4. Lungs & Pleura (In Conjunction with Pulmonary Medicine Department)
A. Anatomy, Physiology, Embryology and Testing
Objectives: This section teaches the student; the embryology and anatomy of the lungs and their relationship to adjacent structures, the physiology of airway
mechanics, gas exchange, and blood flow, and applies the findings of invasive and non-invasive tests to patient management.
1. Student is taught the segmental anatomy of the bronchial tree and bronchopulmonary segments.
2. Student is taught the arterial, venous and bronchial anatomy of the lungs and their inter-relationships.
3 Student is taught the lymphatic anatomy of the lungs, the major nodal stations, and lymphatic drainage of the lung segments; including the anatomy of the thoracic duct.
4. Student is taught the indications for different thoracic incisions, the surgical anatomy encountered, and their physiological impact.
5. Student is taught the indications for plain radiography,CT scan, bone scan, magnetic resonance imaging, and PET scanning for staging of lung cancer.
6. Student is taught the indications, interpretation, and use of nuclear imaging, ventilation/perfusion scanning (V/Q scan) to determine the operability of candidates for pulmonary resection;
7. Student is taught the methods of surgical staging (e.g., mediastinoscopy, Chamberlain procedure, scalene node biopsy, thoracoscopy).
8. Student is taught how pulmonary functions tests are performed and how to interpret pulmonary function tests.
Contents:
1. Normal anatomy and histology of the lung
a. Segmental anatomy of the bronchial tree
b. Bronchopulmonary segments (topography)
c. Hilar anatomy
d. Lymphatic anatomy and drainage of the lung e. Histologic anatomy and cell types of the lung
f. Endoscopic anatomy of the larynx, trachea, and bronchi
2. Normal physiology of the lungs
a. Chest wall mechanics
b. Large and small airway mechanics
c. Alveolar mechanics and gas exchange
3. Imaging of chest and lungs
a. Chest x-ray
b. CT scan of the chest and abdomen
c. MRI of the chest
d. Contrast angiography of major vessels within the chest
e. Radioactive isotope scanning of organs within the chest
4. Surgical approaches (incisions) for pulmonary resections
a. Anterior thoracotomy
b. Posterolateral thoracotomy
c. Posterior thoracotomy
d. Muscle sparing thoracotomy
e. Mediastinotomy
f. Transverse anterior sternotomy
g. Incisions common to video assisted thoracic surgery
h. Incisions common to cervical and anterior mediastinoscopy
Skills gained: During the training program the resident will acquire knowledge and proficiency in;
1. Reading and interpreting pulmonary function studies, ventilation/perfusion scans, pulmonary arteriograms and arterial blood gases, and asses operability.
2. Applying knowledge of thoracic anatomy to the physical examination of the chest, heart, and vascular tree.
3. Applying knowledge of thoracic anatomy with regards to flexible and rigid endoscopic procedures.
4. Knowledge of chest, pulmonary, and cardiac physiology and able to interpret tests involving the thoracic cavity and to understand and treat diseases.
5. Reading and interpreting plain radiography, CT scans, magnetic resonance imaging, and PET scanning of the lungs and pleura.
6. Assisting in performing exercise tolerance tests and pulmonary function tests.
mechanics, gas exchange, and blood flow, and applies the findings of invasive and non-invasive tests to patient management.
1. Student is taught the segmental anatomy of the bronchial tree and bronchopulmonary segments.
2. Student is taught the arterial, venous and bronchial anatomy of the lungs and their inter-relationships.
3 Student is taught the lymphatic anatomy of the lungs, the major nodal stations, and lymphatic drainage of the lung segments; including the anatomy of the thoracic duct.
4. Student is taught the indications for different thoracic incisions, the surgical anatomy encountered, and their physiological impact.
5. Student is taught the indications for plain radiography,CT scan, bone scan, magnetic resonance imaging, and PET scanning for staging of lung cancer.
6. Student is taught the indications, interpretation, and use of nuclear imaging, ventilation/perfusion scanning (V/Q scan) to determine the operability of candidates for pulmonary resection;
7. Student is taught the methods of surgical staging (e.g., mediastinoscopy, Chamberlain procedure, scalene node biopsy, thoracoscopy).
8. Student is taught how pulmonary functions tests are performed and how to interpret pulmonary function tests.
Contents:
1. Normal anatomy and histology of the lung
a. Segmental anatomy of the bronchial tree
b. Bronchopulmonary segments (topography)
c. Hilar anatomy
d. Lymphatic anatomy and drainage of the lung e. Histologic anatomy and cell types of the lung
f. Endoscopic anatomy of the larynx, trachea, and bronchi
2. Normal physiology of the lungs
a. Chest wall mechanics
b. Large and small airway mechanics
c. Alveolar mechanics and gas exchange
3. Imaging of chest and lungs
a. Chest x-ray
b. CT scan of the chest and abdomen
c. MRI of the chest
d. Contrast angiography of major vessels within the chest
e. Radioactive isotope scanning of organs within the chest
4. Surgical approaches (incisions) for pulmonary resections
a. Anterior thoracotomy
b. Posterolateral thoracotomy
c. Posterior thoracotomy
d. Muscle sparing thoracotomy
e. Mediastinotomy
f. Transverse anterior sternotomy
g. Incisions common to video assisted thoracic surgery
h. Incisions common to cervical and anterior mediastinoscopy
Skills gained: During the training program the resident will acquire knowledge and proficiency in;
1. Reading and interpreting pulmonary function studies, ventilation/perfusion scans, pulmonary arteriograms and arterial blood gases, and asses operability.
2. Applying knowledge of thoracic anatomy to the physical examination of the chest, heart, and vascular tree.
3. Applying knowledge of thoracic anatomy with regards to flexible and rigid endoscopic procedures.
4. Knowledge of chest, pulmonary, and cardiac physiology and able to interpret tests involving the thoracic cavity and to understand and treat diseases.
5. Reading and interpreting plain radiography, CT scans, magnetic resonance imaging, and PET scanning of the lungs and pleura.
6. Assisting in performing exercise tolerance tests and pulmonary function tests.
B. Non-Neoplastic Lung Disease
Objectives: This section teaches the student; so that the student understands infectious, inflammatory, and environmental conditions of the lung and the steps of operative and non-operative managements.
1. Student is taught various diagnostic procedures used to evaluate non-neoplastic lung disease.
2. Student is taught common pathogens that produce lung infections, including their presentation and pathologic processes, treatment and indications for operations.
3. Student is taught the natural history, presentation and treatment of chronic obstructive lung disease.
4. Student is taught the indications for bullectomy, lung reduction, and pulmonary transplantation.
5. Student is taught the pathologic results and alterations of pulmonary function due to bronchospasm.
6. Student is taught principles of surgical resection for non-neoplastic lung disease.
7. Student is taught mechanisms by which foreign bodies (FB) reach the airways, how they cause pulmonary pathology, and the management of patients with FB's.
8. Student is taught the causes, physiology, evaluation and management of hemoptysis.
9. Student is taught complications of lung resection and their management.
Contents:
1. Common pulmonary pathogens
a. Bacteria
b. Fungi
c. Mycobacterial (tuberculoisis and atypical [MOTT])
d. Viruses
e. Protozoa
f. Immunocompromised patients
2. Chronic obstructive pulmonary disease
a. Natural history
b. Presentation, evaluation
c. Alteration of lung function
d. Complications requiring operative treatment
e. Treatment (operative and non-operative)
3. Bronchospasm
a. Natural history
b. Evaluation
c. Complications requiring operative treatment
d. Treatment (operative and non-operative)
4. Foreign bodies of the lung and airways
a. Common types
b. Causes, pathology
c. Evaluation
d. Treatment (operative and non-operative)
5. Hemoptysis
a. Causes
b. Physiologic derangements
c. Evaluation
d. Treatment (operative and non-operative)
6. Pneumothorax
a. Etiology
b. Indications for treatment
c. Types of treatment
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Diagnoses and treats patients with bacterial, fungal, tuberculous, and viral lung infections.
2. Assists and performs operative and non-operative management of lung abscess.
3. Assists and performs resections of lung and bronchi in patients with non-neoplastic lung disease.
4. Assists and manages patients with chronic obstructive lung disease, bronchospastic airway disease, foreign bodies of the airways, and hemoptysis.
5. Assists and performs thoracentesis, mediastinoscopy, mediastinotomy, flexible and rigid bronchoscopy, thoracoscopy, and open lung biopsy.
6. Assists and performs bronchoalveolar lavage and transbronchial lung biopsy.
1. Student is taught various diagnostic procedures used to evaluate non-neoplastic lung disease.
2. Student is taught common pathogens that produce lung infections, including their presentation and pathologic processes, treatment and indications for operations.
3. Student is taught the natural history, presentation and treatment of chronic obstructive lung disease.
4. Student is taught the indications for bullectomy, lung reduction, and pulmonary transplantation.
5. Student is taught the pathologic results and alterations of pulmonary function due to bronchospasm.
6. Student is taught principles of surgical resection for non-neoplastic lung disease.
7. Student is taught mechanisms by which foreign bodies (FB) reach the airways, how they cause pulmonary pathology, and the management of patients with FB's.
8. Student is taught the causes, physiology, evaluation and management of hemoptysis.
9. Student is taught complications of lung resection and their management.
Contents:
1. Common pulmonary pathogens
a. Bacteria
b. Fungi
c. Mycobacterial (tuberculoisis and atypical [MOTT])
d. Viruses
e. Protozoa
f. Immunocompromised patients
2. Chronic obstructive pulmonary disease
a. Natural history
b. Presentation, evaluation
c. Alteration of lung function
d. Complications requiring operative treatment
e. Treatment (operative and non-operative)
3. Bronchospasm
a. Natural history
b. Evaluation
c. Complications requiring operative treatment
d. Treatment (operative and non-operative)
4. Foreign bodies of the lung and airways
a. Common types
b. Causes, pathology
c. Evaluation
d. Treatment (operative and non-operative)
5. Hemoptysis
a. Causes
b. Physiologic derangements
c. Evaluation
d. Treatment (operative and non-operative)
6. Pneumothorax
a. Etiology
b. Indications for treatment
c. Types of treatment
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Diagnoses and treats patients with bacterial, fungal, tuberculous, and viral lung infections.
2. Assists and performs operative and non-operative management of lung abscess.
3. Assists and performs resections of lung and bronchi in patients with non-neoplastic lung disease.
4. Assists and manages patients with chronic obstructive lung disease, bronchospastic airway disease, foreign bodies of the airways, and hemoptysis.
5. Assists and performs thoracentesis, mediastinoscopy, mediastinotomy, flexible and rigid bronchoscopy, thoracoscopy, and open lung biopsy.
6. Assists and performs bronchoalveolar lavage and transbronchial lung biopsy.
C. Neoplastic Lung Disease
Objectives: This section teaches the student; the etiology, natural history, pathology, evaluation, and management of lung neoplasms, whilst assessing, planning, assisting and performing operative and non-operative treatments.
1. Student is taught TNM staging of lung cancer and its application to the diagnosis, therapeutic planning, and management of patients with lung cancer.
2. Student is taught how to evaluate and diagnose neoplasia of the lung, using a knowledge of the histologic appearance of the major types. (Pathology Department)
3. Student is taught the signs of opinoperability.
4. Student is taught various therapeutic options for patients with lung neoplasms.
5. Student is taught principles of bronchoplastic surgery.
6. Student is taught complications of pulmonary resection and their management.
7. Student is taught role of induction and adjuvant therapy for lung neoplasms.
8. Student is taught indications for resection of benign lung neoplasms.
9. Student is taught indications for resection of pulmonary metastases.
Contents:
1. Benign tumors of the lung and airways
a. Pathology, biologic behavior
b. Evaluation, diagnosis, treatment (operative and non-operative)
2. Solitary lung nodule
a. Differential diagnosis, evaluation, diagnostic techniques
b. Treatment (operative and non-operative)
3. Malignant tumors of the lung and airways
a. Pathology, biologic behavior
b. Evaluation, diagnosis, treatment (operative and non-operative)
4. Metastatic tumors to the lungs
a. Pathology and biologic behavior
b. Evaluation, diagnosis, treatment (operative and non-operative)
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Evaluation of patients with pulmonary malignancies and recommends therapy based on their functional status, pulmonary function and tumor type.
2. Performs staging procedures under supervision (e.g., bronchoscopy, mediastinoscopy, mediastinotomy, and thoracoscopy).
3. Assists and performs operations to remove neoplasms of the lung (e.g., local excision, wedge resection, segmental resection, lobectomy, pneumonectomy, sleeve lobectomy, carinal resection, chest wall resection).
4. Be able to recognize and manage complications of pulmonary resections (e.g., space problem, persistent air leak, bronchopleural fistula, bronchovascular fistula, empyema, cardiac arrhythmia).
5. Be able to performs bedside bronchoscopies and placement of tracheostomies and/or mini-tracheostomies.
6. Be able to recognize and treat the early signs of non-cardiac pulmonary edema (NCPE).
1. Student is taught TNM staging of lung cancer and its application to the diagnosis, therapeutic planning, and management of patients with lung cancer.
2. Student is taught how to evaluate and diagnose neoplasia of the lung, using a knowledge of the histologic appearance of the major types. (Pathology Department)
3. Student is taught the signs of opinoperability.
4. Student is taught various therapeutic options for patients with lung neoplasms.
5. Student is taught principles of bronchoplastic surgery.
6. Student is taught complications of pulmonary resection and their management.
7. Student is taught role of induction and adjuvant therapy for lung neoplasms.
8. Student is taught indications for resection of benign lung neoplasms.
9. Student is taught indications for resection of pulmonary metastases.
Contents:
1. Benign tumors of the lung and airways
a. Pathology, biologic behavior
b. Evaluation, diagnosis, treatment (operative and non-operative)
2. Solitary lung nodule
a. Differential diagnosis, evaluation, diagnostic techniques
b. Treatment (operative and non-operative)
3. Malignant tumors of the lung and airways
a. Pathology, biologic behavior
b. Evaluation, diagnosis, treatment (operative and non-operative)
4. Metastatic tumors to the lungs
a. Pathology and biologic behavior
b. Evaluation, diagnosis, treatment (operative and non-operative)
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Evaluation of patients with pulmonary malignancies and recommends therapy based on their functional status, pulmonary function and tumor type.
2. Performs staging procedures under supervision (e.g., bronchoscopy, mediastinoscopy, mediastinotomy, and thoracoscopy).
3. Assists and performs operations to remove neoplasms of the lung (e.g., local excision, wedge resection, segmental resection, lobectomy, pneumonectomy, sleeve lobectomy, carinal resection, chest wall resection).
4. Be able to recognize and manage complications of pulmonary resections (e.g., space problem, persistent air leak, bronchopleural fistula, bronchovascular fistula, empyema, cardiac arrhythmia).
5. Be able to performs bedside bronchoscopies and placement of tracheostomies and/or mini-tracheostomies.
6. Be able to recognize and treat the early signs of non-cardiac pulmonary edema (NCPE).
D. Congenital Lung Disease
Objectives: This section teaches the student; embryology, pathology and principles of management of congenital lung abnormalities and appropriate treatments. During this student will become capable of;
1. Recognising various congenital lung abnormalities and understands their anatomy and indications for treatment.
Contents:
1. Pulmonary sequestration
a. Presentation (intralobar and extralobar)
b. Evaluation and management
c. Prognosis
2. Congenital lobar emphysema
a. Presentation and physiology
b. Evaluation and management
3. Cystic fibrosis
a. Presentation and physiology
b. Evaluation and management
c. Complications and their management
d. Role of pulmonary transplantation
4. Bronchogenic cysts
a. Presentation
b. Evaluation and indications for operation
c. Operative options
5. Cystic adenomatoid malformation
a. Presentation and physiology
b. Evaluation and indications for operation
c. Operative options
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Evaluation of patients with congenital lung abnormalities.
2. Assists operations for congenital lung abnormalities and their complications.
1. Recognising various congenital lung abnormalities and understands their anatomy and indications for treatment.
Contents:
1. Pulmonary sequestration
a. Presentation (intralobar and extralobar)
b. Evaluation and management
c. Prognosis
2. Congenital lobar emphysema
a. Presentation and physiology
b. Evaluation and management
3. Cystic fibrosis
a. Presentation and physiology
b. Evaluation and management
c. Complications and their management
d. Role of pulmonary transplantation
4. Bronchogenic cysts
a. Presentation
b. Evaluation and indications for operation
c. Operative options
5. Cystic adenomatoid malformation
a. Presentation and physiology
b. Evaluation and indications for operation
c. Operative options
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Evaluation of patients with congenital lung abnormalities.
2. Assists operations for congenital lung abnormalities and their complications.
E. Diseases of the Pleura
Objectives: This section teaches the student; the benign and malignant abnormalities of the pleura, pleural effusions, and the evaluation and treatment of pleural diseases. During this student will become;
1. Familiar with the clinical presentation of benign and malignant diseases of the pleura.
2. Familiar with the types of pleural effusions, their evaluation and treatment. including chylothorax.
3. Familiar with the management of empyema with and without bronchopleural fistula.
4. Familiar with the indications, contraindications, and complications of video assisted thoracic surgery and has a working knowledge of the equipment.
5. Familiar with the treatment of benign and malignant diseases of the pleura.
Contents:
1. Pleural Mesothelioma
a. Pathology, biologic behavior, and natural history
b. Treatment (operative and non-operative)
2. Pleural effusions
a. Types
b. Diagnosis
c. Treatment (operative and non-operative)
3. Empyema Thoracis
a. Presentation with and without bronchopleural fistula
b. Diagnosis
c. Treatment (operative and non-operative)
d. Surgical options (e.g., thoracentesis, tube thoracostomy, decortication, rib resection, repair of bronchopleural fistula)
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Evaluation of pleural effusions and recommending appropriate therapy.
2. Performs invasive diagnostic studies (e.g., incisional and excisional biopsy, needle biopsy, fluid analysis).
3. Places tube thoracostomies and performs chemical or mechanical pleurodesis.
4. Assists and performs initial drainage procedures and subsequent procedures for empyema (e.g., decortication, empyemectomy, rib resection, Eloesser flap, Claggett procedure, closure of bronchopleural fistula).
5. Assists video assisted thorascopic surgery (VATS) as necessary for the diagnosis and treatment of pleural disease.
6. Assists and performs pleuroperitoneal shunts.
7. Performs pleurectomy for mesothelioma under supervision.
1. Familiar with the clinical presentation of benign and malignant diseases of the pleura.
2. Familiar with the types of pleural effusions, their evaluation and treatment. including chylothorax.
3. Familiar with the management of empyema with and without bronchopleural fistula.
4. Familiar with the indications, contraindications, and complications of video assisted thoracic surgery and has a working knowledge of the equipment.
5. Familiar with the treatment of benign and malignant diseases of the pleura.
Contents:
1. Pleural Mesothelioma
a. Pathology, biologic behavior, and natural history
b. Treatment (operative and non-operative)
2. Pleural effusions
a. Types
b. Diagnosis
c. Treatment (operative and non-operative)
3. Empyema Thoracis
a. Presentation with and without bronchopleural fistula
b. Diagnosis
c. Treatment (operative and non-operative)
d. Surgical options (e.g., thoracentesis, tube thoracostomy, decortication, rib resection, repair of bronchopleural fistula)
Skills gained: During the training program the resident will acquire knowledge and proficiency in the;
1. Evaluation of pleural effusions and recommending appropriate therapy.
2. Performs invasive diagnostic studies (e.g., incisional and excisional biopsy, needle biopsy, fluid analysis).
3. Places tube thoracostomies and performs chemical or mechanical pleurodesis.
4. Assists and performs initial drainage procedures and subsequent procedures for empyema (e.g., decortication, empyemectomy, rib resection, Eloesser flap, Claggett procedure, closure of bronchopleural fistula).
5. Assists video assisted thorascopic surgery (VATS) as necessary for the diagnosis and treatment of pleural disease.
6. Assists and performs pleuroperitoneal shunts.
7. Performs pleurectomy for mesothelioma under supervision.
