25 Thoracic Flashcards
Course of the azygos vein
Right side
Dumps into SVC
Course of thoracic duct
Right side > crosses midline at T4-5 > dumps into L SCV at junction with IJV
Course of phrenic nerve in relation to the lung hilum
Anterior to the hilum
Course of vagus nerve in relation to the lung hilum
Posterior to the hilum
Function of type I pneumocytes
Gas exchange
Function of type II pneumocytes
surfactant production
Function of Pores of Kahn
Direct air exchange between alveoli
Pre-op requirements to allow for pneumonectomy?
- Predicted post-op FEV1 > 0.8
> If borderline, get V/Q scan to see how much the lung you are taking out actually contributes - Predicted post-op DLCO >10mL/min/mmHg CO
- pCO2 <50, pO2 >50
- VO2 max >10-12mL/min (max O2 consumption)
DCLO
Measures carbon monoxide diffusion and represents O2 exchange capacity
Depends on pulmonary capillary surface area, hemogloblin content, alveolar architecture
Common complications after lung resections?
Persistent air leak (segmentectomy/wedge)
Atelectasis (lobectomy)
Arrhythmias (pneumonectomy)
Most common site of lung cancer metastases?
Brain
Other: SCLN, other lung, bone, liver, adrenals
T-staging lung cancer?
T1: <3cm
T2: >3cm but >2cm away from carina
T3: Invasion of chest wall, pericardium, diaphragm or <2cm from carina
T4: Mediatinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion (unresectable)
N-staging lung cancer?
N1: ipsilateral hilum nodes
N2: ipsilateral mediastinal or subcarinal (unresectable)
N3: Contralateral mediastinal or suprclavicular (unresectable)
Non-small cell lung cancer
80% of lung CA
Central - SCC
Peripheral - AdenoCA (most common)
Small cell carcinoma
20% of lung CA
Neuroendocrine
Usually unresectable
Chemo-XRT
Paraneoplastic syndromes - PTH-related peptide?
Squamous cell lung CA
Paraneoplastic syndromes - ACTH?
Small cell lung CA (most common)
Paraneoplastic syndromes - ADH?
Small cell lung CA
Mesothelioma
Most malignant Lung CA
Aggressive local invasion, nodal invasion, distant mets
Risk: Asbestos exposure
Chemo for non-small cell lung CA?
For stage II or higher
Carboplatin, Taxol
Chemo for small cell lung CA?
Cisplatin, etoposide
Best single test for clinical assessment of T and N status in lung CA?
Chest and abdominal CT scan
Best single test for clinical assessment of M status in lung CA?
PET scan
Indications for Mediastinoscopy
Centrally located lung CA Suspicious adneopathy (>0.8cm or subcarinal >1.9cm) on chest CT
What can you assess with mediastinoscopy?
Assess ipsilateral (N2) and contralateral (N3) mediastinal nodes Does NOT assess aorto-pulmonary window nodes (left lung drainage) If mediastinal nodes are positive - unresectable
Looking into middle mediastinum with mediastinoscopy - what do you see?
Left-side: RLN, esophagus, aorta, main pulmonary artery
Right-side: Azygous, SVC
Anterior: Innominate vein, innominate artery, right pulmonary artery
Chamberlain procedure
Anterior thoracotomy or parasternal mediastinotomy
Assesses enlarged AP window nodes (#5)
Go through left 2nd rib cartilage
Bronchoscopy
Good for centrally located nodes
Evaluate for airway invasion
Criteria for surgical intervention for lung cancer?
1) operable (appropriate FEV1/CLCO)
2) Resectable (No T4, N2, N3, or M disease)
Pancoast tumor
Tumor invades apex of chest wall
Can cause:
- Horner’s syndrome (ptosis, miosis, anhidrosis)
- Ulnar nerve symptoms
Features suggesting benign disease in lung coin lesions?
No growth in 2 years
Smooth contour
Bronchoalveolar CA
Can look like pnuemonia
Grows along alveolar walls
Multifocal
What metastases to the lung can be resected?
Colon Renal cell CA Sarcoma Melanoma Ovarian Endometrial CA (If isolated and NOT associated with systemic disease
Carcinoids
Neuroendocrine tumor
Central
Tx: resection
Recurrence risk: positive nodes or tumors >3cm
Mucoepidermoid adenoma
Mucous gland adenoma
Malignant lung tumor
Slow growth, no mets
Resection
Adenoid cystic adenoma
From submucosal glands
Spreads via perineural lymphatics
Slow growing
Tx: resection, XRT (very sensitive)
Hamartoma
Most common benign adult lung tumor
Calcifications - popcorn lesions on CT
Does NOT require resection
Confirm dx with repeat CT in 5 months
Most common mediastinal tumor in adults and children? Location?
Neurogenic tumors
Posterior mediastinum
Mediastinal tumors: anterior
Thymus
- Thymoma*
- Thyroid CA and goiters
- T-cell lymphoma
- Teratoma (and other germ cell tumors)
- ParaThyroid adenoma
Mediastinal tumors: middle
Heart, trachea, ascending aorta
- Bronchiogenic cyst
- Pericardial cyst
- Enteric cyst
- Lymphoma
Mediastinal tumors: posterior
Esophagus, descending aorta
- Enteric cysts
- Neurogenic tumor
- Lymphoma
Thymoma
Require resection
Thymus too big/refractory myasthenia gravis - resection
50% malignant
50% symptoms
50% myasthenia gravis
10% of patient with myasthenia gravis have a thymoma
Myasthenia gravis
Fatigue, weaknes,s diplopia, ptosis
Antibodies to acetylcholine receptors
Tx: anticholinesterase inhibitor (neostigmine), steroids, plasmapheresis
80% have improvement with thyomectomy
Mediastinal teratoma
Most common germ cell tumor in mediastinum
Can be benign or malignant
Tx: resection, chemotherapy
Mediastinal seminoma
Most common malignant germ cell tumor in mediastinum
10% b-HCG positive
Should NOT have AFP
Tx: XRT (very sensitive), chemo for mets/bulky nodal disease, surgery for residual
Mediastinal non-seminoma
90% have elevated b-HCG and AFP
Tx: Chemo (cisplatin, bleomycin, VP-16), surgery for residual disease
Bronchiogenic cyst
Posterior to carina
Tx: resection
Pericardial cyst
Right costophrnic angle
Benign - can leave alone
Benign tumors of the trachea
Adults - papilloma
Children - hemangioma
Malignant tumor of the trachea
Squamous cell caricnoma
Most common late complication after tracheal surgery?
Granulation tissue formation
Most common early complication after tracheal surgery?
Laryngeal edema
Treatment of laryngeal edema?
Reintubation
Racemic epinephrine
Steroids
Post-intubation stenosis
At stoma site with tracheostomy, at cuff site with ET tube
Tx:
Minor - Serial dilatation, bronchoscopic resection, laser ablation
Severe, recurrent - tracheal resection with end-to-end anastomosis
Tracheo-innominate artery fistula
Occurs after tracheostomy
Rapid exsanguination
Tx:
- Place finger in tracheostomy hole and hold pressure
- Median sternotomy with ligation and resection of innominate artery
Avoid this complication by keeping tracheostomy above the 3rd tracheal ring
Tracheo-esophageal fistula
Prolonged intubation
Place large-volume cuff endotracheal tube below fistula
May need decompresisng gastrostomy
Repair after patient is weaned form ventilator
Tx: tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea
Lung abscess
Necrotic area - associated with aspiration
Superior segment of RLL
Tx: Abx alone, CT-guided drainage
Surgery if it fails or cannot r/o cancer (>6cm, failure to resolve after 6wks)
Chest CT can differentiate empyema from lung abscess
Empyema
Secondary to pneumoia and subsequent parapneumonic effusion
Associated with esophageal, pulmonary or mediastinal surgery
Sx: pleuritic chest pain ,fever, cough, SOB
Pleural fluid: WBCs >500, bacteria and positive gram stain
Exudative phase of empyema
1st week
Tx: chest tube, Abx
Fibro-proliferative phase of empyema
2nd week
Tx: chest tube, abx, possibly VATS deloculation
Organized phase of empyema
3rd week
Tx: decortication (remove fibrous peel)
Intra-pleural tPA (dissolve the peel)
Eloesser flap (open thoracic window) in frail/elderly
Chylothorax
Increased lymphocytes, TAGs
Sudan red stain
Fluid is resistant to infection
Above T5-6 - left; below - right
Tx:
- Chest tube, octreotid, low-fat diet, TPN
- Traumatic - Ligation of thoracic duct on right side
- Malignant - Talc pleurodesis, chemo, XRT
Massive hemoptysis
>600cc/24hrs Bronchial arteries Tx: - Bleeding side down - Mainstem intubation to other side - Rigid bronchoscopy - Lobectomy/pneumonectomy - Bronchial artery embolization
Spontaneous pneumothorax
Recurrence: 1st - 20%, 2nd - 60%, 3rd - 80%
Tx: chest tube
Surgery - recurrence, air leak >7 days, non-reexpansion, high-risk profession, live in remote areas
Tx: thorascopy, apical blebectomy, mechanical pelurodesis
Catamenial pnuemothorax
Temporal relation to menstruation
Endometrial implants
Residual hemothorax despite 2 good chest tubes?
OR for thorascopic drainage
Clotted hemothorax
Surgical drainage if: >25% lung, air-fluid levels, signs of infection
Do surgery within 1st week to avoid peel
MCC broncholiths
infection
MCC mediastinitis
Cardiac surgery
Work up of whiteout on CXR?
Midline shift toward whiteout - collapse - bronchoscopy to remove plug
No shift - CT scan
Midline shift away from whiteout - effusion - chest tube
Bronchiectasis
Acquired - infection, tumor, cystic fibrosis
No surgical intervention secondary to diffuse nature
Tuberculosis
Lung apices
Get calcifications, caseating granulomas
Ghon complex = parenchymal lesion + enlarged hilar nodes
Tx: INH, rifampin, pyrazinamide
Sarcoidosis
Non-caseating granulomas
Tx: steroids
Pleural fluid: < 1000 WBC Ph 7.45-7.55 Pleural fluid protein to serum ratio < 0.5 Pleural fluid LDH to serum ratio <0.6
Transudate
Pleural fluid: > 1000 WBC < 7.45 Pleural fluid protein to serum ratio > 0.5 Pleural fluid LDH to serum ratio > 0.6
Exudate
Pleural fluid: > 1000 WBC, or >50,000 very specific < 7.30 Pleural fluid protein to serum ratio > 0.5 Pleural fluid LDH to serum ratio > 0.6
Empyema
Treatment for recurrent pleural effusion?
Mechanical pleurodesis
Malignant - talc
Airway fire
Associated with laser
Tx: Stop gas, remove ET tube, reintubate for 24hrs, then do bronchoscopy
Pulmonary AVMs
Connection between pulmonary arteries and pulmonary veins
Lower lobes
Associated with Osler-Weber-Rendu disease
Symptoms: hemoptysis, SOB, neurologic events
Tx: Embolization
MC benign chest wall tumor
Osteochondroma
MC malignant chest wall tumor
Chondrosarcoma
R to L shunts cause?
Cyanosis
Child who squat when having difficulty breathing?
Increases SVR and decreases R to L shunt
Adverse effects of cyanosis?
Polycythemia, stroke, brain abscess, endocarditis
Eisenmenger’s syndrome
Shift from L-R shunt to R-L shunt
Signs of increased pulmonary vascular resistance and pulmonary HTN
Irreversible
L to R shunts cause?
CHF
Failure to thrive, tachycardia, tachypnea, hepatomegaly
First sign of CHF in children?
Hepatomegaly
L to R shunts - causes?
VSD, ASD, PDA
R to L shunts - causes?
Tetrology of fallot
Fetal connection between descending aorta and left pulmonary artery?
Ductus arteriosus
Shunts blood away from lungs in utero
Fetal connection between portal vein and IVC?
Ductus venosum
Shunts blood away from liver in utero
