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APPROACH TO THORACIC AND CARDIAC DISEASESURGEONS POINT OF VIEW Emmanuel C. San Pedro, M.D. Fellow, PCS Fellow, PATACSI Anatomic considerations Sternal Angle of Louis 2nd rib attachment, a point from which to count the ribs end of the ascending aorta and the beginning of the aortic arch. end of the aortic arch and the beginning of the descending thoracic aorta. bifurcation of the pulmonary artery into right and left pulmonary arteries bifurcation of the trachea level between t4 and t5 vertebral bodies Midclavicular line Midsternal line Parasternal line Anterior axillary line Vertebral line Tip of the scpula Midscapular line a triangle of auscultation lateral border of the trapezius upper border of the latissimus dorsi medial border of the scapula. Save for lower fibers of the rhomboid muscles, this area is free of an intervening mass of muscle tissue. Anatomic considerations Vessels/nerves run underneath the ribs Perform surgery above the rib Anatomic considerations Right lung Upper lobe 3 segments Middle lobe 2 segments Lower lobe 5 segments Left lung Upper lobe 4 segments Lower lobe 4 segments Lingular division= right middle lobe No medial basal segmentleft Thorax Anatomy/Physiology Primary muscles of respiration Diapragm- 75 to 80 % of pulmonary ventilation in quiet breathing Intercostal muscles (external intercostals and anterior portion of the inner intercostals)- 20 – 25 % of ventilation in quiet breathing Respiratory movement Diaphragm can rise up to 4th ICS during expiration- penetrating injuries up and below this level consider abdominal injury Physiologic considerations Intrathoracic pressure Negative pressure (5 cm H2O lower than that of the surrounding atmosphere) Elastic recoil of the lung encased in a rigid/bony thorax Integrity of the thoracic wall is necessary to maintain negative pressure, any break (lung, chest wall)- air is sucked in and lungs collapse Loss of rigidity- lungs collapse Physiologic considerations Intrathoracic pressure End of maximal inspiration- most negative Valsalva- most positive, bear down, positive ressure of abdomen transmiteed to thoracic cavity preventing pneumothorax AIR IN THE PEURAL SPACE Collection of air between the chest wall and lung parenchymapneumothorax Upright patient- air collects in the upper regions of the thoracic cavity AIR IN THE PLEURAL SPACE Spontaneous Primary Subpleural bleb rupture- most common Secondary Bullous disease, including chronic obstructive pulmonary disease TB Metastatic cancer, especially sarcoma Pneumonia with lung abscess Catamenial Asthma, secondary to mucous plugging Lung cancer AIR IN THE PLEURAL CAVITY Acquired Iatrogenic Transthoracic needle biopsy Subclavian (percutaneous) catheterization Central lines Pacemaker insertion Transbronchial lung biopsy Thoracocentesis Chest tube malfunction After laparoscopic surgery Barotrauma Traumatic Blunt trauma Motor vehicle accidents Falls Sports-related Penetrating trauma Gunshot wounds Stab wounds AIR IN THE PLEURAL CAVITY Symptoms Dyspnea -DEGREE DIRECTLY PROPORATIONAL TO SEVERITY OF PNEUMOTHORAX… Cough-NON- PRODUCTIVE Chest pain -PLEURITIC (AGGRAVATED BY INSPIRATION) AIR IN THE PLEURAL CAVITY PE findings Vital signs Tachypnea Tachycardia Hypotension (tension pneumothorax) Inspection Lag Shifting of mediastinal structures (tension pneumothorax) Tracheal shift Apex beat displacement Neck vein distention ( tension pneumothorax) Palpation Decreased transmission of VOCAL fremiti AIR IN THE PLEURAL CAVITY Percussion Hyper resonance Ascultatation Diminished transmission of spoken words Decreased breath sounds FLUID IN THE THORACIC CAVITY Collection of fluid between the chest wall and lung parenchyma Normally- no fluid can be detected by imaging Upright patient Fluid collects in the most dependent region of the thoracic cavity- costophrenic sulci FLUID IN THE THORACIC CAVITY Transudative pleural effusions Infection (pneumonia, tb) Congestive heart failure Pericardial disease Cirrhosis Nephrotic syndrome Peritoneal dialysis Fontan procedure Myxedema Cerebrospinal fluid leaks to pleura Sarcoidosis Urinothorax FLUID IN THE THORACIC CAVITY Exudative pleural effusions Neoplastic diseases Metastatic disease Mesothelioma Primary effusion lymphoma Pyothorax associated lymphoma Infectious diseases Bacterial infections Tuberculosis Fungal infections Viral infections Parasitic infections Pulmonary embolization Gastrointestinal disease Esophageal perforation Pancreatic disease Intraabdominal abscesses Diaphragmatic hernia Collagen vascular diseases Rheumatoid pleuritis Systemic lupus erythematosus Drug-induced lupus Immunoblastic lymphadenopathy Sjogren's syndrome Wegener's granulomatosis Churg-Strauss syndrome FLUID IN THE THORACIC CAVITY Exudative effusion After surgical procedures Post coronary artery bypass surgery Post cardiac injury syndrome Post lung transplantation Post liver transplantation Post abdominal surgery Post endoscopic variceal sclerotherapy Asbestos exposure Sarcoidosis Uremia Meigs' syndrome Yellow nail syndrome Drug-induced pleural disease Trapped lung Radiation therapy Electrical burns Urinary tract obstruction Iatrogenic injury Ovarian hyperstimulation syndrome Chylothorax Hemothorax FLUID IN THE THORACIC CAVITY Symptoms Dyspnea Cough Chest pain Fever PE Inspection Lag Percussion Dullness Palpation Diminished transmission of spoken words Ausculatation Decreased breath sounds Diminished transmission of spoken words Solid in the thoracic cavity Non aerated entity occupies the pleural cavity Atelectatic lung Fibrotic lung Organized pyothorax Clotted blood Tumor Primary lung malignancy Metastatic disease Mesothelioma Large mediastinal masses Solid in the thoracic cavity Symptom Dyspnea Cough Chest pain Fever hemoptysis Solid in the thoracic cavity PE Inspection Loss of lung volume Asymmetric chest Scoliosis Narrowed intercostal space Shoulder drop Non expanding lung Lag or no expansion at all Solid in the thoracic cavity Percussion Dullness to flat Ascultation Non-obstructed bronchus Egophony Increased transmission of spoken words Decreased breath sounds Obstructed bronchus Stridor , wheezing Decreased breath sounds Diminished transmission of spoken words Solid in the thoracic cavity Palpation Non-obstructed bronchus Increased transmission of spoken words Obstructed bronchus Diminished transmission of spoken words Fluid in the pericardium Pericardial effusion Normally- fluid present in the pericardial space, undetectable by imaging Etiology Trauma Infection (tuberculous) Malignancy Uremia Congestive heart failure Fluid in the pericardium Symptoms- possible findings Dyspnea, orthopnea Chest pain Substernal Worsened by supine position Relieved by leaning forward Edema Ascites Fluid in the pericardium PE Vital signs Tachycardia Tachypnea Hypotension (tamponade) Inspection Neck vein distention (tamponade) Edema Ascites Fluid in the pericardium Auscultation Distant/ muffled heart sounds Congenital heart disease Acyanotic Cyanotic Atrial septal defect Tetralogy of fallot (TOF) (ASD) Ventricular septal defect (VSD) Patent ductus arteriosus (PDA) Coarctation Transposition of the great arteries (TGA) Tricuspid stenosis (TS) Total anomalous pulmonary venous return (TAPVR) Pulmonic valve stenosis (PS) Acyanotic heart disease Pathology Connection between pulmonary and venous system (overload of blood in pulmonary system) Obstruction in aortic outflow Symptom Failure to thrive Poor weight gain Easy fatigability Recurrent pulmonary infection Hypertension (coarctation) Acyanotic heart disease PE Vital signs Tachypnea Tachycardia >20 mm hg difference in BP of upper extremity and lower extremity (post ductal coarcatation) Inspection Funny looking kid???? Pigeon breast deformity ( ventricular septal defect) Dynamic precordium Displacement of apex beat Acyanotic heart disease Palpation Heave (forceful ventricular contraction in VSD) Thrill Auscultation Machinery type mumur (Patent ductus arteriosus) Systolic Pansystolic, Lower left sternal border (Ventricular septal defect) Bilateral crackles (pulmonary congestion) Cyanotic heart disease Pathology diminished blood flow to the lungs (TOF, PS, TS) Discordant connection between pulmonic and systemic circulation (TGA, TAPVR) Symptom Cyanosis during crying Failure to thrive Dyspnea Easy fatigability Squatting (tetralogy of fallot) Cyanotic heart disease PE Vital signs Tachypnea Tachycardia Inspection Cyanosis- circumoral, nailbeds Clubbing of fingernails Malnourished Dynamic precordium Cyanotic heart disease Palpation RV heave (TOF) Ascultation Systolic murmur heard best at left upper sternal border Murmur across the pulmonic valve (TOF, PS) Valvular heart disease ACQUIRED HEART DISEASE Mitral stenosis Diseased mitral valve prevents normal emptying of the blood form the left atrium to the ventricle during diastole Pressure overload of left atrium VALVULAR HEART DISEASE MITRAL STENOSIS Only known etiology- rheumatic heart disease Symptoms Cough, hemoptysis Orthopnea, PND, dyspnea on exertion PE: Atrial fibrillation (Irregular heart rate) Normal LV dimension Auscultatory triad- increased first heart sound, opening snap, apical diastolic rumble Mitral Regurgitation Leak of blood from the left ventricle to through the diseased mitral vavle back to the left atrium during systole Volume overload of left atrium and left ventricle= LAE, LVE Mitral Regurgitation symptoms Acute MR- sudden onset of congestive heart failure Dyspnea, orthopnea edema chronic MR -symptoms do not develop until later in the course of the disease when the ventricle eventually fails, resulting in: exertional dyspnea decreased exercise capacity orthopnea. Mitral Regurgitation PE findings Systolic apical murmur transmitted to axilla Forceful apical impulse Aortic stenosis Obstruction to the flow of blood form the left ventricle to the aorta (narrowed aortic orifice) Pressure overload of the left ventricle Effect: LV hypertrophy Aortic stenosis Symptoms PE Exertional dyspnea- Systolic ejection most common symptom Angina- develops in 3040 % of patients, myocardial ischemia associated with silent muscle necrosis Syncope- 10 % of patients murmur- 2nd ICS right sternal border with radiation to carotid artery Pulsus parvus at tardus- pulses pressure is narrow and sustained Aortic Insufficiency Back flow of blood from the aorta to the left ventricle due to weakened aortic valve Volume overload of left ventricle Effect: left ventricular enlargement (cor bovinum) Aortic Insufficiency Symptoms Dyspnea on exertion- most common symptom Palpitations Biventricular failure symptoms Angina Aortic Insufficiency • Auscultatation- systolic ejection murmur, S3 gallop of heart failure, mid-diastolic rumble in mitral valve area (Austin Flint murmur) Inspection/palapation- widened pulse pressure Watson's water hammer pulse - pulse that is bounding and forceful, as if it were the hitting of a water hammer that was causing the pulse. Corrigan pulse- carotid pulsations seen in aortic regurgitation, named after Dominic Corrigan . (rapid upstroke and collapse of the carotid artery pulse) Demuset’s sign- head bobbing