Disorders and Diseases - Thoracic Surgery

Minimally invasive surgical techniques are used preferentially in all facets of the GBMC thoracic surgery practice.  Patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) for diagnostic and/or therapeutic procedures in the chest or laparoscopic procedures for treatment of swallowing problems, generally experience fewer complications, less pain and scarring after surgery and consequently have a quicker recovery

Procedures include lung biopsy, lymph node biopsy for diagnosis or staging, lung wedge resection, lobectomy, pneumonectomy, drainage of pleural or pericardial effusions, decortication, sympathectomy, first rib resection, thymectomy, esophagomyotomy, fundoplication, diverticulectomy or hiatal hernia repair.     

The Division of Thoracic Surgery at Greater Baltimore Medical Center (GBMC) offers expertise in the treatment of the following diseases:

 

Post Thoracotomy Rehabilitation Protocol

Post Thoracotomy Rehab Protocol    Download this information in PDF   Print this information
Developed by Terri Brewer, MS, PT
For Dr. Neri Cohen's patients

Sunrise Health Center will provide Physical Therapy and/or Respiratory
Therapy following thoracic surgery, providing individualized comprehensive
personal care for these patients. The goals of this program are:
  • To strengthen the shoulder girdle and prevent any negative effects of disuse, i.e. frozen shoulder.
  • General reconditioning to increase endurance and overall health.
  • To allow patients to come off their oxygen sooner.
  • To provide education to effectively manage their condition and maximize their physical and emotional independence.
  • To minimize loss of function and morbidity associated with thoracic surgery.
  • To maximize pulmonary function and clearance of secretions.
  • To wean patients off pain medication more rapidly as their function is
    restored.
Download complete protocol - Post Thoracotomy Rehabilitation Protocol

Lung Cancer

Esophageal Cancer

General Information About Esophageal Cancer    Download this information in PDF   Print this information

Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus. The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Esophageal cancer starts at the inside lining of the esophagus and spreads outward through the other layers as it grows.
The two most common forms of esophageal cancer are named for the type of cells that become malignant (cancerous):
Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the esophagus. This cancer is most often found in the upper and middle part of the esophagus, but can occur anywhere along the esophagus. This is also called epidermoid carcinoma.
Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the esophagus produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the esophagus, near the stomach.

Smoking, heavy alcohol use, and Barrett's esophagus can affect the risk of developing esophageal cancer.

Risk factors include the following:
• Tobacco use.
• Heavy alcohol use.
• Barrett's esophagus: A condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to cancer of the esophagus. Gastric reflux (the backing up of stomach contents into the lower section of the esophagus) may irritate the esophagus and, over time, cause Barrett's esophagus.
• Older age.
• Being male.
• Being African-American.

The most common signs of esophageal cancer are painful or difficult swallowing and weight loss.

These and other symptoms may be caused by esophageal cancer or by other conditions. A doctor should be consulted if any of the following problems occur:
• Painful or difficult swallowing.
• Weight loss
• Pain behind the breastbone.
• Hoarseness and cough.
• Indigestion and heartburn.

Tests that examine the esophagus are used to detect (find) and diagnose esophageal cancer.

The following tests and procedures may be used:
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Weight loss
• Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and x-rays are taken. This procedure is also called an upper GI series.
Barium Swallow

Barium swallow. The patient swallows barium liquid and
it flows through the esophagus and into the stomach.
Xrays are taken to look for abnormal areas.
Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope (a thin, lighted tube) is inserted through the mouth or nose and down the throat into the esophagus. Tissue samples may be taken for biopsy.

Esophagoscopy

Esophagoscopy. A thin, lighted tube is inserted through
the mouth and into the esophagus to look for abnormal areas.
Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. The biopsy is usually done during an esophagoscopy. Sometimes a biopsy shows changes in the esophagus that are not cancer but may lead to cancer.
Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:
• The stage of the cancer (whether it affects part of the esophagus, involves the whole esophagus, or has spread to other places in the body).
• The size of the tumor
• The patient's general health.

When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when it is diagnosed. At later stages, esophageal cancer can be treated but rarely can be cured. Taking part in one of the clinical trials being done to improve treatment should be considered. Information about ongoing clinical trials is available from the
NCI Web site.
Stages of Esophageal Cancer

After esophageal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the esophagus or to other parts of the body.


The process used to find out if cancer cells have spread within the esophagus or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope (a thin, lighted tube) is inserted through the nose or mouth into the trachea and lungs. Tissue samples may be taken for biopsy. • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Laryngoscopy: A procedure in which the doctor examines the larynx (voice box) with a mirror or with a laryngoscope (a thin, lighted tube).
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This test is also called computed tomography, computerized tomography, or computerized axial tomography.
Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs and a thoracoscope (a thin, lighted tube) is inserted into the chest. Tissue samples and lymph nodes may be removed for biopsy. In some cases, this procedure may be used to remove portions of the esophagus or lung.
Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen, and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples for biopsy.
PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells.
The following stages are used for esophageal cancer:

As esophageal cancer progresses from Stage 0 to Stage IV, the cancer cells grow through the layers of the esophagus wall and spread to lymph nodes and other organs.
Stage 0 (Carcinoma in Situ) In stage 0, cancer is found only in the innermost layer of cells lining the esophagus. Stage 0 is also called carcinoma in situ.
Stage I — In stage I, cancer has spread beyond the innermost layer of cells to the next layer of tissue in the wall of the esophagus.
Stage II esophageal cancer is divided into stage IIA and stage IIB, depending on where the cancer has spread.
• Stage IIA: Cancer has spread to the layer of esophageal muscle or to the outer wall of the esophagus.
• Stage IIB: Cancer may have spread to any of the first three layers of the esophagus and to nearby lymph nodes.
Stage III — In stage III, cancer has spread to the outer wall of the esophagus and may have spread to tissues or lymph nodes near the esophagus.
Stage IV Stage IV esophageal cancer is divided into stage IVA and stage IVB, depending on where the cancer has spread.
• Stage IVA: Cancer has spread to nearby or distant lymph nodes.
•Stage IVB: Cancer has spread to distant lymph nodes and/or organs in other parts of the body.

When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when it is diagnosed. At later stages, esophageal cancer can be treated but rarely can be cured. Taking part in one of the clinical trials being done to improve treatment should be considered. Information about ongoing clinical trials is available from the
NCI Web site.
Treatment Option Overview

There are different types of treatment for patients with esophageal cancer.

Different types of treatment are available for patients with esophageal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Five types of standard treatment are used:

  1. Surgery - Surgery is the most common treatment for early stage cancer of the esophagus. Part of the esophagus may be removed in an operation called an esophagectomy.
  2. Surgery






















    Esophagectomy. A portion of the esophagus is removed and the stomach is pulled up and joined to the remaining esophagus.

    The surgeon will connect the remaining healthy part of the esophagus to the stomach so the patient can still swallow. A plastic tube or part of the intestine may be used to make the connection. Lymph nodes near the esophagus may also be removed and viewed under a microscope to see if they contain cancer.

  3. Stenting - If the esophagus is partly blocked by the tumor, an expandable metal stent (tube) may be placed inside the esophagus to help keep it open.
  4. Surgery

    Esophageal stent. A device (stent) is placed in the esophagus to keep it open to allow food and liquids to pass through into the stomach.


















  5. Radiation therapy - Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
    A plastic tube may be inserted into the esophagus to keep it open during radiation therapy. This is called intraluminal dilation and stenting.

  6. Chemotherapy - Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

  7. Ablative therapy
    • Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.
    • Electrocoagulation is the use of an electric current to kill cancer cells.


Other types of treatment are being tested in clinical trials.
Patients have special nutritional needs during treatment for esophageal cancer.

Many people with esophageal cancer find it hard to eat because they have difficulty swallowing. The esophagus may be narrowed by the tumor or as a side effect of treatment. Some patients may receive nutrients directly into a vein. Others may need a feeding tube (a flexible plastic tube that is passed through the nose or mouth into the stomach or directly into their bowels) until they are able to eat on their own.
Treatment Options By Stage

Stage 0 Esophageal Cancer (Carcinoma in Situ) — Treatment of stage 0 esophageal cancer (carcinoma in situ) is usually surgery.

Stage I Esophageal Cancer — Treatment of stage I esophageal cancer may include the following:
• Surgery.
• Clinical trials of chemotherapy plus radiation therapy, with or without surgery.
• Clinical trials of new therapies used before or after surgery.

Stage II Esophageal Cancer — Treatment of stage II esophageal cancer may include the following:
• Surgery.
• Clinical trials of chemotherapy plus radiation therapy, with or without surgery.
• Clinical trials of new therapies used before or after surgery.

Stage III Esophageal Cancer — Treatment of stage III esophageal cancer may include the following:
• Surgery.
• Chemotherapy.
• Radiation therapy.
• Clinical trials of chemotherapy plus radiation therapy, with or without surgery.
• Clinical trials of new therapies used before or after surgery.

Stage IV Esophageal Cancer — Treatment of stage IV esophageal cancer may include the following:
• External or internal radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• Ablative therapy as palliative therapy to relieve symptoms and improve quality of life.
• Chemotherapy.
• Clinical trials of chemotherapy.

Swallowing Problems

Cardiothoracic Treatments for Swallowing Problems    Download this information in PDF   Print this information

People who have been diagnosed with a swallowing problem, may be referred to a cardiothoracic surgeon. Swallowing problems, called dysphagia, are a set of disorders that involve difficulty moving food or liquid from the mouth to the stomach, including:
• Reflux Disease, the backward movement of food and digestive acids and enzymes into the esophagus;
• Hiatal Hernia, the movement of part of the stomach into the chest cavity; and • Achalasia, a nerve disorder that causes the esophageal contractions to cease and affects the functioning of the lower esophageal sphincter.

A cardiothoracic surgeon treats swallowing disorders with surgical procedures, which can be open surgical procedures or minimally invasive. In open surgical procedures, the patient is placed under general anesthesia and the surgeon makes large incisions. In minimally invasive procedures, called a laparoscopic procedure, the patient is given a local or regional anesthetic, and the surgeon makes small incisions, through which long, thin instruments are threaded, including one with a fiberoptic camera, which the surgeon uses to guide the work.

Reflux disease

Cardiothoracic surgeons treat reflux disease with a surgical procedure called fundoplication. Fundoplication is a designed to strengthen the lower esophageal sphincter, the muscular ring that opens and closes to allow food and liquid into the stomach. The surgeon makes several small incisions in the abdomen. (In the open procedures, the surgeon will make one long incision in the middle of the abdomen.) To increase visibility, the surgeon will also fill the abdominal cavity with gas. Long, thin flexible instruments are then threaded into the incisions. Using these instruments, the surgeon will wrap the fundus, which is a part of the stomach that lies close to the esophagus, around the lower esophagus and esophageal sphincter. The surgeon will then suture the fundus to the lower esophagus and lower esophageal ring. The increased pressure reinforces the lower esophageal sphincter, preventing reflux. The incisions are closed and the patient is taken to a recovery room. Most patients are discharged the following day.

What is reflux disease?
Reflux disease, also called gastro esophageal reflux disease (GERD), is the backward flow of stomach contents up the esophagus, the tube that carries food from the mouth to the stomach. Reflux disease results from a malfunctioning lower esophageal sphincter, a muscular ring at the junction of the esophagus and the stomach, which opens to allow food into the stomach and closes tightly to keep food and digestive acids and enzymes from moving backward into the esophagus.

Hiatal hernia
Surgical repair for hiatal hernia is almost always performed for a type of hiatal hernia called a paraesophageal hernia. The procedure can either be an open surgical repair through a large incision in the chest called a thoracotomy, or through the abdomen, called a laparotomy. Many physicians use a minimally invasive procedure, in which smaller incisions are made, called laparoscopic. Because it often accompanies GERD, a hiatal hernia is often repaired at the same time as fundoplication. With either form of the surgery, the surgeon moves the part of the stomach and esophagus that have moved through the diaphragm below the diaphragm, and tightens the hiatus with sutures.

What is hiatal hernia?
Hiatal hernia occurs when a small part of the stomach pushes up through the hiatus, the opening in the diaphragm, which is a sheet-like muscle that separates the abdomen from the chest.

Achalasia?
The goal of treatment of achalasia is to allow the lower esophageal sphincter to open more easily. Cardiothoracic surgeons can do this mechanically in a procedure called esophageal dilation. In this procedure, after the patient has been sedated, the physician inserts a long, flexible tube called an endoscope down the patient's esophagus to the lower esophageal ring. Once in place, the physician then inflates a balloon inside the sphincter, forcing it to open more widely. In addition, physicians can inject botulinum toxin (botox) into the sphincter, which paralyzes the muscles of the lower esophageal sphincter, relaxing it. This procedure is relatively new and the long-term results are not known. Surgical procedures to treat achalasia include esophageal myotomy, a procedure performed while the patient is under general anesthesia. The surgeon can use open surgical techniques or can perform the procedure laparoscopically. For open surgery, the physician will make one large incision in the abdomen. For the minimally invasive procedure the physician will make several small incisions and use long, thin flexible surgical instruments to partially cut the muscle tissue of the lower esophageal sphincter to weaken it and allow it to open more easily.

What is achalasia?
Achalasia is a nerve-related disorder that interferes with peristalsis, which is the involuntary constriction and relaxation of the muscles of the esophagus. Peristalsis creates the wave-like movements that push the food through the esophagus to the stomach. Achalasia often also interferes with the opening of the lower esophageal sphincter, a muscular ring at the junction of the esophagus and the stomach, which opens to allow food into the stomach and closes tightly to keep in the contents of the stomach. The failure of the lower esophageal sphincter to open easily causes the portion of the esophagus above it to enlarge.

Hyperhidrosis

Airway Problems

  • Endobronchial tumor ablation
  • Stenting

Thoracic Outlet Syndrome

Thoracic outlet anatomy

Definition:
Thoracic outlet syndrome is a rare condition that involves pain in the neck and shoulder,
numbness and tingling of the fingers, and a weak grip. The thoracic outlet is the area between the rib cage and collar bone.

Causes, incidence, and risk factors:
Blood vessels and nerves coming from the spine or major blood vessels of the body pass through a narrow space near the shoulder and collarbone on their way to the arms. As they pass by or through the collarbone (clavicle) and upper ribs, they may not have enough space.
Pressure (compression) on these blood vessels or nerves can cause symptoms in the arms or hands. Problems with the nerves cause almost all cases of thoracic outlet syndrome.
Compression can be caused by an extra cervical rib (above the first rib) or an abnormal tight band connecting the spinal vertebra to the rib. Patients often have injured the area in the past or overused the shoulder.
People with long necks and droopy shoulders may be more likely to develop this condition because of extra pressure on the nerves and blood vessels.

Symptoms: Symptoms of thoracic outlet syndrome may include:

  • Pain, numbness, and tingling in the pinky and ring fingers, and the inner forearm
  • Pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse)
  • Signs of poor circulation in the hand or forearm (a bluish color, cold hands, or a swollen arm)
  • Weakness of the muscles in the hand

Signs and tests: When you lift something, the arm may look pale due to pressure on the blood vessels.
The diagnosis is typically made after the doctor takes a careful history and performs a physical examination. Sometimes the following tests are done to confirm the diagnosis:

Tests are also done to make sure that there are no other problems, such as carpal tunnel syndrome or a damaged nerve due to problems in the cervical (neck) spine.

Treatment:
When thoracic outlet syndrome affects the nerves, the first treatment is always physical therapy. Physical therapy helps strengthen the shoulder muscles, improve range of motion, and promote better posture. Treatment may also include pain medication.
If there is pressure on the vein, your doctor may give you a blood thinner to dissolve the blood clot. This will help reduce swelling in your arm.
You may need surgery if physical therapy and changes in activity do not improve your symptoms. The surgeon may make a cut either under your armpit or just above your collarbone.
During surgery, the following may be done:

  • An extra rib is removed and certain muscles are cut.
  • A section of the first rib is removed to release pressure in the area.
  • Bypass surgery is done to reroute blood around the compression or remove the area that is causing the symptoms.

Your doctor may also suggest other alternatives, including angioplasty if the artery is narrowed.

Expectations (prognosis):
Having the first rib removed and the fibrous bands broken may relieve symptoms in certain patients. Surgery can be successful in 50% to 80% of patients. Conservative approaches using physical therapy are helpful for many patients.

At least 5% of patients have symptoms that return after surgery.

Complications:
Complications can occur with any surgery and relate to the type of procedure and
anesthesia used.
Damage to nerves or blood vessels may occur during surgery. This could lead to weakness of the arm muscles, or weakness of the muscles that help control the diaphragm when you breathe.

References:
Smythe WR, Reznik SI, Putnam Jr. JB. Lung (including pulmonary embolism and thoracic outlet syndrome). In: Townsend Jr. CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 59.


Review Date: 11/1/2010
Reviewed By: Shabir Bhimji, MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Pneumothorax

A pneumothorax, also known as a collapsed lung, is a collection of air in the space around the lungs. This buildup of air puts pressure on the lung so it can't expand as it normally does when you take a breath.

A pneumothorax occurs when air escapes from the lung and fills up in the space outside of it, inside the chest. It can be caused by a variety of things, such as a wound to the chest, rib fracture or certain types of medical procedures.

It may also occur without cause. This is called a Spontaneous Pneumothorax.

The pneumothorax can cause a sharp chest pain, made worse by coughing or taking a deep breath, shortness of breath, chest tightness and fatigue. It may go away on its own with oxygen and rest; however, in some instances your healthcare provider will have to use a needle to pull out the extra air from around the lung.

A larger pneumothorax may require a chest tube placed between the ribs and the space around the lungs to help drain the air. Lung surgery may also be needed to treat it and prevent future episodes.

Pleural Effusion

Pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and the chest cavity. Pleural fluid is produced by the body in small amounts to lubricate the surfaces of the pleura (thin tissue that lines the chest cavity).

There are two different types of pleural effusion:

• Transudative Pleural Effusion is caused by fluid leaking into the pleural space. This is caused by increased pressure, or low protein content, in the blood vessels.
• Exudative Effusions are caused by blocked blood vessels, inflammation, lung injury and drug reactions.

Pleural effusions typically cause:

• Chest pain
• Cough
• Fever
• Hiccups
• Rapid breathing
• Shortness of breath

To diagnose a pleural effusion, the physician will listen to your breathing and may tap on your chest to listen for dullness. Additional tests, such as CT scans, chest X-rays and fluid analysis may be used to confirm diagnosis.

Treatment usually involves removing the fluid, which allows the lung to expand. Sometimes, small tubes are left in the pleural cavity to drain fluid out.

Empyema

Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall. It is typically caused by an infection that spreads from the lung. The fluid buildup puts pressure on the lungs causing:

• Chest pain
• Dry cough
• Excessive sweating
• Shortness of breath
• Fever/chills

Empyema may be caused from bacterial pneumonia, chest surgery or chest trauma and is typically diagnosed from a chest examination and tests, including a chest X-ray, CT scan or thoracentesis (fluid aspiration).

The treatment for empyema is to cure the infection and remove the collection of pus. A chest tube is used to drain the pus from the space between the lung and chest wall.

Percardial Effusion

Pericardial effusion is an accumulation of fluid around the heart. This is often related to inflammation of the pericardium that is caused by disease or injury.

When there is excess fluid on the pericardium, it begins to put pressure on the heart causing poor function. If left untreated, it can cause heart failure or death.

Symptoms may include:
• Shortness of breath
• Chest pain (typically behind the left breastbone that worsens when you breathe and feels better when sitting up)
• Cough
• Fainting or dizziness
• Rapid heart rate

Pericardial effusion is commonly diagnosed using an echocardiogram, which is a test that uses sound waves to create real-time images of your heart.

Treatment is dependent upon how much fluid has accumulated and what is causing it.

Emphysema

Emphysema occurs when air sacs in the lungs are destroyed over time, making you progressively more short of breath. It is one of several diseases known collectively as Chronic Obstructive Pulmonary Disease (COPD).

As emphysema worsens, it turns healthy sphere-like air sacs into large, irregular pockets with gaping holes in the inner walls. This reduces the surface area of the lungs and in turn, the amount of oxygen that reaches the bloodstream.

Some people may have emphysema for years without showing symptoms. The most common symptom is shortness of breath. The number one cause of emphysema is prolonged exposure to airborne toxins or irritants, such as:

• Tobacco smoke
• Marijuana smoke
• Air pollution
• Manufacturing fumes

Imaging tests are typically used to diagnose emphysema, such as chest X-rays and CT scans. A combination of medications and therapies may be used to treat it, as there is no cure. Bronchodilators, drugs used to help relieve coughing, shortness of breath and trouble breathing, are commonly used, as well as inhaled steroids and antibiotics.

Pulmonary rehabilitation therapy may also be used to treat emphysema. This program helps teach patients breathing techniques that can help reduce breathlessness. Supplemental oxygen may also be used to help patients with very low blood oxygen levels.

For some people, surgery may be the best option. Lung volume reduction surgery removes small wedges of damaged tissue to help remaining healthy tissue work more effectively. And for the most severe patients, lung transplantation might be the best option.

Airway Stents

Airway stents, also known as tracheobronchial prostheses, are tube-shaped devices that are inserted into a patient’s airway to help them breathe. They’re used for a variety of large airway diseases and conditions, such as:

• Airway obstruction in a patient undergoing radiation and/or chemotherapy.
• Airway obstruction that has not responded to other treatments, such as endobronchial resection.
• Severe central airway collapse.

Stents are made from several different materials, including silicone and metal, and are available in a variety of shapes and sizes. Silicone stents are most commonly used to manage central airway obstruction because they are firm, stable in high temperatures and are able to repel water.

Many people learn if they have a need for an airway stent through a diagnostic procedure called a flexible bronchoscopy, which identifies airway lesions and obstructions. Once it’s determined that the lesion is amenable to stenting , the distance from the vocal cords to the lesion, length of the lesion and the diameter of the lesion is measured. After this, the optimal stent type and size can be chosen and insertion can be planned. The choice of airway stent is usually based on many factors and ultimately rests with the good judgment of the inserting physician.

Airway stents can be inserted under local anesthesia with or without conscious sedation, or under general anesthesia.

It’s rare that complications arise for airway stent patients; however, they are possible. Some complications include:

• A local inflammatory reaction can be provoked, resulting in the growth of granulation tissue at the proximal and distal ends of the stent.
• Obstruction of the stent by accumulated respiratory secretions or recurrent tumor growth.
• Migration of the stent, usually due to a violent or persistent cough, tumor growth or resolution of the extrinsic compression that maintained the stent in position.
• Airway perforation or stent rupture (self-expanding metal stents).
• Broken wires or metal fatigue (i.e., decreased strength) (self-expanding metal stents).

Care of the stent after surgery will vary for each case. All patients will be required to see their doctor regularly to be sure the stent is working properly and to make sure complications do not arise.

Pulmonary Nodules

A pulmonary nodule is an abnormal growth on the lung. It may or may not indicate lung cancer. If cancer is suspected, a biopsy of the nodule will be ordered by the physician. A CT scan will also typically be performed to help determine the growth rate, shape of the nodule and the pattern of calcification to help determine if it’s cancerous or not.

Nodules can be caused for a variety of reasons:
• Infection
• Inflammation
• Benign tumor
• Malignant tumor

Most people with lung nodules do not have any symptoms. A majority of the time, they are found incidentally when a chest X-ray is done for another reason.

Treatment for lung nodules will vary widely depending on the cause and if they’re malignant. Most benign lung nodules, especially those that haven’t changed over a period of time, may be left alone.
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