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THORAX
THE CHEST WALL
THORACIC WALL
• It consists of skin, fascia, nerves, vessels,
muscles, cartilages, and bones
...
Skeleton of Thoracic Wall
• The thoracic skeleton forms the
osteocartilaginous thoracic cage
...
• The ribs and their cartilages are separated by
intercostal spaces, which are occupied by
intercostal muscles, vessels, and nerves
...
Sternum and Marrow Biopsy
• Since the sternum possesses red
hematopoietic marrow throughout life
...
Under
a local anaesthetic, a wide-bore needle is
introduced into the marrow cavity through the
anterior surface of the bone
...
THE RIBS
Cervical Rib
• A cervical rib (i
...
, a rib
arising from the anterior
tubercle of the transverse
process of the seventh
cervical vertebra) occurs in
about 0
...
Cervical Rib
• It can cause pressure on the lower trunk of
the brachial plexus in some patients,
producing pain down the medial side of the
forearm and hand and wasting of the small
muscles of the hand
...
This
results in post-stenotic dilatation of the vessel
distal to the rib in which a thrombus forms
from which emboli are thrown off
...
• Below this level, the ant and lat cutaneous
branches of the intercostal nerves supply the
dermatomes
...
They supply dermatomes on the anterior
abdominal wall, muscles of the anterior abdominal
wall, and parietal peritoneum
...
• pulmonary thromboembolism or pneumonia
with pleurisy involving the costal parietal
pleura could give rise to abdominal pain and
tenderness and rigidity of the abdominal
musculature
...
• In old age the costal cartilages undergo
progressive ossification; they then become
radio-opaque and may cause confusion when
examining a chest radiograph of an elderly
patient
...
• The lesion is seen as an inflammation and
degeneration of the sensory neuron in a cranial
or spinal nerve with the formation of vesicles
and inflammation of the skin
...
• Destructive disease of the vertebral column
that produces lateral flexion or scoliosis
results in marked distortion of the thoracic
cage
...
• A knife wound piercing the chest wall injures the
organs along its path
...
In
addition, the kinetic energy generated by a
speeding bullet may damage tissue that is distant
from the actual path of the bullet
...
• Any injury to the chest below the level of the
nipple line may involve abdominal organs as well
as chest organs
...
In severe posterior chest
injuries, the
• possibility of a vertebral fracture with associated
injury to the spinal cord
...
• Rib Contusion: Bruising of a rib, secondary to
trauma, is the most common rib injury
...
• Rib Fractures: It’s a common chest injury
...
TRAUMA TO CHEST CONTD
• In adults owing to the deposit of calcium in the
costal cartilages, and the ribs become brittle
...
• The ribs prone to fracture are those that are
exposed or relatively fixed
...
• The first four ribs are protected by the clavicle and
pectoral muscles anteriorly and by the scapula and
its associated muscles posteriorly
...
• Severe localized pain is usually the most
important symptom of a fractured rib
...
Shape of thoracic cage
• In the adult the chest is more oval owing to the
increase in its transverse diameter than its
anteroposterior one
...
• The shape of the chest is deformed in diseases
as rickets and scoliosis
...
• In severe crush injuries, a number of ribs may break
...
• This causes flail chest, in which a section of the chest
wall is disconnected to the rest of the thoracic wall
...
In either case, the stability
of the chest wall is lost, and the flail segment is
sucked in during inspiration and driven out during
expiration, producing paradoxic and ineffective
• On inspiration the
fractured ribs are pulled
inward as the pressure
within the chest
decreases
...
• On expiration the
fractured ribs are pushed
outward as the pressure
within the chest rises
...
Intercostal Nerve Block
• Intercostal nerve block is indicated for repair of
lacerations of the thoracic and abdominal walls,
for relief of pain in rib fractures, and to allow
pain-free respiratory movements
...
Intercostal Nerve Block
• The needle is directed
toward the rib near the
lower border and the tip
comes to rest near the
subcostal groove, where the
local anaesthetic is
infiltrated around the nerve
...
RESPIRATORY DISTRESS SYNDROME
• Respiratory distress syndrome is caused by a
deficiency of surfactant (composed of
Phosphatidylcholine [mainly dipalmitoyl lecithin] and
proteins)
...
• Thyroxin and cortisol treatment increase the
Pulmonary Embolism
Causes for development of
emboli in veins of legs:
Immobilization
Trauma
Long surgeries
Oral contraceptives
Obesity
Cigarette smoking
Hypertension
Pleural Effusion
• The pleural space normally contains 5 to 10 mL
of clear fluid, which lubricates the apposing
surfaces of the visceral and parietal pleurae
during respiratory movements
...
g
...
g
...
Pleural Effusion
• The presence of 300 mL of fluid in the
costodiaphragmatic recess in an adult is
sufficient to enable its clinical detection
...
• Hydropneumothorax : Air in the pleural cavity
associated with serous fluid is known as
hydropneumothorax
...
Pneumothorax
• As a result of disease or injury (stab or
gunshot wounds), air can enter the pleural
cavity from the lungs or through the chest wall
(pneumothorax)
...
Investigation usually reveals
that air has entered from a
diseased lung and a bulla
(bleb) has ruptured
spontaneous pneumothorax
• ("bleb“ collection of air within layers of viscera
pleura "bulla” air-filled, thin-walled space
within lung (destruction of alveoli)
...
• Deflection of the trachea to the opposite side
Open Pneumothorax
• Occurs when the air enters the pleural cavity
through an opening in the chest wall and may
result from stab or bullet wounds
...
With each inspiration the negative
pressure created is more effective at sucking
air in through the chest wound than air
entering through the glottis; this produces a
sucking sound
...
Tension Pneumothorax
• Occurs when air is sucked into the pleural
cavity through a chest wound with each
inspiration but does not escape
...
• The air pressure builds up on the wounded
side and pushes the mediastinum
progressively over to the opposite side
...
Tension Pneumothorax
• The increase in air pressure within the chest cavity
interferes with blood return to the heart; the patient
may die because of lack of venous return
...
• Eventually, hypotension (secondary to lack of venous
• return) results
...
• It descends and becomes deeply placed about (4
cm) from the surface at the suprasternal notch
...
5 cm) in diameter,
but in a 3-year-old child it may only 1
...
in
diameter
...
• lateral displacement of the cervical part of the
trachea may be caused by a pathologic lesion in
Compromised Airway
• Cricothyroidotomy: In
cricothyroidotomy, a tube
is inserted in the interval
between the cricoid
cartilage and the thyroid
cartilage
...
The incision is made through
the following structures:
The skin, the superficial fascia
(beware of the anterior
jugular veins, which lie close
together on either side of
the midline
Compromised Airway
• The investing layer of deep
cervical fascia, the pretracheal
fascia
• (separate the sternohyoid
muscles and incise the fascia),
and the larynx
...
Complications
• Oesophageal perforation: Because the lower
end of the pharynx and the beginning of the
oesophagus
...
Tracheal Blockage
Heimlich Maneuver or
abdominal thrust
or
Tracheostomy
Heimlich Maneuver or abdominal
thrust
• The Heimlich maneuver is an emergency
procedure for removing a foreign object
lodged in the airway that is preventing a
person from breathing
...
The food
blocks their windpipe (trachea), making
breathing impossible
...
Heimlich Maneuver
• The Heimlich maneuver can be performed on all
people, but modifications are necessary if
the choking victim is very obese, pregnant, a child,
or an infant
...
• The face turns blue from lack of oxygen
...
• The person has a weak cough, and labored
breathing produces a high-pitched noise
...
If the person choking can
talk or cry, Heimlich maneuver is not
appropriate
...
Heimlich Maneuver
• To perform the Heimlich maneuver on a conscious
adult, the rescuer stands behind the victim, who
may either be sitting or standing
...
The rescuer encircles the victim's waist,
placing his other hand on top of the fist
...
If the maneuver fails, it
is repeated
...
In
infants, the rescuer should never attempt to
sweep the baby's mouth without looking to
remove foreign material
...
Heimlich maneuver on an obese
person or pregnant woman
• Stand behind the person with arms directly
under the person's armpits and circle the
chest
...
• Grab the fist with the other hand and perform
backward thrusts until the object pops out or
the person becomes unconscious
...
• Because of the presence of major vascular
structures (carotid arteries and internal
jugular vein), the thyroid gland, nerves
(recurrent laryngeal branch of vagus and
vagus nerve), the pleural cavities, and
oesophagus
...
• A vertical midline skin incision is made from
the region of the cricothyroid membrane
inferiorly toward the suprasternal notch
...
• The anterior jugular veins in the superficial
fascia are avoided by maintaining a midline
position
...
• The investing layer of deep cervical fascia is
incised
...
• The tracheal rings are then palpable in the
midline, or the isthmus of the thyroid gland is
visible
...
The procedure contd
...
• At the latter site, the trachea is receding from the
surface of the neck, and the pretracheal fascia
contains the inferior thyroid veins and possibly
the thyroidea ima artery
...
• The preferred site is
through the second ring
of the trachea in the
midline, with the thyroid
isthmus retracted
inferiorly
...
Complications
• Most complications result from not
adequately palpating and recognizing the
thyroid, cricoid, and tracheal cartilages and
not confining the incision strictly to the
midline
...
Complications contd
• Nerve paralysis: The recurrent laryngeal nerves
may be damaged as they ascend the neck in the
groove between the trachea and the
oesophagus
...
Especially common in children
because of the high level of the pleura in the
neck
...
• Extension of the head and
neck, e
...
maintaining an
airway in an anesthetized
patient, may stretch the
trachea and increase its
length by 25%
...
The needle is passed along the superior
border of the lower rib
...
Thoracocentesis
• Two types: Needle Thoracostomy and tube
thoracostomy
...
• It is also used to withdraw a sample of pleural
fluid for microbiologic examination
...
• The second intercostal space is used through
the anterior axillary line
...
The sternal angle is identified,
and then the second costal cartilage, the
second rib, and the second intercostal space
are found in the midclavicular line
...
Posterior intercostal a
...
Technique for
thoroacocentesis
(in midaxillary line)
Intercostal nerve block
Tube Thoracostomy
• The preferred insertion site for a tube
thoracostomy is the fourth or fifth intercostal
space at the anterior axillary line
...
• Note: Avoid damaging the diaphragm and
entering the peritoneal cavity and injuring the
liver, spleen or stomach
...
Inhaled Foreign Bodies, Suction Catheters,
Endotracheal Tubes, and the Bronchi
• Aspiration of Foreign Bodies and Stomach
Contents In adults; this tends to be aspirated
into the right principal bronchus, since this is
more in line with the trachea than the left
bronchus
...
Tracheitis or Bronchitis
• The mucosa lining the trachea is innervated by
the recurrent laryngeal nerve and, in the
region of its bifurcation, by the pulmonary
plexus
...
The bronchopulmonary segments
• Each bronchopulmonary segment is pyramidal
in shape with its apex directed towards the
hilum
...
• The veins draining each segment are
intersegmental
• If one bronchopulmonary segment is diseased
it may be resected with preservation of the
rest of the lobe
...
Four main
histological types occur of which small cell
carries the worst prognosis
...
Local
invasion and spread to hilar and
tracheobronchial nodes occurs early
...
• During the treatment of lung cancer, the
surgeon may remove a whole lung
(pneumonectomy) , a lobe (lobectomy) , or
one or more bronchopulmonary segments
(segmentectomy)
...
• Excessive accumulation of bronchial secretions in
a lobe or segment of a lung can seriously
interfere with the normal flow of air into the
alveoli
...
• Sound knowledge of the bronchial tree is
necessary to determine the optimum position of
The Thoracic Outlet Syndromes
• The brachial plexus of nerves (C5, 6, 7, and 8 and
T1) and the subclavian artery and vein are closely
related to the upper surface of the first rib and
the clavicle as they enter the upper limb
...
Most of the symptoms are
caused by pressure on the lower trunk of the
plexus producing pain down the medial side of
the forearm and hand and wasting of the small
muscles of the hand
...
The Thoracic Outlet Syndromes
Coarctation of the aorta
• the intercostal arteries derived from the aorta
receive blood from the superior intercostals
(from the costocervical trunk), from the
anterior intercostal branches of the internal
thoracic artery (subclavian artery) and from
the arteries anastomosing around the scapula
...
Coarctation of the aorta
• the intercostal arteries undergo dilatation and
tortuosity and erode the lower borders of the
corresponding ribs to give the characteristic
irregular notching of the ribs, which is very
useful in the radiographic confirmation of this
lesion
...
• It is possible to examine the interior of the
lobar bronchi and the beginning of the first
segmental bronchi
...
Bronchoscopy
• When examining the
bronchi with a
bronchoscope an
endoscope one can
observe a ridge, the
carina , between the
orifices of the main
bronchi
...
• Inspection shows the configuration of the
chest, the range of respiratory movement, and
any inequalities on the two sides e
...
The type and rate of respiration are also noted
e
...
Clinical Examination of the Chest
• Palpation enables the physician to confirm the
impressions gained by inspection, especially of
the respiratory movements of the chest wall
...
Abnormal
pulsations are felt and tender areas detected
...
This produces vibrations that
extend through the tissues of the thorax
...
With
practice, it is possible to distinguish the lungs
from the heart or liver by percussion
...
• Nature of the breath sounds will be altered if the
alveoli or bronchi are diseased or filled with fluid
...
• It may be possible to detect friction sounds
produced by the rubbing together of diseased
layers of pleura or pericardium