Surgery of the lower respiratory tract

Question 1

What are different surgical approaches to the thorax?

Answer 1

• Intercostal thoracotomy
  -Good view of immediate area
  -Poor view of rest of thorax
  -Only allows access to one side
• Median sternotomy
  -More exposure
  -Access to both hemithoraces
  -Can extend incision
  -More invasive & poor dorsal access
• Thoracoscopy

Question 2

What are the most common reasons for thoracic trauma?

Answer 2

• RTA
• Bites
• Falls

Question 3

What are common thoracic injuries?

Answer 3

• Wounds
• Rib fractures
• Haemothorax + pneumothorax
• Pulmonary contusions, traumatic myocarditis
• Diaphragmatic hernia
• Airway obstruction

Question 4

What is initial management of thoracic trauma?

Answer 4

• Establish a patent airway, give oxygen
• Obtain IV access, give fluids
• Control external haemorrhage
• Give analgesia and minimise stress
• Perform a complete clinical examination
• Swab, clean and dress wounds & support fractures
• Further imaging and sampling as indicated

Question 5

What are pulmonary contusions?

Answer 5

• Accumulation of blood, oedema fluid and exudate in the alveoli and interstitium
• Blocks airways preventing ventilation
• Worsen over 24-36h after trauma
• Radiographs show alveolar / interstitial pattern
• Can take 12-24h to become visible
• Severity of radiographic changes ≠ clinical status

Question 6

What is treatment of pulmonary contusions?

Answer 6

• Supportive care
• rest
• analgesia
• oxygen
• antibacterials
• cautious fluid therapy
• Usually resolve over 3-7days

Question 7

How would you approach a rib fracture?

Answer 7

• Treat conservatively if non-displaced
• bandaging
• analgesia
• cage rest
• Stabilise if injuring other tissues
• flail chest = freely mobile section of chest wall - ribs broken top + bottom + get sucked in due to pressure

Question 8

What can cause pneumothorax? (air accumulation in pleural space)

Answer 8

• Penetrating wounds
• Airway, lung or oesophageal laceration
• Blunt trauma to lung / alveolar rupture
• Rupture of bleb, bulla, cyst or abscess
  *Neoplasia
• Pulmonary emphysema

Question 9

What are clinical signs of pneumothorax?

Answer 9

• Dyspnoea
• Tachypnoea
• Tachycardia
• Cyanosis
• Reduced hear / lung sounds + hyper-resonance

Question 10

What should be done with pnuemothorax?

Answer 10

• Dx = radiographs / CT
• Debride / close penetrating wounds
• Tx = conservative if no clinical signs
• Drain = thoracocentesis / thoracostomy tube
• If not resolved in 5d, consider further imaging / surgery

Question 11

What is tension pneumothorax? What should be done?

Answer 11

• Accumulation of air in thorax due to one-way valve effect
• Intrapleural pressure rises
• Restricts ventilation and venous return
• Death due to reduced cardiac output and hypoxia
• If suspected, perform immediate thoracocentesis and give supplementary oxygen