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Extra-Pulmonary

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Introduction

Extra-Pulmonary conditions are a broad, disconnected category of diseases that affect the respiratory system however do not arise from within the respiratory tract.

These are common conditions that can be life threatening.

Pneumothorax Overview

  • What
    • An abnormal connection (a hole) between the LUNG and the PARIETAL PLEURA (the pleural cavity)
    • This causes air to escape the lung into this cavity
    • If lots of air escapes, the pressure acting onto the lung causes it to compress and COLLAPSE (Atelectasis). 
    • Usually Spontaneous
    • Most are primary however can be secondary to another respiratory disease (asthma, COPD, CF)
    • Can also be as a result of trauma -eg stab wound, road traffic accident
    • 2 types – simple and tension (emergency)
      • Tension pneumothorax occurs due to the opening in the lung acting as a one way valve- allowing continuous pressure to build in the pleural cavity- can put pressure onto heart -> leading to cardiac arrest.
  • Who
    • Anyone – however to remember factors that increase risk – think of Snoop Dogg
      • Male
      • Tall
      • Thin
      • Smoker
  • Symptoms
    • If SMALL (<2cm) may be asymptomatic
    • Chest Pain
    • Sudden breathlessness

Investigations

  • Percussion shows hyper-resonance due to air outside the lung.
  • Reduced Lung expansion
  • Auscultation shows reduced breath sounds
  • Palpation of trachea – determines any shift – rare finding – BUT IF SHIFTED = TENSION PNEUMOTHORAX
    • Deviation occurs AWAY from affected side – since air on that side is pushing all other structures away
  • CXR– to estimate size of pneumothorax – guides management– if small enough can be left and will resolve
    • NOTE – If TENSION Pneumothorax suspected should NOT be done
  • If a traumatic cause- Ultrasound (since difficult to take CXR)
  • CT scan if diagnostic doubt – gold standard – especially for small pneumothoraces

Management – IMMEDIATE

  • If pneumothorax <2cm AND no SOB:
    • Review in few weeks on CXR – no immediate management
  • If simple pneumothorax >2cm OR SOB:
    • Canula Needle Aspiration -FIRST LINE
      • If <2cm Review in few weeks on CXR
      • IF NOT REDUCED SUFFIENCETLY – Chest Drain insertion in 4th/5th intercostal space in mid-axillary line – SECOND LINE
  • If TENSION pneumothorax – EMERGENCY
  • Large Bore Canula – 2nd Intercostal space- mid-clavicular line – FOR RAPID DECOMPRESSION
  • Chest drain insertion as normal after to reduce further [Chest Drain insertion in 4th/5th intercostal space in mid-axillary line]

Management- Long term

  • If recurrence of a pneumothorax occurs OR if it is a difficult pneumothorax to treat surgical options are available to resolve this.
    • Open thoracotomy and pleurectomy
      • removes damaged pleura and adheres lung to chest wall
    • If a patient is unfit for this procedure – pleurodesis can be performed.
      • This involves an irritant drug that causes the abnormal space to seal.

Pulmonary Embolism (PE) Overview

  • What
    • Usually a blood clot in a major pulmonary artery that supplies the lung alveoli for gas exchange. (can also be dues to fat, metastasized tumour or air)
    • These blood clots originate in VEINS elsewhere in the body. – They are RBC and FIBRIN rich
      • Usually a result of a DVT (deep vein thrombosis) in legs
        • A condition where there is a large clot in the deep veins of the legs – being overweight and being sedentary is a high risk for this
        • Causes swollen, red hot leg – DO NOT NEED DVT SYMPTOMS TO HAVE A PE
      • Travels back to heart via veins, goes to lungs from heart and blocks this artery
    • Pulmonary infarction can occur due to lack of blood supply if not treated
    • 1/4 of PE’s result in SUDDEN DEATH
  • Who
    • Anyone at risk of DVT
    • Overweight
    • Immobility – long journeys (3hr +), bed rest, +
    • Smoker
    • Over 60
    • Dehydrated
    • Recent surgery -especially on lower body
    • Recent trauma – causes blood clots – can be dislodged and cause PE
  • Symptoms
    • Sharp, pleuritic chest pain – sudden
    • Short of breath
    • Haemoptysis
    • (leg swelling and redness if DVT)
    • History of collapse

Investigation

  • All are done – most very quick and simultaneous- during quick assessment. Echo is done after CTPA – everything else before CTPA.
    • PESI score used – PE Severity Index
      • Assess likely mortality risk given co-morbidities and present status.
    • D-Dimer
      • A non-specific investigation – just shows a clot SOMEWHERE – not necessarily in a pulmonary artery.
      • More useful to RULE OUT a PE – if NORMAL – No clots so NO PE.
    • ECG
      • Shows signs of RIGHT HEART STRAIN
      • “Classic S1Q3T3 Pattern”
      • Tachycardia
      • T-inversion in V1-3
    • Troponin
      • Raised if damage to myocardium (the heart muscle) has occurred due reduced perfusion
      • CTPA –DEFINITIVE
      • CT Pulmonary Angiogram – visualises Pulmonary vasculature – can see and confirm the clot size and location (directs management)
    • Echocardiogram–
      • Assess ventricular heart function as a result of PE

Management

  • If ANY suspicion of PE – ANTICOAGULATE
    • Many types – But first line are DOAC or Factor X inhibitors
      • Dabigatran
      • Rivaroxaban
      • Apixaban
    • Otherwise – LMWH (low molecular weight heparin)
    • Warfarin (last line – need lots of monitoring)

Anticoagulation is continued for 6 months at first presentation – It is continued LIFE LONG if it is recurrent/high chance for recurrence.

  • Further treatment is based on assessment:
    • MASSIVE- any haemodynamic instability.
      • NEED thrombectomy/thrombolysis
    • SUB-MASSIVE- haemodynamically stable BUT have ventricular dysfunction evident on echo.
      • Consider thrombectomy/thrombolysis
    • NON-MASSIVE- Fully stable with NO ventricular dysfunction evident on echo.
      • Just keep on anti-coagulation and monitoring
  • Thrombectomy
    • Surgery to remove the clot
  • Thrombolysis
    • A drug given systemically OR locally via a catheter that breaks down the clots
    • Systemic thrombolysis is commenced asap in life threatening episodes due to risk of sudden death.

Pulmonary Hypertension Overview

  • What
    • Increased pressure within the pulmonary vasculature.
    • Causes Right heart strain leading to failure due to continued hypertrophy of right heart to pump through an continuingly increasing resistance to blood flow.
    • Many causes – but most common is LEFT heart failure –
      • Due to decreased left heart pumping- increased pressure in pulmonary vasculature.
    • Other causes include heart valve failures and systemic connective tissue diseases
    • Can also be caused by lung diseases – such as COPD, Sleep Apnoea and Interstitial Lung Disease
  • Who
    • Those with long standing diseases mentioned above
  • Symptoms
    • Peripheral Oedema
    • SOB
    • Chest pain
    • Palpitations
    • Dizziness/feeling faint (pre-syncope/syncope) – due to overall hypotension due to failing heart

Investigations

  • ECG – heart strain
  • CXR – cardiomegaly
  • Echocardiogram- reduced ventricular function

Management

Complicated. -Beyond scope of undergraduate teaching

More information can be found: here