MINISTRY OF HEALTH PROTECTION OF UKRAINE

ODESSA NATIONAL MEDICAL UNIVERSITY

Faculty of Medicine
Department of Surgery No. 1 with postgraduate training

I APPROVE
Vice-rector for scientific
and pedagogical work
Svetlana Kotyuzhynska
"_____" _________ 2022

METHODOLOGICAL DEVELOPMENT
TO THE PRACTICAL IN THE EDUCATIONAL DISCIPLINE
Faculty, course ___Medical 6th year_________________________
Study discipline _________________Surgery_____________
(name of academic discipline)

PRACTICAL TRAINING
Practical lesson No. 22
Topic 22. "Surgical pathology of lungs and pleura. Principles of diagnostics and
medical treatment"
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Approved:
The meeting of the Department of SURGERY No. 1 with postgraduate
training
Odessa National Medical University

Protocol No. _1 of “29_” _August_ 2022.

Head of the Department _____________________ (Voladymyr Grubnik)

(signature) (First name, last name)

Developers: Prof., dmn. Mishchenko V.V., Assoc. Polyak S. D., Associate

Professor Novosad E. M., Associate Professor Parfentiev R.S., Associate
Professor Nikitenko R.P. .Burgidze Z.D., asst. Degtyarenko S. P., Assistant.
Kanzho N., assistant. kmn. Vorotyntseva K. O., assistant. Kresyun M. S.,
assistant. kmn. Bayazitov D. M., assistant. D. V. Kochovyi, assistant. A. V.
Ponomarenko, assistant. kmn. Hrubnyk V. V., assistant. V. S. Ishchenko,
Assistant. kmn. V. V. Ilyashenko, Assoc. V. M. Kosovan, assistant professor
Demidov S. M., Assistant Professor A. V. Kovalchuk, assistant professor O. M.
Zagorodniuk, assistant Velichko V. V., assistant Vododyuk R. Yu., assistant
Buzinovskyi A. B., assistant. Burlak O.S
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1. Theme of the lesson: "Surgical pathology of lungs and pleura.
Principles of diagnostics and medical treatment" - 2 hours.
2. Actuality of theme. The diseases of respiratory organs, including tuberculo-
sis and tumours of lungs, are an important social-medical problem, because occupy
one of leading places in surgical care. This circumstance predetermines the promoted
attention of scientists, organizers of health care and practical doctors to such diseases.
3. Whole of the lesson:
3.1. General aims.
On the basis of knowledges of etiology, pathogenesis, basic and additional
methods of investigation to be able to diagnose surgical pathology of lungs and
pleura. To conduct differential diagnostics, to be able to work out and to ground plan
of medical treatment, to conduct the prophylaxis of these diseases.
3.2. Educate aims.
To familiarize with contribution of domestic scientists in the study of problem
of modern diagnostics and methods of medical treatment of patients with surgical
pathology of lungs and pleura, to be able to explain to the patient in an accessible
form about a testimony to the appeal for medical help in medical-prophylactic estab-
lishments on the early stages of disease, necessity of prophylactic examinations, pro-
phylaxis of possible diseases and to lead to information about possible complications.
3.3. Concrete aims.
- To know:
1. Etiology and pathogenesis of surgical diseases of lungs and pleura.
2. Clinical displays of this pathology.
3. Classification of diseases.
4. Roentgenologic symptoms and signs.
5. Laboratory diagnostics and additional methods of research.
6. Criteria of clinical diagnosis.
7. Indications to ambulatory and stationary medical treatment.
8. Whole medical treatments.
9. Testimony to the conservative and surgical methods of medical treatment.
3.4. On the basis of theoretical knowledges from a theme: "Surgical
pathology of lungs and pleura" - to Capture methods (to be able):
1. On the basis of these complaints of patient, anamnesis of disease and physical
methods of examination to formulate a previous diagnosis.
2. To define the roentgenologic signs of disease depending on the stage of patho-
logical process and his complications.
3. To analyze information of laboratory diagnostics.
4. To appoint the additional methods of examination.
5. To conduct differential diagnostics with the purpose of clarification of diagno-
sis.
6. To propose a clinical diagnosis.
7. To appoint complex pathogenetic conservative medical treatment.
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8. To be able to diagnose complications of basic disease, which can arise up in the
process of conservative medical treatment.
9. To give exigent surgical help.
10.To be able to formulate a testimony to radical surgical medical treatment.
11.To capture methods: pleural punctures, punctures of cavity of abscess, drainage
of cavity and abscess of lungs, by the methods of sanation of tracheobronchial
tree, technique of adjusting of the systems of active aspiration.
4. Materials to audience individual preparation

Interdisciplinary integration
№ Disciplines To know To be able
1 2 3 4
Previous disciplines
1 Anatomy Morphology and anatomic informa- To estimate functional in-
tion of respiratory system, chart of dexes in a norm.
segmental bronchial tubes.
Кровоснабжение of lungs. Lym-
phatic system and innervation of
lungs and pleura.
2 Normal physiology Functional characteristics of respira- To estimate functional in-
tory organs. Biomechanics of respi- dexes in a norm.
ratory motions. Statistical parame-
ters of the system of the external
breathing.
3 Pathological anatomy Patho-morphology of basic diseases To estimate functional in-
of respiratory organs, morphological dexes in a norm.
signs of damages, elements of in-
flammatory reactions in lungs,
бронхоектазії and basic forms of
dystrophic processes.
Following disciplines
1 Pathological physiol- Pathophysiological mechanisms of To estimate prospects and
ogy violations of the pulmonary breath- degrees of respiratory insuf-
ing at the surgical diseases of lungs. ficiency.
2 Propaedeutics of inter- Method of palpation, percussion and To conduct the valuable
nal diseases auscultation of thoracic organs. physical examination of pa-
tient.
3 Radio-therapy and ra- Methods of roentgenologic and radi- To distinguish the roentgeno-
diology ological investigations of lungs. logic signs of diseases of
lungs as compared to a norm.
4 Microbiology Terms and methods of conducting To conduct the exception of
of microbiological investigation at material for microbiological
patients with surgical pathology of investigation.
lungs.
5 Immunology Determination of indexes of specific To conduct complex im-
immunity, exposure of autoimmune munological investigation.

processes and unspecific immuno-
logical reactivity.
Inter-subject integration
1 Special radio-therapy Roentgenologic signs of surgical
pathology of thoracic organs.
2 Bronchology Topography of bronchial tubes. En-
doscopic and bioptic methods of ex-
amination.
3 Functional diagnostics Dynamic parameters of the system
of the external breathing.
4 Pharmacology Description of medical preparations
and dose in obedience to age and
weight of patients.
5 Thoracic surgery Indications to operative medical
treatment of patients with surgical
pathology of lungs and pleura.
Types of surgical interferences.
5
To be oriented in roentgeno-
logic diagnostics.
To distinguish the pathologi-
cal changes in endoscopic
picture of bronchial tubes.
To estimate the results of
functional investigation with
determination of degree of
respiratory insufficiency.
To appoint adequate com-
plex therapy at surgical dis-
eases of lungs and pleura.
To execute under the control
a teacher: pleural puncture,
drainage of pleural cavity,
puncture or drainage of cav-
ity of abscess, micro-tra-
cheostomy, to give urgent
help at tense pneumothorax.

5. Table of contents of theme.

Among the urgent surgical diseases of breasts have most value the diseases of
lungs and pleura. On the initial stage of examination most value is given to the signs
which determine the clinical picture of disease.
Frequent clinical syndromes at the surgical diseases of lungs and pleura are
most:
 Acute pain in breasts;
 Acute dyspnea;
 Pulmonary bleeding (hemoptysis);
 Cough, that acutely arising up;
 Festering intoxication.
Quite often all transferred symptoms unite with each other in the most different
correlations. In addition, the same clinical picture can show up different pathological
processes which need sometimes different approaches to medical treatment. Conse-
quently, at first necessary analysis of clinical syndromes, and then transition from
them to the nosological diagnosis.
Before the most frequent diseases which the syndromes listed above are at, it
follows to take:
o pneumothorax;
o strange body of bronchi;
o pleurisy;
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o empyema of pleura;
o an abscess is lights;
o gangrene the lights;
o cancer of lights;
o destructive forms of white plague;
o mediastinitis;
o bronchiectatic diseases;
o thromboembolism of lung’s artery;
o trauma of breasts;
o damage of esophagus.
For the decision of main troubleshooting problem the radial methods of examnia-
tion must be used mainly: roentgenologic, ultrasonic, КТ.
Basis of collective urgent radial examination, as usual, there is traditional investi-
gation as survey roentgenoscopy of thorax.

Leading syndromes and character of pathological process

Leading syndrome Character of pathological process
Acute pain in breasts - spontaneous pneumothorax;
- thromboembolism of lung’s artery;
- the strange body of bronchi;
- mediastinitis;
- abscess of lungs;
- bronchiectatic diseases;
- empyema of pleura;
- gangrene of lungs;
- damage of esophagus;
- trauma of breasts
Acute dyspnea - the strange body of bronchi;
- spontaneous pneumothorax;
- thromboembolism of lung’s artery;
- bronchiectatic diseases (in different stages);
- mediastinitis;
- empyema of pleura (total and subtotal);
- pyopneumothorax;
- gangrene of lungs;
- trauma of breasts;
Hemoptysis and pul- - central cancer of lungs;
monary bleeding - disintegration of peripheral cancer of lungs;
- abscess of lungs;
- destructive forms of white plague;
- bronchiectatic diseases
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Cough, that acutely - the strange body of bronchi;
arising up - spontaneous pneumothorax
Festering intoxication - empyema of pleura;
- pyopneumothorax;
- abscess of lungs;
- bronchiectatic diseases (in the period of acute attack);
- mediatinitis;
- gangrene of lungs

Dependence of character of pathological process from position of mediatinum

and features of darkening in lungs on roentgenograms.

Position of mediatinum Character of darkening

Homogeneous Heterogeneous
Normal - Inflammatory infiltration
of lungs
Darkening is displaced in Atelectasis of the lungs Pleural bulge
a side Absence lungs Cirrhosis of the lungs
Displaced in an opposite Liquid in the pleural cavity Diaphragm’s hernia
side Neoplasms

Acute pain in breasts can be conditioned by pathological processes in differ-

ent organs and anatomic structures of thorax. Most frequent its factors are:
- acute infarction of myocardium;
- dissecting aneurism of aorta;
- zoster lichen;
- impression of skeleton (breaks of ribs and vertebrae);
- perforation by esophagus strange body;
- jammed diaphragm’s hernia;
- spontaneous pneumothorax;
- thromboembolism of lung’s artery.
The changes in lungs at acute pain roentgenologic more frequent show up the
syndrome of large lumen and changes of pulmonary picture.
Acute dyspnea - sudden difficulty of breathing in default of cardiac insuffi-
ciency. From the number of acute surgical diseases of lungs and pleura it more fre-
quent appears by the external displays following the pathological states:
- strange bodies of bronchial tree;
- spontaneous pneumothorax;
- thromboembolism of lung’s artery
The changes on roentgenograms show up usually to one of three scialogic syn-
dromes:
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- by the prolonged darkening of the pulmonary field;
- prolonged lumen of the pulmonary field;
- by the change of pulmonary picture.
The pulmonary bleeding (hemoptysis) is the changes in lungs at patients
roentgenologic, more frequent all, represented by the following syndromes:
- limited (particle, segment) darkening;
- cavitary formation;
- by the changes of pulmonary picture.
Cough, that acutely arising up is conditioned by the strange body of bronchial
tree. It is impossible to eliminate authenticity of this state even in default of anamne-
sis indications on aspiration. A strange body will be obturate bronchi, causing viola-
tion of its permeability.
By roentgenogram the strange body of bronchial tree is represented by the syn-
drome of the limited darkening, that has partial (segmental) character severely. As a
result of obturation of bronchi appropriate department of lungs is diminished in a vol-
ume and darkening. Inclusive segments compensate are megascopic, hyper-pneumati-
zating, a pulmonary picture is rarefy. Often there is displacement of mediastinum in
the side of impression and getting up of proper half diaphragm.

Festering intoxication - display of infectious pathological processes in any or-

gans.
The most characteristic roentgenologic changes during festering intoxication
are: prolonged or limited darkening and combinations of darkening with lumen.

Dependence of pathological process character on leading clinical and

roentgenologic syndromes.
Leading clinical Roentgenologic syndrome and pathological states
syndrome Prolonged Limited Cavitary Prolonged lu- Changes of
darkening darkening formation men pulmonary pic-
ture
Acute dyspnea The strange - - Spontaneous pneu- Thromboembolism
body of mothorax. Throm- of lung’s artery.
bronchi with boembolism of Strange body of
atelectasis of lung’s artery. large бронха with
lungs Strange body of valve stenosis.
large bronchi with
valve stenosis.
Pulmonary bleed- - Central can- Destructive - Bronchiectasises
ing (hemoptysis) cer of lungs forms of tu-
berculosis.
Peripheral
cancer, that
disintegrates.
Acute pain in - - - Spontaneous Thromboembolism
breast пневмоторакс of lung’s artery
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Cough, that - Strange body - - -
acutely arising up of bronchi
Festering intoxica- Empyema of Empyema of - Lumen + darken- -
tion pleura pleura ing; pyopneumoth-
orax

However at any clinical picture or at any clinical syndrome (or their combina-
tion), it follows to begin the instrumental examination of patient from roengtenogra-
phy of pectoral cavity which in most cases allows to set the concrete nosological form
of disease.
Algorithm of patients with suspicion on the acute surgical diseases of lungs and
pleura examination.

Pain in breasts, acute dyspnea of breath,

cough, that acutely arosing up, pulmonary
bleeding, festering intoxication.

Sciagraphy of thorax

Spontaneous pneumothorax. Strange body of bronchi. Medias-

tinitis. Abscess of lungs. Bronchoectasises. Empyema of pleura.
Gangrene of lungs. Central cancer of lungs. Peripheral cancer of
lungs. Destructive forms of pyopneumothorax. Tuberculosis.

Additional examination for clarification of diagnosis

Pleural puncture Fibro-esophago-gas- Bronchoscopy CТ

troduodenoscopy

Roentgenologic investigation of esophagus

Empyema of The damage of Central cancer of Pneumothorax.

pleura. Pyopneu- esophagus lungs. Strange body of Cancer of lungs
mothorax Jammed di- bronchi. Damage of Abscess of lungs
aphragm’s hernia trachea. Atelectasis of Destructive forms
particle or all lung of tuberculosis
Bronchiecasises
Pyopneumothorax
Mediastinitis

Features of clinical picture and medical treatment of surgical diseases of

lungs and pleura.
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Pneumothorax is accumulation of air in a pleura cavity, which brings lungs
over and reductions of respiratory surface to squeezing.
Depending on distribution distinguish:
- traumatic,
- spontaneous,
- limited (<1/3 volume),
- subtotal or middle (to 2/3 volume),
- total or large (>2/3 volume),
- one-sided,
- bilateral,
- valval and tense.
Spontaneous pneumothorax is the disease conditioned by the sudden hit of air
in a pleura cavity, unconnected with a trauma or surgical manipulations. Витончення
of walls making progress is a direct factor and located subpleural emphysematous
bulls bursting due to a different increase of intra-abdominal pressure (in 80-85% re-
lated to implementation of physical fag or power exercises during employment by
sport).
Clinical picture: pain in breast, dyspnea, often nascent cough, tachycardia, re-
duction of respiratory noises on the side of impression, warp an eye sound at percus-
sion, displacement of mediastinum in an opposite side.
Principles of medical treatment is complete deleting of air from a pleural cavity
and possible early violence collapsing lungs: pleural puncture, drainage of pleural
cavity, videothoracoscopy, economy resection the lungs.
Exudative pleuritis is inflammation of parietal and visceral pleura that is ac-
companied by accumulation of serous or festering exudates in a pleural cavity. It can
be aseptic or festering and is examined as the pathological state that complicates pro-
cesses in lungs.
Clinic (basic symptoms): pain in a side, violation of breathing (dyspnoe),
cough, increase of temperature of body, weakness, lag of proper half thorax in the act
of breathing, shortening of percutory sound, acute weakness of the vocal shaking and
respiratory noises.
Principles of medical treatment: deleting of the accumulated liquid and vio-
lence of pursing lung equally with by clarification of pathological process, that caus-
ing the exudative reaction of pleura: thoracoscopy, biopsy of pleura and lungs,
drainage of pleural cavity.
Empyema of pleura is inflammation of pleura sheets with accumulation of pus
between them. Distinguish: specific (tuberculosis, actinomycosis) and unspecific.
Classification: On the clinical flow:
1. Acute (to 3 months)
2. Chronic (> 3 months)
On the presence of destruction lungs:
1. Empyema without destruction (simple)
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2. Empyema with destruction of lungs
3. Pyopneumothorax
On communication with an external environment:
1. Closed
2. Opened:
- with bronchi-pleural fistula;
- with pleural-skin fistula;
- with bronchi-pleural-skin fistula;
- with the latticed lung;
- with other cavitary organ.
On prevalence:
1. Limited (encysted);
2. Subtotal;
3. Total.
Clinic: acute beginning, high temperature (38о-39о), fever, pain in breast, pro-
moted perspiration, common indisposition, absence of appetite, cough (dry or with
festering sputum), tachycardia, dyspnea, different weakness or absence of respiratory
noises.
Medical treatment:
1. Valuable aspiration of pus with washing of pleural
cavities by antiseptic (drainage + active aspiration);
2. Temporal occlusion of bronchi at presence of fistula;
3. Massive antibacterial therapy;
4. De-toxicous therapy;
5. Immune-corrective therapy;
6. General strengthening medical treatment;
7. At chronic empyema - operative medical treatment
(pleurectomy with decortication, resections of lungs).
Pneumothorax is one of the heaviest complications of acute infectious destruc-
tions of lungs that are accompanied by violation of cortical surface and visceral pleura
of lungs with the breach of pus and air in a pleura cavity. It is accompanied by devel-
opment of pleural-pulmonary shock in the moment of its origin. Most danger is here
represented by the origin of valvular mechanism that can result in development of
tense pneumothorax, collapse the lungs with acute displacement of mediastinum with
violation of ebb of blood in the system of cavitary veins.
Clinic: the symptoms of cardiovascular (the arterial pressure falling, tachycar-
dia) and respiratory insufficiency (dyspnea, cyanosis), which depend on a volume of
collapsing lungs, prevail, magnitude of infected pleural cavity by festering mainte-
nance, presence or absence of valvular mechanism in pathologic connection with air
ways, dynamics of destructive changes in the staggered lung.
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Medical treatment must begin as possibly earlier and be complex (drainage +
active aspiration + sanation + antibacterial therapy). Surgical medical treatment: tho-
racoscopy, decortication of lungs; thoracoplasty.
The abscess of lungs is the disease that is characterized by formation of cavity
in pulmonary tissue marked off from uncrippled departments by a biogenic capsule
and infiltration billow or fibrous tissue (at chronic abscesses). An infection at an ab-
scess gets in lungs in various ways: aspirate (bronchopulmonary), hematogenous -em-
bolic, lymphogenous and traumatic.
Clinic: two periods are selected: to the breach and after the breach of abscess in
bronchi. Increase of temperature of body to 38 о-40о, pain in a side at the deep breath-
ing and cough, tachycardia and tachypnea, cough up of festering sputum with an un-
pleasant smell in great numbers. At defending of sputum three layers appear in a jar:
lower - pus and detritus middle - serous liquid, overhead - foamy - from mucus.
The gangrene of lungs is diffuse festering-putrid necrosis of lungs’ tissue
without the tendency of limitation with distribution of area of necrosis and disintegra-
tion that is accompanied by heavy intoxication, by the threat of development of sep-
sis, polyorganic insufficiency or septic shock.
Basic principles of medical treatment of festering-destructive disease of lungs:
1. Maximally complete devastated of cavities that have festering mass.
2. Antibacterial therapy with the account of sensitiveness of microflora.
3. General medical treatment, directed on the removal of intoxication, correc-
tion of all types of account, stimulation of protective reactions of organism.
4. Operative medical treatment is indicated:
- at the gangrene of lungs after correction of basic indexes of home-
ostasis, stabilization of the state of patient and sanation of cell
destructions;
- at the pulmonary bleeding which threaten to life of patient, which are
not long stopped;
pulmonary bleeding;
- at the chronic abscess of lungs.
Storages of vent and respiratory volumes of lungs are terms to implementation
of resection of lungs not below 50-60% from the proper, absence of decompensation
of vital. At the widespread gangrene of lungs pulmonectomy is executed, and at gan-
grenous and festering abscesses - lobectomy.
Bronchiectatic disease.
Bronchiectasises are irreversible cylinder or saccate expansions of segmental
and subsegmental bronchial tubes with the loss of their drainage function. They can
be primary (innate) or second (how complication of tuberculosis and chronic purulent
processes of lungs).
Three stages of development of bronchiectasises are distinguished:
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1 stage - changes are limited by expansion of shallow bronchial tubes by the di-
ameter 0,5-1,5 mm of wall of bronchial tubes is not changed, suppuration in them is
not present; cavities are filled by mucus;
2 stage - the inflammatory changes in the walls of bronchial tubes, extended
join bronchial tubes contain pus;
3 stage - transition of suppuration process is marked from bronchial tubes on
surrounding pulmonary tissue with development of pneumosclerosis. The cavi-
ties of the extended bronchial tubes are filled by pus.
Conservative medical treatment is indicated to the patients in the I and the ІІ
stage, and also patients to which surgical medical treatment contra-indicated.
Deleting of the staggered part is operation of choice lungs: segmentectomy,
lobectomy, bilobectomy.
The pulmonary bleeding behaves to the number of most dangerous complica-
tions of lungs and bronchial tubes diseases.
Hemoptysis is distinguished, during the selection with sputum daily to 50 ml
blood and pulmonary bleeding. Three degrees are selected to bleeding:
I degree - volume of daily hemorrhage - to 300 ml.
ІІ degree - volume of hemorrhage daily - 700 ml.
ІІІ degree - volume of hemorrhage > 700 ml.
Bleeding arises out of the extended and refined areas of branches of bronchial
arteries.
In a diagnostic plan there is the row of problems at the grant of help:
Firstly - necessary to conduct differential diagnostics between the pulmonary
and gastrointestinal bleeding.
Secondly - necessary to set localization and source of the pulmonary bleeding.
Thirdly - necessary to specify character and prevalence of pathological hearth
in lungs.
Principles of medical treatment. More for everything it is necessary to conduct
measures after the stop of bleeding, to provide permeability of respiratory tracts, sup-
pression of cough, to the decline of pressure in the small circle of circulation of blood,
medical treatment of anaemia, antibacterial prophylaxis of aspiration pneumonia.
At bleeding from bronchial arteries in a recent year is successfully used en-
dovascular embolization of bronchial arteries.
The uneffective of complex conservative therapy are indications to implementa-
tion of radical interference at continuation of the pulmonary bleeding. The resection
of the staggered particle is operation of choice in such case lungs with the removal of
source of bleeding. Decompensation of function is contra-indication to surgical inter-
ference vital and systems of organism.
6. Materials of the methodical providing of lesson.
6.1 Task for individual control of initial level of knowledges - abilities:
1. Surgical anatomy of lungs and pleura.
2. Functional description of organs of breathing.
 14
3. Pathological mechanisms of violations of the pulmonary breathing.
4. Pathomorphology of basic surgical diseases of organs of breathing.
5. Algorithm of inspection of patients with suspicion on surgical pathology of
lungs and pleura.
6. Syndromal description of pathological process of lungs and pleura.
7. Roentgenologic methods of investigation.
8. Special methods of investigationh.
9. Additional inspections for clarification of diagnosis.

Tasks and tests.

1. What is provided by a diaphragm?
а) inhalation (+)
b) exhalation
2. Specify the tasks of overhead respiratory tracts:
а) cleaning, that air inhales (+)
b) heated (+)
c) moistening (+)
3. What size of vital capacity of lungs at adults in a norm?
а) 2800 ml (+)
b) 4800 ml
c) 6800 ml
d) 8800 ml
4. Most informing research at diagnostics of pulmonary embolism?
а) angiography of lungs (+)
b) scanning
c) analysis of gases
d) roentgenography
e) ECG
5. Clinical symptoms at the shrine of lungs which testify to distribution of tu-
mour outside lungs?
а) pain in a side
b) change of character of cough
c) hoarse of voice
d) pleural exudate
6. Most frequent factors of abscess of lungs:
а) infarction of lungs
b) bronchial adenoma
c) viral pneumonia
d) aspiration pneumonia (+)
e) asthmatic attack
7. Name the most frequent localization of abscess of lungs:
а) overhead particle of left lung
 15
b) lower particle of bottom lung
c) overhead particle and back segment of right lung (+)
d) middle particle of right lung
e) tongue segments
8. In case of recurrent pneumonia what does it follow to think about?
а) tuberculosis of lungs
b) bronchiectatic disease
c) cancer of lungs (+)
d) abscess of lungs
9. Whatever pathology meets at an acute abscess of lungs?
а) pulmonary bleeding
b) pyopneumothorax
c) malignization (+)
d ) sepsis
10. What is the characteristic symptom of acute abscess of lungs?
а) expressed dyspnea
b) cough with a plenty of sputum (+)
c) rapid loss of weight of body
d) change of forms of nail phalanxes of brush

6.2. Information necessary for forming of knowledges - abilities it is possible to

find in textbooks:
-For students
1. General surgery: a textbook / M. D. Zheliba, S. D. Khimich, I. G. Gerych et al.:
edited by professors M. D. Zheliba, S. D. Khimich. - K.: VSV "Medicine", 2016. -
448 p.
2. General surgery: textbook for students. higher education institutions / edited by
prof.: Y. S. Bereznytskyi, M. P. Zakharash, V. G. Mishalova, V.O.Shidlovskyi. –
Vinnytsia: Nova Kniga, 2018. – 344 p. :
3. V. I. Pantio General surgery: a study guide / V. I. Pantio, V. M. Shimon, O. O.
Boldizhar - Uzhhorod: IVA, 2020. - 464 p.
-For teachers
1. Endoscopic surgery: training manual/V. M. Zaporozhan, V. V. Grubnik, etc.;
under the editorship V. M. Zaporozhana, V. V. Hrubnika. - K.: VSV "Medicine",
2019. - 592 p.
2. General surgery: textbook / S. D. Khimich, M. D. Zheliba, , I. G. Gerych et al.:
edited by professors S.D. Khimich, M.D. Zheliba, - K.: VSV "Medicine", 2018. -
608 p.
3. General surgery: a textbook / M. D. Zheliba, S. D. Khimich, I. G. Gerych et al.:
edited by professors M. D. Zheliba, S. D. Khimich. - K.: VSV "Medicine", 2016. -
448 p.
4. General surgery: textbook for students. higher education institutions / edited by
 16
prof.: Y. S. Bereznytskyi, M. P. Zakharash, V. G. Mishalova, V.O.Shidlovskyi. –
Vinnytsia: Nova Kniga, 2018. – 344 p. :

6.3. Orienting card in relation to individual work with literature from the
theme of lesson.
№ Basic tasks Pointing Answers
1 2 3 4

7. Materials for self-control of quality of training

А. Questions for self-control.

1. Classification of suppurative diseases of lungs and pleura.
2. To define a concept "empyema of pleura" and "pyopneumothorax".
3. Roentgenologic diagnostics of surgical diseases of lungs and pleura.
4. Basic factors and classification of spontaneous pneumothorax.
5. Basic clinical syndromes and symptoms of diseases of lungs.
6. Clinic and diagnostics of suppurative processes of lungs and pleura.
7. Differential diagnostics of abscess and gangrene of lungs.
8. Methods of intensive therapy of suppurative diseases of lungs and pleura.
9. General and transfusion therapy.
10.Indications to radical surgical medical treatment.

B. Tests for self-control with the standards of answers.

1. Basic factors of abscess and gangrene of lungs:
а) aspiration of contaminate material from a mouth and nasopharynx (+)
b) penetration of infection by lymphogenic way
c) penetration of infection through a blood
d) penetrating wounds of breast
e) bronchial carcinoma
2. To the late symptoms of cancer of lungs belong:
а) hemoptysis
b) exudative pleurisy
c) atelectasis of lungs (+)
d) increase of temperature of body
3.What is characteristic for tense valvular pneumothorax?
а) tachycardia, falling of arterial pressure
b) collapse of lungs, displacements of mediastinum in a healthy side (+)
c) atelectasis of lungs, displacements of mediastinum in a sick side
d) high standing of diaphragm on the side of impression (+)
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4. The most informing method of examination of the state of bronchial tubes?
a) tomography
b) bronchoscopy (+)
c) bronchography
d) angiopulmonography

5. The factors of penetrating can be:

a) tuberculosis of lungs
b) bronchiectatic disease (+)
c) bronchial carcinoma (+)
d) mitral stenosis
e) thromboembolism of lung’s artery
f) all above enumerated
6. What differs cancerous pulmonitis from pneumonia?
а) by the continued fever
b) by atelectasis of lungs (+)
c) by the abundant selection of festering sputum
d) all answers are faithful
7. Abscesses of lungs more frequent arise up at:
a) lesion of lungs
b) obturation of bronchi by strange body
c) aspiration pneumonias (+)
d) embolisms of lungs’ vessels (+)
8. The factor of spontaneous pneumothorax is:
а) bullous emphysema
b) a cyst of lungs
c) tuberculosis of lungs
d) a cancer of lungs
e) all above enumerated (+)
f) nothing of transferred
9. Most informing at bronchiectatic disease is:
а) roentgenography of thorax
b) angiography
c) scanning of lungs
d) bronchography (+)
e) CТ (+)
10. Treatment of choice at empyema of pleura.
а) decortication
b) pulmonectomy
c) antibecterial therapy
d) injection of streptocynase to the pleural cavity
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C. Tasks for self-control with answers.
Task № 1. At the patient К., 60 years, that treats oneself in hospital with the
acute abscess of right lung suddenly the state became worse: there was acute pain in
breast, which is accompanied by an acute dyspnea. What complication does it follow
to think about?
Answer: pyopneumothorax.
Task № 2. Patient J., 20 years, appealed to the induction centre of hospital with
complaints about pain in left, impossibility of complete inhalation, weakness, sweat-
ing. The state became worse acutely after the physical fag. What disease does it fol-
low to suspect? What is necessary for clarification of diagnosis?
Answer: 1. Spontaneous pneumothorax.
2. Roentgenography.

Task № 3. At patient P., 19 years with spontaneous pneumothorax pleural cavity

was drainaged. Pleural cavity do not closed during 5 days. On a control
roentgenogram the lung collapsed on ½ of the volume. What your subsequent tactic?
Answer: thoracotomy (videothoracoscopy), resection of the lungs.

Task № 4. Patient U., 30 years, grumbles about a permanent cough with the
separation of mucous-festering sputum in great numbers, more frequent in the morn-
ing. It is ill from childhood. During 3 months periodically looks after the veins of
blood in sputum. What pathology does it follow to think about?
Answer: bronchiectatic disease.

Task № 5. At the patient К., 68 years, that appealed to the doctor concerning
hypertensive disease, on the prophylactic roentgenogram of lungs the exposed homo-
geneous darkening of left hemithorax with displacement of mediastinum in the side
of darkening. What research does it follow to appoint to the patient for clarification of
diagnosis?
Answer: broncjoscopy.

Task № 6. Patient Z., 64 years, treats oneself in a hospital concerning right side
exudative pleurisy. In anamnesis is mastectomy 5 years backwards. During pleural
puncture got haemorrhagic exudate by a capacity more than a 1 liter. Name the possi-
ble factor of exudation.
Answer: metastatic lesion of pleura.

Task № 7. At a patient B., 49 years, during dinner there was the fit of the acute
coughing in a restaurant, that does not stop to embarrass him during 2 days. Appealed
to the doctor. What reason of cough does it follow to think about?
Answer: strange body of bronchi.
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Task № 8. At a patient A., 58 years, with an exudative pleurisy after deleting of
2 liters of haemorrhagic exudate at puncture of pleural cavity, acutely the state be-
came worse: pain increased to unendurable in breast and the expressed dyspnea ap-
peared. What pathology is this state conditioned by?
Answer: mesothelioma of pleura.

Task № 9. Patient B., 57 years, during 6 months suffers by a relapsing right

side exudative pleurisy not of clearing genesis. A few times treated oneself in thera-
peutic clinic. What research will allow setting a morphological diagnosis?
Answer: thoracoscopy, biopsy of pleura

Task № 10. At patient C., 42 years, during a prophylactic examination on FG

an exposed round neoplasm in the overhead particle of left lung. In supraclavicular
area a megascopic lymphatic node is certain on the left. What investigation must be
executed above all things?
Answer: grinned biopsy.

8. Materials for audience individual training.

8.1. List of educational practical tasks which it is necessary to execute under
time of practical lesson:
1. Puncture of pleural cavity.
2. Drainage of pleural cavity.
3. Puncture and drainage of abscess of lungs.
4. Intratracheal injection of antibiotics.
5. Imposition of micro-tracheostomy.

9. Instructional materials for the capture by professional abilities, skills:

9.1. Method of implementation of work, stages of implementation.
9.1.1.: treatment of skin by solution of antiseptic;
- anaesthetizing of skin and intercostal cavity 0,25-0.5% solution of
novocain;
- puncture of pleura by a thick needle, oriented on the overhead edge
of lower rib;
- aspiration of maintenance through transitional.
9.1.2.: treatment of the operating field by antiseptic;
- local anaesthetizing of soft tissues in the point of future injection of
drainage;
- diagnostic puncture of pleural cavity;
- additional anaesthetizing of two compatible intercostal intervals with
injection of antiseptic under visceral pleura;
- dissection of soft tissues in the place of injection of drainage by
length of to 1,5 sm;
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- thoracocentesis, injection of drainage to the pleural cavity on a depth
7-10 sm;
- fixing of drainage by a key stitch to the skin;
- connecting of drainage to the vehicle of active or passive aspiration.
9.1.3.: multi-axillar roentgenoscopy with the mark of lungs abscess cavity pro-
jection on a pectoral wall;
- subsequent manipulations to look at p.p. 9.1.1 and 9.1.2.;
- after aspiration maintenance of abscess - washing up its cavity by so-
lution of antiseptic, after the previous taking away of pus for antibi-
otic-gram, to clean waters;
- in the case of cavity of abscess drainage, connecting of drainage to
the system of passive aspiration.
9.1.4. anaesthetizing of skin on a neck by solution of novocain in a tracheas
projection;
- after trachea fixing between fingers to enter a puncture needle be-
tween the rings of trachea in its cavity;
- not taking out a needle through its road clearance to enter solution to
the antibiotic on 5-6 ml of physiological solution.
9.1.5. - after puncture of trachea through the road clearance of needle fish-
ing-line - explorer in direction of bifurcation is entered;
- fit of coughing supressed by intratracheal injection of 0,5-1% solu-
tion of novocain;
- on fishing-line - explorer in a trachea micro-irrigator by diameter
more than 1,0 is entered and is fixed on a neck;
- through micro-irrigator solution of antibiotics is entered in a trachea
5-6 times per day.

10. Materials for self-control of capture by knowledges, by abilities, skills:

10.1. Tests of different levels
1. For the differential diagnosis of large emphysematous bulls and pneumothorax the
most sensible method is:
а) roentgenography on height of output;
b) multi-axillary roentgenoscopy;
c) roentgenogram in lateral position;
d) CТ;
e) bronchogram.
2. Name the primary purpose of medical treatment of spontaneous peumothorax:
а) prophylaxis of origin of bronchial asthma;
b) cupping of pain syndrome;
c) removal and prevention of repeated pneumothorax;
d) reduction the degree of dyspnea;
e) reduction terms of stay in hospital.
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3. What is iatrogenic pneumothorax?
а) complication of lungs diseases;
b) arises up in default of lungs diseases;
c) as a result of dull trauma of thorax;
d) at the penetrating wounds of lungs;
e) as a result of raising of subclavicular catheter.
4. Specify the method of urgent medical care at tense of pneumothorax:
а) injection of analgetics, including narcotic;
b) conducting of intercostal novocaine blockade;
c) intubation of trachea and conducting of artificial ventilation of lungs;
d) urgent thoracocentesis;
e) urgent thoracotomy.
5. What factors are predisposed to the thromboembolism of lung’s artery develop-
ment?
а) not mobility after operation;
b) cardiac insufficiency;
c) obesity and declining years;
d) plastered fractures of lower extremities;
e) varicose expansion of veins of extremities.
6. Name possible complications at the abscess of lungs:
а) abscess of cerebrum;
b) meningitis;
c) dissemination of process;
d) pulmonary bleeding;
e) pyopneumothorax.
7. Transfer contra-indication to conducting of bronchography:
а) cylinder bronchoectasises;
b) hemoptysis;
c) intolerance of iodine;
d) atelectatic bronchiectasises;
e) destructive bronchiectasises.
8. What in the analysis of pleural liquid at empyema of pleura is not faithful?
а) exudate (relative closeness higher 1,015);
b) level of albumen higher 30 г/л;
c) the Rivalt’s test is positive;
d) leucocytes - higher 15;
e) concentration of glucose more high to concentration of glucose in a blood.
9. Name roentgenologic signs characteristic for atelectasis:
а) collapse of lungs with displacement of mediastinum in a healthy side;
b) rounded cavitary forms in lungs with the horizontal levels of liquid;
c) three-cornered form intensive homogeneous shade with clear scopes with the
top directed to the root the lungs;
 22
d) reduction of volume of staggered parts of lungs with displacement of medi-
astinum in a sick side;
e) poly-cyclic expansion of mediastinum from one or both sides with reduction
of pulmonary surface.
10. What is decortication of lungs?
а) imposition of artificial oleothorax on the side of impression;
b) at presence of bronchial fistula - tamponada proper bronchi;
c) deleting of the thickened layer of pleura;
d) wide thoracotomy with the resection of ribs
e) resection of lungs with pleurectomy.

11.Theme of a next lesson - in obedience to the curriculum of lessons.