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%