Approach to Thoracic and Cardiac Disease
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Transcript Approach to Thoracic and Cardiac Disease
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