Pleural Procedure Anatomy

Bronchial tree ●​ Trachea to main bronchi ○​ Trachea bifurcates at carina ○​ Around T4/5 plane ■​ Right main bronchus ●​ Wider ●​ Shorter ●​ Vertical ■​ Left main bronchus ●​ Narrower ●​ Longer ●​ Horizontal ○​ Passes under aortic arch ○​ Around mediastinal structure ●​ Cx ○​ Aspiration more likely to end up in the right side ■​ Food ■​ Vomit ■​ Foreign body… ●​ Lobar bronchi ○​ Right lung ■​ 3 Lobar bronchi ●​ Superior ●​ Middle ●​ Inferior ○​ Left lung ■​ 2 Lobar bonchi ●​ Superior ●​ Inferior ○​ Lingula is part of left lobe ○​ NOT separate lobe ●​ Segmental bronchi ○​ Bronchopulmonary segment ○​ Segment are surgical units ■​ Segmentalectomy possible ■​ Each ahs its own parts ●​ Segmental bronchus ●​ Segmental pulmonary artery ■​ Pulmonary veins ●​ Between segments ●​ Aspirational patterns ○​ Aspirated material follows gravity +airway angle ○​ When upright ■​ Go to right lower lobe ■​ Basal segments ○​ Supine ■​ Posterior segments on right upper lobes ■​ Superior segments of right lower lobes ○​ Dependent and align with path of right main bronchus Pleura and lung ●​ Pleura ○​ Parietal pleural ■​ Lines up multiple parts of lung ●​ Thoracic wall ●​ Mediastinum ●​ Diaphragm ○​ Visceral pleura ■​ Covers lung surface ■​ Doesn’t separate easily ○​ Pleural cavity ■​ Potential space of thin fluid layer ■​ Lubricating ●​ Partial pleural regions ○​ Costal pleura ■​ Inner chest wall ○​ Mediastinal pleura ○​ Diaphragmatic pleura ○​ Cervical pleura ■​ Capula ■​ Extending into neck ■​ Superior to rib 1 ■​ Thoracic inlet are tied back ●​ Recessess ○​ Fluid pools here ○​ Costodiaphramatic recess ■​ Significant ○​ Costomediastinal recess ■​ Anterior ■​ Pronounced more on the left side ■​ In close proximity to cardiac notch Lungs ●​ Right lungs ○​ 3 lobes ■​ Superior ■​ Middle ■​ Inferior ○​ 2 fissures ■​ Oblique fissures ■​ Horizontal fissures ●​ Left lungs ○​ 2 lobes ■​ Superior and inferior ○​ 1 fissures ○​ Oblique fissure ■​ Cardiac notch ■​ Lingula ●​ Left middle lobe like regions ●​ Cx ○​ Fissures guide on how infection/effusion spreads ○​ Significant for imaging Pleural procedure anatomy ●​ Intercostal VAN bundle ○​ In costal grooves ○​ Inferior border of rib superior to it ●​ For needles or tubes to go through intercostal space ○​ Must aim superior to the rib below ■​ Avoid VAN in groove superior to it ○​ Must be aware on smaller collateral bundle ■​ Close to superior border of the rib inferior to it ■​ It must not stay low (not TOO low) ■​ Controlled Thoracentesis ●​ Removal of pleural fluids on diagnosis and symptom relief ●​ Pools in costodiaphragmatic recess ○​ Posterior/inferior once upright ○​ Collection of fluid here ●​ Around 7th to 9th intercostal space at midaxillary line ○​ Varies with imaging ○​ Don’t go too low ■​ Diaphragm will rise high ■​ Expiratory abdominal organ will sit inferior ●​ Liver on right ●​ Spleen on left ●​ Needle through chest wall ○​ Parietal pleura ○​ Through pleural cavity ■​ Fluid ○​ Entering above rib below ⇒ protect VAN ●​ Use ultrasound guidance ○​ Anatomy alone is not enough Chest tube ●​ Drainage of air or fluid or blood ○​ Air = pneumothorax ○​ Fluid/blood = effusion/hemothorax ●​ Choose area ○​ Easy access ○​ Avoidance of major nerves and vessels ○​ Avoiding breast tissues + diaphragm risks ●​ Boundaries ○​ Anterior borders = lateral edge of pectoralis major ○​ Posterior border = Anterior edge of latissimus dorsi ○​ Inferior border = Line about 5th intercostal space ■​ About in nipple line for males ○​ Superior apex = base of axilla ●​ Needed to minimalize risk of long thoracic nerve and major vessels ○​ Avoidance of going too low ■​ If too low, will go towards diaphragm and abdominal organs ●​ Air rises ⇒ Superior, anterior directed for tube for pneumothorax ●​ Fluid sinks ⇒ Tube for effusion and hemothorax are more inferior and posterior Pleural fluid pathology ●​ Hemothorax ○​ Blood in the pleural space ○​ Cause ■​ Trauma ●​ Rib fracture ●​ Penetrating injury ■​ Iatrogenic ●​ Procedures ■​ Malignancy and vascular injury ○​ Features ■​ Pleuritic pain and dyspnea ■​ Signs of blood loss if large ●​ Tachycardia ●​ Hypotension ○​ Imaging ■​ Dull percussion ■​ Reduction in breath sounds ■​ CXR ●​ Fluid layering ●​ Large collection shift through mediastinum away ○​ Concept of Mx ■​ Drain and treat source ●​ Bleeding control ●​ Chylothorax ○​ Chyle in pleural space ■​ Lymph rich in triglycerides ○​ Injury or obstruction of thoracic duct ■​ Surgical trauma ●​ Mediastinal ●​ Neck procedure ■​ Malignancy ●​ Lymphoma ■​ Trauma ○​ Pleural fluid can appear milky ○​ Thoracic duct runs posterior mediastinum → drain to left venous angle ○​ Loss of fats, proteins or lymphocytes will lead to nutritional and immune effects if persistent ●​ Empyema ○​ Pus in pleural space ■​ Infected pleural fluid ○​ Pneumonia spreading to pleura ■​ Parapneumonic effusion → empyema ■​ Post-surgery infxn ○​ Cx ■​ Fever and systemic illness ■​ Pleuritic chest pain ■​ Dyspnea ○​ Imaging ■​ Effusion ●​ Stony dull + decrease in breath sounds ■​ Is loculated ●​ Not layered freely ○​ Mx ■​ Antibiotic mixed with drainage ●​ Commonly, need more than a simple tap