Consequences of Chronic Cough Flashcards
What is dynamic airway compression?
When during expiration the intrapleural pressure rises above alveolar pressure which compresses the airways
Why is expiration more difficult than inspiration?
In expiration, the intrapleural pressure rises which compresses the airways narrowing them, making expiration more difficult
What can the build up of air in the alveoli due to dynamic airway compression lead to?
A rupture of the visceral pleura
What is the consequence of a rupture of the visceral pleura?
Air can enter the pleural cavity and the transmural pressure gradient is lost
What is a pneumothorax?
Air in the pleural space which results in the loss of the connection between the lung and the body wall
What defines a small pneumothorax?
Less than a 2cm gap between the lung and the parietal pleura
What defines a large pneumothorax?
Greater than 2cm between the lung and parietal pleura
What can cause a pneumothorax?
Penetrating injury to the parietal pleura
Rupture of the visceral pleura
What would be seen on examination of a patient with a pneumothorax?
Ipsilateral reduced chest expansion and breath sounds
Hyper-resonant percussion
What is a tension pneumothorax?
A pneumothorax where the torn pleura forms a one way valve which allows air into the pleural cavity on inspiration but prevents it leaving on expiration
What can a tension pneumothorax cause?
Mediastinal shift due to the increased pressure on one side of the thorax with each inspiration
What are the regions of the mediastinum?
Superior mediatstinum
Inferior mediastinum, made up of
- anterior mediastinum
- middle mediatstinum
- posterior mediastinum
What level divides the superior and inferior mediatstinum?
Level of the sternal angle
Which region of the mediatstinum is the heart located in?
Middle mediastinum
What divides the anterior, middle and posterior mediatstinum?
The heart forms the middle mediastinum which puts anything anterior to the heart in the anterior mediastinum and anything posterior to the heart in the posterior mediastinum
What are the consequences of a tension pneumothorax?
Tracheal deviation
SVC compression can reduce venous return to the heart
What direction does the trachea deviate to in a unilateral tension pneumothorax?
Away from the side of the pneumothorax
What structure can be compressed in a tension pneumothorax which reduces venous return to the heart
What is the management of a large pneumothorax?
Thoracentesis (needle aspiration)
or
Chest drain
What is the purpose of thoracentesis/chest drain in the management of a large pneumothorax?
To remove the excess air from the pleural cavity
4th or 5th intercostal space in the midaxillary line
In the ‘safe triangle’
- anterior border of lattismus dorsi
- posterior border of pectoralis major
- axial line superior to nipple
What are the borders of the ‘safe triangle’ in drainage of a large pneumothorax?
Anterior border of lattismus dorsi
Posterior border of pectoralis major
Axial line superior to nipple
From superficial to deep, which layers are penetrated in the drainage of a large pneumothorax?
Skin (superficial)
Superficial fascia
Deep fascia
External intercostal muscles
Internal intercostal muscles
Innermost intercostal muscles
Parietal pleura (deep)
What is the management of a tension pneumothorax?
Insertion of large bore cannula into the pleurl cavity via the 2nd or 3rd intercostal spaces in the midclavicular line on the side of the tension pneumothorax
Where is the large bore cannula inserted in the management of a tension pneumothorax?
2nd or 3rd intercostal space, midclavicular line
What is used in the emergency management of a tension pneumothorax?
Large bore cannula
From superficial to deep, which layers must the large bore cannula penetrate in the treatment of a tension pneumothorax?
Skin
Superficial fascia
Deep fascia
External intercostal muscle
Internal intercostal muscle
Innermost intercostal muscle
Parietal pleura
What is a hernia?
The protusion of a structure outside the compartment meant to contain it
Which two factors are normally required for the development of a hernia?
Weakness of part of the wall containing a structure
Increased pressure on one side of that wall
Which parts of the body wall have a normal anatomical weakness and what are the herniae which can arise from this?
Diaphragm - diaphragmatic hernia
Umbilicus - umbilical hernia
Inguinal canal - inguinal hernia
Femoral canal - femoral hernia
Name a congenital hernia
Congenital diaphragmatic hernia
What is the name of the hernia which results from the weakness of the body wall due to surgical scars?
Incisional hernia
What can weaken the body wall?
Congenital abnormalities
Surgical scars
Some parts of the body have a natural anatomical weakness
What can cause an increase the pressure leading to herniae?
Cough
How can chronic cough cause herniae?
Coughing increases the pressure exerted on the anterolateral abdominal wall, diaphragm and inguinal/femoral regions which can push structures through any weak spots
What is the most common diaphragmatic hernia?
Hiatus herniae
What is a hiatus hernia?
Where part of the stomach pushes up into the thoracic cavity
Where are the natural weak spots in the diaphragm?
Oesophageal hiatus
At the attachments to the xiphoid process
Aortic hiatus
Caval opening
Posterior attachments
What are the two classes of hiatus hernia?
Paraoesophageal hiatus hernia
- part of stomach passes into chest and is parallel to the oesophagus
Sliding hiatus hernia
- part of stomach passes into chest with the gasto-oesophageal junction
What kind of hernia is this?
Paraoesophageal hiatus hernia
What kind of hernia is this?
Sliding hiatus hernia
Where do the inguinal ligaments attach?
On the anterior superior iliac spine (ASIS) and the pubic tubercle
What is the oesophageal hiatus?
Hole in the diaphragm which the oesophagus passes through
What is the aortic hiatus?
Hole in the diaphragm which the aorta passes through
What is the caval opening?
Hole in the diaphragm which the inferior vena cava passes through
What is the iguinal canal?
A 4cm passageway through the anterior abdominal wall in the inguinal region
What is the anterior superior iliac spine?
Bony projection of the iliac bone
Name the numbered boney prominences
- Anterior superior iliac spine
- Pubic tubercle
What is the pubic tubercle?
Bony projection of the iliac bone
What forms the floor of the inguinal canal?
The medial half of the inguinal ligaments
What are the inguinal ligaments?
Inferior border of the external oblique aponeuroses
What are the entrance and exit to the inguinal canal called?
Deep ring (entrance)
Superficial ring (exit)
What is the superficial ring?
A v-shaped defect in the external oblique aponeurosis
Where is the superficial ring located?
Immediately superolateral to the tubic tubercle
Where is the deep ring?
Superior to the midpoint of the inguinal ligament
What is an inguinal herniae?
Protusion of the contents of the abdominal cavity through the inguinal canal
Where do inguinal herniae form?
In the medial half of the inguinal region
What causes the weakness of the body wall in the development of inguinal herniae?
Presence of the inguinal canal
When is the inguinal canal formed?
Formed embryologically during the passage of the testes/round ligament of the uterus into the perineum
What does the inguinal canal contain in adults?
Spermatic cord (men)
Round ligament of the uterus (women)
Name the numbered structures
- Ureter
- Rectus abdominus
- Inguinal canal
- Testes
- Parietal peritoneum
- Kidneys
Where do the testes descend from during their development?
Abdomen into the scrotum
Which layers of the anterolateral abdominal wall do the testes pass through during their developent?
Transversalis fascia
Internal oblique muscle
V-shaped defect of external oblique aponeurosis
(pass into but don’t penetrate) Superficial fascia
What forms the inguinal canal?
Descent of the spermatic cord/round ligament of the uterus through the anterolateral abdominal wall during embryonic development
What layer of tissue forms the deep ring?
Transversalis fascia
What layer of the spermatic cord does the internal oblique muscle become when the spermatic cord passes through it?
Cremasteric fascia
What layer of the spermatic cord does the transversalis fascia become when the spermatic cord passes through it?
Internal spermatic fascia
What layer of the spermatic cord does the external oblique aponeurosis become when the spermatic cord passes through it?
External spermatic fascia
From deep to superficial, what are the 3 layers of the spermatic cord and what tissue are they formes from?
Internal spermatic fascia - transversalis fascia (deep)
Cremasteric fascia - internal oblique muscle
External spermatic fascia - external oblique aponeurosis (superficial)
Name the numbered structures
- Testiular artery
- Testicular vein
- Visceral peritoneum
- Parietal peritoneum
- Tranversalis fascia
- Transversus abdominus
- Internal oblique muscle
- Inguinal ligament/external oblique aponeurosis
- Deep fascia
- Superficial fascia
- Skin
- Anterior superior iliac spine
- Pubic tubercle
- Peritoneal cavity
- Testes
- Abdominal organs
- Vas deferens
Name the numbered structures
- Testicular artery
- Testicular vein
- Parietal peritoneum
- Transversus fascia
- Transversalis abdominus
- Internal oblique muscle
- Inguinal ligament/external oblique aponeurosis
- Deep fascia
- Superficial fascia
- Tunica vaginalis
- Skin
- Anterior superior iliac spine
- Pubic tubercle
- Deep ring of the inguinal canal
- Spermatic cord
- Superficial ring of the inguinal canal
What is the processus vaginalis?
Embryonic outpouching of parietal peritoneum
What is the tunica vaginalis?
Pouch of serous membrane which covers the testes
What embryonic structure is the tunica vaginalis derived from?
Processus vaginalis
What does the spermatic cord consist of?
3 layers developed as it passes through the inguinal canal
- external spermatic fascia (from external oblique aponeurosis)
- cremasteric fascia (from internal oblique muscle)
- internal spermatic fascia (from transversalis fascia)
Structures within it
- testicular artery
- vas deferens
- pampiniform plexus
What layer of the abdominal wall is the internal spermatic fascia derived from?
Transversalis fascia
What layer of the abdominal wall is the cremasteric fascia derived from?
Internal oblique muscle
What layer of the abdominal wall is the external spermatic fascia derived from?
Aponeurosis of the external oblique muscle
What structures run within the spermatic cord?
Testicular artery
Vas deferens
Pampiniform plexus
Autonomic nerves
Genitofemoral nerve
Lymphatics
From superficial to deep, what are the three layers of the spermatic cord and what skin tissues are they derived from?
External spermatic fascia - aponeurosis of external oblique (superficial)
Cremesteric fascia - internal oblique muscle
Internal spermatic fascia - transversalis fascia (deep)
Name the numbered structures
- Transversus abdominus
- Internal oblique
- External oblique
- Ilioinguinal nerve
- Inguinal ligament
- Superficial ring
- Internal spermatic fascia (transversalis fascia)
- Cremasteric fascia
- External spermatic fascia (aponeurosis of external oblique)
- Visceral peritoneum
- Parietal peritoneum
- Transversalis fascia
- Peritoneal cavity
- Abdominal organs
- Deep ring
- Rectus abdominus
- Conjoint tendon
What is the conjoint tendon?
Medial end of the combined aponeuroses of the internal oblique and transversus abdominus which anchours those muscles to the pubic bone
What is the function of the conjoint tendon?
Anchors the internal oblique and transversus abdominus to the pubic bone
Name the numbered structures
- Spermatic cord
- Vas deferens
- Testicular artery
- Pampiniform plexus
Name the numbered nerves
- Iliohypogastric nerve
- Ilioinguinal nerve
What anterior ramus is the iliohypogastric nerve from?
Half of L1 (other half from ilioinguinal nerve)
What anterior ramus is the ilioinguinal nerve from?
Half of L1 (other half for iliohypogastric nerve)
Name the numbered structures
- Inguinal ligament (cut)
- Cremasteric fascia
- Spermatic cord (severed)
- Ilioinguinal nerve
Name the numbered structures
- Inguinal canal
- Spermatic cord
- Superficial ring
- Ilioinguinal nerve
Where does the ilioinguinal nerve lie in the inguinal canal?
Within inguinal canal but external to spermatic cord
Name the numbered structures
- Vas deferens
- Testicular artery
- Pampiniform plexus
Which sex more commonly develop inguinal hernias and why?
Males
Larger inguinal canal
What passes through the inguinal canal in females?
Round ligament of the uterus
What are the two classes of inguinal herniae and what is the difference?
Direct (structure directly pushes out of superficial ring)
Indirect (structure passes through both deep and superficial rings)
How can you distinguish between direct and indirect herniae?
Reduce the hernia
Occlude the deep ring with finger
Ask patient to cough
If direct hernia, lump will reappear
If indirect hernia, lump won’t reappear
What is a direct hernia?
One which directly protudes out the superficial ring without passing through deep ring
What is an indirect hernia?
One which passes through both the deep and superficial rings
If you reduce a direct hernia, occlude the deep ring and ask the patient to cough, what would be seen?
The hernia would reappear
If you reduce an indirect hernia, occlude the deep ring and ask the patient to cough, what would be seen?
The hernia would not reappear
