years- 5 years of age: H. influenza

DIAGNOSIS

Clinical -History of

predisposing factors -Fever, pleuritic chest

pain -Signs of pleural

effusion -Signs of chronicity

Investigation1. Routine-Hg, WBC, ESR2.CXR-fluid level, meniscus

sign3. Fluid analysis a) Cloudy/purulent fluid pus b) Gram stain & culture c) AFB4. Ultrasound

loculation/septation

TREATMENT

_depends on – stage _ nature of primary infection _ source of contaminationAntimicrobials Drainage of pus to achieve full lung

expansion

Drainage

1. Thoracentesis2. Closed tube thoracostomy3. Open tube drainage4. Rib resection & open drainage5. Thoracotomy & decortication

Prognosis

depends _microbial agent, host defense, severity of disease, and duration /adequacy of antibiotics & drainage

Mortality rate -healthy young - 5%-immunocompromised/debilitated- 40-70%

LUNG ABSCESS

is a localized area of suppuration & cavitation in the lung with parenchymal necrosis

ETIOLOGY

1. Aspiration pneumoniacommonest 2. Primary necrotizing pneumonia3. Bronchial obstructionneoplasm/FB 4. pulmonary trauma5. systemic sepsis6. Direct extension

MICROBIOLOGY -mixed aerobic & anaerobic bacteriaDX sudden onset of coughproductive of purulent sputum Fever with or without hemoptysischronically sick, febrile with coexisting effusive

finding

INVESTIGATION

Sputum Gram Stain, Culture & sensitivityCXR consolidation with or without

cavitation & air fluid level

TREATMENT

1. Conservative: antibiotics, penicillin + metronidazole for up to 6 wks

2. Operative: indication-failure of conservative -massive hemoptysis-thick or large cavity -suspected malignancy

COMPLICATIONS

1. Bronchogenic spread2. Empyema3. Cerebral abscess4. Chronicity5. Septicemia

PROGNOSIS

uncomplicated -mortality rate < 5% with prolonged & adequate abcs

Complicated-mortality rate - 75-90%