Joe B. (Bill) Putnam, Jr., MD, FACS Ingram Professor of Surgery and Chairman Department of Thoracic Surgery Professor, Department of Biomedical Informatics Vanderbilt University Medical Center Nashville, Tennessee 37232-5734 Thoracic Surgery: A Pleural Problem Primer Vanderbilt University Medical Center February 14, 2007
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Joe B. (Bill) Putnam, Jr., MD, FACS Ingram Professor of Surgery and Chairman Department of Thoracic Surgery Professor, Department of Biomedical Informatics.
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Joe B. (Bill) Putnam, Jr., MD, FACSIngram Professor of Surgery and Chairman
Department of Thoracic Surgery
Professor, Department of Biomedical Informatics
Vanderbilt University Medical CenterNashville, Tennessee 37232-5734
•Spontaneous PTX More common males ages 20-40, smokersMay occur following a scream, valsalva, or coughSudden sharp pleuritic chest pain and dyspnea Tachypnea, tachycardia, subcutaneous
emphysema
Expiratory CXR may be needed to make diagnosis
Treatment: Observation for PTX less than 15-20% and no symptomsOthers: needle/catheter decompression and/or chest tube
• 25% of all pleural effusion in a general hospital setting are secondary to cancer
• 30-70% of all exudative effusions are secondary to cancer
• 50-60% of MPE are positive on first thoracentesis (70-80% after 3)
• Thoracoscopy is diagnostic in 92%
Median Life Expectancy(months)
• Ovarian 9.4• Breast 7.4• Non-small cell lung 4.3• Small cell lung 3.7
Sanchez-Armengol A, Rodriguez-Panadero F: Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases. Chest 1993;104:1482-1485.
• Dissect and tunnel with a curved clamp over top of rib!– Neurovascular bundle runs along the inferior border of rib
• In a controlled fashion, puncture into the pleural space• Insert a finger into the pleural space to identify potential space
and guide chest tube. • With a clamp onto the end of the chest tube, and guided by the
finger track, insert the drain into the chest directing it towards the apex and posterior.
• ALL DRAIN HOLES to be within the pleural cavity– Special eye!
Chest Tube Insertion (Tube Thoracostomy) 3
• Check for leaks in the system (persistent air drainage, or inability to re-expand the lung)
• Persistent leak: ruptured bronchus, bronchopleural fistula, ruptured bleb.• Connect to underwater drainage system (Pleurovac). • Secure tube on skin.
– Vaseline gauze not needed ! • Remove when air leak or fluid drainage ceases
– A functionless tube is only a nidus for infection– Have patient take a deep breath in– As patient begins to exhale, remove the tube quikly– Patient involuntarily Valsalva’s, minimizing potential for sucking air into the