Pathophysiological mechanism of post-lobectomy air leaks.

BACKGROUND: Air leak post-lobectomy continues to remain a significant clinical problem, with upper lobectomy associated with higher air leak rates. This paper investigated the pathophysiological role of pleural stress in the development of post-lobectomy air leak. METHODS: Preoperative characteristics and postoperative data from 367 consecutive video assisted thoracic surgery (VATS) lobectomy resections from one centre were collected prospectively between January 2014 and March 2017. Computer modelling of a lung model using finite element analysis (FEA) was used to calculate pleural stress in differing areas of the lung. RESULTS: Air leak following upper lobectomy was significantly higher than after middle or lower lobectomy (6.3% versus 2.5%, P=0.044), resulting in a significant six-day increase in mean hospital stay, P=0.004. The computer simulation model of the lung showed that an apical bullet shape was subject to eightyfold higher stress than the base of the lung model. CONCLUSIONS: After upper lobectomy, the bullet shape of the apex of the exposed lower lobe was associated with high pleural stress, and a reduction in mechanical support by the chest wall to the visceral pleura due to initial post-op lack of chest wall confluence. It is suggested that such higher stress in the lower lobe apex explains the higher parenchymal air leak post-upper lobectomy. The pleural stress model also accounts for the higher incidence of right-sided prolonged air leak post-resection.

Physiological rules for the heart, lungs and other pressure-based organs.

BACKGROUND: The adherence of the heart to physical laws, such as Laplace's Law, may act as a measure of the organ's relative efficiency. Allometric relationships were investigated to assess the heart's efficiency concerning end-diastolic and end-systolic volumes, cardiac pressurization energy, cardiac output and mass. METHODS: Data to generate allometric relationships was obtained using a literature search, identifying heart and lung data across different mammalian and bird species. Statistical analysis was carried out using ordinary least squares (OLS) estimation. RESULTS: Near isometric relationships exist between body mass and seven parameters indicating no "efficiency of size" with scaling of the heart, and size-matching of the heart to the lungs and whole body. Even though there was equal efficiency in pressurization energy generation, cardiac output was maximally efficient in small mammals <10 kg and birds; the human heart reached only 71% efficiency. This loss in cardiac efficiency with increasing body mass can be explained by the aortic cross-section that scales following the three-quarter allometry law, compared to end-systolic and end-diastolic volumes that scale isometrically. The heart is therefore throttled by a relatively small aorta at large body size. CONCLUSIONS: Mammalian and avian hearts operate at similar efficiencies, demonstrating a high degree of symmorphosis, however cardiac output efficiency decreases in larger animals due to a relatively negative aortic cross-section allometry. This work has a myriad of potential applications including explaining cardiac dysfunction in athletes, patient-prosthesis mismatch in aortic valve replacement and why heavy exercise is associated with a worse prognosis than mild or moderate exercise.

Pleural pressure theory revisited: a role for capillary equilibrium.

BACKGROUND: Theories elucidating pleural pressures should explain all observations including the equal and opposite recoil of the chest wall and lungs, the less than expected pleural hydrostatic gradient and its variation at lobar margins, why pleural pressures are negative and how pleural fluid circulation functions. METHODS: A theoretical model describing equilibrium between buoyancy, hydrostatic forces, and capillary forces is proposed. The capillary equilibrium model described depends on control of pleural fluid volume and protein content, powered by an active pleural pump. RESULTS: The interaction between buoyancy forces, hydrostatic pressure and capillary pressure was calculated, and values for pleural thickness and pressure were determined using values for surface tension, contact angle, pleural fluid and lung densities found in the literature. Modelling can explain the issue of the differing hydrostatic vertical pleural pressure gradient at the lobar margins for buoyancy forces between the pleural fluid and the lung floating in the pleural fluid according to Archimedes' hydrostatic paradox. The capillary equilibrium model satisfies all salient requirements for a pleural pressure model, with negative pressures maximal at the apex, equal and opposite forces in the lung and chest wall, and circulatory pump action. CONCLUSIONS: This model predicts that pleural effusions cannot occur in emphysema unless concomitant heart failure increases lung density. This model also explains how the non-confluence of the lung with the chest wall (e.g., lobar margins) makes the pleural pressure more negative, and why pleural pressures would be higher after an upper lobectomy compared to a lower lobectomy. Pathological changes in pleural fluid composition and lung density alter the equilibrium between capillarity and buoyancy hydrostatic pressure to promote pleural effusion formation.

Method of Hemorrhage Control From the Aorta After Repair of a Dissected Aortic Aneurysm.

Patients with Marfan syndrome and presenting with acute aortic dissection have fragile aorta, causing bleeding problems in the anastomosis between the graft and the aorta. Hemostatic impairment following circulatory arrest and prolonged cardiopulmonary bypass contribute to these problems. We describe a technique to control persistent bleeding from the anastomosis in the aortopulmonary recess using two kissing inflated balloons at the tip of two Foley catheters to tamponade the bleeding sites.

A biomechanical hypothesis for the pathophysiology of apical lung disease.

OBJECTIVE: A hypothesis is presented suggesting that the pathogenesis of apical lung disease is due to progression of subclinical congenital apical bullae in people with low Body Mass Index (BMI), a combination present in 15% of the population, due to high pleural stress levels present in the antero-posteriorly flattened chests of these individuals. DESIGN: The hypothesis was tested for validity in two apical lung pathologies with widespread epidemiological literature, namely tuberculosis (TB) and primary spontaneous pneumothorax (PSP), assessing whether the hypothesis could identify high-risk populations, explain exceptional cases like apical lower lobe disease and confirm predictions. RESULTS: The biomechanical hypothesis can explain the high-risk factors of apical location, age, gender and low-BMI build, as well as the occurrence of disease in the apex of the lower lobe, in both TB and PSP patients. A predicted common pathogenesis for apical lung disease was confirmed by the higher-than-expected incidence of concomitant TB and PSP. CONCLUSION: Pleural stress levels depend on chest wall shape, but are highest in the apex of young males with low BMI, leading to growth of congenital bullae that can eventually limit clearance inhaled material, superinfect or burst. This hypothesis suggests that low-dose computerized tomography may be used to screen for TB eradication. This paper is the first to propose a biomechanical mechanism for all apical lung disease pathophysiology.

Internal rib structure can be predicted using mathematical models: An anatomic study comparing the chest to a shell dome with application to understanding fractures.

The human rib cage resembles a masonry dome in shape. Masonry domes have a particular construction that mimics stress distribution. Rib cortical thickness and bone density were analyzed to determine whether the morphology of the rib cage is sufficiently similar to a shell dome for internal rib structure to be predicted mathematically. A finite element analysis (FEA) simulation was used to measure stresses on the internal and external surfaces of a chest-shaped dome. Inner and outer rib cortical thickness and bone density were measured in the mid-axillary lines of seven cadaveric rib cages using computerized tomography scanning. Paired t tests and Pearson correlation were used to relate cortical thickness and bone density to stress. FEA modeling showed that the stress was 82% higher on the internal than the external surface, with a gradual decrease in internal and external wall stresses from the base to the apex. The inner cortex was more radio-dense, P < 0.001, and thicker, P < 0.001, than the outer cortex. Inner cortical thickness was related to internal stress, r = 0.94, P < 0.001, inner cortical bone density to internal stress, r = 0.87, P = 0.003, and outer cortical thickness to external stress, r = 0.65, P = 0.035. Mathematical models were developed relating internal and external cortical thicknesses and bone densities to rib level. The internal anatomical features of ribs, including the inner and outer cortical thicknesses and bone densities, are similar to the stress distribution in dome-shaped structures modeled using FEA computer simulations of a thick-walled dome pressure vessel. Fixation of rib fractures should include the stronger internal cortex.

A hypothesis for reactivation of pulmonary tuberculosis: How thoracic wall shape affects the epidemiology of tuberculosis.

This study was aimed at determining the cause for the high incidence of tuberculosis (TB) reactivation occurring in males with a low body mass index (BMI). Current thinking about pulmonary TB describes infection in the lung apex resulting in cavitation after reactivation. A different hypothesis is put forward for TB infection, suggesting that this occurs in subclinical apical cavities caused by increased pleural stress due to a low BMI body habitus. A finite element analysis (FEA) model of a lung was constructed including indentations for the first rib guided by paramedian sagittal CT reconstructions, and simulations were conducted with varying antero-posterior (AP) diameters to mimic chests with a different thoracic index (ratio of AP to the transverse chest diameters). A Pubmed search was conducted about gender and thoracic index, and the effects of BMI on TB. FEA modeling revealed a tenfold increase in stress levels at the lung apex in low BMI chests, and a four-fold increase with a low thoracic index, r(2) = 0.9748 P < 0.001. Low thoracic index was related to BMI, P = 0.001. The mean thoracic index was statistically significantly lower in males, P = 0.001, and increased with age in both genders. This article is the first to suggest a possible mechanism linking pulmonary TB reactivation to low BMI due to the flattened thoracic wall shape of young male adults. The low thoracic index in young males may promote TB reactivation due to tissue destruction in the lung apex from high pleural stress levels.

A large pulmonary arteriovenous malformation causing cerebrovascular accidents.

The incidence of pulmonary arteriovenous malformations (PAVMs) is 2.5 in 100,000. 80% are associated with Osler-Weber-Rendu syndrome or hereditary haemorrhagic telangiectasia. We report the case of a 70-year-old man with a 6 cm spherical mass incidentally found on chest X-ray. There was a localised systolic bruit over the right lower zone posteriorly; however, he was asymptomatic. He had suffered a stroke, affecting his right hand and his speech, from which he recovered. He experienced regular transient ischaemic attacks, on an average of every 2 months. He underwent a right lower lobectomy and on ligating the right lower lobe pulmonary artery the saturations of oxygen rose from 92% to 97%, demonstrating a significant right to left extracardiac shunt. Postoperative recovery was excellent and 1 year later the patient reports no further neurological symptoms. 40% of such lesions exhibit symptoms, however, only one-third are neurological. Treatment should be by percutaneous embolisation.

External rib structure can be predicted using mathematical models: An anatomical study with application to understanding fractures and intercostal muscle function.

As ribs adapt to stress like all bones, and the chest behaves as a pressure vessel, the effect of stress on the ribs can be determined by measuring rib height and thickness. Rib height and thickness (depth) were measured using CT scans of seven rib cages from anonymized cadavers. A Finite Element Analysis (FEA) model of a rib cage was constructed using a validated approach and used to calculate intramuscular forces as the vectors of both circumferential and axial chest wall forces at right angles to the ribs. Nonlinear quadratic models were used to relate rib height and rib thickness to rib level, and intercostal muscle force to vector stress. Intercostal muscle force was also related to vector stress using Pearson correlation. For comparison, rib height and thickness were measured on CT scans of children. Rib height increased with rib level, increasing by 13% between the 3rd and 7th rib levels, where the 7th/8th rib was the widest part or "equator" of the rib cage, P < 0.001 (t-test). Rib thickness showed a statistically significant 23% increase between the 3rd and 7th ribs, P = 0.004 (t-test). Intercostal muscle force was significantly related to vector stress, Pearson correlation r = 0.944, P = 0.005. The three nonlinear quadratic models developed all had statistically significant parameter estimates with P < 0.03. External rib morphology, in particular rib height and thickness, can be predicted using statistical mathematical models. Rib height is significantly related to the calculated intercostal muscle force, showing that environmental factors affect external rib morphology.

A novel method of personnel cooling in an operating theatre environment.

An optimized theatre environment, including personal temperature regulation, can help maintain concentration, extend work times and may improve surgical outcomes. However, devices, such as cooling vests, are bulky and may impair the surgeon's mobility. We describe the use of a low-cost, low-energy 'bladeless fan' as a personal cooling device. The safety profile of this device was investigated by testing air quality using 0.5- and 5-µm particle counts as well as airborne bacterial counts on an operating table simulating a wound in a thoracic operation in a busy theatre environment. Particle and bacterial counts were obtained with both an empty and full theatre, with and without the 'bladeless fan'. The use of the 'bladeless fan' within the operating theatre during the simulated operation led to a minor, not statistically significant, lowering of both the particle and bacterial counts. In conclusion, the 'bladeless fan' is a safe, effective, low-cost and low-energy consumption solution for personnel cooling in a theatre environment that maintains the clean room conditions of the operating theatre.

Mechanism of sternotomy dehiscence.

OBJECTIVES: Biomechanical modelling of the forces acting on a median sternotomy can explain the mechanism of sternotomy dehiscence, leading to improved closure techniques. METHODS: Chest wall forces on 40 kPa coughing were measured using a novel finite element analysis (FEA) ellipsoid chest model, based on average measurements of eight adult male thoracic computerized tomography (CT) scans, with Pearson's correlation coefficient used to assess the anatomical accuracy. Another FEA model was constructed representing the barrel chest of chronic obstructive pulmonary disease (COPD) patients. Six, seven and eight trans-sternal and figure-of-eight closures were tested against both FEA models. RESULTS: Comparison between chest wall measurements from CT data and the normal ellipsoid FEA model showed an accurate fit (P < 0.001, correlation coefficients: coronal r = 0.998, sagittal r = 0.991). Coughing caused rotational moments of 92 Nm, pivoting at the suprasternal notch for the normal FEA model, rising to 118 Nm in the COPD model (t-test, P < 0.001). The threshold for dehiscence was 84 Nm with a six-sternal-wire closure, 107 Nm with seven wires, 127 Nm with eight wires and 71 Nm for three figure-of-eights. CONCLUSIONS: The normal rib cage closely fits the ellipsoid FEA model. Lateral chest wall forces were significantly higher in the barrel-shaped chest. Rotational moments generated by forces acting on a six-sternal-wire closure at the suprasternal notch were sufficient to cause lateral distraction pivoting at the top of the manubrium. The six-sternal-wire closure may be successfully enhanced by the addition of one or two extra wires at the lower end of the sternotomy, depending on chest wall shape.

Is there a biomechanical cause for spontaneous pneumothorax?

OBJECTIVES: Primary spontaneous pneumothorax has long been explained as being without apparent cause. This paper deals with the effect of chest wall shape and explains how this may lead to the pathogenesis of primary spontaneous pneumothorax. METHODS: Rib cage measurements were taken from chest radiographs in 12 male pneumothorax patients and 12 age-matched controls. Another group of 15 consecutive male thoracic computerised tomography (CT) were investigated using paramedian coronal and sagittal CT reconstructions to assess apical lung shape. A finite element analysis (FEA) model of a lung apex was constructed, including indentations for the first rib guided by CT scan data, to assess pleural stress. This model was tested using different anteroposterior diameter ratios, producing a range of thoracic indexes. RESULTS: The pneumothorax patients had a taller chest (P = 0.03), wider transversely (P = 0.009) and flatter (P = 0.03) when compared with controls, resulting in a low thoracic index. Prominent rib indentations were found anteriorly and posteriorly on the lung surface, especially on the first rib on CT. FEA of the lung revealed significantly higher stress (×5-×10) in the apex than in the rest of the lung. This was accentuated (×4) in low thoracic index chests, resulting in 20-fold higher stress levels in their apex. CONCLUSIONS: The FEA model demonstrates a 20-fold increase in pleural stress in the apex of chests with low thoracic index typical of spontaneous pneumothorax patients. Mild changes in thoracic index, as occurring in females or with aging, reduce pleural stress. Spontaneous pneumothorax occurring in young male adults may have a biomechanical cause.

Intrathoracic schwannoma with Horner syndrome.

Horner syndrome (HS) results from the interruption of the sympathetic pathway to the eye and face, and describes a collection of signs consisting of ipsilateral miosis, partial ptosis, anhidrosis and apparent enophthalmos. It is a clinical observation, and has a plethora of possible causes, ranging from the benign to the malignant. Involvement of the stellate ganglion on the sympathetic chain by malignant tumours of the lung is a well-recognised cause of HS. On the other hand, HS secondary to the excessive growth of a benign intrathoracic neoplasm is a very rare finding, with only a few cases described in the literature. Our patient was found to have such a diagnosis when he presented to medical attention with a 1-month history of cough that was associated with features of HS that he had ignored for the preceding 9 years.

Sternal wrapping: developments and results.

BACKGROUND: Postoperative sternal wound complications are infrequent events that negatively affect recovery and may have serious consequences. Sternal wrapping, a technique of sternal care, has hemostatic properties without bone wax, and offers mechanical and microbiologic protection. METHODS: From February 1998 to December 2011, 258 patients in 2 Italian institutions underwent various cardiac surgery procedures with sternal wrapping in place, and were followed up for no less then 6 months. RESULTS: Two (0.8%) extremely compromised patients with ischemic sternal osteonecrosis and deep sternal wound infection required a sternal stabilizing procedure. Four (2%) other patients developed sternal wound complications that were treated entirely medically; 3 of them were very trivial, and 1 was an atypical mediastinitis without sternal involvement. Overall, 46.1% of patients (45.3% of isolated coronary artery bypass, 49.3% of isolated on-pump coronary artery bypass, and 18.2% of off-pump coronary artery bypass patients) were transfused. None of the complications was related to sternal wrapping, bleeding from the sternal edge, or sternal wound problems. CONCLUSIONS: Sternal wrapping showed a very low incidence and severity of sternal wound complications, with good prevention of sternal osteomyelitis. Hemostatic properties were satisfactory, with transfusion rates within an acceptable range.

Cardiopulmonary bypass line sternal wrapping: technical tips.

Cardiopulmonary bypass line sternal wrapping (SW) is a new approach to sternal care which avoids bone wax and offers mechanical protection and a shield from bacterial contamination, with beneficial effects on sternal healing. Since its introduction in February 2008, the technique has undergone some developments: it is possible to harvest internal thoracic arteries with SW in place and its haemostatic properties have improved.

Cardiopulmonary bypass line sternal wrapping for protection and haemostasis.

Sternal marrow haemostasis is often obtained with the application of bone wax, with potential side effects pertaining to sternal wound healing. We illustrate an alternative technique which also offers some protection to sternal edges. Two lengths of tubing from the discarded cardiopulmonary bypass (CPB) circuit are cut longitudinally on one side. After sternotomy they are placed across each sternal edge and kept in position by two stitches and the spreader blades. They are removed just before sternal closure.

Early dialysis in acute kidney injury after cardiac surgery.

Acute kidney injury following cardiac surgery (AKICS) remains a frequent cause of major morbidity and mortality. The aim of this study was to examine the influence of timing of dialysis. A retrospective analysis of 3528 patients undergoing cardiac surgery between April 1995 and July 2006 was performed. In group 1 (April 1995-January 2000) intermittent haemodialysis was resorted to when other supportive measures failed. In group 2 (January 2000-July 2006) intermittent haemodialysis was commenced immediately when oliguria did not respond to fluid replacement or single-dose diuretics. In group 1, 49/1511 (3.2%) patients developed AKICS. Thirty-four patients did not receive dialysis and six patients died (18%). Of the remaining 15 patients who underwent dialysis, 13 died (87%). The overall mortality for group 1 AKICS patients was 19/49 (39%). In group 2, 87/2017 (4.3%) patients developed AKICS. Thirty-one patients did not require dialysis and none died. Of the 56 patients who were dialysed, 14 died (25%). During January 2005-July 2006, mortality following dialysis fell further to 17% (4/24). The overall mortality for group 2 patients developing AKICS was 14/87 (16%). Although the incidence of AKICS increased from 3.2% to 4.2%, earlier dialysis resulted in significantly improved survival (P=0.00001).

Empyema thoracis caused by a foreign body inhaled 30 years previously.

We present the case of a 73 year old Caucasian male who developed a left sided pneumonia and empyema secondary to a foreign body inhaled 30 years before. The foreign body, a bone fragment, was lodged at the bifurcation of the left main bronchus and could only be removed via bronchotomy. The patient experienced a swift recovery and was well at follow-up 6 months later.