Download Chest Lectures

Chest Lectures
Pr. Dr.Waleed Mustafa
Consultant Thoracic & Vascular Surgeon
Indications for flexible Bronchoscopy
1-For routine examinations .
2-Treatment of acute respiratory problems in the ICU.
3-Suction under visual control .
4-Use of catheter and brushes for cytology.
5-For obtaining secretions for bacteriological tests.
6-Localization of the bleeding site in case of hemoptysis.
7-Theraputic suction & irrigation .
8-Transbronchial lung biopsy .
9-Selective bronchography .
10-Autofluorescence & photodynamic diagnosis .
Major disadvantage of the flexible Bronchoscope is that it is a closed system that does not
provide an airway , and the relatively small inner channel is considered to be
incapable of allowing adequate suction when confronted with copious secretions or
massive haemoptysis .
It is not so much effective in the removal of foreign bodies .
Tracheo-Bronchial Trainer
Suction
Lever
Saline for irrigation
Lecture scope
Sample collection (BAL)
Contra indications
Rigid Bronchoscopy
Is best avoided in the presence of Cervical spine injury thoracic
to prevent hyperextension of the neck & in patient with Aneurysm of the
aorta
Flexible Bronchoscopy
Best avoided in patient with Massive Haemoptysis & patients with air way
problems
In cases of doubt as to whether bronchoscopy should be done or not , bronchoscopy
should always be done ( Jackson’s 1915 statement ) .
In suspected cases of F.B inhalation it is better to have a negative bronchoscopy rather
than to miss a F.B inside with all its pathological consequences .
Normal Bronchoscopic Findings
Abnormal Bronchoscopic Findings
COMPLICATIONS
When bronchoscopy performed by properly trained individuals
It is a safe procedure .However a variety of other problems have been reported
including
Pneumothorax , bronchospasm , Bronchial perforation (Surgical emphysema
& tension pneumothorax ) ,
Subglottic edema , Uncontrolled bleeding , Infections
Arrhythmias rarely ( Cardiopulmonary arrest )
Hypoventilation (Hypoxia& hypercapnia)
Majority related to a biopsy procedure So explorative thoracotomy may be safer than
(injudicious biopsy )
Some minor complications
Damage of teeth , Injuries to lips or mouth
Post bronchoscopy care
1-Close monitoring for 2-4 hours after the procedure
2-Eating and drinking is not allowed until the effect of anesthesia have worn off .
3-Some may advise routine CXR after performing a biopsy to check for signs of
pneumothorax .
3-Those patients develop complications may need to stay in the hospital for
additional time .
4-The patients may have sore throat , hoarseness ,cough or muscle ache .
Fever up to temperature 38 “ c is common after bronchoscopy but usually for
only 24 hours .
Advances in Bronchoscopy
1- Brochoscopic Ultra-sound
2-Bronchoscopic stenting (Air way prosthesis )
3-PDD & AF Bronchoscopy .
4-Bronchoscopic Laser therapy .
5-Bronchoscopic Electro Cautery
6-Cryo therapy
7-Brachy therapy
8-Photo therapy
Bronchoscopy need cooperation and mutual understanding Between
1-A well trained endoscopist
2-a qualified staff
3-Expert and well trained anesthetist
Bronchoscopy
is now an integral part of respiratory medicine.
Diagnostic indications include tissue diagnosis, detection and staging of lung
malignancy, evaluation of diffuse lung diseases like sarcoidosis and idiopathic interstitial
pneumonias, pulmonary inspection of burn patients, identification of organisms infecting
the respiratory tract and lungs.
As a therapeutic modality, bronchoscopy is used to place stents to protect
airways vulnerable to collapse or occlusion, to remove foreign bodies or masses, to treat
early stage endobronchial malignancy.
Pleural Tumors
Classified as primary and secondary tumors .
Primary Pleural tumors are Mesotheiloma which may be
1-Localized benign
2- Diffuse Malignant
Malignant Mesothelioma causes chest pain , bloody pleural effusion and chest X-Ray findings of
diffused pleural thickening with nodularity and limited pleural effusion .There is a possible
relationship with asbestos exposure .
Metastases are uncommon .Death usually occurs within 1-2 years .It has a poor response to surgery ,
radiotherapy and chemotherapy .
Pleural involvement by metastatic diseases is more common than primary tumor and usually comes
from lung , breast and stomach .
Benign Tumors of Trachea and Bronchi
Are rare ,more in males .They are slowly growing .Their presentation is is as a result of luminal
obstruction or mucosal irritation .Patients may present with dyspnea , cough and
haemoptysis .A sub glottic tumor presents with stridor ,The diagnosis is by bronchoscopy and
treatment is surgical excision .E.g Papilloma , Haemangioma ,Chondroma and Fibroma
Bronchial Adenomas
1-Bronchial Carcinod
2-Muco epidermoid Tumors
3-Adenoid Cystic Carcinomas (Cylindromas )
4-Mucous Gland Adenomas
The first three are potentially malignant ,the 4th. Is benign
The first three are slowly growing , invade locally and surgical excision is the treatment of choice .
Bronchial Carcinoid Tumors
Resemble intestinal carcinoid as the cytoplasm as the cytoplasm of their cells contains neurosecretory
granules .In the bronchus these tumors arise from the neuro endocrine argentafin cells of bronchial mucosa
(Kultchitsky ‘s cells ) .They are grouped among APUD tumors (Amine Percursor Uptake Decaboxylation) .
They are capable of producing a number of hormones like Serotonin , histamine and gastrin .They are
slowly growing tumors , but sometime they are aggresaive termed (atypical carcinoid ) .They present with
cough , haemoptysis and dyspnea ) .
Carcinoid Syndrome is a rare ,presents with episodes of flushing , diarrhea and in addition to the systemic
manifestations ,there may be cardiac manifestations .Elavated 5-HIAA may be detected in the urine ,which
may be diagnostic .Bronchoscopic appearance is diagnostic and severe bleeding may follow a biopsy .Surgical
excision is the treatment of choice .
Carcinoma of the lung
Affects both sexes , It is however commoner in men
It has poor prognosis .
The incidence has shown a marked rise during recent years partly because
of improved methods of diagnosis and partly due to
1-Ecessive cigarette smoking ,both active & passive smoking are implicated
2-Inhalation of irritants , such as silica ,cobalt dust .
Pathology :A-Central type is the commonest (75%).It arises in one of the main bronchi
or their primary division leading to bronchial obstruction with secondary
changes in the lung such as atelectasis .
B-Peripheral type (25%) arises from the smaller bronchi and remains
symptom less for long time .
Histologically
Squamous cell Ca (SCC) 60% , smoker , centrally located
,metastasizes to mediastinal & supraclavicular LN .
Adenocarcinoma (15% ) , located peripherally , more in
women .Tends to metastasizes to the liver , brain ,bone &
adrenals in addition to the LN
Undifferentiated carcinoma (oat) cell carcinoma and large
cell carcino(20-30%) which includes small ma
Alveolar cell carcinoma , located peripherally ,metastasizes
to the liver and adrenals
Recent classification..Non small & small cell carcinoma
Superior sulcus tumor of Pancoast
It is a low grade epidermoid carcinoma that grows slowly and
metastasize late, infiltrates and involves lower root of Brachial
plexus, intercostal nerves , Cervical sympathetic nerves & eroding
the upper ribs ,producing pain in the shoulder & Horner's syndrome .
Clinical features :1- cough dry or productive
2-Haemoptysis
3-Chest pain
4-Dyspnea
5-Pleural effusion
6-Anorexia & loss of weight
7-Clubbing of the fingers
8-Hoarseness of the voice (recurrent LN)
9-Dysphagia involvement of the esophagus
10-Hormonal syndromes ..ectopic ACTH , ADH, hypercalcaemia ,carcinoid
syndrome
Diagnosis
Clinical , sputum cytology
Chest X-ray ,CT chest ..
Bronchoscopy ,BAL ,bronchial brush &biopsy
FNAC….or Trucut biopsy , pleural fluid aspiration & cytology
Diagnostic Thoracoscopy & mediastinoscopy
TNM classification for staging
Thank you