Benign Pleural Disease Flashcards
MCC of spontaneous pneumothorax
ruptured apical subpleural bleb
- MC in males (6:1 ratio)
- Other conditions predisposing to spontaneous ptx:
- cystic fibrosis
- COPD
T/F
Tension pneumothorax common after spontaneous ptx
False:
tension pneumothorax rare as collapsed segmetn usually closes off leak
Rare causes of secondary ptx
- catamenial ptx (d/t pleural endometriosis)
- lymphangiomatosis
- proliferation of spindle cells along bronchioles resulting in air trapping and thin walled cysts
Appearance of minimal and moderate ptx on CXR
- Minimal
- rim of air surrounds lung
- Moderate
- lung is collapsed half way to heart boarder
Early treatment options for spontaneous ptx
- Observation
- Aspiration
- Tube thoracostomy (water seal or Heimlich valve)
- Percutaneous thoracostomy
Indications for operative intervention of spontaneous ptx
- Persistent air leak >= 1 week
- Second recurrence
- Patients with only 1 lung
- High risk patients for recurrence where recurrence is dangerous
- Piolets
- Divers
Chance of recurrence after resoluation of primary spontaneous ptx
20-50%
Surgical interventions for spontaneous ptx
- VATS blebectomy
- Some groups advocate apical resection (even in absence of blebs)
- Talc or doxycycline pleurodesis (VATS vs. open)
Complications of talc or doxycycline pleurodesis
- Fever
- Pleuritic chest pain (more common with doxycycline)
Best treatment for fibrothorax
Prevention
MCC of fibrothorax
Failure to recognize and treat hemothorax, empyema or large pleural effusions
*Regardless of effusion character, resultant inflammatory response eventually leads to dense, avascular collagen matrix
Dx characteristics of fibrothorax
- PE:
- collapsed intercostal spaces (decreased thorax size)
- CXR:
- radiodensities in dependent portions of chest
- PFTs:
- restrictive ventilatory defect
- reduced TLC, VC, FEV1
- normal DLCO
- Maybe confused with mesothelioma of malignant process of pleura (r/o with VATS pleural biopsy before definitive treatment)
Surgical treatment of fibrothorax
Decortication
- Three main steps
- Blunt dissection of the parietal peel
- Plane between endothoracic fascia and parietal pleura
- Pleural cavity entered and fluid/debris evacuated
- Visceral pleua is dissected
- Plane between visceral pleura and fibrous peel
- Blunt dissection of the parietal peel
- Avoid injury to phrenic nerve
Definition of emypema
Pleural effusion with positive bacteriologic cultures
Pleral fluid characteristics of empyema
- pH < 7
- glucose < 50 mg/dL
- LDH > 1000 IU/L
Etiology of empyema
- PNA
- Trauma
- Instrumentation
- Spread from other sites of infection
- BPF
- can either be an etiology or complicaton of empyema
3 stages of empyema
- Stage I: parapneumonic effusion (exudative)
- Stage II: fibrinopurulent phase (includes bacteria invasion)
- Stage III: chronic phase (organizing phase)
- includes in-growth of fibroblasts and capillaries
MC organisms responsible for empyema
- S. aureus
- GN bacteria
- Anaerobes
50% polymicrobial
Surgical TOC for empyema
- Prompt drainage
- often tube thoracostomy insufficient (requires VATS or open drainage)
- Full lung re-expansion (to close off potential space where infection can collect)
- Decortication
- chronic empyema with entrapped lung
Often requires open pleural drainage procedure (Clagett window or Eloesser flap)
BPF or severe empyema
Priniples of Clagett window or Eloessar flap drainage
- Continued drainage
- Irrigation
- Frequent dressing changes
- Eloessar flap considered more permanent because skin is sutured to pleura to epithelialize tract
Alternative option to obliterate space lost to infection during surgical treatment of empyema
Muscle flap coverage (latissimus most common)
