How to present a Thoracic Case | IACTS SCORE 2020

Approach to a Thoracic
Case
Dr S.V.Srikrishna MS, MCh, FRCS Ed, FIACS
Prof & Sr Consultant Cardiothoracic Surgeon
Narayana Hrudayalaya, Bengaluru
SCORE 7th Mar2020

Specific respiratory symptoms
• Breathlessness
• Wheeze
• Cough
• Sputum/haemoptysis
• Chest pain
• Fever/rigors/night sweats
• Weight loss
• Drowsiness

Past medical history
• Respiratory disease
• Other illness/hospital encounters
Drug and allergy history
• Drugs causing or relieving respiratory symptoms
• Allergies to pollens/pets/dust; anaphylaxis

Social and family history
• Family history of respiratory disease
• Home circumstances/effect of and on disease
• Smoking
• Occupational history
Systematic review
• Systemic diseases involving the lung
• Risk factors for lung disease

Breathlessnes
Onset
Instantaneous – Pneumothorax, PE, Acute Allergy
Hours – Asthma, Acute Pulmonary edema, Acute
infection
Insiduous – Effusions, Interstitial disease, Tumours
Grading
Aggravating and relieving factors

Grade Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous
exercise
2 Short of breath when hurrying on the level or
walking up a slight hill
3 Walks slower than most people on the level, stops
after a mile or so, or stops after 15 minutes walking
at own pace
4 Stops for breath after walking about 100 yds or
after a few minutes on level ground
5 Too breathless to leave the house, or breathless
when undressing
Medical Research Council (MRC) breathlessness scale

Wheeze
• Age of onset
• Relation to exertion – if yes COPD, even if at rest
Asthma
• Associated with Cough and expectoration –
suppurative infection
• Related to posture – Tumors
• Seasonal - Asthma

Cough
• Duration
• Dry / Productive
• Postural variation
• Associated with Fever, Chest pain, hemoptysis
• Aggravating or relieving factors

Sputum
In acute or chronic airways infection,
accumulation of neutrophils, mucus and
proteinaceous secretions in the airways results in
cough with expectoration of sputum.
Colour
• Clear (mucoid): COPD/bronchiectasis without current infection/rhinitis.
• Yellow (mucopurulent): acute lower respiratory tract infection/asthma.
• Green (purulent): current infection – acute disease or exacerbation of
chronic disease, such as COPD.
• Red/brown (rusty): pneumococcal pneumonia

Sputum …
Consistency
• An increase in stickiness (viscosity) may indicate exacerbation in
bronchiectasis.
• Large volumes of frothy secretions over weeks/months are a feature of the
uncommon bronchoalveolar cell carcinoma.
• Occasionally, sputum is produced as firm ‘plugs’ by patients with asthma
,sometimes indicating underlying allergic bronchopulmonary aspergillosis.
Volume
In 24 hrs ; postural variation

Haemoptysis
• Quantity – Streaks, copious or massive
• Quality – Frank blood, clots or pink & frothy
• Duration and frequency
• Differentiate from
• Epistaxis
• Oropharyngeal bleed
• Haematemesis

Chest pain
Site and severity.
Character: sharp suggests pleural pain.
Onset: gradual or rapid?
Exacerbating or relieving factors: worsening with
cough or deep breaths suggests pleural disease.
Associated symptoms: breathlessness, fever and
cough suggest an infective cause.

Respiratory causes of Chest Pain
• Chest pain from respiratory
causes is a common complaint
and may indicate the presence of
a serious or even life-threatening
pathologic condition. Most chest
pains are the result of irritation
or inflammation of the parietal
pleura, as the visceral pleura is
insensate, although pain may
arise from direct malignant
invasion or trauma to the chest
wall. Rapid recognition with
appropriate understanding of the
anatomy and physiology of chest
pain from respiratory causes is
vital to ensure timely and
appropriate therapy.
• Pneumothorax
• PE
• Malignant Pleural diseases
• Pneumonia and pleural infection
• Connective tissue disesase
• Tracheobronchitis
• Rare causes
• Pulmonary arterial hypertension (PAH)
• asbestos-related pleural plaques
• Epidemic myalgia (Bornholm disease)
• Iatrogenic
• Pleural interventions
• Thoracotomy/Thoracoscopy
• PleurodesisMedical Clinics of North America, 2010-03-01, Volume 94, Issue 2, Pages 217-232,

Others
• Fever
• Rigors
• Night sweats
• Weight loss
• Stridor
• Smoking history or other form of Tobacco
addiction– No. of Pack years, past or current
smoker,

Inspection
• Look for asymmetry of the chest, deformities, operative
scars and chest drains, remembering that thoracotomy
scars may be visible only on the lateral and posterior
aspects of the chest.
• Quietly observe and time respiratory rate.
• Inspect the remaining skin for relevant abnormalities.
• Examine the hands for finger clubbing, tar staining, nail
discoloration and cyanosis.
• Check the pulse while examining the hands.
• Examine the JVP, distended veins on the chest wall
• Check for tracheal deviation

Palpation
• Locate the apex beat
• Assessing chest expansion from the front and back
• Check for any asymmetry
• Surgical emphysema may be present
• Look for vocal fremitus in all areas of the chest
• Examine the cervical lymph nodes from behind

Percussion
• Correctly performed,
percussion can
distinguish areas of the
chest wall over air-filled
lung from those overlying
consolidated lung or
fluid.
• Look for clavicular
resonance
• Diffrentiate Resonant,
Hyper resonant, dull and
stony dull notes

Auscultation
• The tracheobronchial tree branches 23 times between the trachea and the
alveoli.
• During a maximal breath in and out, the vital capacity (about 5 L of air in
healthy adults) passes through each generation of airway.
• In the larynx and trachea, this volume must all pass through a cross-
sectional area of only a few square centimetres and therefore flow rate is
fast, causing turbulence with vibration of the airway wall and generating
sound giving rise to “Bronchial breath sounds”
• In the distal airway, the very large total cross-sectional area of the
multitude of bronchioles means that 5 L can easily pass at slow flow rates,
so flow is normally virtually silent.
• Most of the sound heard when auscultating the chest wall originates in the
large central airways but is muffled and deadened by passage through
overlying air-filled alveolar tissue; this, together with a small contribution
from medium-sized airways, results in “normal breath sounds” at the
chest wall, sometimes termed “vesicular”.

Added Sounds
• Wheeze - is a musical whistling sound accompanying airflow and
usually originates in narrowed small airways.
• Crackles - accompanying deep breathing are thought to represent
the sudden opening of small airways but sometimes may indicate
secretions in the airways or underlying lung fibrosis.
• Crackles that persist after several breaths and do not clear with a
deliberate cough are pathological. They are graded as ‘fine’,
meaning soft, multiple crackles, to ‘coarse’, indicating loud, scanty
crackles that tend to change with each breath.
• Pleural rub is a rasping, grating sound occurring with each breath
and sounding superficial, just under the stethoscope. It indicates
pleural inflammation, and is often accompanied by pleuritic chest
pain.
• Look for vocal resonance in all areas of the chest

Some Pearls
Extrathoracic stridor: High-pitched, monophonic, isolated
inspiratory sound implying extrathoracic, upper airway/laryngeal
obstruction, as occurs from mucus, swollen tissue, external
compression, or tumor.
Harmonic, polyphonic sound indicating intrathoracic airway
obstruction
• Airway structures inside the chest collapse during expiration and
open during inspiration
• Mild airway narrowing causes an isolated expiratory wheeze
• Severe airway narrowing causes an inspiratory and expiratory wheeze
• An isolated inspiratory wheeze equals extrathoracic stridor until
proven otherwise (examine the neck)
• It is not possible for an airway structure inside the chest to produce an
isolated inspiratory wheeze

The relative effects on expiratory and
inspiratory flow of intra- and
extrathoracic large airway obstruction.
(1) Large airway obstruction within the
thorax. (a) Positive intrathoracic
(alveolar) pressure generated during
expiration acts to compress the airway
and further narrow the point of
obstruction. (b) Negative intrathoracic
pressure during inspiration acts to reduce
narrowing at the point of obstruction.
Therefore in large airway obstruction
within the thorax, expiratory flow is
diminished to a greater degree than
inspiratory flow .
(2) Large airway obstruction outside the
thorax. (c) Positive pressure within the
airway during expiration in relation to
atmospheric (‘zero’) pressure outside,
acts to reduce narrowing at the point of
obstruction. (d) Negative pressure
within the airway during inspiration acts
to compress the airway and further
narrow the point of obstruction.
Therefore
in large airway obstruction outside of
the thorax, inspiratory flow is diminished
to a greater degree than expiratory
flow

Chest
Disease
Trachea Fremitus Percussion
note
Breath
Sounds
Adventitiou
s
Breath
sounds
Transmitted
Sounds
Consolidation Midline Increased Dull Bronchial Late
Inspiratory
crackles
Egophony
Large Pleural
Effusion /
Empyema
Shifted to
opposite
Decreased to
absent over
the effusion
Stony dull Absent
over effusion
Bronchial
immediately
above
? Rub over
effusion
Absent
Atelectasis
( Patent
Bronchi)
Shifted to
same side
Increased Dull Bronchial Absent Egophony
Atelectasis
(Plugged
Bronchi)
Shifted to
same side
Absent Dull Absent Absent Absent
Pneumothorax Shifted to
opposite
side
Absent Tympanic Absent Absent Absent

Chest
Disease
Trachea Fremitus Percussion
note
Breath
Sounds
Adventitious
sounds
Transmitted
sounds
Pulmoary
Fibrosis
Midline Normal/
Increased
Resonant Broncho -
vesicular
Late Inspiratory
crackles
Absent
Bronchitis Midline Normal Normal /
Hyperresonant
Vesicular Rhonchi Absent
Bronchiectasis Midline Normal Resonant Vesicular Coarse Mid
Inspiratory
crackles
Absent
Emphysema Midline Decreased Hyperresonant Diminished
Vesicular
Usually Absent Absent

• Summarize your findings
• Suggest a diagnosis / differential diagnosis
• Suggest initial investigations
• Most common and relevant investigation is
Radiological Imaging
• Chest X ray, Ultrasound, CT Scan, MR Scan, PET/CT, Bone
scan

• Does the patient require Surgery
• Is the patient fit for Surgery
• Is the patient's lifestyle likely to
improve after Surgery

Pulmonary Function Tests
• Airway function tests
• Lung volume and ventilation tests
• Diffusing capacity tests
• Blood gases and gas exchange tests
• Cardiopulmonary exercise tests
• Metabolic measurements

• FVC (forced vital capacity):
the amount of air that can
be forcefully exhaled from
total lung capacity to
residual volume, in a single
breath, is determined by
several factors aside from
height (positive correlation)
and age (negative
correlation).
• Inspiratory muscle strength
• Elastic recoil forces of the
lung
• Chest wall compliance
• Dynamic closure of airways
(and thus the balance
between lung recoil and
airways resistance upstream
of a flow limiting collapse
point)
• Expiratory muscle strength
• Patient cooperation and
ability

• FEV1 (forced expiratory
volume in one second): the
amount of air that can be
forcefully exhaled in the first
second of an FVC maneuver.
• Factors determining flow,
such as lung recoil and
airways resistance
upstream of a flow
limiting collapse point
• Reduced in the presence
of restriction of lung
volume (in proportion to
curtailment of FVC or
increased in relation to
FVC, in the presence of
increased lung recoil)

• MVV (maximum ventilatory volume):
the total volume of air that can be
cycled during 1 min of maximum
ventilation (extrapolated from a 12-
or 15-second maneuver)
• Elastic and flow resistive
factors determining flow
• Respiratory muscle strength
• Respiratory system
coordination
• Can be disproportionately
reduced relative to the
FEV1 (lower limit ¼ FEV1
32.8) with neuromuscular
weakness, upper airways
obstruction, and poor effort

• A DLCO measurement screens
for pulmonary vascular disease
and interstitial lung disease
• DLCO: single breath diffusing
capacity for carbon monoxide
(also termed transfer factor)
• Total surface area
available for gas exchange
• Membrane thickness a
minor factor
• Total capillary blood
volume
• Hemoglobin concentration
• Maldistribution of gas
• Carboxyhemoglobin
concentration

• VO2max: highest oxygen
consumption achievable
during maximal effort for
an incremental exercise
test and fails to increase
further, i.e., plateaus.
Usually we measure the
maximum VO2, which is
the highest VO achieved
with a maximal effort
(this may equal or be
similar to VO2max, but
not in all cases).
• Essential before major
lung resection
• Recommended for many
patients undergoing
esophagectomy
• Of little value in patients
undergoing lesser
operations unless
respiratory status is
tenuous

Estimated postoperative FEV1
• No further respiratory
function tests are required
for a lobectomy if the
post-bronchodilator FEV1
is >1.5 litres and for a
pneumonectomy if the
post-bronchodilator FEV1
is >2.0 litres, provided that
there is no evidence of
interstitial lung disease or
unexpected disability due
to shortness of breath

Other Systems
Nutritional status
• Impaired immune
function
• Impaired wound
healing
• Little can be done to
correct this in the short
term
Hepatic Dysfunction
Coagulopathy
Renal dysfunction
• Difficult fluid
management
• Increased risk of
bleeding
• Impaired wound
healing
• Impaired immune
function

Measurement of Lung Volumes and Capacities by Spirometry
In this spirogram, beginning on the left, the subject breathed quietly for a few breaths, exhaled maximally, breathed
quietly for a few breaths, inhaled maximally, and then breathed normally again. Note that residual volume, functional
residual capacity (FRC), and total lung capacity cannot be measured by spirometry alone. FRC is measured by another
technique (often helium dilution); when FRC is known, total lung capacity and residual volume can be calculated from
the spirometry tracing. The volumes represented in the tracing are those of a typical healthy adult.
Netter's Essential Physiology, Second Edition

PFT
• Lung volumes screen
for restrictive physiology
• Restrictive disease associated with
parenchymal lung disease (DPLD) limits
exercise by increasing the work of
breathing (small, stiff lungs are more work
to inflate) and by profound exercise-
induced oxygen desaturation (as diffusion is
severely limited by interstitial fibrosis or
alveolar filling)

PFT
• Spirometry screens for obstructive physiology
• Obstructive disease limits exercise by causing a
prolonged exhalation, which limits the individual’s
ability to increase his or her minute volume (MV)
• An inability to increase MV limits exercise as
symptomatic lactic acidosis ensues instead of
appropriate respiratory compensation

Interpretation of Spirometry
Step 1. Look at the Flow-Volume loop
Step 2. Look at the FEV1 (Nl ≥ 80% predicted).
Step 3. Look at FVC (Nl ≥ 80%).
Step 4. Look at FEV1/FVC ratio (Nl≥ 70%).
Step 5. Look at FEF25-75% (Normal (≥ 60%)
PFT II 46

• If FEV1, FEV1/FVC, and FEF25-75% all are normal, the patient has a
normal PFT.
• If both FEV1 and FEV1/FVC are normal, but FEF25-75% is ≤ 60% ,then
think about early obstruction or small airways obstruction.
• If FEV1 ≤ 80% and FEV1/FVC ≤ 70%, there is obstructive defect, if FVC is
normal, it is pure obstruction. If FVC ≤ 80% , possibility of additional
restriction is there, get lung volume to confirm.
• If FEV1 ≤ 80% , FVC ≤ 80% and FEV1/FVC ≥ 70% , there is restrictive
defect, get lung volumes to confirm.
PFT II 47

Pulmonary Function in
Obstructive Lung Disease
In emphysema, a chronic
obstructive lung disease often
associated with smoking,
inflammatory destruction of
elastic tissues in the lung occurs,
resulting in reduced elastic
recoil of the lung. Changes in
lung volumes (A) , flow-volume
curves (B) , and spirometric
measurements (C) associated
with emphysema are illustrated.
Notably, forced expiratory
volume in one second (FEV1 ) is
reduced in persons with
obstructive lung disease, as is
the ratio of FEV 1 to forced vital
capacity (A) . The forced
expiratory flow rate during the
middle portion of a forced
expiration (FEF 25%-75% ) is also
reduced.

Pulmonary Function in Restrictive
Lung Disease
Lung compliance is reduced in
restrictive lung diseases such as
interstitial fibrosis, resulting in
diminished lung volumes. Changes
in spirometric measurements (A) ,
flow-volume curves (B) , and lung
volumes (C) associated with
restrictive lung disease are
illustrated. Because both forced
expiratory volume in one second
(FEV 1 ) and forced vital capacity
(FVC) are reduced in restrictive
lung disease (A) , the ratio of
FEV 1 to FVC is usually normal but
may even be increased when FVC
is greatly reduced. The forced
expiratory flow rate during the
middle portion of a forced
expiration (FEF 25%-75% ) is normal or
reduced in persons with restrictive
disease.

Three patterns of major airway obstruction can be
observed on the flow–volume loop. These are
fixed, variable intrathoracic and variable
extrathoracic.

Variable extrathoracic obstruction. Reduction of the peak inspiratory
flow causes flattening of the inspiratory portion of the flow–volume loop.

Variable intrathoracic obstruction. There is marked reduction of
the PEF, causing flattening or ‘decapitation’ of the flow–volume loop.
Major airway obstruction can also be identified on a volume–time graph
and produces a pattern known as a straight line spirogram shown.
However, this may be mistaken for an incomplete expiration or a leak, and
these defects are much easier to identify on a flow–volume graph.

Flow–volume loop showing fixed upper airway obstruction. There
is marked reduction of both the peak inspiratory and peak expiratory
flow (PEF).

Diffusing Capacity
 Diffusing capacity of lungs for CO
 Measures ability of lungs to transport inhaled
gas from alveoli to pulmonary capillaries
 Depends on:
- alveolar—capillary membrane
- hemoglobin concentration
- cardiac output

• A DLCO measurement screens for pulmonary
vascular disease and interstitial lung disease
• Pulmonary vascular disease limits exercise by
increasing dead space (vascular obstruction creates
physiologic dead space) and by right ventricular
(RV) afterload, which limits RV cardiac output (CO)
and thus left ventricular (LV) CO

Dlco and disease. Some of the more common disease disorders which affect gas exchange. (A) Depicts the normal
alveolar capillary interface where gas exchange occurs; (B) Emphysema–destruction of the alveolar capillary interface
and hyperinflation; (C) Anemia – reduction in oxygen–carrying capacity; (D) Pulmonary emboli and/or A-V
malformations affect oxygen transport; (E) Interstitial lung disease such as pulmonary fibrosis scars the alveolar
membrane surface; (F) Alveolar volume loss from resection, alveolar collapse, or filling processes.
Ruppel's Manual of Pulmonary Function Testing

Modified scheme for interpretation of transfer factor
measurement in different lung pathologies. RV ¼ residual
volume, TLCO ¼ transfer factor for carbon monoxide, VA ¼
alveolar volume.

DLCO
 Decreased DLCO
(<80% predicted)
 Obstructive lung
disease
 Parenchymal disease
 Pulmonary vascular
disease
 Anemia
 Increased DLCO
(>120-140% predicted)
 Asthma (or normal)
 Pulmonary
hemorrhage
 Polycythemia
 Left to right shunt

LLN - Lower Limit of Normal

Indian J Anaesth, 2002:46 (4); 287-298

C P E T
The three systems linking oxygen
uptake, oxygen delivery, and oxygen
utilization to muscle work are
evaluated
Subject on a cycle ergometer outfitted
for a CPET, with device for airflow
measurement and gas sampling leads
attached to mask. Airflow and gas
sampling leads are connected to
system analysis equipment and
computer, along with inputs from ECG,
oximeter, blood pressure
measurements and ergometer.

Pre operative Bronchoscopy
• Essential to know the site and extent of lesion
• Possible causative factors
• Operability - rule out signs of inoperability
• Distance from the Carina
• Recurrent laryngeal nerve involvement
• Sub carinal disease / lymph nodes
• Fixity to the mediastinum
• R/o presence of endobronchial disease

Bronchoscopic view of the tracheobronchial tree.

Perioperative care
Prophylaxis
Cessation of smoking
Control of Diabetes
DVT Prophylaxis
Atrial Fibrillation
Stress Ulceration and Gastritis
Infection – Antibiotics

3-Legged Respiratory Assessment

Intraoperative Care
• Ventilation
• Monitoring
• Body temperature
• Positioning
• Fluid administration
• Drainage
• Specimen management

Postoperative care
• Fluid management
• Blood administration
• Medications
• Analgesia
• Nutrition
• Respiratory therapy
• Wound care
• Management of Drainage tubes
• Physical therapy

Early Complications
• Bleeding
• Postoperative pneumonia / atelectasis
• Prolonged drainage
• Prolonged air leak
• Pulmonary edema
• ARDS
• Myocardial infarction
• Atrial fibrillation

Late Complications
• Empyema
• Space problem
• Bronchopleural fistula
• Bronchovascular fistula
• Post pneumonectomy Syndrome
• Post thoracotomy pain
• Miscellaneous – Myaesthenic crisis, CSF leak

STAGES OF EMPYEMA
American Thoracic Society in 1962-3 stages
• Exudative stage (1-3 days )
• Fibrino purulent stage (4 to 14 days)
• Organizing stage (after 14 days)

Exudative stage (1-3 days)
• Immediate response with outpouring of the
fluid.
• Low cellular content
• It is simple parapneumonic effusion with normal
pH and glucose levels.
• pH more than 7.30
• glucose more than 60 mg/dl
• pleural fluid/serum glucose ratio more than 0.5
• LDH less than 1000 IU/L
• Gram stain and culture is negative for micro-
organism.

Fibrino purulent stage (4 to 14 days)
• Large number of poly-morphonuclear leukocytes and fibrin accumulates
• Fluid pH and glucose level fall while LDH rises.
• Acumulation of neutrophils and fibrin, effusion becomes purulent and
viscous leading to development of empyema.
• There is progressive tendency towards loculations and formation of a
limiting membranes.
• Pleural fluid analysis
• Purulent fluid or pH less than 7.10, glucose less than 40 mg/dl and LDH more than
1000 IU/L. Gram stain and culture reports show microorganism.

Organizing stage (after 14 days)
• Fibro-blasts grow into exudates on both the
visceral and parietal pleural surfaces
• Development of an inelastic membrane "the
peel".
• Thickened pleural peel may prevent the entry
of anti-microbial drugs in the pleural space and
in some cases can lead to drug resistance.
• Most common in S. aureus infection.
• Thickened pleural peel can restrict lung
movement and it is commonly termed as
trapped lung

Empyema
• The goals in the management of empyema are to
evacuate the infected material and ensure re-
expansion of the lung parenchyma with no residual
space
• “No Space, No Problem”

• The chain of intervention from least to most invasive then
proceeds from smallbore catheters to chest tubes to VATS
evacuation and decortication to thoracotomy for
decortication to open window thoracostomy.
• The surgical principles of decortication remain the same,
regardless of approach (open or VATS).
• The infected material needs to be evacuated, the
adhesions of the lung to the chest wall, mediastinum, and
diaphragm need to be taken down, and the underlying
lung parenchyma needs to have the thickened pleural rind
removed enabling expansion of the lung, allowing it to fill
the hemithorax and obliterate any residual space
• Thickened parietal pleura over the lateral chestwall and
diaphragm need to be removed to restore chest wall
mechanics

Treatment Options For Pneumothorax

Management of spontaneous pneumothorax: British Thoracic Society

Indications for Operative Intervention
for Pneumothorax Treatment

Bronchiectasis
Cylindrical Varicose
Saccular Traction

Causes of Bronchiectasis
• Primary infections
• Bronchial obstruction
• Aspiration
• Cystic fibrosis
• Primary ciliary dyskinesia
• Allergic
bronchopulmonary
aspergillosis
• Immunodeficiency states
• Congenital anatomic
defects
• Connective-tissue
disorders
• Alpha1-antitrypsin (AAT)
deficiency
• Autoimmune diseases
• Idiopathic inflammatory
disorders
• Autosomal dominant
polycystic kidney disease
• Traction from other
processes
• Toxic gas exposure

Bronchiectasis
• Therapy for bronchiectasis involves treatment of
the underlying disorder if possible; suppression of
the bacterial load through appropriate use of
antibiotics; encouragement of proper pulmonary
hygiene, including the routine use of
bronchodilators, mucolytic agents, and postural
drainage; and surgery in select cases

Role of surgery in Bronchiectasis
• First, patients with focal areas of disease with
localized lung parenchymal destruction are
candidates for resection therapy, usually via a
segmentectomy or lobectomy
• Second, the rare patient who presents with
massive hemoptysis should be considered for
surgical therapy
• Finally, some patients with bilateral end-stage
bronchiectasis may be candidates for lung
transplantation

Surgery for Lung Abscess
• Indications for surgical intervention would include
empyema, development of a bronchopleural
fistula, significant hemoptysis, persistence of the
abscess despite adequate therapy, and suspicion of
underlying malignancy

Natural History of TB
PRIMARY
COMPLEX
Heals with / without
calcification
Actively
progressive
Enters blood
stream
Walled off by
Collagen tissue
Dormant, can
get reactivated
PROGRESSIVE
PULMONARY
TUBERCULOSIS
POST
PRIMARY
TUBERCULOSIS
Acute
form
Chronic
form
MILIARY
TB Meningitis
Lung
Pleura
Bones
Joints
Kidneys
Brain
Pericardium

Sequelae of Tuberculosis
• Parenchymal lesions
• Tuberculoma
• Thin walled cavities
• Cicatrization
• End stage Lung destruction
• Aspergilloma
• Bronchogenic Carcinoma

Sequelae of Tuberculosis..
• Airway Lesions
• Bronchiectasis
• Tracheo-bronchial stenosis
• Broncholithiasis

Sequelae of Tuberculosis…
• Vascular Lesions
• Pulmonary or bronchial arteritis &/or thrombosis
• Bronchial artery dilatation
• Rasmussen’s aneurysm

Sequelae of Tuberculosis….
• Mediastinal lesions
• Lymph node calcification
• Esophago bronchial fistula
• Constrictive pericarditis
• Fibrosing mediastinitis

Sequelae of Tuberculosis…..
• Pleural lesions
• Pneumothorax
• Pleurisy / effusion
• Chronic empyema
• Fibrothorax
• Bronchopleural fistula

Sequelae of Tuberculosis……
• Chest wall lesions
• Cold abscesses
• Tuberculous osteomyelitis
• Tuberculous spondylitis
• Pott’s Spine
• Malignancy

Indications for Surgery in TB
• Persistent sputum positive cavity
• TB bronchial stenosis
• Post TB bronchiectasis
• Massive haemoptysis
• TB empyema
• TB bronchopleural fistula
• Scar cancer

Complications of Surgery for TB
• Post pneumonectomy space Empyema
• Bronchopleural Fistula
• Residual space problem
• Pneumonia
• Wound breakdown
• Bleeding
• Respiratory failure

Emphysema
Paraseptal
Bleb
Coalesced alveoli
<1cm
Bulla
Coalesced alveoli
>1cm
Giant Bulla
Sub pleural bulla
occupying >30%
chest cavity
Centrilobular
Heterogenous
(upper lobe)
Homogenous
Panacinar Homogenous

Bleb
Coalesced
alveoli<1cm
Bulla
Coalesced
Alveoli >1cm
Giant Bulla
Occupying >30%
Chest cavity

Bullectomy
• Bullectomy is the surgical removal of a bulla which
is causing increase in the physiological dead space
or causing pneumothorax
• Involves 3 stages
Bullectomy(Stapled,ligated or sewn/ open or VATS)
Apical pleurectomy / pleural tent
Pleurodesis (abrasion / talc)

Bullectomy - Indications
The most common indications for bullectomy include
the following
• Severe dyspnea due to giant bulla (ie, 30% or more
of the hemithorax)
• Spontaneous secondary pneumothorax
• Pain
• Repeated infection
• Hemoptysis

Bullectomy - Contraindications
Contraindications to bullectomy include the
following:
• Significant comorbid disease
• Poorly defined bullae on chest imaging
• Pulmonary hypertension

Heterogenous distribution
(Upper Lobes Only)

The objectives of concern for surgeon are the
following:
• How much of the lung adjacent to bulla to remove
• The method of resection
• The prevention of air leaks

LVRS / Lung Tx
Indications common to both procedures
● Emphysema with destruction and
hyperinflation
● Marked impairment (FEV1 < 35%
predicted)
● Marked restriction in activities of
daily living
● Failure of maximal medical treatment
to correct
symptoms
Contraindications to both procedures
● Abnormal body weight (< 70% or >
130% of ideal)
● Coexisting major medical problems
increasing surgical risk
● Inability or unwillingness to
participate in pulmonary
rehabilitation
● Unwillingness to accept the risk of
morbidity and mortality of surgery
● Tobacco use within the last 6 months
● Recent or current diagnosis of
malignancy
● Increasing age (> 65 y for
transplantation, > 70 y for LVRS)
● Psychological instability such as
depression or anxiety disorder

LVRS / Lung Tx
Discriminating conditions
favouring LVRS
● Marked thoracic
distention
● Heterogeneous disease
with obvious apical target
areas
● FEV1 > 20% predicted
● Age, 60-70 y
Discriminating conditions
favouring lung
transplantation
● Diffuse disease without
target areas
● FEV1 < 20% predicted
● Hypercarbia with PaCO2
> 7.3 kPa (55 mm HG)
● Pulmonary hypertension
● Age < 60 y
● alpha-1 antitrypsin
deficiency

Cartoon images depicting the typical presenting computed tomography (CT)
imaging pattern for the most common lung cancer cell types. When one of
these classic patterns is seen, the cell type may be anticipated ~ 85% of the
time.
Clinical Practice Manual for Pulmonary and Critical Care Medicine , Clinical Key – Books, Pulmonology

Histologic and immunohistochemical staining
pattern of lung adenocarcinoma.

pattern of squamous cell carcinoma.

pattern of neuroendocrine tumors of the lung.

Surgical Principles
1. Whenever possible, the tumor and all associated lymphatic drainage must be
removed completely, most frequently by lobectomy or pneumonectomy.
2. Care must be taken not to transgress the tumor during resection to avoid
tumor spillage.
3. En bloc resection of closely adjacent or invaded structures is preferable to
discontinuous resection.
4. Resection margins should preferably be assessed by frozen section. Re-excision
is preferred whenever possible if positive resection margins are encountered.
5. All accessible mediastinal lymph node stations should be sampled or removed
for pathological evaluation.

Resectable Lesion
N1 Disease
Surgery Treatment of
Choice

Resectable Lesion
N3 Disease
NO SURGERY

N2 Disease
Treatment is Controversial

Single Station N2 Disease
Resectable Lesion
Surgery should be offered

Multiple Station N2 Disease
Resectable lesion
No Surgery
Referred for CT &/or RT

Generally M1 lesions are
not suitable for Surgery

Solitary Metastases (M1)
Patients occasionally present with resectable lung
cancer and evidence of a solitary metastasis on
complete organ scanning. These patients should
be considered for resection of both the primary
tumor and the solitary metastasis.

Brain Mets in Lung Ca
1. Untreated patients with brain metastases have a
median survival of less than 3 months
2. When brain metastases are multiple or advanced
systemic disease is also present, the therapy of
choice is whole-brain irradiation
3. One third of patients presenting with brain
metastases have solitary lesions
4. Surgery offers the best form of palliation

Brain mets
• When the brain lesion is detected first and the
search for the primary tumor is negative, resection
of the brain metastasis is the therapy of choice
• When the brain metastasis presents subsequent to
the resection of primary, resection of brain mets is
indicated
• When both brain and lung lesions are detected
simultaneously, craniotomy is done first and
thoracotomy shortly thereafter
• Postoperative whole-brain irradiation is required

Solitary Metastases (M1)..
• Adrenal - Resection of the primary tumor and the
solitary metastatic focus should be considered if
both are completely resectable
• It is rare for true solitary metastases from a lung
primary to occur in the bone, liver, and other
common metastatic sites, such as the skin
• If both lesions (primary and solitary metastatic
focus) are completely resectable, surgical therapy
can be offered if the risks are low

Primaries most commonly
metastatic to lungs
• Thyroid
• Breast
• Colon
• Kidney
• Uterus
• Prostate
• Oropharyngeal
Tumors with highest
prediliction
to pulmonary
metastases
• Choriocarcinoma
• Osteosarcoma
• Testicular Tumors
• Melanoma
• Ewing'sSarcoma
• Kaposi's Sarcoma
Metastatic Tumors

Selection Criteria for
Metastasectomy
• Local control of the primary tumor or ability to
completely resect the primary with synchronous
presentations
• Radiologic findings consistent with metastatic disease
• Absence of extrathoracic metastases (i.e., metastasis is
confined to the lung)
• Ability to perform a complete resection of the
metastases
• No significant comorbidity that would preclude surgery
• No alternative therapy that is superior to surgery

Disorders of the Mediastinum
• Anterior mediastinum
– Anterior to line drawn
along anterior border
of trachea and heart
• Posterior mediastinum
– Posterior to line
drawn along anterior
borders of vertebrae
• Middle mediastinum –
Space in between the
two

Anterior Mediastinal Tumours
• 4 Ts
Thymoma or thymic cysts
Teratoma ( & other germcell tumours)
Thyroid (goitre or neoplasm)
Tuberculous Lymph nodes ( also Sarcoid & Lymphoma)

Middle Mediastinal Tumors
• 3 As
1 Adenopathy
Infection (TB)
Neoplastic
Sarcoidosis
2 Aneurysm
Aorta
Pulmonary artery
3 Abnormalities of
development
Bronchial cyst
Esophageal cyst
Pleuro-pericardial
cyst

Posterior Mediastinal Tumors
Common
• Neurogenic
• Neuroblastoma
• Ganglioneuroma
• Ganglioneuroblastoma
• Nerve root tumours
• Schwannoma
• Neurofibroma
• Malignant Schwannoma
Less Common
• Paraganglion cell tumour
• Spinal tumours / abscesses
• Lymphoma
• Bochdalek hernia
• Descending thoracic
aneurysms
• Esophageal tumours

Mediastinal Tumors
EBRT - External Beam RadioTherapy

Thymoma & MG
• Thymic Hyperplasia
• Thymoma
• Thymic Carcinoma
• Thymic Neuroendoine Tumors
• Carcinoid
• Small Cell Carcinoma
• Thymic Cysts (not rhizomatous)
• Thymolipoma
• Metastases to the Thymus

Pathophysiology
Approximately 10% to 15% of patients with MG will have an associated
thymoma, whereas 30% or more of patients with thymoma will have MG.

Basic Principles of Surgery
• Mediastinal exploration,
• En bloc resection of the thymus gland including the
cervical poles and adjacent mediastinal fat,
• Protection of the phrenic nerves,
• Prevention of intrapleural dissemination

Preoperative Preparation
• If the myasthenic patient cannot be stabilized with
medication, preoperative plasmapheresis is required
prior to thymectomy.
• Preoperative anesthetic medication is minimal, usually
consisting only of atropine and a mild sedative.
• Preoperative anticholinergic medications are avoided.
• Muscle relaxants should be avoided.
• Deep anesthesia is maintained by an inhalational agent
and short-acting narcotic

Chest wall Lesions
• Tumors
• Primary tumors – Benign or Malignant
• Metastatic
• Congenital defects
• Pectus Carinatum or excavatum
• Poland’s syndrome
• Infections
• Radionecrosis
• Trauma

Tumors
Malignant Benign
Chondrosarcoma Fibrous dysplasia (40%)
Myeloma Chondroma (30%)
Osteogenic Sarcoma Osteochondroma
Ewing’s Sarcoma Desmoid

Principles of treatment
• Excisional rather than incisional biopsy should be
peformed if a primary chest wall tumor is
suspected
• Full thickness excision of the tumor with 1 rib
margin is necessary; do not compromise resection
to avoid large chest wall defect
• Needle biopsy is best for suspicious mets or
myeloma
• Sternal tumors should be treated by sternectomy

Principles of reconstruction
• A defect less than 5 cm does not require
reconstruction
• Posterior defects do not require
reconstruction due to scapula
• Defects larger than 5 cm will require
reconstruction
• Skeletal stabilization can be accomplished
with a mesh patch or methyl methacrylate
• Soft tissue reconstruction can be done in a
variety of ways, including myocutaneous flaps
(latissimus dorsi, pectoralis major, rectus
abdominus) and omental transposition

Causes of Hemoptysis
• Infectious
• Vascular
• Iatrogenic
• Coagulopathic
• Traumatic
• Neoplastic
• Pulmonary miscellaneous

OESOPHAGEAL RESECTIONS
Staging of Oesophageal CA :
T is – in situ, T1 – lamina propria / submucosa, T2 –
muscularis mucosa, T3 – adventitia, T4 – adjacent
structures
N regional nodes = cervical, mediastinal, coeliac &
gastro-oesophageal nodes depending on location
of primary in the oesophagus
N0 – No nodal mets. N1 = positive loco-regional
nodal mets.
M – no distant mets. , M1 = positive distant mets.

Staging of Oesophageal CA:
I = T1, N0, M0
II A = T2 or 3, N0, M0
II B = T1 or 2, N1, M0
III = T3, T4, N1, M0
IV = Any T, any N, M1

Oesophageal replacement:
Stomach – best option when healthy and usable
Colon – left preferable for length, transverse & right
can also be used
Isolated Jejunum/ileum – vascularity is tenuous –
microvascular anastomosis improves survival

Where to place the conduit?
a) Shortest distance = posterior mediastinum –
oesophagus should be resectable
b) Longest distance = subcutaneous
c) In between = sub / retrosternal
(b) & © can be used when the posterior
mediastinum cannot be accessed for any reason

Where to place the
conduit?
a) Shortest distance is
posterior mediastinum –
oesophagus should be
resectable
b) Longest distance is
subcutaneous
c) In between is sub /
retrosternal
(b) & (c) can be used when
the posterior
mediastinum cannot be
accessed for any reason

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