1. Primary spontaneous pneumothroax (PSP)
• spontaneous
• Ø primary pathology
• <45y
• Contralateral lung normal on Xray
2. Secondary spontaneous pneumothorax (SSP)
• pre-existing pathology
• pulmonary symptom preceeding PT
• >45y + smoker
• contraleteral lung with Xray abnormalities
3. Iatrogenic → THoracocentesis, transbronchial biopsy, CVC, Barotrauma
4. Post-traumatic

5. Catamenial

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6. PT during pregnancy

• Pulmonary blebs are small subpleural thin-walled air-containing spaces, not larger than 1 or 2 cm in diameter (with the precise limit varying by source).
• Their walls are less than 1 mm thick.
• If they rupture, they allow air to escape into the pleural space resulting in a spontaneous pneumothorax.
• Blebs are a very common finding in otherwise normal individuals. They are often found in young patients. They are more common in thin patients and in cigarette smokers 1

SSP → ↑mortality, more difficult treatment, longer hospitalization

• COPD/emphysema
• lung cancer
• Pneumonia
• lung fibrosis

⇒ but every lung disease can cause SSP

1. Partial - Incomplete pulmonary collapse 📷
2. Total - lung collapse 📷

1. Closed 📷
• #1
• small lesion visceral pleura
• mostly benign evolution
2. Open ("sucking chest wound) 📷
• open penetrating trauma
• severe respir. insuff.

T

T

• smoking
• age
• sex
• constitutinal size (skinny+ tall)

• Pleuritic pain → sudden onset
• Dyspnea (progressive)
• Cough (non-productive)
• Physical exam:
• Signs of unilateral air accumulation
• ↓/absent breath sounds
• Percussion: Tympanism/Hyper-resonance
• Tracheal deviation
• Subcutaneous emphysema
• Tachycardia+tachypena + hypotension (obstruct. shock), distended neck veins ⇒ tension P.

1. Xray #1 → pleural line is moved more medially and lateral part shows Øvascular signs 📷

if tension p → mediastinal/tracheal deviation

2. US → intens. pleural reflex + recurr. ecchos (A-line); loss of Sea shore sign → bar code sign; 📷
3. CT → Underlying cause of SSP, esp in TRAUMA❗, DDx with emphysem bulla or ruptured pulmonary cyst

Acute:

• reexpansion of the lung
• prevention of recurrence

Observation and Aspiration

1. Aspiration (Thoracocentesis)
2. Chest drainage(Tube thoracostomy or catheter)
3. and Pleurodesis (↑connection betw parietal+viscel pleura due to fibrosis) 📷 📷

• classic treatment fails
• P. recurrence
• persistent P.
• prolonged air leaks (> 5 days)
• tension P.
• bilateral P.
• professions at risk (pilot, diver)
• need for pulmonary biopsy

atypical resection of affected lung and partial parietal pleurectomy (VATS or thoracotomy(open) 📷

severity of symptoms

optimal time frame in which treatment can bring signif. benefit in patients w/ severe trauma

• lesion most lethal should be treated first
• absence of a definitive diagnosis should not delay the initiation of the needed treatment
• detailed anamnesis is not necessary for the initial evaluation of patients

Airway obstruction

Pulmonary insuffic.

Blood blood

↑intra-cranial pressure

⇒ ABCDE Evaluation ❗📷

hypoxia

• airway control (tubus)
• thorcocentesis (aspiration)/chest tube

1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Flail chest + lung contusion
5. Massive hemothorax
6. Cardiac tamponade

• Asphyxia:
• Foreign body aspiration
• Larynx trauma
• Sternoclavicular luxation → post dislocation of medial clavicle
• Rupture trachea or main bronchi

• inspection oral cavity + pharynx
• aeric sounds at the level of etiology (nose, trachea, lung)
• clavicular dislocaiton

• Cyanosis
• Dysphonia
• Pneumomediastium + Subcutaneous emphysem

• removal foreign body
• conitomy (cricotyroidotomy) 📷
• clavicle repositon

(ventil mechanism = can only go in but not out)

Rip frature + lung injury → Lung surface

Pentrating wound + Inaapropriate occlusion after open PT → Chest wall

1. lung collapse (complete)
2. mediastinal shift
3. compression contralateral lung
4. reduction blood inflow into heart

⇒ cardiogenic shock ("obstructive shock")

• SHOCK: dyspnea, tachycardia, hypotension
• contralateral shift trachea
• ↓/absent breathing sounds + lack of resp. movement
• distended hemithorax (ipsilateral)
• venous distension
• cyanosis (late)

URGENT DECOMPRESSIOn

1. Thoracocentesis → 2nd ICS mid clavicular line ⇒ for immediate relief 📷
2. Chest tube 5th ICS Mid axillary line 📷⇒ Ø for immediate relief

penetrating trauma

Severe respiratory insufficiency

→ "Pendelluft" if wound >2/3x tracheal diameter

= paradoxial breathing pattern: lung → small on insipration; larger on expiration

• #1 (initial Tx): partial close with sterile foil fixed only on 3 sides (functions as a external valve) 📷
• #2 (follow up Tx): chest tube in pleura + occlusive wound dressing

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• Definite tx: surgical wound closure

acumulation of blood in pleural cavity

>1500ml or >1/3x blood volume of patient

• pentrating wound with great vessel injury or lung hilum
• closed trauma with internal injuries secondary to fracture (→ aortic rupture)

1. Hypovolemia (↓BP, ↑HR, collapse jugular vein)
2. Lung collapse (↓/absent breath sound, hypoxia)
3. Dullness
4. mediastinal shift (→evtl associated tension pneu❓❗)

1. Tension pneu

→ tympanism (eig. hyperresonance)

→ tracheal/mediastinal shift

→ distension involved hemithorax

2. Endotracheal tube in right main bronchus

1. Large chest tube
2. if >1500ml blood → emergency thoracotomy
• also in persistent blood loss
• if no ↑in Hb despite transfusion
• penetrating injury
• esp betw. mid axillary line or betw. the two scapulae (heart, great vessel or lung hilum injury)

• Fracture of ≥2 consecutive ribs
• on ≥2 fracture lines OR 1 fracture line + 1 chondro-costal or sterno-chondral 📷 disjunction line
• Mobile chest area = flail chest

• acute: fixation of flail chest with compressive bandage 📷
• definite:
• internal pneumatic stabilization with mechanical ventilation
• osteosynthesis (surgical repair)

PARADOXIAL MOVEMENTS 📷 → “Pendelluft”, inefficient ventilation, mediastinal movement

lung contusion

paradocial chest wall movement

(can be less evident due to pain → superfic. breathing + antalgic position)

pentrating trauma

BECKS TRIAD:

1. jugular distension
2. hypotension
3. muffled heart sound

other:

• Kussmaul sign: ↑jugular pulse during insipration
• ↑CVP
• ECG abnormalities

tension pneu

• pericardicentesis = percut. pericardial drainge
• cardiac surgery

pus in the pleural cavity

(also known as purulent pleural effusion or pyothorax)

1. Primary purulent pleural effusion: hematogenous spread
2. Secondary = parapneumonic pleural empyema
1. Infection neigboring organ → pneumonia + lung abcess
2. subphrenic abscess
3. posttraumatic (open trauma)
4. iatrogenic: thoacocentesis

community aquired: s.pneumoniae, Staph, G-, anerobic

nosocomial: MRSA, Pseudomonos, Fungi etc.

• Age < 60 years
• Predisposition for aspiration: stroke, alcoholism, neurologic diseases
• Predisposition for infections:
• Poor oral hygiene, Drug abuse, Immunodeficiencies (HIV, Diabetes, malignancies)
• Chronic disease
• Cardiovascular diseases
• Liver cirrhosis

classic inflammation

1. Exudative stage
2. Fibrino-purulent stage
3. Organized stage

• fever
• dypnea
• cough chest pain
• ↓chest wall movement of affected side + ↓breath sounds
• narrowing ICS
• dullness (percussion)

1. xray 📷

→ pleural opacity (generalized)

→ collapsed lung

→ narrow ICS

2. CT contrast 📷

→ effusion

→ collapsed lung

→ thickend pleura + contrast enhanced

3. US

→ Stages 📷 (stage 1: upper left, stage 2: upper right, stage 3: lower left and right, stage 4: not shown)

• Other effusions:
• Hemothorax
• Chlyothorax
• Malignant pleural effusion
• Transudative pleural effusion
• Giant lung abcess
• TBC
• Pleural mesothelioma

Thoracocentesis

→ Turbis effusion or pus

→ bacterial evidence

LDH >1000 U/l

Leukos > 500/mm3

↓ph+gluc

• children: repeated thoracocentesis
• Chest tube
• lavage
• fibrinolysis
• Stage 1: Thorcoscopic debridement

• Stage 2: VATS pleural decortication 📷

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• Stage 3: Open surgery + pleural decortication

Pleural effusion with malignant cells in pleural liquid or pleural tissue

F - it present in 50% of metastatic malignancies

🫁 Lung cancer, 🍈 Brest cancer, Other malignant tumors, Lymphoma

• Classics
• Xray
• US 📷
• CT
• thrococentesis → cytologic exam
• percutaneous pleural biopsy
• pleuroscopy 📷
• surgical thoracoscopy + biopsy (also allow pleurodesis) #most sensitive

→ other exudative effusion

→ other effusion due to malginancies (=paramalignant effusion)

• Atelectasis due to lung cancer
• Pulmonary infarction
• Chylothroax (Lymphoma)
• Transudative effusion (hypoproteinemia assoc. with cancer)

1. Oberservation → in asymptomatic with know etiology for a short time (recurrence/progression is the rule)
2. Thoracocentesis (us-guided)→ symptom relief + cytologic exam → but high recurrance rate in 4w → in SCLC, lymphoma + breast cancer (sensitive to chemo) & patient with reduced life expect.

3. Pleurodesis with talc

a. insufflation(thoracoscopic) OR

b. slurry(tube) → reduction of recurrance,

throacoscopic: confirms dg+drainage → indicated: life exp >1month

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4. Indwelling pleural catheter → catheter with multiple orfices at intrapleural end → spontaneous pleurodesis

→ indicated: trapped lung, altered general condition, reduced life exp.

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"air or germs introduction"

• pneumothorax
• empyema

<1.5l at one sitting

OR until symptoms (dypnsea, cough, chest pain)

• infection
• catheter obstruction/displacement/deterioration
• tumor growth along catheter canal

1. NSCLC: Non-small cell lung cancer
1. AdenoCa
2. SCC
3. large cell undifferatiated carcinoma
2. SCLC: Small cell lung cancer

25-30% (every 3rd to 4th)

• smoking (85%)
• Asbestos
• Radon
• Diesel

SCC → male

Adeno → female

→ Adeno is more common in total

SCC:

• smoker
• central: lobar/segmental bronchi (2/3 of cases)
• keratinisation
• endoluminal → obstructive symptoms
• slow growth, late mets

• SCC-specific IHC (cytokeratin, p40,p63)

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AdenoCa:

• non-smoker
• peripheral
• columnar epithelium/acinar/glandular cells
• AdenoCa-specific IHC (Napsin A, TTF-1)

• smoke assoc.
• centrally or periph
• IHC: 80% Adenoca-IHC, 20% SCC-IHC
• histology: hyperchromic nucleus

• almost exclusively in smokers
• centrally
• IHC: neuroendocrine markers
• early distant + LN mets
• poor prognosis → manly Ø operable
• Histo: monomorphic, small cells, few cytoplasma

• smoker❓
• asbestos exposure❓
• Symptoms❓ (see below)

• B-symptomatic → fever, night sweats, weight loss, fatigue
• hemoptysis (🚩)
• dyspnea
• chest pain
• endoluminal obstruction
• endocrine imbalance aka paraneoplstic syndrome.
• SIADH
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Serum: ↑Na ↓Osmolarity Urine: ↑Osmolarity

• hypercalcemia
• Cushings
• thrombophlebitis migrans
• etc.

1. SVC syndrome 📷

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2. cervical adenopathy
3. pleural effusion
4. atelectasis
5. digital clubbing 📷

• ESR
• CBC
• GGT + ALP
• calcium
• LDH

1. Xray: unilat. opacity 📷, pl. effusion, atelectasis
2. CT (contrast) 📷→ staging (TNM)
3. Bronchoscopy *→ visualizatiom, biopsy (also transbronchial possible) , lavage for cytologic exam,
4. PET → (T)NM
5. MRI → cerebral Mets (M)

1. Percutaneous biopsy (US/CT guided)

2. *EBUS-TBNA → LN puncture
3. Mediastinoscopy 📷
4. Toracoscopy → Biopsy (primary tumor, LN, pleural)

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lymphnodes

large tissue biopsy

• Histologic type: NSCLC (non-small cell lung cancer) vs. SCLC (small cell lung cancer)
• Tumor stage: Assessment using the TNM system
• Functional reserves / life expectancy: Evaluation of the patient's overall health and prognosis

I+II

IIIA

IIIB

IV (↓number of mets)

• IV
• IIIA → bulky+multilevel
• IIIB, IIIC

open thoracotomy

in stage 1 NSCLC (<5cm, >2cm distance to bronchus)→ VATS thoracoscopy (lobectomy)

Lobectomy:

• anatomical resection
• minimally-invasive approach
• without rib spreading
• video system

• NSCLC
• stage I
• diameter <5cm
• >2cm distance to lobar bronchus (CT)
• PET-CT → suspected N+ → EBUS/Madistinoscopy