Station 1.9: Surgical respiratory cases Flashcards
Surgical respiratory cases
Clinical signs
What are the clinical signs of Lobectomy
Surgical respiratory cases
Please examine this man who initially presented to doctors with a cough and weight loss.
* Reduced expansion and chest wall deformity
* Thoracotomy scar: same for either upper or lower lobe
* Trachea is central
* Lower lobectomy: dull percussion note over lower zone with absent breath sounds
* Upper lobectomy: may have normal examination or may have a hyper‐resonant
percussion note over upper zone with a dull percussion note at base where the
hemidiaphragm is elevated slightly
Clinical signs
How would you investigate a surgical respiratory cases?
Surgical respiratory cases
Please examine this man who initially presented to doctors with a cough and weight loss.
* CXR: maybe no overt abnormality apparent other than slight raised hemidiaphragm;
remember that the right hemidiaphragm should be higher than the left in health
* CT chest: loss of a lobe with associated truncation of bronchus or pulmonary vessels
Clinical signs
What are the clinical signs of Pneumonectomy?
Surgical respiratory cases
Please examine this man who initially presented to doctors with a cough and weight loss.
- Thoracotomy scar (indistinguishable from thoracotomy scar performed for a lobectomy)
- Reduced expansion on side of the pneumonectomy
- Trachea deviated towards the side of the pneumonectomy
- Dull percussion note throughout the hemithorax
- Absent tactile vocal fremitus beneath the thoracotomy scar
- Bronchial breathing in the upper zone with reduced breath sound throughout
remainder of hemithorax (bronchial breathing is due to transmitted sound from major
airways)
Dicussion
Pneumonectomy discussion
Surgical respiratory cases
Please examine this man who initially presented to doctors with a cough and weight loss.
- CXR: complete white out on side of pneumonectomy
- Pneumonectomy space fills with gelatinous material within a few weeks of the
operation
Lung transplantation
Single lung transplant
Surgical respiratory cases
Please examine this man who initially presented to doctors with a cough and weight loss.
- Clinical signs: thoracotomy scar; normal exam on side of scar; may have clinical signs
on opposite hemithorax - Indications for ‘dry lung’ condititions: COPD; pulmonary fibrosis
Lung transplantation
Double lung transplant
Surgical respiratory cases
Please examine this man who initially presented to doctors with a cough and weight loss.
- Clinical signs: clamshell incision – from the one axilla along the line of the lower ribs,
up to the xiphisternum to the other axilla - Indications: ‘wet lung’ conditions: CF, bronchiectasis or pulmonary hypertension
Chronic obstructive airways disease
What are the clinical signs of Chronic obstructive airways disease?
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
- Inspection: nebulizer/inhalers/sputum pot, dyspnoea, central cyanosis and pursed lips
- CO2
retention flap, bounding pulse and tar‐stained fingers - Hyper‐expanded
- Percussion note resonant with loss of cardiac dullness
- Expiratory polyphonic wheeze (crackles if consolidation too) and reduced breath sounds
at apices - Cor pulmonale: raised JVP, ankle oedema, RV heave; loud P2
with pansystolic murmur
of tricuspid reurgitation - COPD does not cause clubbing: therefore, if present consider bronchial carcinoma or
bronchiectasis
Discussion - Chronic obstructive airways disease
Chronic obstructive airways disease discussion
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
- Inspection: nebulizer/inhalers/sputum pot, dyspnoea, central cyanosis and pursed lips
- CO2
retention flap, bounding pulse and tar‐stained fingers - Hyper‐expanded
- Percussion note resonant with loss of cardiac dullness
- Expiratory polyphonic wheeze (crackles if consolidation too) and reduced breath sounds
at apices - Cor pulmonale: raised JVP, ankle oedema, RV heave; loud P2
with pansystolic murmur
of tricuspid reurgitation - COPD does not cause clubbing: therefore, if present consider bronchial carcinoma or
bronchiectasis
Discussion - Chronic obstructive airways disease
What are the causes of Chronic obstructive airways disease?
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
- Environmental: smoking and industrial dust exposure (apical disease)
- Genetic: α1
‐antitrypsin deficiency (basal disease
Discussion - Chronic obstructive airways disease
What investigations are required for Chronic obstructive airways disease?
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
- CXR: hyper‐expanded and/or pneumothorax
-
ABG: type II respiratory failure (low PaO2
high PaCO2
) -
Bloods: high WCC (infection), low α1
‐antitrypsin (younger patients/FH+), low albumin
(severity) -
Spirometry: low FEV1
, FEV1
/FVC < 0.7 (obstructive) -
Gas transfer: low TL
CO
Discussion - Chronic obstructive airways disease
What medical treatment is required for Chronic obstructive airways disease? 1/2
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
-
Medical – depends on severity (GOLD classification):
⚬ Smoking cessation is the single most beneficial management strategy
⚬ Cessation clinics and nicotine replacement therapy
⚬ Long‐term oxygen therapy (LTOT)
⚬ Pulmonary rehabilitation
⚬ Mild (FEV1 >80) – beta‐agonists
⚬ Moderate (FEV1
<60%) – tiotropium plus beta‐agonists
⚬ Severe (FEV1
<40%) or frequent exacerbations – above plus inhaled corticosteroids;
although avoid if patient has ever had an episode of pneumonia (TORCH trial)
⚬ Exercise
⚬ Nutrition (often malnourished)
⚬ Vaccinations ‐ pneumoccoal and influenza
Discussion - Chronic obstructive airways disease
What Surgical treatment is required for Chronic obstructive airways disease? 2/2
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
-
Surgical (careful patient selection is important)
⚬ Bullectomy (if bullae >1L and compresses surrounding lung)
⚬ Endobronchial valve placement
⚬ Lung reduction surgery: only suitable for a few patient with heterogeneous
distribution of emphysema
⚬ Single lung transplant
Discussion - Chronic obstructive airways disease
What LONG-TERM OXYGEN THERAPY (LTOT) is required for Chronic obstructive airways disease?
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
-
Inclusion criteria:
⚬ Non‐smoker
⚬ PaO2
<7.3kPa on air
⚬ PaCO2
that does not rise excessively on O2
⚬ If evidence of cor pulmonale, PaO2 <8kPa
⚬ 2–4L/min via nasal prongs for at least 15 hours a day
⚬ Improves average survival by 9 months
Discussion - Chronic obstructive airways disease
How to apply Treatment of an acute exacerbation for Chronic obstructive airways disease?
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
- Controlled O2
via Venturi mask monitored closely - Bronchodilators
- Antibiotics
- Steroids 7 days
Discussion - Chronic obstructive airways disease
what is the prognosis for Chronic obstructive airways disease?
Surgical respiratory cases
Please examine this patient’s chest; he has a chronic chest condition.
COPD patients with an acute exacerbation have 15% in‐hospital mortality
