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TnJ > 105. Thoracic Cavity > Flashcards

105. Thoracic Cavity Flashcards

1
Q

Reported outcomes of nonsx tx for chylothorax

A

Pleural evacuation–26%Rutin–67%(cats)Octreotide–40%Low fat diets

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2
Q

Octreotide to tx chylothorax

A

Octreotide = somatostatin analogue (also used to treat insulinoma)Decreases chyle flowVariable success 40%

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3
Q

Rutin for tx of chylothorax

A

Rutin= benzopyrene from Brazilian fava d’anta treeMx suspected to decrease lymphatic leakage, increase protein removal/increased proteolysis, increase macrophagic numbers and phagocytic function

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4
Q

TDL alone success for chylothorax

A

Dog 50-59%Cat 14.3-53%not much better than 50:50 when alone

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5
Q

TDL + subtotal pericardiectomy success for chylothorax

A

Dogs 60-100%Cats 80%

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6
Q

TDL+ CCA success rates for chylothorax

A

Dogs 83-87.5% (>80%)Cats not reported

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7
Q

TDL+ subtotal pericardiectomy + thoracic omentalization success rates for chylothorax

A

Dogs 72.7%Dogs and cats 57%not much benefit than TDL and pericardectomy combo

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8
Q

Thorascopic TDL w pericardiectomy success rates for chylothorax

A

Dogs 85.7%

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9
Q

Consider CCA with recurrence of chyle flow for treatment of recurrent chylothorax

A

Lymphatic hypertension leads to formation of secondary lymphatics following TDLRecurrent chylothorax may be seen–consider CCA Reported in dogs 83-87.5% success

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10
Q

Fossum et al in 2004 Success rates for subtotal pericardiectomy for chylothorax

A

TDL+ SP100% (10/10) dogs80% (8/10) cats

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11
Q

Thoracic omentalization for chylothorax treatment

A

Pass mall amount of omentum through the pars costalis of the diaphragm or through SQ tunnelShould help w absorption however some speculate that lymph from omentum will drain into TD anyways

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12
Q

Pleurodesis

A

Creation of adhesion between parietal and visceral pleuraMechanical (gauze)Chemical (tetracycline)autologous blood has also been reported

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13
Q

most complication of chylothorax surgery

A

Persistent effusion ( most common )– chylothorax or nonchylous40% occur even despite diagnostic imaging confirmation of occlusionDue to failure to locate branches at time of surgery, new branches forming, or previously non patent branches now open 1-50 days post op

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14
Q

TD Embolization for chylothorax treatment

A

Cyanoacrylate glue- inject from catheterization of mesenteric lymph vessel. Eliminates need for thoracotomy 1989 Pardo et al success8/8 healthy dogs 2/6 33% in natural dz dogs

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15
Q

DeSilva and Monnet in 2011 stated what about long term outcome of dogs tx w TDL, thoracic omentalization and subtotal pericardiectomy for chylothorax treatment

A

w TDL thoracic omentalization and subtotal pericardiectomy 73% (8/11) were free of clinical signs up to 5 years post opnot much benefit than TDL and pericardectomy combo

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16
Q

Dog vs cat anatomy of TD

A

begins sublumbar region (btwn diaphragmatic crura) as an extension of the cisterna chyli (retroperitoneal lymph channel sits on floor of 1-4 lumbar vertebra)Dog right in caudal thorax then crosses to left at 5th-6th thoracic vertebra Cat leftterminates in the left external jugular vein or jugulosubclavian anglePRIMARY CHANNEL FOR THE RETURN OF LYMPH FROM MOST OF THE BODY EXCEPT RIGHT thoracic limb, shoulder and cervical region

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17
Q

Location of cisterna chili and surgical approach

A

The cisterna chyli is a bipartate, dilated, retroperitoneal lymph channel that lies ventral to the first through fourth lumbar vertebrae along the cranial abdominal aortaMEDIAL to left kidney hilusapproach: ventral midline or LEFT paracostalcan use intestinal lymphangiography or methylene blue injection to visualize

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18
Q

normal pleural fluid

A

cell < 500protein < 1.5

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19
Q

exudate pleural fluid

A

cell >5000-7000protein > 3.0SG >1.025

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20
Q

transudate vs modified transudate pleural fluid

A

TRANSUDATEcell < 1500protein < 2.5SG < 1.015MODIFIED TRANSUDATEcell 1500-7000protein 2.5-5SG 1.015-1.025

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21
Q

origin of thymus

A

3rd pharyngeal pouchgrows until 45 days of age and then involutescranial to heartHassal bodies (seen on cytology)fx Cell mediated immunity (T cells–maturation and enhancement)

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22
Q

volume of air remaining in the lung at the end of normal exhalation

A

45 ml/kgfunctional residual capacity

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23
Q

minute ventilation

A

= tidal volume (volume taken in with each breath) x RRestimated tidal volume is usually 10-15 ml/kg

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24
Q

based on the summation of starling forces how is net absorption and fluid production achieved

A

fluid production: parietal pleura produces fluid into parietal spacefluid absorption: visceral pleural absorbs fluid via lymphatics/capillariesabsorption is encouraged by movement

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25
Q

4 mechanisms of fluid production within the thoracic cavity

A
  1. incr hydrostatic pressure (R-CHF)2. decr colloid oncotic pressure (hypoalbuminemia)3. incr vascular permeability (inflm conditions)4. decrease lymphatic drainage (vascular/lymphatic obstruction)
26
Q

clinically useful classification (not laboratory classification) of thoracic pleural effusion

A
  1. pure transudate2. hemorrhagic/serosanguineous 3. inflammatory4. chylous5. neoplastic
27
Q

chylous effusion characteristics

A

—white/pink white opaque–modified transudate with cell counts < 7000 but higher protein 2.5-4–SMALL LYMPHOCYTES PREDOMINATE , but can have mixed inflammation

28
Q

4 methods to confirm effusion is chyle

A

–Sudan black test–ether clearance test–detect chylomicrons in fluid–effusion: high TG and low cholesterol

29
Q

causes of chylothorax

A

anything that increases hydrostatic P in the cranial cavaor leakage of lymphatics1. trauma (penetrating/blunt)–may resolve on own 1 wk2. iatrogenic (surgery–ie. post op PDA)3. idiopathic****4. R CHF5. Heartworms6. obstructive disease–pericardial effusion7. neoplasia (heart base, mediastinal)8. lymphangectasia9. congenital malformations of thoracic duct10. diaphragmatic hernias11. jugular vein thrombosis

30
Q

septic effusion with pyothorax microorganisms cultured

A

usually poly microbial (aerobes and anaerobes)also culture for actinomyces and nocardia ( gm positive acid fast filamentous rods—sulfur granules)

31
Q

diagnostic tests for pleural effusion

A
  1. rads 3 view thoracic2. diagnostic/therapeutic thoracocentesis3. cytology, culture, cell counts, biochem analysis4. US +/- FNA, trucut5. CT +/- FNA, trucut6. echocardiogram is suspect cardiac disease7. CBC/Chem/UA8. arterial blood gas
32
Q

radiographs as a sensitive indicator of pleural effusion

A

SNcan detect small volumes 100 ml in dogs 50 ml in cats

33
Q

continuous suction pressure recommendations for evacuation of fluid/air from thoracic cavity

A

5-10 cm H20

34
Q

what is the complication rate for maintaining a thoracostomy tube and list possible complications

A

22%–discharge at insertion site–accidental removal/premature removal–kinking/obstruction–tube/adapter leakage –>pneumothorax–sub cutaneous emphysema

35
Q

descrube a three bottle suction system

A
  1. suction control 2. water seal chamber 3. collection reservoir (collects fluid from patient: quantify and visualize color, clarity characteristic)
36
Q

goal of thoracostomy tube production prior to removal

A

< 2 ml/kg/daysome studies showed average of 3-5 ml/kg/d at tube removal with no significant difference in time to discharge from hospital so 2 ml/kg/day is a guidelinealso do cytology and cell counts +/- culture if indicated to note progress

37
Q

recommended intercostal thoracotomy site for thoracic duct ligation in dog vs cat

A

dog RIGHT 8-11 ICcat LEFT 8-11 IC+/- addition of a paracostal abdominal approach for lymphangiography and/or CC ablation

38
Q

common complications after thoracotomy

A

–wound complications up to 70%–thoracostomy tube complications 22%–death or euthanasia up to 20%–painpatients w chylothorax and pyothorax had longer duration of tube placement and more complications

39
Q

most common cause of pneumothorax in small animals

A

leakage from thoracic wall penetration (dog bites, gunshots, stab wounds)other causes leakage from airway (blunt trauma, bullae/blebs, spontaneous) or esophagus (trauma, FB, neoplasia, fistula, diverticulum)

40
Q

treatment for spontaneous pneumothorax

A

siberian huskies over representedbilateral and bled/bullae presentCT to look for underlying parenchymal disease and to look for location of lung lobectomy.+/- pleurodesis (autologous blood, mechanical)continuous vs intermittent suction post op

41
Q

recurrence rate and mortality for surgical and medical therapies for spontaneous pneumothorax

A

WITH SURGERY recur 3% mortality 12%WITHOUT SURGERY recur/mortality 50%

42
Q

breeds predisposed to chylothorax

A

Afghan hounds (also 133 x risk of lung lobe torsion)siamese cats

43
Q

sequele of chronic chylothorax

A

fibrosing pleuritisdesquamated mesothelial cells increase production of type 3 collagen and promote fibrosismay restrict pulmonary expansion

44
Q

list diagnostic (pre and intraoperative) methods to determine thoracic duct location and branches

A

preop: lymphangiography with CT, MRI, or rads following iohexol injection of a popliteal LNintraop: inject <0.2 ml and dilute methylene blue into popliteal or mesenteric LN, canalization of an intestinal lymphatic efferent with injection of methylene blue/iohexol (intestinal lymphangiography) OR feed patient heavy whipping cream 3-4 hours before surgery

45
Q

list surgical options for treatment for chylothorax

A
  1. pericardectomy2. TD ligation3. CC ablation4. omentalization5. pleurodesis6. MI thorascopic TD ligation7. embolization of TD8. pleuro-peritoneal shunting9. VAP placement for palliative removal of fluidANY COMBINATION OF THE ABOVE
46
Q

dose of iohexol for popliteal lymphangiography, how long will it take to appear in TD

A

iohexol 60 mg of iodine/kg (can dilute 1:1)contrast appears in TB in 2-13 minutesrads, CT, MRI

47
Q

dose of methylene blue for intraop intestinal lymphangiography, how long will it take to appear in TD

A

0.2 ml methylene blue dilute with salineseen within 10 min and persists for 60 minscomplications: heinz body anemia and renal failure

48
Q

methods of TD ligation

A

as far caudally in the chest as possible (area of the fewest branches)–hemoclips–individual ligation with non absorbable suture–enbloc (all tissue above aorta, ventral to sympathetic trunk, may or may not need to ligate azygous vein)

49
Q

which branches of the TD are most commonly missed

A

left sided branches!bc approach is right sided in dogs may need to repeat postligation lymphangiography

50
Q

other than recurrent chylous or nonchylous effusion what are other complications with surgery for chylothorax

A

–lung lobe torsion–pneumothorax–recurrent effusion

51
Q

management for recurrent effusion

A

—percutaneous drainage system (indwelling SQ vascular access ports or JP drain)–pleuroperitoneal shunting (50% short term comp/75% long term comp)–Denver catheter

52
Q

T/Fmedical therapy has been associated with success in more feline than canine patients

A

TRUEmedical management in canines was 5.4 times more likely to fail than surgical management

53
Q

thoracic lavage with chest tube for pyothorax cases

A

10-20 ml/kg sterile crystalloidsencouraged to move30 minutes then aspirate

54
Q

pyothorax DFI with surgery vs med mgmt

A

DFI with pyothoraxat 6 months 85% sx vs 30% without sxat 12 months 75% sx vs 25% without sx

55
Q

most common neoplasia causing malignant effusion

A

–mesothelioma–carcinoma(less frequently thymoma and lymphoma)

56
Q

T/FNeoplastic conditions associated with pleural effusion have a significantly shorter survival time than those associated with inflammatory effusions

A

TRUEneoplastic effusion–15 daysinflammatory effusion– >785 days

57
Q

most common thymic mass in dogs vs cats

A

dogs–thymomacats–thymic lymphoma (usually FeLV +)US/CT to look for invasivenessgood prognosis if noninvasive and surgical excision achievedlymphoma suspect on cytology/biopsy (flow cytometry to ddx and thymoma has more epithelial cells) is a contraindication to surgery!

58
Q

MST of surgically excised thymoma

A

dogs 800 dayscats 1800 days

59
Q

paraneoplastic syndromes seen with thymoma

A

myasthenia gravis (50% dogs with thymoma +/- megaesophagus)hypercalcemia

60
Q

name possible causes for spontaneous pneumothorax

A

–bullae–blebs–heartworm–eosinophilic bronchitis–chronic pneumonia–abscessation–asthma–neoplasia–emphysema–migrating plant material

TnJ (128 decks)

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