Presents with dyspnea, persistent cough w/o purulent sputum, facial fullness and neck pain. Progresses to hoarseness, dysphagia, chest pain, and syncope. Veins of the arms and neck are dilated. What syndrome are you suspecting?
Superior Vena Cava Syndrome
Imaging for SVCS: initial, best
Initial: CXR - can reveal upper lobe opacity on symptomatic side
Best: CT w/ contrast - shows mass effect from primary or metastatic cancer or IV thrombus. Sets up for percutaneous biopsy.
The role of MRI: no visual advantages and more expensive, use if allergic to contrast dye or venous access cannot be obtained.
Indications for tube thoracostomy
- Chemical pleurodesis
In patients with pleural adhesions from infection, previous surgery, or past pleurodesis, what should be considered in placement of chest tubes?
CT or US guidance
In patient w/ pleural effusion, what are the indications for diagnostic versus therapeutic thoracentesis?
- Diagnostic thoracentesis: establish the nature of the effusion (ie, transudate, exudate) and identify potential causes (eg, malignancy, infection).
- Therapeutic thoracentesis: relieve symptoms of new-onset dyspnea due to a moderate to large pleural effusion (indication for large-volume thoracentesis).
Relative contraindications to chest tube placement include...
anticoagulation or bleeding diathesis
Relative contraindications for thoracentesis are...
- bleeding diathesis
- very small effusion
- active skin infection (risk of empyema)
- positive-pressure MV (risk of pneumothorax)
Given a patient who requires chest tube insertion, be able to idenfy and prepare all instruments required to perform the procedure
Local anesthetic w/ needles/syringes (25 gauge, 18-21 gauge)
- Scalpel, kelly clamps
- Chest tube, drainage system
Needle driver, heavy suture, straight scissors
Petroleum gauze, drain sponges occlusive dressing/elastic tape
PPE, sterile drapes, gown, and gloves
Risks of tube thoracostomy
intercostal vessel bleeding, persistent pleural effusion, pneumothorax, and infection
In the elderly patient, what anatomy should be considered that can increase the bleeding risk in tube thoracostomy? What can be done to mitigate this risk?
- Be mindful of intercostal arteries with tortuous course (plan for puncture site lateral to the spine) and collateral arteries that can traverse through the intercostal space
- Use of color Doppler to identify these vessels should be considered before performing the procedure
Be able to accurately describe the anatomic landmarks for the optimal site of chest tube insertion without assistance.
The incision should be made at the fourth to fifth intercostal space (to avoid diaphragmatic injury)—in the anterior or midaxillary line between anterior and posterior axillary folds (pectoralis major and latissimus dorsi).
- In males, this corresponds to the level of the nipple.
- In females, this corresponds to the inframammary crease.
Should ultrasound not be available, in patients with a nonloculated, free-flowing effusion, the puncture site is chosen according to the following landmarks after positioning the patient...
- Sitting upright, resting arms on a bedside table
- One to two interspaces below the level at which breath sounds decrease and/or percussion becomes dull
- Above the ninth rib, to avoid subdiaphragmatic puncture
- Midway between the spine and the posterior axillary line
Indications for immediate thoracotomy after chest tube insertion include greater than what volume drained?
- 1500 mL of blood drained initially
- more than 300 mL/h x3 hrs
Other than immediate/ongoing bleeding, what are some indications for thoracotomy s/p thoracostomy tube?
- Massive air leak with associated pneumothorax
- Drainage of esophageal or gastric contents from the chest tube
A general guideline is to stop fluid removal when chest discomfort ensues or when the total amount of fluid removed reaches...
1000 to 1500 mL - re-expansion pulmonary edema
When is CXR indicated after thoracentesis?
- not routine
- air aspirated
- multiple needle passes
In evaluating a patient with a tube thoracostomy in place, what clinical findings would be of concern and warrant further workup?
- persistent voluminous bloody output
- hemodynamic instability
- persistent air leak
What are risk factors for primary pneumothorax?
increased height, youth, male sex, and tobacco/cannabis use, often associated with apical subpleural blebs on imaging
What are some secondary pneumothorax causes?
- bullous disease
- cystic fibrosis
- congenital cysts
- thoracic endometriosis
Do all cases of secondary PTX require admission?
Secondary pneumothorax is associated with greater symptomology, morbidity, and cardiorespiratory compromise as a result of underlying lung disease. As such, the American College of Chest Physicians (ACCP) and the British Thoracic Society guidelines recommend admission for all episodes of secondary pneumothorax.
What are some signs and symptoms of tension PTX?
- most common: chest pain, dyspnea
- increased work of breathing
- tracheal deviation (away from affected lung)
Decreased breath sounds, hypoxia, tachycardia, increased work of breathing, JVD, tracheal deviation, hyperresonance are signs of what?
Accumulated air in the pleural space
Be able to give indications for surgery in the setting of pneumothorax.
- persistent leak after 4 days
- failure to expand after adequate chest tube
- high-risk profession (pilot, scuba diver)
- limited access d/t geography/social
What is the standard approach for an operation for pneumothorax?
What should be done intraoperatively?
resect blebs if found