CAPÍTULO 3 ANÁLISIS DE LESIONES
3.2.1. Fichas de reconocimiento
Sir, this patient has a right sided moderate pleural effusion affecting the lower two thirds of the right hemithorax.
There is reduced chest excursion of the right hemithorax associated with stony dullness with reduced/absent vesicular breath sounds and vocal resonance affecting the lower two thirds of the right hemithorax. Apex beat was not displaced and trachea was central in position. There are no scars on the chest wall to suggest a previous chest tube or a thoracotomy.
Patient respiratory rate is 14 bpm with no signs of respiratory failure or distress.
With regards to aetiology: (State the positives first and rearrange accordingly)
1. Patient does not have any raised JVP, S3or pedal oedema to suggest CCF. There are also no stigmata of chronic liver disease or generalised oedema or renal biopsy scar to suggest nephrotic syndrome. Patient does not have features of hypothyroidism.
2. There is no nicotine staining of the fingers, no clubbing, no palpable cervical lymph nodes and he is not cachexic. I did not detect any signs of SVCO, Horner‟s syndrome and patient does not have a hoarse voice to suggest a malignant effusion.
I could not detect any bronchial breathing above the effusion. The patient is not toxic looking and did not detect any Mantoux testing with respect to TB pleural effusion.
There is also no deforming polyarthropathy of RA or cutaneous signs of SLE.
There is no calf swelling or tenderness noted to suggest DVT.
With regards to treatment, I did not notice (if there are features of malignancy) any radiation marks on the right hemithorax and there are also no features of side effects of chemotherapy such as alopecia or oral ulcers.
I would like to complete the examination by looking at the patient‟s temperature chart as well as examining his sputum and examine the patient‟s breasts (if female).
In summary, this patient has got a moderate size right sided pleural effusion. He is not in respiratory distress or failure. In view:
1. Patient is cachexic, the likely underlying aetiology includes tuberculous pleural effusion or a malignant pleural effusion.
2. Fever, (young patient, short history) the most likely aetiology for this patient includes a parapneumonic effusion. Other diagnosis includes tuberculous effusion, malignant effusion or autoimmune cause.
3. Patient has Cx lymphadenopathy, I would like to offer the diagnosis of tuberculous effusion. Another possibility is a malignant effusion.
4. Patient has complications of SVCO/Horner‟s syndrome/Clubbing with HPOA/Nicotine staining of the nails/tender ribs/chest wall, he has a malignant effusion.
5. Patient has vasculitic lesions of the hands, joint deformities/tenderness, malar rash. The aetiology of the effusion is most likely due to collagen vascular disease/SLE/RA.
6. Young female, aetiologies include CTD, hypothyroidism and TB Questions
What are your differential diagnoses for dullness on percussion of the right lower zone?
1. Pleural thickening :Old TB, old empyema, mesothelioma, asbestosis, PHx of hemothorax 2. Basal consolidation
3. Lower lobe collapse 4. Raised hemidiaphragm:
a. phrenic nerve palsy from Ca or phrenic nerve crush for old TB treatment with supraclavicular fossa scar b. hepatomegaly
5. Mitotic mass
What are the causes of a pleural effusion?
o Transudative
o CCF, constrictive pericarditis
o Nephrotic syndrome, hypoalbuminemia, peritoneal dialysis o Chronic liver disease (hepatic hydrothorax)
o Myxoedema o Atelectasis o Exudative
o Malignancy
Primary - bronchial or pleural
Secondaries – Breast, pancreas, kidneys, ovaries, lymphomas o Infective – parapneumonic, TB
o CTD – SLE, RA
o PE (can also be transudative but less common) o Pancreatitis (left sided)
o Drug induced – nitrofurantoin, bromocriptine
o Meig‟s syndrome (ovarian fibroma with ascites and pl effusion)
o Yellow nail syndrome (triad of yellow nails/onycholysis, pl effusion/bronchiectasis and lymphedema) What are the causes of hemothorax?
o Trauma
o Rupture of pleural adhesion containing blood vessel, carcinoma
36 What are the causes of a chylothorax?
o Trauma or surgery to the thoracic duct
o Carcinoma or lymphoma affecting the thoracic duct What are the causes of an empyema?
o Pneumonia o Abscess o Bronchiectasis o TB
How do you confirm the diagnosis of a pleural effusion?
o Perform a lateral decubitus film to look for layering o USS
How do you differentiate between an exudative and transudative effusion?
o Light‟s criteria
o Sensitive but not specific for exudates o One out of 3 criteria
Pl fluid protein: serum protein > 0.5 Pl fluid LDH:serum LDH>0.6
Pl fluid LDH > 2/3 upper limit of serum LDH
o If suspect transudate still, can do the serum to pleural albumin gradient (difference). If > 1.2 g/dL, transudate. (less sensitive for exudates)
How would you investigate?
o CXR
o Sputum for gram stain, c/s and AFB smear, cytology o Diagnostic pleural tap and pleural biopsy
o Indications for a diagnostic thoracocentesis
>10mm thick on a lateral decubitus film or USS o Appearance
Bloody appearance
<1% insignificant
1-20% = malignancy, PE or trauma
>50% cf to peripheral Hct = hemothorax Turbid (parapnemonic, chylothorax)
Putrid odour (anaerobic) o Haemotological Ix
Total cell > 1500 cell/ml
>50% neutrophils (parapneumonic)
Lymphocyte predominant (cancer, TB, lymphoma, CTDs) Mononuclear cells – chronic
Eosinophils
Blood or air in the pleural space
Drugs – nitrofurantoin, bromocriptine, dantrolene Churg-Strauss
Paragonimiasis Asbestosis o Biochemical
Light‟s criteria and serum pleural albumin gradient pH
Glucose (<0.5 cf to peripheries = TB, malignancy, RA) Amylase level (pancreatitis)
o Microbiological
Smear and C/S AFB smears
PCR, ADA(adenosine deaminase) or gamma interferon o Cytology
Fluid
Pleural biopsy o Others
o Blood Ix, mantoux o Bronchoscope, CT scan When must you order a CXR post Dx tap?
o When you suspect complications of pneumothorax o Air is aspirated
o Patient develops cough, chest pain or dyspnea
o Loss of tactile fremitus over the superior part of the aspirated hemithorax
How would you manage?
o Treat the underlying cause o Treat symptoms
o Fever, pain
o SOB – therapeutic thoracentesis (up to 1500mls) o Chest tube insertion (tube thoracostomy)
o Complicated parapneumonic effusion Gross pus or empyema pH <7.2
Glucose <3.0
G/S positive for organism LDH >1000
o Hemothorax
o Pleurodesis for malignant effusions
What are the surface markings for a respiratory examination?
Anteriorly
o 4th rib and above = upper lobe on right o between 4th to 6th rib = middle lobe on the right o 6th rib and below on the left = lower lobe
Horizontal fissure extends on the right extends from 4th rib to midaxillary line where it bisects the oblique fissure at the 5th rib Oblique fissure extends from the 6th rib anteriorly to the back at T2
Lower lobe extends posteriorly from T2 to T11 Upper lobe posteriorly extends from T2 and above Prominent Cx spine = C7
Inferior angle of the scapula = T7
38 18. Collapse
Presentation
Sir, this patient has a right upper lobe collapse as evidenced by reduced chest excursion of the right hemithorax associated with dullness on percussion and reduced vesicular breath sounds and reduced vocal resonance affecting the upper one third of the right hemithorax. This is associated with tracheal deviation to the right. There was no displacement of the apex beat.
Patient‟s respiratory rate is 14 bpm and is not in respiratory distress or failure.
With regards to aetiology:
There are signs to suggest underlying malignancy. Patient is cachexic looking and is clubbed. I did not detect any tenderness in the wrists to suggest HPOA. There were no enlarged palpable Cx LNs. There is also no conjunctival pallor or jaundice noted. I did not detect any associated pleural effusion or raised hemidiaphragm. There were no signs of SVCO, patient‟s does not have a right Horner‟s syndrome and there is no wasting of the intrinsic muscles of the right hand (hoarseness of voice for left sided lesion).
In considering other etiologies:
There are also no ronchi on auscultation to suggest asthma or allergic bronchopulmonary aspergillosis.
There are no Mantoux testing detected on the upper limbs but endobronchial TB is a possible differential diagnosis.
I did not find any signs of treatment such as radiotherapy hyperpigmentation or side effects of chemotherapy such as alopecia, phlebitic veins or oral ulcers.
I would like to complete my examination by looking at the patient‟s temperature chart as well as examining his sputum.
In summary, this patient has a right upper lobe collapsed and is clinically comfortable. In view that patient has:
1. A history of weight loss and is cachexic looking, the possible diagnoses include endobronchial mitotic lesion or an endobronchial tuberculous infection.
2. Fever/cough/hemoptysis/Cx lymphadenopathy, the possible diagnoses includes an endobronchial tuberculous infection, endobronchial mitotic lesion or a collapse consolidation from a pneumonia.
3. Complications of Right Horner‟s syndrome, signs of SVCO, clubbed with HPOA, the most likely cause is an endobronchial mitotic lesion affecting the right upper lobe.
Questions
What are the causes of a lung collapse?
Intraluminal – Mucus plugging from asthma or ABPA, FB Endobronchial tumor, TB
Extrinsic compression – enlarged LNs for mitotic lesion (pri or sec), lymphomas or TB What is Brock‟s syndrome?
Collapse of the right middle lobe from enlarged LNs How would you investigate?
Simple investigations o CXR
o ABG, FBC and biochemical profile o Sputum AFB smear and c/s and cytology Diagnostic - Bronchoscopy and Bx
Staging – CT thorax and abdomen with adrenal cuts, bone scan Physiological staging: Lung function test
o FEV1 >1.5
o Transfer factor>50%
How would you treat the patient?
Depending on the underlying cause For mitotic lesion
o Multidisciplinary approach
o Education and counselling, support groups and stop smoking o Symptomatic treatment
o For non-small cell
Assessment for surgical resectability
Staging (up to stage IIIA); ie once T4, N3 or M1 not a candidate Physiological staging
o Dyspnea from bronchial obstruction, dysphagia o SVCO, pancoast syndrome
Chemotherapy o For small cell: Chemotherapy
How does patient with bronchogenic carcinoma present?
Primary tumor
o Cough, dyspnea, hemoptysis, pneumonia Mediastinal spread
o SVCO, Horner‟s, pleural effusion, phrenic nerve palsy, hoarseness of voice, T1 wasting, pericardial effusion Metastasis
o Liver, bone, brain, skin, adrenal glands Paraneoplastic symptoms
Systemic effects
o LOA, LOW, fatigue What are the paraneoplastic syndromes?
Endocrine
o PTH-related peptide (hypercalcemia) – SCC o SIADH – Small cell (usually asymptomatic)
o ACTH – Cushing‟s (usually hypokalemic metabolic alkalosis) o Gynaecomastia
Neurological
o Subacute cerebellar degeneration o Peripheral neuropathies
o Lambert-Eaton syndrome Cardiovascular
o Non-thrombotic endocarditis Renal
o Nephrotic syndrome, GN (membranous) Skin
o Migratory venous thrombopleblitis (Trosseau‟s sign) o Acanthosis nigricans
o Dermatomyositis o Zoster
Tumour with obstruction of the SVC Plethoric facies
Facial and UL oedema Conjunctival suffusion
Undersurface of the tongue with multiple venous angiomata Fixed engorgement of the neck veins
Stridor
Upper chest telangiectasia Radiation marks
(NB think of polycythemia which also have plethoric facies) Causes
o Lung carcinoma, especially small cell o Lymphoma
o Others – mediastinal goiter
40 19. Consolidation
Presentation
Sir, this patient has a right upper lobe consolidation as evidenced by reduced chest excursion of the right hemithorax associated with a dull percussion note, bronchial breath sounds and crepitations and increased vocal resonance. These signs were best heard in the upper one third anteriorly in the right hemithorax. The trachea is central and apex beat is not displaced.
There are no signs to suggest that the patient is in respiratory distress or in failure.
With regards to aetiology, an underlying malignancy is considered as there is associated complication of SVCO (hoarseness of voice if left sided), with plethoric facies, ruddy complexion a/w oedema of the face and upper limbs associated with suffusion of the eyes, fixed engorgement of the neck veins, dilatation of the superficial veins of the neck, and venous angiomata detected on the undersurface of his tongue. There is no Horner‟s syndrome, wasting of the intrinsic muscle of the hands and no soft heart sounds to suggest pericardial effusion. There was also no associated pleural effusion or a raised right hemidiaphragm.
He is also clubbed with HPOA and has nicotine staining of his fingers. He is cachexic looking with enlarged palpable cervical LNs.
There is also thrombophiblitis of the forearms which may suggest Trosseau‟s sign.
(if there are no signs of cancer, proceed to mention TB/pneumonia ie mantoux testing, toxic looking, productive cough with purulent sputum; DVT ie swelling and tender calves)
There is presence of radiation therapy marks on the right chest wall as well as side effects of chemotherapy such as alopecia and oral ulcers.
In summary, patient has a right upper lobe consolidation complicated by SVCO. He is not in respiratory distress. The underlying cause is most likely a mitotic lesion of the lung.
Questions
What are the causes of a consolidation?
Infection
o Pneumonia o Abscess o TB
o Aspergilloma, cryptococcoma, hydatid cyst Neoplastic or mass
o Carcinoma o Lymphoma Pulmonary infarction How would you investigate?
Simple o CXR
o ABGs, blood tests FBC and biochemical profile, blood c/s o Sputum
Directed tests o Infection
o Cancer – Bronchoscopy and Bx, CT staging, bone scan, physio staging o Infarction
What are the causes of an unresolved pneumonia?
FB Tumor Abscess
Inappropriate antibiotics, resistant organism Bronchopulmonary sequestration
o Rare, congenital
o Non-functioning lung tissue with anomalous arterial supply with no connection to the bronchopulmonary tree What are the extrapulmonary manifestations of Mycoplasma?
CNS – meningitis, encephalitis CVS – percarditis, myocarditis Hepatitis, GN
DIC, AIHA EM, SJS
Arthralgia, arthritis
What are the complications of pneumonia?
Local
o Abscess o Empyema o Respiratory failure Sepsis
o Septic shock o ARDS o MOF o DIC
What are the pulmonary eosinophilic disorders?
Defined as radiographic infiltrates with hypereosinophilia (>1.5 x109L) Includes
o Churg-Strauss – Asthma with vasculitis and hypereosinophilia o Tropical pulmonary eosinophilia – high anti-filarial Ab
o Chronic pulmonary eosinophilia – cough, progressive SOB, weight loss with “photographic negative” pulmonary oedema ie diffuse peripheral pulmonary infiltrates
How do you manage pneumonia? BTS 2004 Depending on the type of pneumonia
o CAP o HCAP o HAP
o note that HCAP is Rx the same way as CAP in BTS guidelines Risk Stratify - CAP
o CURB-65 score – 6 point score from 0 to 5 Confusion
Urea >7 mmol/L RR >30 bpm BP <90/60 Age 65 and above
o 0 to 1 – low risk of death and home Rx
o 2 – increased risk of death and short hospitalization or supervised home treatment o 3 and above – high risk of death and urgent hospitalization
Ix – FBC, CRP, Bld c/s (for those with severe indicators or co-morbidities), sputum g/s and c/s, Lg and Pneumococcal Urine Ag only for severe pneumonia
Mx
o Use of SpO2 monitoring advocated in GP setting
o NIV not for use in severe pneumonia unless in ICU setting o Antibiotics
CAP- Penicillins or macrolides; fluoroquinolones if intolerant or selected inpatient treatment with PO moxifloxacin preferred over levofloxacin
o Discharge planning
Should not be discharged within 24Hrs if have >1 of T >37.8
HR>100 RR>24 SpO2<90%
BP sys <90
Inability to maintain oral intake Abnormal mental status
42 How do you mange pulmonary infarction? BTS 2003
All patients with suspected PE should have clinical probability assessed Hence evaluate patients for
o SOB or tachypnea, chest pain or hemoptysis o Absence of an alternative explanation (a) o Presence of a major risk factor (b) Therefore if
o (a) and (b) present = high probability
o Only (a) or (b) present = intermediate probability o None present = low probability
D-dimer
o To use only if low or intermediate probability o Highly specific = if negative, no need to do imaging o Not to order if high probability; image immediately Imaging
o Done within 1 hr for massive and 24 hrs for non massive o Imaging options
CTPA
Isotope lung scan
Facilities available CXR normal
No cardiopulmonary disorder Standardised reporting criteria
Non-diagnostic results followed by other imaging USS DVT
Can be used if presence of clinical DVT and if positive, is sufficient to confirm VTE If negative, cannot be used to confirm absence of VTE
o Management
Massive (BP compromised or cardiopulmonary collapse)
Thrombolysis with alteplase (No lowering BP effect cf with streptokinase) Thrombus fragmentation and IVC filters if expertise present and available Non-massive PE
NO thrombolysis
Use of heparin before imaging in high or intermediate clinical probability Use LMWH as first choice
Use unfractionated heparin if o First dose bolus o Massive PE
o Acute reversal desired If VTE confirmed
o Commenced oral anticoagulation o INR 2-3
o Duration is 4-6 wks for temporary risk factors. 3 months for first idiopathic episode and 6 months for other clinical situations
Special populations o Pregnancy
LMWH during pregnancy UFH approaching delivery
UFH stopped or reduced 4-6hrs prior delivery
Oral anticoagulation commenced after delivery and continued for 6 weeks or 3 months after PE whichever is longer
o Cancer patients
Oral anticoagulation as per above Duration unknown
Higher risk of thrombosis and bleeding If recurrent thrombosis
INR 3-3.5 or
LMWH + anticoagulation or IVC
44 20. Lobectomy/Pneumonectomy
1. Sir, this patient has left lobectomy as evidenced by a left sided thoracotomy scar associated with asymmetrical deformity of the chest. There is reduced chest excursion of the left and the percussion note is dull in the lower third of the left hemithorax with decreased breath sounds and vocal resonance in this area. The tracheal is not deviated and the apex beat is not displaced.
2. Sir, this patient has a left pneumonectomy as evidenced by a left thoracotomy scar associated with asymmetrical deformity of the chest. There is reduced chest wall excursion on the left with a dull percussion note and absent breath sounds and vocal resonance over the entire left hemithorax. Trachea is deviated towards the left with the apex beat displaced in the same direction. This is associated with hyperinflation of the right chest with hyper-resonant percussion note and loss of liver dullness.
He is comfortable at rest with a RR of 12 bpm with no evidence of respiratory failure or distress.
With regards to aetiology
1. I did not detect any coarse inspiratory crepitations to suggest bronchiectasis nor was there any ronchi or prolonged expiratory phase to suggest COPD or ABPA.
2. Patient is not clubbed and there is nicotine staining of the fingers. There is no palpable enlarged cervical lymph nodes and he is not cachexic looking to suggest mitotic lesion of tuberculosis.
I would like to look at the patient‟s temperature chart as well as his sputum.
In summary, this patient has a left lobectomy/pneumonectomy and the possible causes include:
1. surgical resection for early stage mitotic lesion of the lung or a SPN of uncertain cause.
2. Resistant lung abscess 3. Mycetoma
4. Treatment modality for pulmonary tuberculosis in the past (1950s, pt should be late 60s) 5. lung volume reduction surgery in COPD (lobectomy)
6. Localised bronchiectasis or its complications 7. Trauma
Questions
What are the indications for a lobectomy/pnemonectomy? (7) Causes of lobectomy and pneumonectomy
o Mitotic lesion or SPN of uncertain nature o Abscess
o Bronchiectasis – localised or complications
o Mycetoma, ABPA (remaining lungs may have ronchi) o TB treatment
o LVRS for COPD o Trauma
Lobectomy and splenectomy o TB
o Sarcoidosis
What are the contraindications to a lobectomy/pneumonectomy in a lung cancer patient?
Resectability
o T4 (mediastinal structures), N3 (contralateral mediastinal or hilar or ipsilateral supraclavicular LNs or scalene) or M1 o Tumor within 2 cm of carina (potentially curable by radiotherapy)
o Bilateral endobronchial tumor (potentially curable by radiotherapy) Physiologic staging
o Severe pulmonary hypertension o CO2 retention
o FEV1< 1L
o Transfer factor <40%
o Concomitant disease that would shorten life expectancy o Recent MI in the past 3 months
o Borderline function with cardiopulmonary exercise testing with a maximal oxygen consumption <15ml/kg/min What are the indications for lung volume reduction surgery in COPD patients?
Emphysema
Predominantly upper lobes
No or mild pulmonary hypertension (PASP > 45 mmHg) No concomitant disabling disease
FEV1>20%
DLCO >20%
21. Approach to Lateral Thoracotomy Scar