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Anatomy of the Chest Wall & Pleura

The chest wall is an airtight, expandable, cone-shaped cage. Lung ventilation


occurs by generation of negative pressure within the thorax due to
simultaneous expansion of the rib cage and downward diaphragmatic
excursion.
The ventral wall of the bony thorax is the shortest dimension. It extends from
the suprasternal notch to the xiphoida distance of approximately 18 cm in
the adult. It is formed by the vertically aligned manubrium, sternum, and
xiphoid process. The first seven pairs of ribs articulate directly with the
sternum, the next three pairs connect to the lower border of the preceding rib,
and the last two terminate in the wall of the abdomen. The sides of the chest
wall consist of the upper ten ribs, which slope obliquely downward from their
posterior attachments. The posterior chest wall is formed by the 12 thoracic
vertebrae, their transverse processes, and the 12 ribs (Figure 181). The upper
ventral portion of the thoracic cage is covered by the clavicle and the
subclavian vessels. Laterally, it is covered by the shoulder girdle and axillary
nerves and vessels; dorsally, it is covered in part by the scapula.
The superior aperture of the thorax (also called either the thoracic inlet or the
thoracic outlet) is a downwardly slanted 5- to 10-cm kidney-shaped opening
bounded by the first costal cartilages and ribs laterally, the manubrium
anteriorly, and the body of the first thoracic vertebra posteriorly. The inferior
aperture of the thorax is bounded by the 12th vertebra and ribs posteriorly and
the cartilages of the 7th to 10th ribs and the xiphisternal joint anteriorly. It is
much wider than the superior aperture and is occupied by the diaphragm.
The blood supply and innervation of the chest wall are via the intercostal
vessels and nerves (Figures 182 and 183), and the upper thorax also receives
vessels and nerves from the cervical and axillary regions. The underside of the
sternums blood supply derives from the internal thoracic artery branches,
which anastomose with the intercostal vessels along the lateral aspect of the
chest wall.
The parietal pleura is the innermost lining of the chest wall and is divided into
four parts: the cervical pleura (cupula), costal pleura, mediastinal pleura, and
diaphragmatic pleura. The visceral pleura is a mesodermal layer investing the
lungs and is continuous with the parietal pleura, joining it at the hilum of the
lung. The potential pleural space is a capillary gap that normally contains only
a few drops of serous fluid. However, this space may be enlarged when fluid
(hydrothorax), blood (hemothorax), pus (pyothorax or empyema), lymphatic
fluid (chylothorax), or air (pneumothorax) is present.
Physiology of the Chest Wall & Pleura
Mechanics of Respiration
Breathing entails expansion of thoracic volume by elevation of the rib cage and
descent of the diaphragm. Infants, in whom the ribs have not yet assumed
their oblique contour, are dependent on diaphragmatic breathing. Furthermore,

accessory muscles of respiration contribute to the conformational change in


the thoracic cage during periods of intense exercise or respiratory distress
(Figure 184).

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

The mediastinum is the compartment between the pleural cavities. It extends


anteriorly from the suprasternal notch to the xiphoid process and posteriorly
from the 1st to the 11th thoracic vertebrae. Superiorly, fascial planes in the
neck are in direct communication; inferiorly, the mediastinum is limited by the
diaphragm. Apertures through the inferior extent of the mediastinum are
traversed by the aorta, inferior vena cava, esophagus, and vagus nerve.
In the Burkell classification (Figure 186), the anterior mediastinum contains
the thymus gland, the lymph nodes, the ascending aorta and transverse aorta,
the great vessels, and areolar tissue. The middle mediastinum contains the
heart, the pericardium, the trachea, the hila of the lungs, the phrenic nerves,
lymph nodes, and areolar tissue. The posterior mediastinum contains the
sympathetic chains, the vagus nerves, the esophagus, the thoracic duct, lymph
nodes, and the descending aorta.
Congenital abnormalities within the mediastinum are numerous. A defect in the
anterior mediastinal pleura with communication of the right and left
hemithorax is rare in humans. This retrosternal part of the anterior
mediastinum is normally thin, and overexpansion of one pleural space may
cause mediastinal herniation or a bulge of mediastinal pleura toward the
opposite side.
Displacements of the mediastinum occur from masses or from accumulations
of air, fluid, blood, or chyle interfering with vital functions. Tracheal
compression, vena caval obstruction, and esophageal obstructions cause
clinical symptoms. The mediastinum can also be displaced laterally when
pathologic processes of one hemithorax cause mediastinal shift. Fibrosis and
lung volume loss can shift the mediastinum toward the affected side. Open
pneumothorax and massive hemothorax shift the mediastinum away from the
affected side. Open pneumothorax produces alternating paradoxic mediastinal
shifts with respiration and will adversely affect ventilation. Acute mediastinal
displacement may produce hypoxia or reduced venous return and cause
dysrhythmias, hypotension, or cardiac arrest.
Anatomy of the Lung
See Figure 187 for lung anatomy.
The lobes of the lung comprise multiple bronchopulmonary segments. The right
lung has three lobes: upper, middle, and lower. The left lung consists of two
lobes: upper and lower. On the left, the lingular segments of the upper lobe are
the homolog of the right middle lobe. Two fissures of varying completeness
separate the lobes on the right side. The major, or oblique, fissure divides the
upper and middle lobes from the lower lobe. The minor, or horizontal, fissure
separates the middle from the upper lobe. On the left side, the single oblique
fissure separates the upper and lower lobes. These are the normal anatomic
segments; congenital defects such as situs inversus reverse this arrangement,
and bilateral right-sided anatomy (asplenia) or bilateral left-sided anatomy
(polysplenia) can also occur. The parenchymal anatomy can be seen by
studying the sequential division of the bronchopulmonary tree down to the

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

Cervical mediastinoscopy remains a mainstay of evaluation of the mediastinum


despite advances in imaging. Properly performed mediastinoscopy samples
nodes from at least three stations, including ipsilateral and contralateral
paratracheal levels 2, 3, and 4 and subcarinal level 7. Cervical mediastinoscopy
is performed through a 3- to 4-cm incision one fingerbreadth above the sternal
notch. Dissection proceeds beneath the pretracheal fascia, allowing safe access
to mediastinal nodes and avoiding major vascular structures. After palpation,
the mediastinoscope can be inserted and nodes biopsied under direct vision.
Unclear structures can be aspirated prior to attempted biopsy.
Enlarged lymph nodes in the aorticopulmonary window are technically
inaccessible by means of standard cervical mediastinoscopy. Extended cervical
mediastinoscopy, however, is a technique that provides access to these
aorticopulmonary window nodes. It is performed through the same small neck
incision as standard mediastinoscopy except the dissection is carried laterally
beside the left carotid artery toward and then over the aorta into the
aorticopulmonary space. In older patients with densely calcific aortas,
extended mediastinoscopy is contraindicated because of the risk of embolic
phenomena and stroke from aortic manipulation.
In experienced hands, the complications of mediastinoscopy are minimal (< 1
2%). Major bleeding complications requiring sternotomy or thoracotomy for
repair are infrequent (12%). Other possible complications include
pneumothorax, recurrent nerve injury, infection, and esophageal injury.
Mediastinoscopy is almost invariably accurate in the diagnosis of sarcoidosis. It
is also useful to diagnose tuberculosis, histoplasmosis, Castleman silicosis,
metastatic carcinoma, lymphoma, and carcinoma of the esophagus. It should
not be used in the investigation of primary mediastinal tumors, which should
be approached by an incision permitting definitive excision.
Chamberlain Procedure
Anterior mediastinotomy (the Chamberlain procedure) is used to sample nodes
and biopsy tissue in the anterior mediastinum and most commonly in the
aorticopulmonary window. A small (3- to 4-cm) incision is made over the
second or third interspace on the appropriate side of the lesion. Alternatively,
the procedure can be performed with videoscopic guidance (VATS). The
mediastinum is approached through the interspace directly or after excising the
costochondral cartilage using either the mediastinoscope or open technique.
Careful attention is paid to preserving the mammary vessels encountered in
the dissection. The mediastinum is approached extrapleurally unless lesions
specifically within the thoraxeffusions, tumors invading the hilum or chest
wallneed to be investigated. Furthermore, if additional access is required to
facilitate the dissection or to treat a complication, the incision can be converted
easily to a larger anterior thoracotomy.
Complications resulting from anterior mediastinotomy are similar to those
encountered with cervical mediastinoscopy and include bleeding, recurrent
nerve injury, and infection. Major morbidity should be less than 12%.

Video-Assisted Thoracoscopic Surgery (VATS)


With the advent of sophisticated video technology and optics, VATS has
evolved as an important tool in thoracic surgery. While thoracoscopic
procedures have been used for many years, newer technical advances as well
as increasing surgeon familiarity with minimally invasive surgery have made
VATS increasingly popular and useful.
VATS plays an important role in the diagnosis and staging of thoracic
malignancies (lung cancer, mesothelioma, etc) as well as in the resection of
isolated peripheral pulmonary nodules and bullous lung disease. Furthermore,
it has been an advance in lung biopsy and pleurodesis procedures.
However, despite gaining popularity, many thoracic surgeons consider the
approach suboptimal for lung cancers. Full mediastinal lymph node dissections
are not generally obtainable with standard VATS. Even for metastasectomy,
concerns over pleural and chest wall seeding with VATS have been documented
in the literature, highlighting the need for assiduous attention to detail during
these procedures. The improved resolution from new-generation CT scanners
have in part supplanted the need for palpation of the entire lung, and
increasingly advanced resections are now being performed via VATS
approaches. At present VATS is most commonly applied to benign processes,
including spontaneous pneumothoraces and pleural effusions, as well for
thoracic sympathectomy and thoracic vertebral discectomy.
As instruments and techniques have evolved, complications from VATS
procedures (persistent air leaks, hemorrhage, tumor seeding, etc) have
decreased. Overall, major complication rates of 12% are reported. Faster
patient recovery, shorter hospital stays, decreased pain are major advantages
of VATS, although long-term differences between videoscopic and formal
thoracotomy using muscle-sparing incisions are yet to be demonstrated.
Scalene Lymph Node Biopsy
Scalene lymph node biopsy has been largely replaced by mediastinoscopy in
the evaluation of pulmonary disease because it offers the same information but
is less reliable and does not evaluate nodes within the mediastinum.
Furthermore, scalene lymph nodes are accessible via cervical mediastinoscopy
using the mediastinoscope. In the evaluation of lung cancer, about 15% of
scalene node biopsies are positive when the cervical nodes are not palpable
compared with 85% when the nodes are palpable. The risk of major
complications is about 5%. Deaths are rare.
Pleural Biopsy
Needle Biopsy
This procedure is indicated when the cause of a pleural effusion cannot be
determined by analysis of the fluid or when tuberculosis is suspected. Any one
of three needles can be used: Vim-Silverman, Cope, or Abrams (Harefield). A
definitive diagnosis can be obtained in 6080% of cases of tuberculosis or

cancer. The principal complication is pneumothorax. Five to 10 percent of


biopsy specimens are inadequate for diagnosis.
Surgical Biopsy
Biopsy of the pleura can be performed via videoscopic or open technique with
minimal morbidity, providing the pathologist with a specimen superior to that
of needle biopsy.
Lung Biopsy
Needle Biopsy
The indications for percutaneous needle biopsy are not well established. It may
be indicated in diffuse parenchymal disease and in some patients with localized
lesions. The diagnosis of interstitial pneumonia, carcinoma, sarcoidosis,
hypersensitivity lung disease, lymphoma, pulmonary alveolar proteinosis, and
miliary tuberculosis has been established by this method.
Needle biopsies are done by any of three techniques: by aspiration with a
cutting needle, by trephine, or by air drill. Needle biopsy of the lung is also
possible by a transbronchial technique in which a modified Vim-Silverman or
ultrathin needle is used.
There is controversy concerning the risks of spreading the tumor by needle
biopsy in localized disease. Complications following percutaneous needle
biopsy include pneumothorax (530%), hemothorax, hemoptysis, and air
embolism. Pulmonary hypertension or cysts and bullae are contraindications.
Several deaths have been reported. There is about a 60% chance of obtaining
useful information.
Surgical Biopsy
Thoracoscopy or VATS has become the procedure of choice for open lung
biopsy in patients who can tolerate single lung ventilation. A single anterior
axillary line incision can be used for introduction of a stapler and operating
thoracoscope. For open biopsies a limited intercostal or anterior parasternal
incision is used to remove a 3- to 4-cm wedge of lung tissue in diffuse
parenchymal lung disease. The site of incision is selected for accessibility and
potential diagnostic value. The incision is generally made at the fifth interspace
on the right at the anterior axillary line to allow for access to all three lobes for
biopsyor at the lower lobes bilaterally. The middle lobe and lingula are
selected in specific cases when pathology exists only in these areas, as they
generally yield results of the poorest quality. Open lung biopsy is associated
with a lower death rate, fewer complications, and greater diagnostic yield than
needle biopsy. It is especially useful in critically ill, immunosuppressed patients
for differentiation of infectious infiltrative lesions from neoplastic infiltrative
lesions. Open lung biopsy can be performed in the ICU setting and does not
require single lung ventilation. When a focal lesion is biopsied, a larger incision
is used. Peripheral lesions are totally excised by wedge or segmental resection,
and deeply placed lesions are removed by lobectomy in suitable candidates.

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.