MRCP PACES Lobectomy and Pneumonectomy

Relevant physical signs

  • General inspection
    • Asymmetry of chest wall movement
    • Scars
    • Respiratory distress
    • Supplemental oxygen
  • Hands
    • Clubbing (bronchiectasis / malignancy / pulmonary fibrosis)
    • Tar staining (underlying malignancy)
    • Wasting of dorsal interossei (underlying malignancy)
  • Pulse: bounding +/- CO2 retention flap (COPD)
  • Face
    • Conjunctival pallor (anaemia of chronic disease)
    • Horner’s syndrome (underlying Pancoast tumour)
    • Central cyanosis
  • Neck
    • JVP (complication of pulmonary hypertension)
    • Cervical lymphadenopathy (underlying malignancy)
    • Tracheal deviation – usually deviated in upper lobectomy / pneumonectomy, towards the side of the surgery. May be central in lower lobectomy.
  • Chest
    • Inspect
      • Scars: lateral thoracotomy, VATS, chest drain
      • Ribs: pulled on over affected area
    • Palpate
      • Chest expansion:
        • Lobectomy: reduced anteriorly OR posteriorly
        • Pneumonectomy: completely reduced anteriorly AND posteriorly
      • Apex beat (displaced towards side of lobectomy / pneumonectomy)
      • Right ventricular heave (pulmonary hypertension complicating COPD / bronchiectasis)
    • Percuss: dull over area of lobectomy / pneumonectomy
    • Auscultate
      • Reduced breath sounds over lobectomy site
      • Normal breath sounds over normal lung
      • Absent breath sounds over whole hemithorax in pneumonectomy
      • May sound bronchial if overlying deviated trachea
      • Vocal resonance reduced over affected area
      • Listen for underlying aetiology:
        • Coarse crepitations in bronchiectasis
        • Prolonged expiratory phase / wheeze in COPD
  • Sacral oedema / pedal oedema for right heart failure
  • Complete examination by:
    • Looking at vitals chart, specifically temperature and SpO2
    • Obtain a chest radiograph
    • Inspect sputum mug

Differential diagnosis of reduced breath sounds with tracheal deviation

  • Collapse of a lobe
  • Pneumothorax
  • Pleural effusion (but would expect trachea to be deviated away from area of reduced breath sounds)

 Indications for lobectomy / pneumonectomy

  • Localized bronchiectasis
  • Uncontrolled haemoptysis (e.g. following failed bronchial artery embolisation) from bronchiectasis / tuberculosis / underlying pneumonia
  • Early non-small cell lung cancer
  • Lung volume reduction surgery for COPD
  • Lung abscess
  • Trauma
  • Solitary pulmonary nodule of unknown cause
  • Cystic fibrosis
  • Years ago: TB treatment

Suitability for lobectomy / pneumonectomy

  • FEV1 > 1.5L for lobectomy
  • FEV1 > 2L for pneumonectomy
  • If FEV1 < 1.5L or 2L respectively, for full spirometry to allow calculation of:
    • Post-operative FEV1 > 40% predicted, and
    • Post-operative TLCO > 40% predicted, and
    • SpO2 > 90% on air
  • Exercise testing: desaturation of > 4% or inability to tolerate more than 25 shuttles (250m) indicates high risk for surgery. Surgery is contraindicated if peak oxygen consumption (VO2) < 15ml/kg/min
  • For malignancy, generally only an option for:
    • Stage 1 small cell lung cancer
    • Stage 1 (T1N0, T2N0) or stage 2 (T1N1, T2N1, T3N1) NSCLC
    • Stage 3A (T3N1, T1-3N2) NSCLC with adjuvant chemotherapy
  • For COPD lung volume reduction:
    • Predominantly emphysema
    • Predominantly upper lobe disease
    • FEV1 > 20% predicted
    • DLCO > 20% predicted
    • No or mild concomitant pulmonary hypertension (PASP < 45mmHg)
    • No concomitant disabling disease

Presentation

Sir, this patient has a lateral thoracotomy scar with reduced chest expansion on the left side. The apex beat is deviated to the left. The trachea is deviated towards the left, and the percussion note is dull over the left anterior chest wall. Breath sounds are reduced over the left anterior chest wall, with reduced vocal resonance. They are normal at the bases. This would be most in keeping with a left upper lobectomy. With regards to aetiology, there are no crepitations to suggest co-existent bronchiectasis, prolonged expiratory phase or hyper-expansion to suggest chronic obstructive pulmonary disease, or palpable lymphadenopathy, signs of Horner’s syndrome or wasting of the dorsal interossei to suggest underlying malignancy. There is no evidence of pulmonary hypertension, as the jugular venous pulse is not raised, there is no right ventricular heave, and there is no dependent oedema.

In summary, this patient has had a left upper lobectomy. The aetiology is difficult to ascertain, but may include localized bronchiectasis, a limited stage mitotic lesion in the area, a previous episode of haemoptysis which proved refractory to initial therapy with bronchial artery embolisation, or a lung abscess.

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