CHEST CONDITION-DCM 2021.pptx

1. CHEST CONDITIONS DCM MARCH 2021 CLASS

2. AIRWAY OBSTRUCTION DEFINITION: It occurs when you cant move air in or out of your longs. it may be part or the whole airway blocked. EPIDEMIOLOGY: It is the commonest cause of emergence departmental visits and most common cause in the adults is inflammation, infection and trauma .In children its foreign bodies

3. CAUSES: INTRALUMINAL: Inhaled foregin bodies,neoplasm, abscess INTRAMURAL: Congenital stenosis, fibrous stricture EXTRAMURAL: Neoplasm{thyroid cancer} and aortic aneurysm Other causes are allergy, trauma vocal cord issues, infections, tracheomalasia and asthma

4. TYPES OF AIRWAY OBSTRUCTION: Upper Airway obstruction from nose to larynx Lower Airway obstruction from larynx to narrow passageways of lings Partial and complete Acute or chronic

5. RISK FACTORS Age Severe allergies Smoking Neuromuscular disorders

6. CLINICAL FEATURES: Chocking Cyanosis Wheezing Coughing Pyrexia Confusion Difficulty in breathing Panic Unconcsiuosness Gasping for air

7. INVESTIGATIONS: Chest X-rays Bronchonscopy Laryngoscopy CT scan

8. COMPLICATIONS: Respiratory failure Arythmiasis Cardiac Arrest

9. MANAGEMENT: A B C Heimlich manouver Back blow manouver Epinephrine for allergic reactions, usually epipen 1 injections at the outer thigh Cardiopulmonary rescucitation{CPR} In hospital, endotracheal or nasotracheal tube may be inserted Tracheostomy and chricothyrotomy are openings made to by pass the obstruction Resection of up to 6cm of trachea is possible

10. SURGERY I : CHEST CONDITION. GROUP 3-DCM MARCH 2021 ASSIGNMENT 1 Belinda 2 Beatrice 3 Peter 4 Victor 5 Felix COMPILED BY ROJAR 5/29/2023 10

11. CONTENT TO BE COVERED 1 PNEUMOTHORAX 2 HAEMOTHORAX 3 EMPYEMA THORACIC 4 SURGICAL EMPHYSEMA 5 CARDIAC TAMPONADE 5/29/2023 11

12. objectives • Definition • Epidemiology/Incidence • Pathophysiology • Classification • Risk factors/Causes • Clinical presentation • Investigation • Management • Complication 5/29/2023 12

13. 1 PNEUMOTHORAX DEFINITION • A pneumothorax is the presence of air or gas within the pleural cavity i.e. the potential spaces between the visceral pleural & parietal pleural of the lungs. • This is usually from the defect on the lung surface e.g. rapture bullae(Large blister ) or through the damage of the chest wall e.g. following trauma. • Air within the pleural cavity causes the physiological pleural seal to be lost ,meaning the normal negative pressure in this space , that aid the lung expanding within the chest wall movement is lost. • This impedes(prevent) lung expansion & leads to partial or total lung collapse. 5/29/2023 13

14. Cont.. 5/29/2023 14

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16. EPIDEMIOLOGY/INCIDENCE • Annual incidence of pneumothorax is around 9% per 100,000 • Primary pneumothoraces occur most commonly in tall thin men aged between 20-40 • They are less common in women- consider the possibility of underlying lung disease e.g. LAM, Catamental pneumothorax • Cigarette or cannabis smoking is a major risk factor for pneumothorax increasing the risk by factor of 22 in men & 9 in women 5/29/2023 16

17. Cont.. • The mechanism is unclear ; a smoking induced influx of inflammatory cells may both break down elastic lung fibers (causing bulla formation ) & cause small airway obstruction (increasing alveolar pressure & the likelihood of interstitial air leak) • More common in patient with Marfans syndrome & homocystinuria • May rarely be farmilial 5/29/2023 17

18. PATHOPHYSIOLOGY • As air enters the pleural space which normally have a negative pressure , the elastic recoil in the lung tissue causing either a partial or full lung collapse. NORMAL PHYSIOLOGY • Pleural space has a negative pressure • Chest wall expand ►surface tension between parietal & visceral pleural expands the lungs. • Lung tissue has an elastic recoil► innate tendency to collapse inward. 5/29/2023 18

19. Traumatic pneumothorax • Closed pneumothorax : blunt trauma →lung damage →air flow from the lung into the pleural spaces. • Open pneumothorax : penetrating trauma to the chest wall→ pathway for air directly into pleural spaces. • Close & open pneumothorax : In closed pneumothorax air travel in & out of the pleural spaces from the lungs . • However in an open pneumothorax a defect in the chest wall allows air to move in & out of the pleural spaces. 5/29/2023 19

20. Cont.. 5/29/2023 20

21. Iatrogenic pneumothorax • Induced in a patient by the treatment or comment of a physician • Lung surgery • Central venous catheter insertion • Thoracentesis -removal of fluid around the lung • Mechanical ventilation • Esophageal procedure 5/29/2023 21

22. Spontaneous pneumothorax • Ruptured bleb→ air flow from the lungs into the pleural spaces→ positive pleural pressure→ compressed lung. • Lung collapse until an equilibrium is achieved or the rupture seals • Vital capacity & ↓ partial pressure of oxygen • Primary/idiopathic Rapture apical subpleural bleb or bullae • Secondary • Chronic obstruction-COPD account for 50% 5/29/2023 22

23. Cont.. • Bronchiectasis • Lung malignancies • Lung infection- pneumocystic jirovecii, TB, bacterial pneumonia, • Genetic disease-cystic fibrosis, marfans syndrome , homocystinuria • Cystic lung disorders – lymphangioleimyomatosis, diffuse Langerhans cell histiocytosis, lymphocytic interstitial pneumonia, thoracic endometriosis (catemanial pneumothorax) • Smoking is a mojor risk for primary & secondary 5/29/2023 23

24. Tension pneumothorax • Life threatening & can develop from any type of a pneumothorax. • Air enters the pleural space through a one way mechanism →air cannot escape. • Air accumulate in the pleural space with each inspiratory phase→ ↑ pleural space pressure → shifting of mediastinum→ compression of the contralateral lung → hypoxia. • Eventually compress of the vena cava & atria →↓ venous return to the heart & ↓ cardiac function . • Leads to rapid cardiopulmonary collapse. 5/29/2023 24

25. Cont.. 5/29/2023 25

26. Cont.. • Tension pneumothorax: • Spontaneous & traumatic pneumothorax can develop into a tension pneumothorax if the defect that allow air into the pleural space becomes one way valve (air enters during inspiration but cannot escape during exhalation which causes rising pressure in the pleural cavity , shifting the mediastinum to the contralateral side 5/29/2023 26

27. Cont.. • Simple • Mediastinum remains central • Clinical condition stable • Can wait for CXR to confirm diagnosis • Tension • Progressive build up of air in the pleural space, causing a shift of the heart and mediastinal structures away from side of pneumothorax • Clinical condition unstable • Do not wait for CXR to confirm diagnosis 5/29/2023 27

28. CLASSIFICATION 5/29/2023 28

29. Cont.… 5/29/2023 29

30. RISK FACTORS/CAUSES • Sex-men are at high risk • Smoking • Age • Genetics • Lung disease • Mechanical ventilation • History of pneumothorax 5/29/2023 30

31. CLINICAL PRESENTATION • Shortness of breath of varying degree depending on the size of the pneumothorax & patients factors e.g. lung disease. • Sudden onset chest pain, often pleuritic in nature , small spontaneous pneumothorax can be asymptomatic particularly in younger patients. • O/E there will be: Hyperresonance on percussion Reduced or absent breath sound on auscultation Reduced chest expansion Decrease in tactile fremitus 5/29/2023 31

32. Cont.. • In cases of tension pneumothorax: Patients will be hypoxic Tachycardiac Hypotensive Potential distended neck vein Tracheal deviation away from the affected side Cyanosis Tachypnea-abnormal rapid breathing • Cardiovascular-jugular venous distension -Pulsus paradoxus-↓ stroke volume 5/29/2023 32

33. Cont.. MNEMONIC • Signs & symptoms of tension pneumothorax is summarized with P- THORAX • P-Pleuritis pain • T-Tracheal deviation • H-Hyper- resonance • O-Onset sudden chest pain • R-Reduced breath sound • A-Absent fremitus • X-X-ray showing collapes 5/29/2023 33

34. INVESTIGATION • Initial investigation should run alongside this(expect for cases of tension pneumothorax when urgent needle decompression is required in 2 or 3rd ICS • Tension pneumothorax is a clinical diagnosis & management should not wait for imaging confirmation 1 Plain chest radiograph(CXR) • The size of pneumothorax is determined by measuring interpleural distance at the level of hilum. • Should be performed in upright position (when possible) 5/29/2023 34

35. Cont.. General findings • White visceral pleural lining defining lung & pleural air • Bronchovascular markings are not visible beyond pleural edge • Deep sulcus • Ipsilateral hemidiaphragm elevation Tension pneumothorax • Potential mediastinum shift • Trachea deviation • Ipsilateral hemidiaphragm flattening • Ribs are spread a part 5/29/2023 35

36. Cont.. 2 Routine blood –FBC -CPR -U & Es & clotting • Arterial blood gas (ABG) • Electrocardiogram (ECG) 3 CT imaging • determine underlying cause in context of trauma & concurrent injuries • Findings –air in the space , can evaluate the location , pleural pathology & lung disease 5/29/2023 36

37. Cont.. 5/29/2023 37

38. Cont.. 4 Ultrasound • Presence of a lung point –boundary between the lung & pneumothorax • Lung sliding will be absent at the location of pneumothorax 5/29/2023 38

39. MANAGEMENT • Management is determined by both size or type of the pneumothorax & patient factor. • As a minimal ensure all patient have sufficient analgesia & started on oxygen if required. • For patient with chest drain inserted ensure it is attached to underwater seal. INITIAL MANAGEMENT • Primary spontaneous pneumothorax those that are small (<2) & asymptomatic patients should be admitted for observation. 5/29/2023 39

40. Cont.. • Symptomatic or large primary pneumothoraces needle decompression should be attempted placed in 2nd or 3rd intercostal spaces at the midclavicular line if no improvement chest drain via seldinger technique to be placed • 5th ICS space in the anterior or midaxillary line in SAFTEY TRIAGE is another option-followed by chest tube placement. • Small spontaneous pneumothorax will required admission for observation with a low threshold for attempting needle decompression , • Those that are large & symptomatic required chest drain via seldinger technique to be placed. 5/29/2023 40

41. Cont.. • Traumatic pneumothoraces will normally require surgical chest drain insertion or otherwise admitting for observation if small & asymptomatic. • Importantly there is no role in needle decompression in traumatic non-tensioning pneumothoraces. • For traumatic tension pneumothoraces either needle decompression (in 5th intercostal space mix-axillary line) or finger thoracostomy is required prior to chest drain insertion. 5/29/2023 41

42. Cont.. FURTHER INVESTIGATION • Considered in those with persistence air leak or failure of lung re- expansion. • Spontaneous cases medical pleurodesis is often trailed resulting in partial obliteration of the pleural space through introducing irritant agent aiming to prevent recurrences ,alternatively Heimlich valve can be trailed a one way valve attached to a chest tube & enable evacuation of air that is not under tension. • Those failing these intervention or in traumatic cases should ne considered surgical intervention which includes video assisted thoracoscopic surgery (VATS) for pleurectomy +/- pleural abrasion or open thoracostomy& pleurectomy . 5/29/2023 42

43. COMPLICATIONS • Hypoxemic respiratory failure-low level of oxygen • Respiratory or cardiac arrest-heart suddenly stop pumping blood • Hemopneumothorax-combination of pneumothorax & hemothorax. • Bronchopulmonary fistula-abnormal communication btwn bronchial tree & pleural cavity • Pulmonary edema –following lung re-expansion • Empyema-collection of pus in the pleural cavity • Pneumomediastinum-presence of air in mediastinum • Pneumopericardium-presence of air in pericardium • Pneumoperitoneum-presence of air in peritoneal cavity • Pyopneumothorax-accumulation of gas & pus in pleural cavity 5/29/2023 43

44. Cont.. COMPLICATIONS OF SURGICAL PROCEDURE • Failure to cure the problem • Acute respiratory distress or failure • Infection of the pleural spaces • Cutaneous or systemic infection • Persistent air leak • Re-expansion pulmonary • Pain at the site of chest tube insertion • Prolonged tube drainage & hospital stay 5/29/2023 44

45. DIFFERENTIAL DIAGNOSIS • Pulmonary embolism(PE) • Hemothorax • Pleural effusion • Myocardial infarction • Pericarditis 5/29/2023 45

46. R •Right lung more translucent than left •Faint line just visible (zoomed view to follow) 5/29/2023 46

47. •Pencil-thin white line running parallel to chest wall •No lung markings lateral to the line Blade of right scapula Right pneumothorax 5/29/2023 47

48. Simple Left Pneumothorax 5/29/2023 48

49. Simple Left Pneumothorax No mediastinal shift Small pleural effusion (common finding) Visceral pleural line (zoomed view on next slide) 5/29/2023 49

50. Note absence of lung markings lateral to this line 5/29/2023 50

51. Pneumothorax with rib fractures 5/29/2023 51

52. Tension right pneumothorax 5/29/2023 52

53. Tension right pneumothorax Mediastinal shift to left 5/29/2023 53

54. HEMOTHORAX • Hemothorax is the accumulation of blood in the intrapleural spaces. • Bleeding is usually from intercostal artery in lacerated chest wall or from underlying contused lung, heart or great vessel. • Massive hemothorax is bleeding of more than 1500ml into pleural cavity 5/29/2023 54

55. EPIDEMIOLOGY • Hemothorax can be associated with a single rib fracture. • Approximately 150,000 deaths occurs from trauma each year. • Approximately 3times this number of individuals are permanently disabled because of trauma. • Chest injuries occurs in approximately 60% of multiple trauma cases. 5/29/2023 55

56. PATHOPHYSIOLOGY • Accumulation of blood in the pleural space caused by bleeding from; penetration or blunt lung injury, chest wall vessels or intercostal vessels. • Hemothorax is manifested by; • >hemodynamic response-hypovolemic shock rapid bleeding. • >respiratory response-slow bleeding. • Blood that enters the pleural cavity is exposed to the motion of the diaphragm, the lungs, and other intrathoracic structures. 5/29/2023 56

57. CLASSIFICATIONS TRAUMATIC HEMOTHORAX • Occurs due to penetration injury of the lungs, heart, great vessels, or chest wall non Traumatic hemothorax • Malignancy pleural diseases(sarcoma, angiosarcoma) • Bleeding disorders(hemophilia, thrombocytopenia, rupture of thoracic aorta) • Necrotizing infection • Pulmonary embolism with infarction Iatrogenic hemothorax • Causes; Central venous catheterization 5/29/2023 57

58. Cont.. • Injury during trans lumber aortography • Thoracocentesis • Pleural biopsy • Trans brachial biopsy 5/29/2023 58

59. CAUSES OF HEMOTHORAX • Traumatic • Infection/infestation • Congenital • Degenerative • Neoplastic(benign/malignant) • Rib fractures associated with pneumothorax • Iatrogenic • Tuberculosis • Non pulmonary intrathoracic vascular pathology(e.g. Pancreatic pseudocyst, splenic artery aneurysm) 5/29/2023 59

60. Clinical presentation • Restlessness • Hypovolemic shock • Tachypnea • Dyspnea • Cyanosis • Diminished breath sounds on affected side • Hypo resonance(dullness on percussion) on affected side. • Chest wall deformity • Crepitus upon palpation over fractured ribs 5/29/2023 60

61. investigations • Imaging studies X-ray USG(ultrasound sonography test) CT chest Angiography MRI(Magnetic resonance test) Thoracoscopy Nuclear scan 5/29/2023 61

62. management • ABC of resuscitation • Large bow cannular &begin IV fluids-crystolliods • Vital check up including SPO2 • Intercostal drainage tube thoracostomy • Large bore tube in 5th spacing between mid and posterior axillary lines • Can be done before x-ray • Draining of blood from chest cavity • Thoracostomy(indicated when total chest tube output exceeds 1500ml within 24hrs) • Video assisted thoracoscopic surgery(VATS) • Shock care due to blood loss 5/29/2023 62

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65. complication • Clot retention • Pleural infection • Pleural effusion • Fibrothorax • Collapsed lung • Respiratory failure • Hemorrhagic shock 5/29/2023 65

66. SURGICAL EMPHYSEMA/ SUBCUTANEOUS DEFINITION • Infiltration of air in the subcutaneous layer of the skin ETIOLOGY • It can result from: • surgical • traumatic infection or spontaneous etiologies • rapture esophagus • lung injury • tracheal injury 5/29/2023 66

67. EPIDEMIOLOGY • Incidence is worldwide • Woman in labor i.e. 2nd stage can experience subcutaneous emphysema from pushing which can increase intrathoracic pressure PATHOPHYSIOLOGY • Injury to the parietal pleural that allows for the passage of air into the parietal & subcutaneous tissue • Air from the alveolus spreading into the endothelial sheath & lung hilum into the endothelial fascia • Air in the mediastinum spreading into the cervical visceral & other connected tissue 5/29/2023 67

68. Cont.. • Air originating from external sources • Gas generation locally by infection especially necrotizing infection TYPES • Localized –trauma • Extensive -extensive in neck ,face ,eyelid & scrotum CLINICAL FEATURES • Pain • Swelling of subcutaneous region • Palpable crepitus • Painless & small nodule feel bubble 5/29/2023 68

69. COMPLICATIONS • Cardiac arrest • Dysphagia • Respiratory failure • Tension pneumothorax • N/B – It requires a breach of an air containing viscus in communication with soft tissue & the generation of positive pressure to push air a long tissue planes • Is the hallmark of Fournier's gangrene 5/29/2023 69

70. CAUSES • Trauma during surgery • Injury to esophagus during insertion of feeding tube • Infections –bacteria • Bowel perforation INVESTIGATION • Radiography (x-ray) of chest & neck • CT • Both will show dark pocket in the subcutaneous layer indicating of gas. 5/29/2023 70

71. TREATMENT & MANAGEMENT • Treatment of the underlying cause of precipitating factor • Mild cases –observation is appropriate • Patient with discomfort –give high oxygen concertation • Use of empiric broad spectrum antibiotic • Extensive phase -2cm intravascular incision bilaterally can reduce further subcutaneous expansion • In severe cases ICT on one side or both sides placement 5/29/2023 71

72. DIFFERENTIAL DIAGNOSIS • Esophageal rapture • Pneumothorax • Tracheal /lower/diaphragm perforation 5/29/2023 72

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76. 5 CARDIAC TEMPONADE • Compression of the heart caused by fluid collecting in the pericardium e.g. bleeding in the pericardial cavity. • Cardiac tamponade puts pressure in the heart & keeps it from filling properly with resulting dramatic drop in blood pressure that can be fatal. 5/29/2023 76

77. PATHOPHYSIOLOGY • The pericardium space normally contain 20-50ml of fluid • Increase in this amount causes the accumulation of pericardial fluid which impairs relaxation & filling of the ventricles, requiring a higher filling pressure. • With further fluid accumulation the pericardial pressure increases above the ventricular filling pressure ,resulting in reduced cardiac output. • A further decrease in cardiac output occur which result to the equilibration of pericardial & left ventricle filling pressure 5/29/2023 77

78. Cont.. • The underlying process for the development of tamponade is a marked reduction in diastolic filling , which result when transmural distending pressure becomes insufficient to overcome increased intrapericardial pressure • Tachycardia is the initial cardiac response to these changes to maintain the cardiac output • Because the heart is compressed throughout the cardiac cycle due to increased intrapericardial pressure ,systemic return is impaired & right atrial & right ventricle collapse occur 5/29/2023 78

79. Accumulation of fluid in the pericardial space 5/29/2023 79

80. Cont.. 5/29/2023 80

81. AETIOLOGY • Trauma to the chest • TB • Uremia • Idiopathic pericarditis • Infectious disease • Anticoagulation • hyperthyroidism • Connective tissue disease • Post pericardiotomy syndrome • Malignant disease 5/29/2023 81

82. CLINICAL FEATURES /SIGNS • Hypotension/shock(rapid weak pulse) • Grossly distended neck vein (raised JVP) • Elevated central venous pressure • Severe distress • faint heart sound • Penetrating injury in the proximity to the heart • The classic findings /a hallmark signs of beck triad 1Hypotension • 2 Distended neck vein • 3 Faint heart sound 5/29/2023 82

83. BECKS TRAID • Collection of three clinical signs associated with pericardial tamponade which is due to excessive accumulation of fluid within the pericardial sac 5/29/2023 83

84. SYMPTOMS 1 Sharp pain in the chest –pain may radiate to the nearby parts of the body like abdomen ,arm ,neck & shoulder 2 trouble breathing /breathing rapidly 3 fainting ,dizziness/light headache 4 changes in skin color 5 heart palpitation 6 fast pulse 7 Altered mental status /confusion 8 decreased urine output 5/29/2023 84

85. DIAGNOSI/INVESTIGATION • History taking • Physical examination • Echocardiogram • Chest x-ray • Computerized tomography • Heart catheterization • Ultrasound 5/29/2023 85

86. MANAGEMENT • Removal of the fluid around the heart • Its done through pericardiocentesis –the procedure use a needle that is inserted into the chest until in enters the pericardial sac & the fluid is aspirated • Surgery 5/29/2023 86

87. COMPLICATION • Shock • Heart failure • Death PERICARDIOCENTESIS & SURGERY COMPLICATION • Bleeding • Injury to the heart chambers • Heart attack • Infections • Injury to nearby organs 5/29/2023 87

88. DIFFERENTIAL DIAGNOSIS • Cardiogenic shock • Constrictive pericarditis • Pneumothorax • Pulmonary embolism 5/29/2023 88

89. Chest injury by group two MEMBERS  ALVIN KIBII-GROUP LEADER  SHARON JEBET  COLLINS MURITHI  LATIFAH SULEIMAN  JOHN KILACHE  GREGORY VOLEMI

90. Ribs

91. INTRODUCTION • Chest injuries is defined as a form of injury to the chest including the ribs, heart, lung and great vessels trachea and esophagus • Chest injuries are potentially life threatening because of immediate disturbances of cardiorespiratory physiology and hemorrhage and later development of infections, damaged lung and thoracic cage Traumatic injuries to the chest contribute to 75% of all traumatic deaths • Thoracic injuries range from simple rib fractures to complex life threatening rapture of organ • The mechanism of injuries causing chest trauma are dived into two: • Blunt trauma and penetrating trauma INCIDENCE • 25% of all death form traumatic injury

92. CAUSES OF CHEST INJURY Blunt injury cause e.g. motor vehicle accident, pedestrian accident, fall, sports injury, assault with blunt object or altercations, crush injury and explosion injury Penetrating injury causes: knife, gun short, stick, arrow and occupational injury

93. TYPES OF CHEST INJURY 1. Flail chest 2. Rib fractures 3. Pulmonary contusion 4. Hemothorax 5. Cardiac tamponade

94. RIB FRACTURE • DEFINITION: a complete or incomplete fracture of any of the 12 ribs on either side • Most are accompanied by sprain or rupture of muscles, tendons or ligaments between ribs • Ribs 4-9 are most commonly broken due to blows because they are less protected

95. PATHOPHYSIOLOGY • This morbidity and mortality associated with rib fracture is caused by three main problems: • Hypoventilation due to pain • Impaired gas exchange in damaged lung underlying the fractures • Altered breathing mechanism RISK FACTORS 1. Osteoporosis 2. Sport participation 3. Cancerous lesion in a rib 4. Poor nutrition 5. History of bone and joint disease

96. CAUSES RIB FRACTURE 1. Direct blow to the chest from blunt a object 2. Trauma to the chest 3. Hard coughing or sneezing 4. Compression to the chest 5. Repetitive trauma 6. CPR 7. A fall for elderly

97. CLINICAL PRESENTATION • Severe pain at the fracture site • Tenderness to the touch • A feeling that the “ wind has being knocked out” • Abdominal pain if the fractured side are below the diaphragm • Severe chest pain when coughing, sneezing or breathing deeply • A feeling of small air pockets under the skin of the chest or neck if the lung has been injured and leaked air • Swelling and bruising over the fracture site • Shallow breathing

99. DIAGNOSTIC EVALUATION • History taking • Physical examination; while doing physical examination assess for- cyanosis, tenderness on the fracture site INVESTIGATIONS • Chest-x ray • CT scan • MRI • ABGs

100. MANAGEMENT • Give analgesic (usually non opioids) to assist ineffective coughing and deep breathing • To decrease pain when you cough hold a small pillow or folded towel over the site and press firmly • Avoid strenuous activities • Do not where a rib belt or binder • Eat normal well balanced high fiber diet • Avoid constipation • Take deep breaths several times a day

101. COMPLICATIONS 1. Pain 2. Hemothorax 3. Pneumothorax 4. Pulmonary contusion 5. Pulmonary lacerations 6. Acute vascular injury 7. Abdominal solid organ injury

102. FLAIL CHEST • The breaking of two or more ribs in two or more places resulting in free floating rib segment • When this occurs one portion of the chest has lost its bony connection to the rest of rib cage PATHOPHYSIOLOGY • During respiration the detached part of the chest will be pulled in on respiration and blown out on expiration (paradoxical movement) leading to hypoventilation and hypoxemia

107. INVESTIGATION 1. Palpation: crepitus and tenderness near fractured rib 2. Chest x-ray 3. CT scan 4. ABGs

108. IMPLICATIONS Pulmonary contusion Pain Mediastinal flutter Pneumothorax Hemothorax

110. MANAGEMENT • Frequent and prompt respiratory assessment • Adequate oxygenation • Analgesia to improve ventilation • Stabilizing thoracic cage • Deep breathing exercises • Intubation and mechanical ventilation maybe required to prevent further hypoxia • Pain control • Alternative to relief pain: intercoastal nerve block, epidural anesthesia and wearing a chest binder • Maintain IV fluids • Monitoring adequate tissues perfusion • Anxiety reducing technique • Health education

111. MANAGEMENT  ANALGESIA  INTUBATION AND VENTILATION  CHEST TUBE INSERTION  RIB FRACTURE FIXATION

112. ANALGESIA  opioid analgesics(risk of respiratory depression)  NSAIDs  Thoracic or high lumbar Epidurals with or without opioid derivatives INTUBATION & VENTILATION  Rarely indicated  indicated for hypoxia due to pulmonary contusions  Double lumen tracheal tube,Each lumen connected to a different ventilator where each lung may require different pressures and flows to adequately ventilate

113. CHEST TUBE INSERTION  To treat hemothorax  To treat pneumothorax PHYSIOTHERAPY  To aid better drainage of secretions  To rebuild musculature  To reposition chest wall  Coughing exercises  Resistance exercises  Trunk exercises

114. REHABILITATION  12 week outpatient program for at least 3 days a week  Patient should be seen for 30-45 mins a day after a 5-10 minute warm up session  After a discharge , patient should be given an exercise regimen to be performed at home

115. COMPLICATIONS • Pneumonia • ARDS • Lung abscess • Emphysema • Hypoventilation • Atelectasis • Mediastinal flutter

116. THORACIC EMPYEMA OBJECTIVES •Definitions •Epidemiology •Pathopysiology •Classifications •Risks factors •Clinical presentations •Investigations •Managements •complications 5/29/2023 116

117. 5/29/2023 117

118. DEFINITIONS • also known as pyothorax or purulent pleuritis. • it is the accumulations of pus in the pleural cavity. • it is not a primary disease, it is secondary to other underlying disease. • it is complication to other diseases 5/29/2023 118

119. Epidemiology • incidence 5-10% of hospitalised patients with parapneumonic effussion 5/29/2023 119

120. CAUSES/ETIOLOGY LOCAL CAUSES chest causes • osteomyelitis of the ribs • penetrating wound • thoracic wall abscess Pleural causes • pneumothorax • haemothorax 5/29/2023 120

121. Pulmonary causes • pneumonia • bronchitis • PTB • lungs abscess & bronchiestasis Subdiaphgramatic causes • subphrenic causes • hepatic abscess 5/29/2023 121

122. Latrogenic causes • esophageal perforations during esophagoscopy • postpneumonectomy • postthoracostomy SYSTEMIC CAUSES • septicaemia Bacteriology • staph aureas-90% • strep pneumoniae • strep pyogene & H influenza 5/29/2023 122

123. Risk factors • alcoholism • smoking • HIV infections • neoplasm • pre existence pulmonary disease 5/29/2023 123

124. Pathopysiology • presence of parapneumonic effusion • release of inflammatory mediators • increases permiability of the capilaries • attracts WBCs to the site ,escape of albumin and other protein from capillaries • increase pleural fluid • presences of free flowing protein rich pleural fluid (stage 1) • inflammation worsen • attracts more wbcs to the site 5/29/2023 124

125. PATHOPHYSIOLOGY …. • extensive purulent exudate production • initiation of fibrinoblastic activity (stage 2) • adherance of the two pleural membranes (stage 3) • formation of the peel. 5/29/2023 125

126. Stages of empyema formation • Development of empyema passes through 3 stage; • stage 1 (exudatives stage) • stage 2 Fibrino purulent stage • Stage 3 organising stage 5/29/2023 126

127. • Stage 1; exudative (early) stage • this is purely an inflammatory process in which there is increase in permeability of small blood vessels leading to exudation of fluid in the pleural cavity. • The fluid is very thin with low cellular content and underlying lungs that re-epands easily. 5/29/2023 127

128. • stage 2; fibrino purulent • stage is characterized by; • large number of polymorphonuclear leucocytosis. • deposition of fibrin on both visceral and parietal surfaces of the involved pleura. • bacteria invasion of the pleural space. • tendency towards loculation formation. 5/29/2023 128

129. Classifications • Anatomical classifications • total thoracic empyema-the whole pleural cavity is involved. • Localised or encysted thoracic empyema- only part of the thoracic cavity is involved. 5/29/2023 129

130. Clinical classifications • acute- pt presents with high grade fever, cough with pleuritic chest pain and shallow breath. • sub acute thoracic empyema- this is less severe form in patient who was on antibiotics for pneumonia. • chronic thoracic empyema- this resuits from mismanagement of the acute form. 5/29/2023 130

131. CLINICAL PRESENTATIONS • SYMPTOMS • Cough • pleuritic chest pain • breathlessness • haemotypsis • rigor • fatigue • fever 5/29/2023 131

132. SIGNS • Febrile • dyspnoea • stony dullness chest on percussion 5/29/2023 132

133. Investigations • lab studies • hb levels • wbc count + ESR • ELISA test for HIV • bacteriological investigations • sputum for AFB • Sputum for c/s • pus for c/s 5/29/2023 133

134. IMAGING INVESTIGATIONS • Chest ray • abdominal USS to rule out hepatic abcess • CT scan –differentiates empyema ,lung abcess & subdiaphragmatic fluids • Diagnostic procedure –aspiration of pus to confirm empyema. 5/29/2023 134

135. 5/29/2023 135

136. MANAGEMENT AND TREATMENT OF EMPYEMA • Objectives of treatment;  to control primary infections bu appropriate medications  evacuations of purulent contents of empyema sac and eradications to control chronicity.  to prevent complications 5/29/2023 136

137. Modalities of treatments • Depends on the stage of empyema • divided into; • Non surgical therapy- Antibiotics cefuroime 150mg/kg/day-3 doses, clindamycin 25-40 mg/kg/day (3 doses) • Needle aspiration (Thoracocentesis) 5/29/2023 137

138. SURGICAL THERAPY • Thoracoscopy • Closed chest drainage (UWSD) • Open chest drainage(rib resection) • Decortication • Thoracoplasty 5/29/2023 138

139. Needle aspiration(thoracocentesis) • both diagnostic and therapeutic , adequate only in eudate stage Closed Chest Drainage(UWSD) –this is done if the fluid (pus) in the pleural sac is thick to be evacuated by simple needle aspiration 5/29/2023 139

140. 5/29/2023 140

141. Open chest drainage(rib resection) • 2-3 ribs are resected to allow evacuation of pus , break up loculations , wash the cavity and pus (UWSD) to prevent re-accumulations • done if the pus is too thicker to be evacuated by UWSD Decortication- in this case thoracostomy is done and peel out the cortival layer over the parietal & visceral surfaces. 5/29/2023 141

142. THORACOPLASTY • Ribs are taken away to compress the chest . • NB-Due to high mortality and morbidity, the procedure has been ABANDONED 5/29/2023 142

143. COMPLICATIONS • Lungs collapse • Empyema neccessitants • septic emboli to the brain • systemic septicaemia • pulmonary fibrosis • mediastinal abscess • suphrenic abscess 5/29/2023 143

144. LUNG TUMORS GROUP 4 5/29/2023 144

145. Definition • Is the abnormal growth of cells which tend to proliferate in an uncontrolled way and in some cases metastize (spread). • Cancer is a group of more than 100 different and distinctive diseases. 5/29/2023 145

146. Epidemiology and incidence • Overall, the chances that a man will develop lung cancer in his lifetime is about 1 in 15;for a woman is 1 in 17.The numbers include both people who smoke and who don’t. • According to WHO data published in 2018,lung ca deaths in Kenya reached 481or 0.19%of total deaths. • The age adjust death rate is 2.67 per 100000 of population ranks kenya#152 in the world. 5/29/2023 146

147. Classification 1 Benign tumors: papilloma fibroma chondroma 2 Locally malignant tumors: bronchial carcinoid. 3 Malignant tumors: 1. Primary: bronchogenic carcinoma, lymphoma, sarcoma. 2. Secondary: small cell lung cancer and non small lung cancer. 5/29/2023 147

148. Small cell lung cancer (sclc)20-25% of all lung cancer • It starts in the bronchi then affect the whole lung. • They metastases to other body parts(brain, liver, bone marrow). 5/29/2023 148

149. Non-small cell lung cancer (NSCLC) • Most common-80-85% • Is any type of epithelial ca other than SCLC. • Spreads more slowly than SCLC. 1. Squamous cell carcinoma:arise centrally in larger bronchi. 2. Adenocarcinoma:formed from mucus secreting glands in the periphery of the lungs. 3. Large cell carcinoma:occur in any part of the lung and tend to grow spread faster than squamous cell carcinoma and adenocarcinoma. 5/29/2023 149

150. Squamous cell carcinoma • Moderate to poor differentiation. • Makes up 30-40% of all lung cancer. • More common in males. • Most occur centrally in the large bronchi. • Uncommon metastasis that is slow affects the liver,adrenal glands and lymph nodes. • Associated with smoking. • Not easily visualized on x-ray. 5/29/2023 150

151. Adenocarcinoma • Increasing in frequency.Most common type of lung cancer (40- 50% of all lung cancers) • Clearly defined peripheral lesions. • Glandular appearance under a microscope. • Easily seen on a CXR. • Can occur in non-smokers. • Slow metastatic in nature. • Patients present with or develop brain,liver,adrenal or bone metastasis. 5/29/2023 151

152. Large cell carcinoma • Makes up 15-20% of all lung cancers. • Poorly differentiate cells. • Tends to occur in the outer part(periphery) of lung,invading sub- segmental bronchi or larger airways. • Metastasis is slow but early metastasis occur to the kidney,liver and adrenal glands. 5/29/2023 152

153. Causes and risk factors • Gender • Smoking: Active-85-87% and passive 3-5%. • Older age. • Presence of airflow obstruction. • Genetic predisposition. • Pollution and occupation exposure. • Industry work due to asbestos (Heat resistant fibrous). • Lung disease eg TB. • Diet(low in fruits and vegetables). • Exposure to asbestos 5/29/2023 153

154. Pathophysiology • Carcinogens like smoke, occupation and environmental agents, genetics • Binds with cell’s DNA and damage the cell • Cellular changes and abnormal cell growth occur • Malignant transformation of pulmonary epithelial cells • Abnormal proliferation of lung cells.These cells grow slowly and covers the segmental bronchi and lobes of the lung. • Nonspecific inflammatory changes with hypersecretion of mucus, desquamation of the cells. • Lessions formation in the lung tissues involving the bronchi, bronchioles or even alvoeli. • Bronchogenic carcinoma. 5/29/2023 154

155. Signs and symptoms 1. Localized s/s-involving the lung. 2. Generalized s/s-involves other areas throughout the body where it has spread. • Early s/s • Late s/s 5/29/2023 155

156. Localized S/S • Cogh and fatigue • Breathing problems,stridor • Blood in phlegm • Lung infection, haemoptysis • Hoarseness, hiccups • Weight loss • Chest pain and tightness • Pleural effusion 5/29/2023 156

157. Generalized-early/late s/s Early s/s Late s/s Cough/chronic cough Dyspnoea Hemoptysis Chest/shoulder pain Reccuring temperature Reccuring resp. infections Bone pain,spinal cord compression Chest pain/tightness Dysphagia Head and neck edema Blurred vision, headache Weakness,anorexia,weight loss,cachexia Pleural effusion Liver metastasis/regional spread 5/29/2023 157

158. Diagnosis • Hx of the patient • CXR • CT scan • MRI • Sputum cytology • Bronchoscopy-view airway • Thoracic fine needle aspiration • Lab tests: blood tests-cbc,blood chemistry tests for liver and kidney functions. • Biopsy 5/29/2023 158

159. Cancer staging systems • Most common staging system for lung cancer is the TNM system developed by International Union Against Cancer(IUAC) • Guides best course of treatment • Estimates prognosis • Only useful in staging NSCLC, when surgery is considered. 5/29/2023 159

160. TNM staging • T-tumors: tumor size(local invasion) • N-node: node involvement (size and type) • M-Metastasis: general involvement in organs and tissue Tumor size Tx-tumor unknown or CA cells are only found in sputum T0-present only in the cells lining the airway T1-tumor size less than or equal to 3cm T2-tumor size 4-7cm T3-tumor size more than 7cm T4-tumor that invade structures in the chest eg heart,major blood vessels near the heart, the trachea and esophagus n1 5/29/2023 160

161. Nodal involvement N0-No nodes involved N1-tumor has spread to the nearby nodes on the same side of the body N2-tumor has spread to the nodes farther away but on the same side of chest. N3-tumor has spread to the lymph nodes on the other side of the chest from the original tumor or has spread to the nodes near the collar bone or neck muscles. Metastasis Mo-tumor has not spread to distant regions. M1-M1a:tumor has spread to the opposite lung, to the lung linin M1b:tumor has spread to distant regions of the body e.g., brain or bones. 5/29/2023 161

162. Staging • Stage 1-tumor is small and localized, no lymph node involvement . A-tumor less than 3cm B-tumor greater than 3cm and invading surrounding local area • Stage2-A-tumor less than 3cm with invasion of lymph nodes . B-tumor greater than 3cm involving the bronchus lymph nodes on the same side of the chest and tissue of local organs • Stage3-A-tumor spread to the nearby structure and regional lymph nodes . B-tumor involving the heart,trachea, esophagus, mediastinum,and lymph nodes. • Stage4-distant metastasis. 5/29/2023 162

163. Management 1. Surgery (lung resection) 2. Radiation therapy 3. Chemotherapy 4. Hormonal therapy 5. Biological or stem cell transplant 5/29/2023 163

164. Surgical treatment • Labectomy: single lobe of lung is removed • Bilectomy:2 lobes of lung are removed (only on the right side) • Sleeve resection: cancerous lobe is removed and segment of the main main brochus is resected • Pneumoectomy: removal of the entire lung • Segmentectomy: segment of the lung is removed • Wedge resection: removal of small,pie shaped area of the segment • Chest wall resection with removal of the cancerous lung tissue. 5/29/2023 164

165. Radiation treatment and chemotherapy Radiation • Useful in controlling the neoplasm that cannot be surgically removed • Used to reduce the size of the tumor • May help to remove the symptoms like cough, chest pain, dyspnea and hemoptysis Chemotherapy Used to alter tumor growth and to treat the patient with metastasis • NSCLC :2 drug regimen-cis/carbo playing + 1 other(taxol/taxotere/gemcitabine) • SCLC:cisplatin/etoposide Other drugs involved Paclitaxel Cyclophosphamide Doxorubicin vinblastin 5/29/2023 165

166. Side effects of treatments Surgery Radiation Chemotherapy Pain Hemotomas Hemorrhage Altered resp.function Risk of atelectasis, pneumonia,hypoxia Risk of DVT Fatigue Decreased nutritional intake Radiodermatitis Decreased hemopoeitic functions Risk of pneumonitis, esophagitis,cough Lung fibrosis Grief Anemia, thrombocytopenia Fatigue Alopecia Cold pale skin Tingling Irritable Dizziness, weakness 5/29/2023 166

167. Complimentary therapy • Foods: green tea, garlic,fish oil, lactobacillus • Mind-body:help to reduce anxiety, mood disturbance or chronic pain in CA patients (audiotapes,videotapes, books, music, relaxation,yoga, meditation) • Acupuncture • Hypnosis • Massage therapy 5/29/2023 167

168. Complications • Airway obstruction, dyspnea, hypoxemia,resp.failure • Bleeding (hypotension,cardiogenic shock) • Cardiac dysthymias,CHF, fluid overload • Fever, sepsis • Pneumonia • Pneumothorax • Pulmonary embolism • Hypercalcemia-bones leak calcium in the blood • Superior venacava syndrome • Prolonged hospilization • Death 5/29/2023 168

169. BREAST CANCER DR. MUNGAI M.O

170.  Breast carcinoma is the commonest cause of cancer death in women.  It accounts for 6% of all female deaths

174. Other risk factors 1)Early menarche 2)Family history of breast ca, GIT or Ovarian cancer. 3)Benign breast disease with hyperplasia and atypia, benign breast disease with multiple papillomas. 4)Breast cancer in the contralateral breast 5)Oral combined contraceptives. 6)Hormonal replacement therapy. 7)Whether breastfed and length of breastfeeding. 8)Exposure to radiation, occupational or therapeutic.  >>Diet.

177. Peau d’orange

178. Paeu d’orange

184. palpation  Start from the normal side.  Quadrant by quadrant.  Squeeze nipple for any discharge.

185. Lymph nodes exam  Examine the tail of the breast  Axillary lymph nodes; apical,lateral,posterior and anterior, medial  Supraclavicular,infraclavicular, and axillary lymphadenopathy can be suggestive of advanced disease  Characteristics suggestive of malignancy include, skin involvement, fixation to the chest wall, irregular border, firmness, and enlargement.

186. Other systems to be examined  Respiratory  Abdominal  Musculoskeletal

187. Differential diagnosis  Giant fibroadenoma, fibrosarcoma  Deep breast mycosis  Chronic breast abscess e.g TB  Secondary malignancies to the breast; melanoma, lungs  Cystsarcoma phylloides

192. Mammogram

193. Mammogram

198. Staging TNM staging TUMOR SIZE  TX-Primary tumour cannot be assessed  T0 -No evidence of primary tumour  Tis- Carcinoma in situ  T1- Tumour <2 cm in greatest dimension  T2- Tumour > 2 cm but< 5 cm  T3- Tumour > 5 cm  T4- Tumour of any size with direct extension to chest wall or skin(including inflammatory carcinoma)

199. LYMPH NODE INVOLVEMENT  Nx- Regional lymph nodes cannot be assessed.  N0- No regional node metastases.  N1- Metastases to ipsilateral axillary lymph nodes withOUT fixation.  N2- Metastases to ipsilateral axillary lymph nodes with fixation.  N3- Metastases to ipsilateral supraclavicular or internal mammary lymph node.

200. METASTASIS  MX- Cannot be assessed.  M0- No metastases.  M1- Distant metastases including ipsilateral supraclavicular lymph nodes.

201. Manchester staging  Stage 1- tumour confined to the breast.  Stage 2- tumour confined to breast, palpable, mobile axillary nodes.  Stage 3- tumour extends beyond the breast tissue because of skin fixation in an area greater than the size of the tumour or because of ulceration. Tumour fixed to underlying fascia.  Stage 4- Distant metastases.

211. OTHER TREATMENT MODALITIES Systemic hormonal therapy: Selective estrogen receptor modulators(SERM), Estrogen receptor antagonists e.g Tamoxifen Oral aromatase inhibitors e.g. anastrazole  Monogonadorelin(LHRH) analogues e.g Goserelin monoclonal antibody- E.g, Tras-tuzu-mab

213. Prevention of breast cancer  Breast self-examination.  Annual evaluation with mammography.  Removal of breast lumps.  Tamoxifen for those at high risk.  Lifestyle modification- alcohol, sedentary lifestyle.  Prophylactic mastectomy in those at higher risk.

214. Prognostic factors  Chronological prognostic factors include: -Age; younger women have poorer prognosis. -Tumour size; diameter of tumour correlates directly with survival. - Lymph node status; direct correlation between number and level of nodes and survival. -Metastases; distant metastases have worse prognosis.

215. Mastectomy  Indications: 1. Congenital supernumerary breast. 2. Extensive destruction of breast archtecture due to chronic infections(TB,Fungi), Sarcoidosis, severe trauma. 3. Tumours. a) Early breast cancer(carcinoma in- situ). b) Large tumours in relation to the size of the breast. c)Central tumours beneath the nipple.

216. Indications for mastectomy d) Multifocal disease. e) Local recurrence after breast conserving surgery f) Palliative( toilet mastectomy). g) Prophylaxis where there is a strong family history. h) Patient preference.

CHEST CONDITION-DCM 2021.pptx

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