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Lecture notes, cheat sheets
Pediatric surgery. Acute diseases of the lungs and pleura (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 3. Acute diseases of the lungs and pleura Respiratory tract injuries requiring emergency care are diverse. These include congenital malformations of the lung tissue (lobar emphysema, congenital lung cysts), inflammatory diseases of the lungs and pleura (destructive pneumonia with intrapulmonary and pulmonary-pleural complications). Clinically, each pathological condition is manifested by specific features. For malformations, signs of respiratory failure are characteristic, the degree of which may be different. In inflammatory diseases, in addition to respiratory failure, signs of intoxication of the body are usually expressed to a large extent. Diagnosis of pulmonary-pleural complications is often difficult. This is especially true of lung lesions in destructive pneumonia. Correct recognition of the pathological process, its nature, prevalence determines the timeliness and volume of surgical care. The range of intervention is wide: from puncture to segmentectomy or, extremely rarely, removal of the affected lung. Despite the differences in surgical treatment, the principles of postoperative management of patients are to a certain extent the same: in addition to the fight against respiratory failure, sanitation of the pleural cavity and tracheobronchial tree, they provide for antibacterial, restorative and stimulating therapy. It should only be emphasized that the diverse nature of pathological processes determines the indications for the use of various forms of treatment, which are based on an individual approach to each patient. 1. Malformations of the lungs. Lobar emphysema Congenital lobar emphysema is rare. It occurs as a result of rupture of the alveolar septa in stenoses of the adducting bronchi of various origins (malformation of the lobar bronchus, partial blockage of the excessively growing mucosa, compression by an abnormally located vessel) or is a consequence of a defect in the development of the lung parenchyma (fibrous dysplasia, collagenization). With lobar emphysema, the altered lobe of the lung is enlarged, stretched by air, tense, and does not collapse. As a result, the remaining parts of the lung are compressed and do not participate in breathing. The upper lobes of the lung are most often affected, less often the middle and lower lobes. clinical picture Lobar emphysema is manifested by shortness of breath, often with prolonged expiration, bouts of cyanosis, shortness of breath, cough. The severity of symptoms depends on the degree of bronchial obstruction. According to the clinical course, lobar emphysema should be divided into acute and chronic. Acute course of lobar emphysema is usually observed in children during the first months of life (often soon after birth). The disease is manifested by a progressive increase in signs of respiratory failure. The general condition of the child is severe, the skin is pale with a cyanotic tint; punctate subcutaneous hemorrhages are visible, cyanotic lips. Sharp shortness of breath is determined, auxiliary muscles are involved in breathing. The chest is barrel-shaped. Percussion over the lung field on the side of the lesion reveals high tympanitis, with auscultation there are no respiratory sounds. The boundaries of the heart are shifted to the healthy side. Heart sounds are muffled. X-ray data are of decisive importance in making the diagnosis of lobar emphysema. A plain X-ray of the chest shows that the affected part of the lung is sharply swollen, with shadows of medium- and large-caliber vascular branches against its highly airy background. Neighboring areas of the lung are collapsed. The swollen lobe partially penetrates into the opposite side of the chest, displacing the mediastinum and forming a mediastinal hernia. In addition to the usual clinical and radiological methods, bronchography and bronchoscopy help to establish the correct diagnosis, in the chronic form of the disease, in which narrowing of the lobar bronchus, displacement and convergence of the bronchi of healthy parts of the lung are determined. In the acute course of lobar emphysema, other additional diagnostic methods of research are often impossible, since the growing deterioration in the general condition of the child requires immediate surgical care. Chronic lobar emphysema is extremely rare. In such cases, the phenomena of respiratory failure increase slowly, the body adapts to the changes that have occurred and compensates for them. The disease is usually detected during preventive examinations or x-ray examinations. Differential diagnosis Lobar emphysema should be differentiated from pulmonary cyst and diaphragmatic hernia. With a pulmonary cyst, the clinical manifestations of the disease can be acute or chronic, with signs of respiratory failure. X-ray data help to make a correct diagnosis. Pulmonary cysts on radiographs look like well-defined air cavities of a rounded shape, without a mesh pattern characteristic of lobar emphysema. Quite often nevertheless the differential diagnosis on the basis of clinical and radiological data is extremely difficult. Finally, the nature of the pathological process in such cases is revealed during surgery and after a histological examination of the drug. Diaphragmatic hernia in the presence of an asphyxic component in newborns is similar to the acute form of lobar emphysema. In doubtful cases, the final diagnosis is made after x-ray examination with a contrast agent. Contrasting intestinal loops located in the pleural cavity makes the diagnosis of diaphragmatic hernia undoubted. Treatment Treatment of congenital lobar emphysema in all cases is surgical. In the acute course of the disease with a clinical picture of severe respiratory failure, the operation should be undertaken according to emergency indications. In cases of a chronic course, intervention is carried out in a planned manner. Preoperative preparation. The volume and duration of the patient's preparation for surgery depend on the nature of the clinical manifestations. In acute cases, preoperative preparation is limited to a few (2-3) hours. The patient is prescribed oxygen, cardiac agents, warmed up and transferred to the operating room. Surgical treatment. The nature of the surgical intervention is determined by the localization of the lesion and comes down to lobectomy. Removal of the lung lobes is performed from an anterolateral thoracotomy approach in the fourth or fifth intercostal space with the patient in a semilateral position. Technically, lobectomy is carried out according to the rules set out in special guidelines for operative surgery, with the obligatory separate processing of the elements of the lung root. After removal of the affected lung section, high drainage is established in the pleural cavity, which is introduced through a separate incision - a puncture in the seventh-eighth intercostal space along the midaxillary line. The operation is completed by layer-by-layer suturing of the thoracotomy wound. The skin is sutured with nylon threads. postoperative treatment. High drainage is left in the pleural cavity for active aspiration of exudate during the first 24-48 hours. For pain relief in the immediate postoperative period, prolonged epidural anesthesia is performed. It is advisable to prescribe parenteral fluid administration for the first 12-24 hours after surgery (10% glucose solution with insulin, protein preparations) according to the weight and age of the child. In the absence of vomiting, the next day after the intervention, the child begins to feed through the mouth. Blood transfusions are done taking into account the indicators of red blood tests, as well as taking into account the amount of exudate aspirated from the pleural cavity. To prevent pulmonary complications (blockage of the bronchial tree, atelectasis), from the first hours after the operation, the patient is prescribed respiratory and cough exercises, alkaline aerosols. If these measures are ineffective, direct laryngoscopy is performed with suction of the secret and the introduction of antibiotics into the respiratory tract. From the 3-4th day, older children begin to walk. The presence of atelectasis is an indication for the appointment of more intense breathing exercises, which usually leads to the complete elimination of this complication, and in case of ineffectiveness, tracheobronchoscopy is resorted to. In the postoperative period, patients receive broad-spectrum antibiotics for 6-7 days, vitamins, oxygen therapy, physiotherapy and massage. The sutures are removed on the 7-8th day. 2. Complicated congenital lung cysts Lung cysts are a relatively rare disease of childhood, occurring from 3,5 to 5,5% in relation to the total number of patients with various nonspecific lung diseases. Cysts are single and multiple. Multiple lung cysts include their polycystic lesion. Cysts are more common in the right lung than in the left. The sizes of cysts vary widely. They can be single or multi-chamber, very small, sometimes reaching gigantic sizes, occupying almost the entire lobe or lung. If the cysts do not communicate with the tracheobronchial tree (closed), then they usually contain a sterile mucous liquid, colorless, yellowish or brown. Cysts communicating with the bronchi are filled with air and infected fluid. In cases of air cysts, fluid from them is well evacuated through the draining bronchus. All lung cysts are usually divided depending on their origin into true and false, and according to the nature of the clinical course - into uncomplicated and complicated. In children, true cysts (lung malformation) are more common. Uncomplicated cysts, as a rule, do not manifest themselves clinically, and therefore are usually an incidental finding during an X-ray examination of a child. The majority of congenital pulmonary cysts are detected when there are complications that require urgent surgical treatment. Festering and air strained cysts are most often observed. clinical picture Each of the complications is characterized by specific features of the clinical manifestation. Suppurated cysts of the lungs. With suppuration of single lung cysts, the disease develops acutely, with a sharp deterioration in the general condition of the child, an increase in body temperature to high numbers, chills, and sweating. On examination, the patient noted pallor of the skin, cyanosis in the area of the nasolabial triangle. Breathing is fast, pulse is tense. Physical data depend on the size of the cyst, the degree of its drainage through the bronchus, and other factors. On the side of the localization of the cyst, areas of dullness of percussion sound and tympanitis are revealed, respectively, inflammatory infiltration, accumulation of exudate and air. During auscultation in these places, breathing is weakened, after coughing, moist coarse rales appear. Changes in the blood indicate an acute inflammatory process: high leukocytosis with a shift to the left, increased ESR. X-ray examination reveals a cavity filled with fluid, around which there is an inflammatory infiltrate. With partial emptying of purulent contents, a horizontal level appears in the cyst cavity. Differential diagnosis It is necessary to differentiate infected cysts with lung abscess and pyopneumothorax. The clinical course of an infected cyst and lung abscess is very similar. Radiographically, these processes are also difficult to differentiate. The final diagnosis of a lung cyst can be made in cases where the anamnesis indicates the presence of an air cavity in the lung, which was previously found during an X-ray examination, or there is repeated suppuration in the lung with the same localization of the focus. Pyopneumothorax develops against the background of severe asbestos pneumonia and is its complication. Radiologically, the cavity is located along the outer edge of the lung field. In doubtful cases, a dynamic x-ray examination helps to make the correct diagnosis, as well as additional examination methods - tomography, bronchography, which reveal the normal structure and location of the airways. With a purulent-inflammatory lesion of a polycystic lung, if infection occurs at an early age, the disease becomes protracted with frequent exacerbations. The general condition of the child is progressively deteriorating, the phenomena of intoxication are increasing, the patient is exhausted, the body temperature rises. When examining a child, a rigid chest wall is revealed on the side of the lesion, which is not involved in the act of breathing. The borders of the heart are not changed. Percussion above the pulmonary field - a motley picture: areas of pulmonary sound alternate with tympanitis and dullness. Auscultatory determined a large number of different-sized moist rales. X-ray shows multiple thin-walled air cavities of various sizes with horizontal levels. There is no noticeable displacement of the mediastinal organs. A polycystic lung with suppuration should be differentiated from abscess pneumonia and bronchiectasis. The course of destructive pneumonia is characterized by a rapid onset. X-ray reveals characteristic infiltrative (with subsequent abscessing) changes in the lungs. With bronchiectasis, the course of the disease is chronic with periodic exacerbations, with expectoration of purulent sputum. X-ray and bronchography revealed deformed, dilated rigid bronchi in all lobes of the lung. However, correct recognition is often extremely difficult. Sometimes even a histological examination does not clarify the final diagnosis. Air tight lung cysts are clinically manifested by the development of severe respiratory failure with frequent attacks of suffocation. Children lag behind in physical development A severe clinical picture develops with lung cysts with a valve mechanism in the afferent bronchus. The valve is formed due to the kink of the bronchus, its oblique communication with the cavity of the cyst, hypertrophy of the mucous membrane, blockage of the bronchus with sputum, mucus. Often, from the first days of life, such children experience shortness of breath, shortness of breath with the participation of all auxiliary muscles. Even at rest, they retain a cyanotic shade of the skin. Scream and anxiety are accompanied by bouts of asphyxia. This condition may develop gradually with progressive deterioration, but sometimes it comes on suddenly. During a clinical examination of a child on the side of the lesion, a lag in the act of breathing of half of the chest is determined. Percussion sound over the lung field is tympanic in nature. The boundaries of the heart are shifted to the healthy side, breath sounds are not auscultated X-ray reveals a vast air cavity occupying the entire half of the chest, there is no pulmonary pattern, the shadow of the heart and mediastinal organs is sharply shifted to the healthy side. There are signs of a mediastinal hernia Treatment All congenital pulmonary cysts are subject to surgical treatment, however, the timing of the operation is determined by the course of the disease, the condition of the child. The same factors dictate the volume and duration of preoperative preparation. Preoperative preparation depends on the nature of the complication. An infected cyst or cysts of the lung require intensive complex therapy, which is a kind of preoperative preparation. Therapeutic measures in these patients are aimed at removing intoxication and restorative therapy. Sanitation of the purulent cavity is carried out by puncturing it, with the suction of pus, washing with antiseptic solutions and the introduction of antibiotics. The cyst is punctured again after 2-3 days (depending on the accumulation of exudate). At the same time, the patient is prescribed therapeutic exercises with a drainage position. With insufficient drainage function of the afferent bronchus, it is advisable to include repeated tracheobronchoscopy in the complex of therapeutic measures. The degree of sanitation of the cavity is controlled by crops of its contents. Often it is possible to achieve complete inhibition of the growth of pathogenic microflora. The patient receives alkaline aerosols with antibiotics and local anti-inflammatory physiotherapy. Drainage of festering cysts with the establishment of passive or active aspiration is not indicated due to the possible formation of a persistent internal bronchial fistula. As a result of the rehabilitation of the purulent focus, the patient's symptoms of intoxication are reduced, which is also facilitated by vigorous general strengthening therapy - transfusion of blood, plasma, intravenous fluids, parenteral administration of vitamins and massive antibiotic therapy. With giant strained cysts, as well as cysts with a valve mechanism, an emergency measure of assistance that allows the child to be taken out of a serious condition due to respiratory failure is the puncture of the cyst. Reducing intrapulmonary pressure can significantly improve the general condition of the patient and successfully carry out urgent surgical intervention. Operative treatment. The extent of the operation depends on the nature of the pathological process. It should be remembered that the introduction of anesthesia in patients with tense cysts has its own characteristics: forcible injection of air into the lungs and into the cyst during artificial respiration leads to an increase in pressure in the air cavity, and therefore the conditions of pulmonary ventilation significantly worsen. There is a vicious circle - despite vigorous artificial respiration, hypoxia continues to grow. This complication can be prevented by puncturing the cyst with an open needle prior to intubation of the patient and maintaining the needle in its cavity until the moment of thoracotomy. With single cysts, surgery can be reduced to thoracotomy and cyst exfoliation. Operation technique. Thoracotomy is performed according to the general rules with an anterolateral incision. The lung is isolated from the adhesions Above the cyst, the pleura is carefully dissected, after which the lung is gradually exfoliated from the cyst wall. Fibrous strands, by which the cyst is connected with the surrounding lung tissue, are cut and ligated. There are especially many strands at the basal pole of the cyst. Here, quite large vessels and one or more bronchial branches that communicate with the cyst can pass. They are ligated with silk. Bleeding areas of the lung edge are sheathed with catgut. If it is impossible to enucleate the cyst, a lobectomy is performed according to the general rules. After removal of the cyst in the pleural cavity, drainage is left for 24-48 hours. The extent of surgery for polycystic lung depends on the extent of the lesion. With lobar localization, the operation is reduced to a lobectomy. In the case of cystic degeneration of the entire lung, a pneumonectomy is performed. Drainage of the pleural cavity after pneumonectomy is not mandatory. However, after a traumatic operation or if there are doubts about the reliability of the bronchus suture, it is better to introduce drainage for 36-48 hours, with the help of which the exudate is passively aspirated. postoperative treatment. Basically, the treatment of patients who underwent surgery for lung cysts does not differ from that for lobar emphysema. After removal of previously infected cysts, special attention should be paid to antibiotic therapy. Careful care of the postoperative wound is also necessary - daily dressings, suture treatment, ultraviolet irradiation. In children who have undergone pneumonectomy, after removal of the drainage, the residual pleural cavity is filled with a displaced mediastinum and an organizing blood clot. In these cases, it is especially important to prevent infection of the cavity and the development of pleural empyema, so careful antibiotic therapy takes on special meaning. The fight against intoxication and respiratory failure is carried out systematically by intravenous infusions of blood, plasma, constant oxygen therapy. Such children require dispensary observation and periodic sanatorium treatment. Authors: Drozdov A.A., Drozdova M.V. << Back: Preoperative preparation. Features of preoperative preparation for acute surgical diseases accompanied by intoxication (Preoperative preparation against the background of traumatic shock. Therapy of traumatic shock) >> Forward: Malformations of the esophagus. Esophageal obstruction (Esophageal obstruction)
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