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

Department of Thoracic Surgery

Professor, Department of Biomedical Informatics

Vanderbilt University Medical CenterNashville, Tennessee 37232-5734

bill.putnam@vanderbilt.edu

Thoracic Surgery:A Pleural Problem Primer

Vanderbilt University Medical Center

February 14, 2007

STEP 1.

Take your own pulse.

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…..!

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

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.

Diseases of the pleura

Air - Pneumothorax

Blood - Hemothorax

Infection - Empyema

Air - Pneumothorax

Chyle - Chylothorax

Tumor - ‘Tumor-thorax’ or tumor tamponade

Fluid - Pleurothorax

Pneumothorax

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.

Traumatic pneumothorax

• Penetrating

–GSW / stab

• Blunt trauma

Tension pneumothorax

• Progressive air pressure within chest impairing venous return.

• Life threatening emergency

Tension Pneumothorax

Respiratory distressHyper-resonanceAbsent breath soundsTracheal deviation

NOT AN X-RAY DIAGNOSISRx: Immediate needle decompression,

chest tube

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!

Tension Pneumothorax

• Respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absence of breath sounds, neck vein distention, cyanosis

• Hyperresonance!

•Spontaneous PTX More common males ages 20-40, smokersMay occur following a scream, valsalva, or coughSudden sharp pleuritic chest pain and dyspnea Tachypnea, tachycardia, subcutaneous

emphysema

Expiratory CXR may be needed to make diagnosis

Treatment: Observation for PTX less than 15-20% and no symptomsOthers: needle/catheter decompression and/or chest tube

Pneumomediastinumpneumopericardiumsubcutaneous emphysema

Barotrauma

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

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

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

Massive Hemothorax

• Massive pleural effusions can mimic hemothorax.

• Trauma patients are unlikely to have a pleural effusion that is not blood

Pleural Effusion

• Fluid that accumulated in the pleural space–Trauma–Disease

•Heart failure•Cancer•Pulmonary embolism• Inflammation

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

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

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

It’s time we face reality, my friends…..

We’re not exactly rocket scientists.”

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%

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.

Malignant Pleural Effusions (MPE)

Increased capillary permeability

Disruption of capillary endothelium

Impaired lymphatic drainage

Direct invasion of pleural space by tumor

Malnourishment and hypoalbuminemia

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

Pleural Fluid Analysis

• Cell Count• Cytology• Cultures• LDH• Protein• Glucose• pH

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)

Treatment Goals for MPE

• Relieve or eliminate dyspnea

• Optimize patient function

• Minimize/eliminate hospitalization

• Minimize cost

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.

Drainage system

• Pleuravac

– Water

– Air

• Three chambers

– Collection

– Water seal

– Suction

• Pleur-Evac System:

Suction Water Seal Drainage

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!

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.

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

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)

Congratulations and Good Luck!