Surgical Management of Empysema

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John A Odell MB ChB, FRCS(Ed), FACS

Emeritus Professor of Surgery Mayo Clinic College of Medicine Previously Surgical Director Lung Transplantation

Problem case. How would you manage?

• 64yr male

• Previous RLL bullectomy.

• Recent left pneumothorax managed elsewhere

with chest tube placement.

• Because of continued air-leak talc pleurodesis. • Air-leak continues.

• On nasal oxygen. Dyspneic on walking

• Significant air-leak. More dyspneic when suction

applied to chest drain. • FEV1 40% predicted. DLCO 12% predicted.

Options?

• Thoracotomy and close air leak surgically • Videothoracoscopy and closure of air-leak

• Thoracotomy and decortication

• Remove chest drain • List for transplantation

Historical Treatment of Emphysema

• Abdominal compression belts. The stimulus was the observation

that emphysematous patients lean forward when breathing.

• Pneumoperitoneum. In an attempt to restore diaphragmatic curvature.

• Lungs too large for the chest – costochondrectomy or transverse

sternotomy to provide more room. Multiple wedge excisions.

• Chest grown too large – thoracoplasty • Pleurodesis. Emphysema results from alveolar wall ischemia.

• Phrenectomy. Overvigerous inspiration was ripping alveolar walls.

• Hilar denervation. To decrease bronchoconstriction and mucous production mediated by the parasympathetic nervous system.

• Whole lung irradiation. To increase elastic recoil by inducing fibrosis.

Variants of Emphysema that may be Surgically Managed

• Congenital

• lobar emphysema

• Bronchogenic cyst
• Post infectious bullous cavities
• Tuberculosis • Staphlococcus • Bronchiolitis (Swyer-James)

• Emphysema associated with parenchymal lung disease

• Birt-Hogg-Dube syndrome

• Alpha one antitrypsin deficiency • Lympahangiomyomatosis

• “Undefined”
• Typical “COPD”

Congenital Lobar Emphysema

Post infectious

Post Tuberculosis Cavity
Large post TB Cavity Compressing RML +RLL

Cavitated PTB with Left pneumothorax
10/9/1984
Seven months treatment Improvement on Right Large cavities on Left
5/8/1985
Development large bullae
4/22/1989

Recommended publications

Effect of an Indwelling Pleural Catheter Vs Talc Pleurodesis On

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2019 coding and payment information Pleural effusions and ascites management The information contained in this document, including Reimbursement rates shown are Medicare national the codes supplied, is provided for informational payments for 2019 and do not reflect actual payments purposes only. BD makes no statement, promise or made to individual providers, as payments are adjusted guarantee concerning the appropriateness of any codes specific to particular geographic regions. for a particular procedure, actual levels of All information is subject to change without notice. In reimbursement, payment or charge or that addition, payers or local carriers may have their own reimbursement will be made. coding and billing requirements. Consult your payer This is not intended to be a comprehensive guide to all organization with regard to local reimbursement policies. coding and payment information. 2019 Medicare outpatient facility rates CPT® 2019 APC OPPS 2019 ASC Description APC Status code base rate* base rate Pleural catheter procedures 32550 Insertion of indwelling tunneled pleural catheter 5341 J1 $2,947 $1,790 32552 Removal of indwelling tunneled pleural catheter with cuff 5181 Q2 $620 $319 32560 Instillation via chest tube/catheter, agent for pleurodesis 5181 T $620 N/A 32650 Thoracoscopy, surgical, with pleurodesis (e.g., mechanical or chemical) N/A; inpatient procedure Peritoneal catheter procedures Insertion of tunneled intraperitoneal catheter (e.g., dialysis, intraperitoneal chemotherapy instillation, management of ascites), 49418
FAQ Document

The Society of Thoracic Surgeons Frequently Asked Questions: General Thoracic Database Version 2.07 December 2008 How to use the “interactive” FAQ Document: 1. To review all clinical questions in an individual section, click on the section title below. Section A: seq# 10 - 190 Section C: seq# 285 - 650 Section E: seq# 770 - 1210 Section B: seq# 200 - 260 Section D: seq# 660 - 750 Section F: seq# 1220 - 1340 2. To review an individual Seq# clinical question, click on the Seq# title below. Participation in both General Thoracic and Adult Cardiac Databases GENERAL STATEMENT #2 Seq# 200: Zubrod Score Seq# 775: Postop Events Seq# 300: WtLoss3Kg Seq# 860: Pneumonia Seq# 310: Category of disease Seq# 930: Other Pulmonary Event Seq# 390: PreOp Chemotherapy Seq# 940: Atrial Arrhythmia Seq# 400: PreOp Thoracic RT Seq# 1020: Anastomotic leak Seq# 430: Other Cormorbidity Seq# 1190: Empyema Seq# 540: Clinical Stage Not Applicable (2.06) Seq# 1200: Other event req. Rx Seq# 725: Reoperation Seq# 1250: 30 Day Status Seq# 740: Procedure Seq# 1280: Chest Tube Out Date Seq# 750: Primary Procedure Seq# 751: Thoracoscopy Approach NEW Date SeqNo FieldName Definition 3/06 Participation in both General We participate in both Adult Cardiac and Yes, enter into both. In the Adult Cardiac DB, the Thoracic and Adult Cardiac General Thoracic Database. Our question primary procedure would be Seq# 1310 pertains to whether the patient should end up OpOCard=Yes; Seq# 2510 ONCAoAn=Yes; Databases in both databases. Scenario--We had a Seq# 2530 ONCArch=Yes; Seq# 2540 patient who had an aortic aneurysm repair ONCDesc=Yes; Seq# 3220 Readm30=Yes; (arch/descending thoracic) and was entered Seq# ReadmRsn=either Pneumonia or other into the Adult Cardiac Database.
Agenda Item 5

List A (O) Respiratory system treatments and procedures. (1) Biopsy and/or excision (removal) of lesion of larynx, vocal cords, trachea (A) Loss or change of voice. (B) Swallowing or breathing difficulties. (C) Perforation (hole) or fistula (connection) in esophagus (tube from throat to stomach). (2) Rhinoplasty (surgery to change the shape of the nose) or nasal reconstruction with or without septoplasty A) Deformity of skin, bone or cartilage. (B) Creation of new problems, such as perforation of the nasal septum (hole in wall between the right and left halves of the nose) or breathing difficulty. (3) Submucous resection of nasal septum or nasal septoplasty (surgery to remove blockage in or straighten the nose) (A) Persistence, recurrence or worsening of the obstruction. (B) Perforation of nasal septum (hole in wall between the right and left halves of the nose) with dryness and crusting. (C) External deformity of the nose. (4) Sinus surgery/endoscopic sinus surgery (A) Spinal fluid leak (B) Visual loss or other eye injury (C) Numbness in front teeth and palate (D) Loss or reduction in sense of taste or smell (E) Recurrence of disease (F) Empty Nose Syndrome (sensation of nasal congestion, sensation of not being able to take in adequate air through nose) (G) Injury to tear duct causing drainage of tears down the cheek (H) Brain injury and/or infection (I) Injury to nasal septum (J) Nasal obstruction (5) Lung biopsy (A) Air leak with pneumothorax (leak of air from lung to inside of chest causing the lung to collapse) with need for insertion of chest drainage tube into space between lung and chest wall or repeat surgery.
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Lymphangioleiomyomatosis (LAM)

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Tracheotomy in COVID-19 Patients: Optimizing Patient Selection and Identifying Prognostic Indicators

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A Proof-Of-Principle Study of Hyperbaric Oxygen As a Radiosensitizer Prior to Stereotactic Radiosurgery for Brain Metastases

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Lam-Guideline-Pt2.Pdf

AMERICAN THORACIC SOCIETY DOCUMENTS Lymphangioleiomyomatosis Diagnosis and Management: High-Resolution Chest Computed Tomography, Transbronchial Lung Biopsy, and Pleural Disease Management An Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guideline Nishant Gupta, Geraldine A. Finlay, Robert M. Kotloff, Charlie Strange, Kevin C. Wilson, Lisa R. Young, Angelo M. Taveira-DaSilva, Simon R. Johnson, Vincent Cottin, Steven A. Sahn, Jay H. Ryu, Kuniaki Seyama, Yoshikazu Inoue, Gregory P. Downey, MeiLan K. Han, Thomas V. Colby, Kathryn A. Wikenheiser-Brokamp, Cristopher A. Meyer, Karen Smith, Joel Moss*, and Francis X. McCormack*; on behalf of the ATS Assembly on Clinical Problems THIS OFFICIAL CLINICAL PRACTICE GUIDELINE WAS APPROVED BY THE AMERICAN THORACIC SOCIETY OCTOBER 2017 AND BY THE JAPANESE RESPIRATORY SOCIETY AUGUST 2017 Background: Recommendations regarding key aspects Results: For women who have cystic changes on high-resolution related to the diagnosis and pharmacological treatment of computed tomography of the chest characteristic of LAM, but who have lymphangioleiomyomatosis (LAM) were recently published. We no additional confirmatory features of LAM (i.e., clinical, radiologic, or now provide additional recommendations regarding four specific serologic), the guideline panel made conditional recommendations questions related to the diagnosis of LAM and management of against making a clinical diagnosis of LAM on the basis of the high- pneumothoraces in patients with LAM. resolution computed tomography
Signs in Chest Imaging

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Physicians As Assistants at Surgery: 2016 Update

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