- •Table of Contents
- •Copyright
- •Dedication
- •Introduction to the eighth edition
- •Online contents
- •List of Illustrations
- •List of Tables
- •1. Pulmonary anatomy and physiology: The basics
- •Anatomy
- •Physiology
- •Abnormalities in gas exchange
- •Suggested readings
- •2. Presentation of the patient with pulmonary disease
- •Dyspnea
- •Cough
- •Hemoptysis
- •Chest pain
- •Suggested readings
- •3. Evaluation of the patient with pulmonary disease
- •Evaluation on a macroscopic level
- •Evaluation on a microscopic level
- •Assessment on a functional level
- •Suggested readings
- •4. Anatomic and physiologic aspects of airways
- •Structure
- •Function
- •Suggested readings
- •5. Asthma
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic approach
- •Treatment
- •Suggested readings
- •6. Chronic obstructive pulmonary disease
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic approach and assessment
- •Treatment
- •Suggested readings
- •7. Miscellaneous airway diseases
- •Bronchiectasis
- •Cystic fibrosis
- •Upper airway disease
- •Suggested readings
- •8. Anatomic and physiologic aspects of the pulmonary parenchyma
- •Anatomy
- •Physiology
- •Suggested readings
- •9. Overview of diffuse parenchymal lung diseases
- •Pathology
- •Pathogenesis
- •Pathophysiology
- •Clinical features
- •Diagnostic approach
- •Suggested readings
- •10. Diffuse parenchymal lung diseases associated with known etiologic agents
- •Diseases caused by inhaled inorganic dusts
- •Hypersensitivity pneumonitis
- •Drug-induced parenchymal lung disease
- •Radiation-induced lung disease
- •Suggested readings
- •11. Diffuse parenchymal lung diseases of unknown etiology
- •Idiopathic pulmonary fibrosis
- •Other idiopathic interstitial pneumonias
- •Pulmonary parenchymal involvement complicating systemic rheumatic disease
- •Sarcoidosis
- •Miscellaneous disorders involving the pulmonary parenchyma
- •Suggested readings
- •12. Anatomic and physiologic aspects of the pulmonary vasculature
- •Anatomy
- •Physiology
- •Suggested readings
- •13. Pulmonary embolism
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic evaluation
- •Treatment
- •Suggested readings
- •14. Pulmonary hypertension
- •Pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic features
- •Specific disorders associated with pulmonary hypertension
- •Suggested readings
- •15. Pleural disease
- •Anatomy
- •Physiology
- •Pleural effusion
- •Pneumothorax
- •Malignant mesothelioma
- •Suggested readings
- •16. Mediastinal disease
- •Anatomic features
- •Mediastinal masses
- •Pneumomediastinum
- •Suggested readings
- •17. Anatomic and physiologic aspects of neural, muscular, and chest wall interactions with the lungs
- •Respiratory control
- •Respiratory muscles
- •Suggested readings
- •18. Disorders of ventilatory control
- •Primary neurologic disease
- •Cheyne-stokes breathing
- •Control abnormalities secondary to lung disease
- •Sleep apnea syndrome
- •Suggested readings
- •19. Disorders of the respiratory pump
- •Neuromuscular disease affecting the muscles of respiration
- •Diaphragmatic disease
- •Disorders affecting the chest wall
- •Suggested readings
- •20. Lung cancer: Etiologic and pathologic aspects
- •Etiology and pathogenesis
- •Pathology
- •Suggested readings
- •21. Lung cancer: Clinical aspects
- •Clinical features
- •Diagnostic approach
- •Principles of therapy
- •Bronchial carcinoid tumors
- •Solitary pulmonary nodule
- •Suggested readings
- •22. Lung defense mechanisms
- •Physical or anatomic factors
- •Antimicrobial peptides
- •Phagocytic and inflammatory cells
- •Adaptive immune responses
- •Failure of respiratory defense mechanisms
- •Augmentation of respiratory defense mechanisms
- •Suggested readings
- •23. Pneumonia
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features and initial diagnosis
- •Therapeutic approach: General principles and antibiotic susceptibility
- •Initial management strategies based on clinical setting of pneumonia
- •Suggested readings
- •24. Bacterial and viral organisms causing pneumonia
- •Bacteria
- •Viruses
- •Intrathoracic complications of pneumonia
- •Respiratory infections associated with bioterrorism
- •Suggested readings
- •25. Tuberculosis and nontuberculous mycobacteria
- •Etiology and pathogenesis
- •Definitions
- •Pathology
- •Pathophysiology
- •Clinical manifestations
- •Diagnostic approach
- •Principles of therapy
- •Nontuberculous mycobacteria
- •Suggested readings
- •26. Miscellaneous infections caused by fungi, including Pneumocystis
- •Fungal infections
- •Pneumocystis infection
- •Suggested readings
- •27. Pulmonary complications in the immunocompromised host
- •Acquired immunodeficiency syndrome
- •Pulmonary complications in non–HIV immunocompromised patients
- •Suggested readings
- •28. Classification and pathophysiologic aspects of respiratory failure
- •Definition of respiratory failure
- •Classification of acute respiratory failure
- •Presentation of gas exchange failure
- •Pathogenesis of gas exchange abnormalities
- •Clinical and therapeutic aspects of hypercapnic/hypoxemic respiratory failure
- •Suggested readings
- •29. Acute respiratory distress syndrome
- •Physiology of fluid movement in alveolar interstitium
- •Etiology
- •Pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic approach
- •Treatment
- •Suggested readings
- •30. Management of respiratory failure
- •Goals and principles underlying supportive therapy
- •Mechanical ventilation
- •Selected aspects of therapy for chronic respiratory failure
- •Suggested readings
- •Index
1.Percutaneous needle aspiration or biopsy
2.Endobronchial ultrasound-guided aspiration
3.Mediastinoscopy
4.Parasternal mediastinotomy
5.Video-assisted thoracic surgery
Treatment
Treatment of the various mediastinal masses depends to a large extent on the nature of the lesion. In many cases, complete removal of the mass by surgery is the preferred procedure if technically feasible. Because benign lesions may slowly enlarge and compress vital mediastinal structures, excision of even low-grade neoplasms is frequently indicated. In addition, there may be complicating hemorrhage or infection of a benign lesion and eventually even malignant transformation of an initially benign tumor; these factors also favor removal, if possible, following initial diagnosis.
Treatment of malignant tumors depends on the type of tumor and the presence or absence of invasion of other mediastinal structures. Because surgical removal of malignant lesions often is not possible, chemotherapy and radiotherapy are frequently the primary forms of treatment.
Pneumomediastinum
Normally, free air is not present within the mediastinum. When air enters the mediastinum for any number of reasons, pneumomediastinum is said to be present.
Etiology and pathogenesis
The three major sources of air entry to the mediastinum are (1) through the skin and chest wall, as occurs commonly in the setting of penetrating trauma; (2) from a tear or defect in the esophagus or the trachea, allowing air to enter the mediastinum directly; and (3) from a localized loss of integrity of the alveoli. In the last circumstance, an increase in intraalveolar pressure may induce air entry into interstitial tissues of the alveolar wall. This interstitial air may then dissect alongside the wall of blood vessels coursing through the interstitium. After air tracks back proximally, it can eventually enter the mediastinum at the site of origin of the vessels in the mediastinum. When pneumomediastinum occurs as a result of this final mechanism, it is termed the Macklin effect.
Sources of air entry in a pneumomediastinum:
1.External (penetrating trauma)
2.Tracheal or esophageal tear
3.Alveolar rupture and tracking of air proximally
Proximal dissection of extraalveolar air is probably the most common cause of a pneumomediastinum. In some cases, the reason for the increase in intraalveolar pressure is obvious—for example, severe coughing, vomiting, or straining. In patients receiving mechanical ventilation, the positive pressure produced by the ventilator may result in alveolar rupture and a pneumomediastinum, particularly if the patient’s spontaneous breathing is dyssynchronous with the ventilator. A pneumomediastinum may develop in persons with asthma, presumably because of the development of high intraalveolar pressure in a lung
unit behind a partially obstructed bronchus through which air can enter more easily than exit. In other circumstances, the immediate cause of the pneumomediastinum is not apparent, and the patient truly has a “spontaneous pneumomediastinum.”
Pathophysiology
With accumulation of air in the mediastinum, an increase in pressure might be expected to cause a decrease in venous return to the great veins, with resulting cardiovascular compromise. However, when pressure builds up within the mediastinum, air usually dissects further along fascial planes into the neck, allowing release of the pressure and preventing disastrous cardiovascular complications. In addition, an increase in mediastinal pressure sometimes results in rupture of the mediastinal pleura and escape of air into the pleural space, with consequent development of a pneumothorax (see Chapter 15).
After air has entered the soft tissues of the neck, the patient is said to have subcutaneous emphysema. With continued entry of air from the mediastinum into the neck, the air dissects further over soft tissues of the chest and abdominal walls, producing more extensive subcutaneous emphysema.
Mediastinal air often results in subcutaneous emphysema.
Because of the escape route available for mediastinal air and the opportunity for decompression, major cardiovascular complications are quite uncommon. The development of subcutaneous emphysema, although unsightly and frequently uncomfortable, usually is not associated with major clinical sequelae.
Clinical features
At the onset, patients with a pneumomediastinum often experience relatively sudden substernal chest pain. They may have dyspnea and (very rarely) cardiovascular compromise and hypotension. In some cases, the pneumomediastinum causes no symptoms, and the problem is detected on chest radiograph (e.g., on a film obtained during an acute asthma exacerbation).
Physical examination may reveal a crunching or clicking sound synchronous with the heartbeat on cardiac auscultation (Hamman sign). If the patient has subcutaneous emphysema associated with the pneumomediastinum, popping and crackling sounds (crepitations) may be heard and palpated over the affected skin and subcutaneous tissue.
Diagnostic approach
The chest radiograph and chest CT scan are the most important studies for documenting a pneumomediastinum. Gas may be seen within the mediastinal tissues and is frequently accompanied by gas within and tracking along soft tissues of the neck and/or chest wall (subcutaneous emphysema) (Fig. 16.5).
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FIGURE 16.5 Chest computed tomography scan shows air within the mediastinum
(pneumomediastinum) and air in subcutaneous tissues of the anterior chest wall
(subcutaneous emphysema).
Treatment
Generally, no treatment is necessary for a pneumomediastinum, even when accompanied by subcutaneous emphysema. The air is usually resorbed spontaneously over time. When a pneumomediastinum is a consequence of tracheobronchial or esophageal rupture, surgery may be necessary to repair the underlying tear. Esophageal rupture can result in a rapidly progressive and fatal bacterial mediastinitis, and urgent surgical intervention must be considered if esophageal perforation is suspected. In the rare circumstance when pressure builds up within the mediastinum, an incision or placement of a catheter or chest tube into the mediastinum may be necessary to allow escape of air from the mediastinum and release of positive pressure.
Suggested readings
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