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Expiration is mainly passive and depends upon elastic recoil of the lungs except
with deep breathing, when the abdominal musculature contracts, pulling the rib
cage downward and simultaneously elevating the diaphragm by compressing
the abdominal viscera against it.
Physiology of the Pleural Space
Pressure
The pleural cavity pressure is normally negative, owing to the opposing forces
of elastic recoil of the lung and active expansion of the space by the chest wall.
During quiet respiration, it varies from 15 cm H 2O with inspiration to 02 cm
H2O during expiration. Deep breathing may cause large pressure changes (eg,
60 cm H2O during forced inspiration to +30 cm H 2O during vigorous expiration).
Because of gravity, pleural pressure at the apex is more negative when the
body is erect and changes about 0.2 cm H 2O per centimeter of vertical height.
Fluid Formation & Reabsorption
Transudation and absorption of fluid within the pleural space normally follow
the Starling equation, which depends on hydrostatic, colloid, and tissue
pressures in addition to permeability of the pleural membrane. In health, fluid
is formed by the parietal pleura and absorbed by the visceral pleura (Figure 18
5). Systemic capillary hydrostatic pressure is 30 cm H 2O, and intrapleural
negative pressure averages 5 cm H2O. Together, these give a net hydrostatic
pressure of 35 cm H2O that causes fluid transudation from the parietal pleura.
The colloid osmotic pressure of the systemic capillaries is 34 cm H 2O; this is
opposed by 8 cm H2O of pleural space osmotic pressure. Thus, a net 26 cm H 2O
osmotic pressure draws fluid back into systemic capillaries. Systemic
hydrostatic pressure (35 cm H2O) exceeds osmotic capillary pressure (26 cm
H2O) by 9 cm H2O; thus, there is a 9 cm H2O net drive of fluid into the pleural
space by systemic capillaries in the chest wall. Similar calculations for the
visceral pleura involving the low-pressure pulmonary circulation will show that
there is a resulting net drive of 10 cm H2O that attracts pleural fluid into
pulmonary capillaries.
In health, pleural fluid is low in protein (<100 mg/dL). When it increases in
disease to about 1 g/dL, the net colloid osmotic pressure of the visceral pleural
capillaries is equaled and pleural fluid reabsorption becomes dependent on
lymphatic drainage. Thus, abnormal amounts of pleural fluid may accumulate
(1) when hydrostatic pressure is increased, such as in heart failure; (2) when
capillary permeability is increased, as in inflammatory or neoplastic disease; or
(3) when colloid osmotic pressure is decreased.
Anatomy of the Mediastinum
smallest unit of ventilation, the alveolus. The trachea and main stem bronchi
and their branches contain a posterior membranous area and are prevented
from collapsing by horseshoe-shaped anterior segments of cartilage in their
walls. The cartilaginous reinforcement of the airway gradually becomes less
complete as the branches become smaller, and reinforcement ceases with
bronchi of 12 mm. The bronchopulmonary segmental anatomy is designated
by numbers (Boyden) or by name (Jackson and Huber). The segmental
bronchial anatomy is most constant with the pulmonary vascular structures
showing more variability.
The lungs have a dual blood supply: the pulmonary and the bronchial arterial
systems. The pulmonary arteries transmit venous blood from the right ventricle
for oxygenation. They closely accompany the bronchi. The bronchial arteries
usually arise directly from the aorta or nearby intercostal arteries and are
variable in number. They transmit oxygenated blood at systemic arterial
pressure to the bronchial wall to the level of the terminal bronchioles.
The pulmonary veins travel in the interlobar septa and do not correspond to the
distribution of the bronchi or the pulmonary arteries.
The Lymphatic System
The lymphatics travel in intersegmental septa centrally as well as to the
parenchymal surface to form subpleural networks. Drainage continues toward
the hilum in channels that follow the bronchi and pulmonary arteries. The
lymphatics eventually enter lymph nodes in the major fissures of the lungs, the
hilum, and the paratracheal regions.
The direction of lymphatic drainageirrespective of the primary siteis
cephalad and usually ipsilateral, but contralateral flow may occur from any
lobe. The lymphatics from the left lower lobe may be almost equally distributed
to the left and right. From the left upper lobe, distribution is often to the
anterior mediastinal group (A-P window and para-aortic lymph nodes).
Otherwise, the usual sequence of lymphatic spread of pulmonary cancer is first
to the regional parabronchial nodes and then to the ipsilateral paratracheal,
subcarinal, scalene, or inferior deep cervical nodes.
Diagnostic Studies
Skin Tests
Skin tests are used in the diagnosis of tuberculosis, histoplasmosis, and
coccidioidomycosis. Tuberculin testing is usually done with purified protein
derivative (PPD) injected intradermally. Intermediate-strength PPD should be
used in patients who seem likely to have active disease. Induration of 10 mm
or more at the injection site after 4872 hours is called positive and indicates
either active or arrested disease. Because false-negative reactions are rare, a
negative test fairly reliably rules out tuberculosis. Mumps antigen is usually
placed on the opposite forearm to test for anergy. Skin tests for histoplasmosis
and coccidioidomycosis are performed in a similar way, but skin tests for fungal
infections are unreliable and serologic tests should be performed instead.
Endoscopy
Laryngoscopy
Indirect laryngoscopy is used to assess vocal cord mobility in patients
suspected of having lung carcinoma, especially when there has been a voice
change. It should be performed also to search for an otherwise occult source
for malignant cells in sputum or metastases in cervical lymph nodes.
Bronchoscopy
Roentgenographic evidence of bronchial obstruction, unresolved pneumonia,
foreign body, suspected carcinoma, hemoptysis, aspiration pneumonia, and
lung abscess are only a few of the indications for bronchoscopy. The procedure
can be done using either the standard hollow metal (rigid) or the flexible
fiberoptic bronchoscope under local or general anesthesia. Rigid bronchoscopy
must be done under general anesthesia and is most often used for clearing
major airways of bulky obstructing lesions such as tumors, foreign bodies, or
blood clots. Traditionally, the CO2 laser required use of the rigid bronchoscope,
though more recently developed technology (Nd:YAG) can be applied with
flexible bronchoscopy.
Flexible bronchoscopy is a highly effective diagnostic and therapeutic tool. It
can be performed under local and intravenous sedation. Washings are usually
obtained for bacterial or fungal culture and cytologic examination. Visible
lesions are biopsied directly, and biopsy specimens are sometimes taken from
the carina even though it appears normal. Brush biopsies are obtained from
specific bronchopulmonary segments. Occasionally, transcarinal needle biopsy
of a subcarinal node is obtained. Bronchoscopically, 3050% of lung tumors are
visible. Brushing, random biopsies, and sputum cytology may still yield a
positive diagnosis of cancer or tuberculosis in the absence of a visible lesion.
The yield is influenced by size, location, and histologic cell type of the lesion.
Mediastinoscopy
Sputum Analysis
Exfoliative sputum cytology is most valuable for detection of lung cancer.
Specimens are obtained by deep coughing or by abrasion with a brush, or
bronchial washings are obtained by either bronchoscopic or percutaneous
transtracheal washing techniques. Specimens should be collected in the
morning and delivered to the laboratory promptly. Centrifugation or filtration
can be used to concentrate the cellular elements.
In primary lung cancer, sputum cytology is positive in 3060% of cases.
Repeated sputum examination improves the diagnostic return. Examination of
the first bronchoscopic washing material yields a diagnosis in 60% of cases.
Postbronchoscopy sputum analysis should always be made at 612 and 24
hours, as findings may be positive at these times when previous tests were
negative.
Newer technologies, including better sputum-inducing agents, are currently in
clinical trials and appear effective. Also, more sophisticated cytologic analysis
using immunohistochemistry to molecular markers (cytokeratins, hnRNP, etc)
has improved accuracy and sensitivity and the ability to detect premalignant
lesions.
Computed Tomography (CT) Scan
Computed tomography is a cornerstone of evaluation of chest pathology. CT
scanning is critical in the staging of carcinoma, and has value in defining the
extent of metastatic disease. Mediastinoscopy remains the gold standard for
evaluation of the mediastinum in lung cancer.
Magnetic Resonance Imaging (MRI)
Although the major value of MRI in the thorax has been in cardiovascular
imaging, it has been moderately helpful in showing invasion of lung cancer into
the chest wall, vertebrae, and spinal cord as well as mediastinal structures. MRI
has a particular niche in the evaluation of superior sulcus (Pancoast) tumors to
establish involvement of the brachial plexus, subclavian vessel, or bony chest
wall.
Positron Emission Tomography (PET)
PET has become an important tool in staging and workup of the cancer patient.
PET scanners are more widely available, and current data suggest that PET
scanning identifies unsuspected regional or distant disease in 2030% of
patients with lung cancer or esophageal cancer compared with conventional
imaging methods (CT, bone scan). PET scanning is more accurate than CT scan
in detection of cancer spread to mediastinal lymph nodes. Because of the high
negative predictive value of PET scanning, a negative PET scan in the
mediastinum permits direct progression to thoracotomy. The presence of a
positive PET scan in the mediastinum mandates either mediastinoscopy or,
more recently, endoscopic evaluation of mediastinal lymph nodes because of
false-positive PET scan results.
The combined PET/CT is highly accurate (> 90%), but by itself it has a 1020%
false-positive rate in the mediastinum. Therefore, interpretations of PET results
must be accepted with caution and must be confirmed by surgical staging
when inconsistent with the overall clinical picture.