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General Surgery: Pulmonology (PEARLS)

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The General Surgery End of Rotation Blueprint Pulmonology section covers seven topics and represents 3% of your General Surgery EOR exam

Hemoptysis The most common causes include:

Other causes: bronchiectasis, pulmonary catheters, trauma, pulmonary hemorrhage
Lung carcinoma Small Cell (15% of cases) (central mass) - 99% smokers, does not respond to surgery and metastases at presentation

  • Location: Central, very aggressive
  • Treatment: Combination chemotherapy needed
  • Paraneoplastic syndromes: Cushing's, SIADH

Non-Small Cell  (85 percent of lung cancer cases)

  • Squamous cell (central mass) with hemoptysis, 25-35% of lung cancer cases
    • Location: central
    • May cause hemoptysis
    • Paraneoplastic syndrome: hypercalcemia
    • Elevated PTHrp
  • Large cell - fast doubling rates - responds to surgery rare (only 5%)
    • Location: Periphery 60%
    • Paraneoplastic syndrome: Gynecomastia
  • Adenocarcinoma - most common (peripheral mass), 35-40% of cases of lung cancer
    • Most common
    • Associated with smoking and asbestos exposure
    • Location: Periphery
    • Paraneoplastic syndrome: Thrombophlebitis

Treatment:

Non-Small Cell can be treated with surgery

  • Treatment depends on staging:
    • Stage 1-2 surgery
    • Stage 3 Chemo then surgery
    • Stage 4 palliative

Small Cell: CAN NOT be treated with surgery will need chemotherapy

Associated manifestations:

  • Superior vena cava syndrome (facial/arm edema and swollen chest wall veins)
  • Pancoast tumor (shoulder pain, Horner’s syndrome, brachial plexus compression)
  • Horner’s syndrome (unilateral miosis, ptosis, and anhidrosis)
  • Carcinoid syndrome (flushing, diarrhea, and telangiectasia)
Pleural effusion Dyspnea, and a vague discomfort or sharp pain that worsens during inspiration

  • Differentiate exudate and transudate with pleurocentesis and Light’s Criteria
    • Exudate: (local pleural disease) - protein ratio ↑, LDH ↑, infection, malignancy, trauma
    • Transudate: Congestive heart failure, atelectasis, cirrhosis
  • Decreased tactile fremitus, dullness to percussion, and diminished breath sounds over the effusion
  • Lateral decubitus x-ray and upright films: Blunting of the costophrenic angle. A mediastinal shift away from effusion
  • Thoracentesis is the gold standard

Picmonic
Light’s Criteria

IM_MED_Lightscriteria_V1.3_Light’s Criteria is a diagnostic tool used to determine of the cause of a pulmonary effusion; transudate versus exudate. This relies on a comparison of the chemistries in the pleural fluid to those in the blood. According to Light’s criteria, a pleural effusion is likely exudative if at least one of the following exists: The ratio of pleural fluid protein to serum protein is greater than 0.5, the ratio of pleural fluid LDH and serum LDH is greater than 0.6, or the pleural fluid LDH is greater than 0.6 or 2⁄3 times the normal upper limit for serum.

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Pneumonia (postoperative) Currently, postoperative pneumonia is the third most common complication for all surgical procedures and is associated with increased patient morbidity and mortality

  • Prolongs the length of stay by a mean of 7 - 9 days as well as increases medical costs ranging from $12,000 to $40,000
  • Hospital-acquired pneumonia (pneumonia developing 48 - 72 h after admission)
  • Ventilator-associated pneumonia (VAP, pneumonia developing 48 - 72 h after endotracheal intubation) occurring in the post-surgical patient

The most important pathogens are

  • Pseudomonas aeruginosa
  • Methicillin-sensitive Staphylococcus aureus
  • Methicillin-resistant S. aureus (MRSA)

Diagnosis:

  • Chest x-ray or chest computed tomography
  • Sometimes bronchoscopy or blood cultures

Treatment includes empirically chosen antibiotics active against resistant organisms

  • Piperacillin/tazobactam
  • Cefepime
  • Levofloxacin
  • Imipenem
  • Meropenem

In treatment settings where MRSA rates are > 20%, vancomycin or linezolid should be added
Pneumothorax An absence of breath sounds and hyperresonance to percussion with tracheal deviation

Spontaneous:

  • Primary spontaneous pneumothorax occurs in the absence of underlying disease - tall, thin males between 10 and 30 years of age are at the greatest risk of primary pneumothorax
  • Secondary spontaneous pneumothorax occurs in the presence of underlying disease - asthma, COPD, cystic fibrosis, interstitial lung disease

Tension:

  • Etiology: Penetrating injury
  • Physical exam: Hyperresonance to percussion and tracheal shift to the contralateral side

Small pneumothoraces <15% of the diameter of the hemithorax will resolve spontaneously without the need for chest tube placement

  • For large, > 15% of the diameter of hemithorax, and symptomatic pneumothoraces, chest tube placement is performed
  • Patients should be followed with serial CXR every 24 hours until resolved
Shortness of breath Shortness of breath can have causes that aren't due to underlying disease. Examples include exercise, altitude, tight clothing, a prolonged period of bed rest, or a sedentary lifestyle
Weight loss and fatigue Weight loss and fatigue can have causes that aren't due to underlying disease. Examples include dieting, exercise, malnutrition, or lack of access to food, lack of sleep, heavy exertion, jetlag, a large meal, or aging
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