Page 101 - Medicine and Surgery

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Chapter 3: Respiratory infections 97

Thoracic surgery Aetiology
The primary cause is usually a respiratory virus, e.g. rhi-
Open lung surgery requires intubation and ventilation.
novirus, influenza, parainfluenza and respiratory syncy-
Doublelumenintubationallowsonelungtobecollapsed
tial virus.
for surgery.
Alobectomy is used for lesions confined to a sin- Pathophysiology
gle lobe. The potential space created by the removal is The virus enters via the airway by droplet inhalation
filled with remaining lung, elevation of the diaphragm and causes local inflammation, inducing secretions and
and mediastinal shift. Pneumonectomy is the removal
impairing ciliary clearance.
of a whole lung usually due to a tumour. The hilar
vessels are ligated and the bronchus is divided and Clinical features
closed close to the carina. The space resulting from Initially there is an irritating non-productive cough. The
the operation not occupied by shift of other struc- patient may feel short of breath, wheezy and complain
tures fills with blood and serum which organises and of chest tightness and retrosternal discomfort. There is a
fibroses. low-orhigh-gradepyrexia.Thecoughthenbecomeswet
Thoracoscopy is used for diagnosis of pleural disease, and productive of yellow or green sputum. Discoloured
mediastinoscopy to sample upper mediastinal lymph sputum signifies infection, which may be of bacterial or
nodes and mediastinotomy to sample lower mediasti- viralorigin. Streaky haemoptysis may occur. On aus-
nal lymph nodes. Video-assisted thoracoscopic surgery cultation wheezes and medium to coarse late or pan-
(VATS) is increasingly used for minimal access surgery. inspiratory crackles may be heard.
Single lung ventilation is used to allow the collapse of the
lung being operated on, e.g. for lung biopsy, overstapling Macroscopy/microscopy
of a broncho-pleural fistula or pleurectomy. The airway mucosa becomes red and oedematous, there
Specific complications following thoracic surgery in- is often an overlying mucopurulent exudate.
clude pneumonia (related to intubation, ventilation and
lungcollapse),pneumothorax,haemothorax,empyema, Complications
pulmonary oedema and acute respiratory distress Secondary bacterial infection with Streptococcus pneu-
syndrome. moniae, Moraxella catarrhalis or Haemophilus influenzae
may occur leading to bronchopneumonia, particularly
in the elderly, smokers and individuals with underlying
lung disease.
Respiratory infections
Investigations
Acute bronchitis These are usually not required, there may be a mild neu-
trophil leucocytosis even in viral infections.
Definition
An acute infectious condition of the lower respiratory
tract. Management
Antipyretic agents are used. Patients presenting with
acute bronchitis during an influenza epidemic may ben-
Incidence
efit from treatment with a neuraminidase inhibitor if
Very common.
started in the first 48 hours. Only if secondary bacterial
infection is suspected should a course of antibiotics be
Age prescribed.
Any
Prognosis
Sex The illness usually lasts up to a week in healthy adults,
M = F prolonged symptoms may occur. Changes in the course