25 Thoracic Flashcards
1
Q
Course of the azygos vein
A
Right side
Dumps into SVC
2
Q
Course of thoracic duct
A
Right side > crosses midline at T4-5 > dumps into L SCV at junction with IJV
3
Q
Course of phrenic nerve in relation to the lung hilum
A
Anterior to the hilum
4
Q
Course of vagus nerve in relation to the lung hilum
A
Posterior to the hilum
5
Q
Function of type I pneumocytes
A
Gas exchange
6
Q
Function of type II pneumocytes
A
surfactant production
7
Q
Function of Pores of Kahn
A
Direct air exchange between alveoli
8
Q
Pre-op requirements to allow for pneumonectomy?
A
- 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)
9
Q
DCLO
A
Measures carbon monoxide diffusion and represents O2 exchange capacity
Depends on pulmonary capillary surface area, hemogloblin content, alveolar architecture
10
Q
Common complications after lung resections?
A
Persistent air leak (segmentectomy/wedge)
Atelectasis (lobectomy)
Arrhythmias (pneumonectomy)
11
Q
Most common site of lung cancer metastases?
A
Brain
Other: SCLN, other lung, bone, liver, adrenals
12
Q
T-staging lung cancer?
A
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)
13
Q
N-staging lung cancer?
A
N1: ipsilateral hilum nodes
N2: ipsilateral mediastinal or subcarinal (unresectable)
N3: Contralateral mediastinal or suprclavicular (unresectable)
14
Q
Non-small cell lung cancer
A
80% of lung CA
Central - SCC
Peripheral - AdenoCA (most common)
15
Q
Small cell carcinoma
A
20% of lung CA
Neuroendocrine
Usually unresectable
Chemo-XRT
16
Q
Paraneoplastic syndromes - PTH-related peptide?
A
Squamous cell lung CA
17
Q
Paraneoplastic syndromes - ACTH?
A
Small cell lung CA (most common)
18
Q
Paraneoplastic syndromes - ADH?
A
Small cell lung CA
19
Q
Mesothelioma
A
Most malignant Lung CA
Aggressive local invasion, nodal invasion, distant mets
Risk: Asbestos exposure
20
Q
Chemo for non-small cell lung CA?
A
For stage II or higher
Carboplatin, Taxol
21
Q
Chemo for small cell lung CA?
A
Cisplatin, etoposide
22
Q
Best single test for clinical assessment of T and N status in lung CA?
A
Chest and abdominal CT scan
23
Q
Best single test for clinical assessment of M status in lung CA?
A
PET scan
24
Q
Indications for Mediastinoscopy
A
Centrally located lung CA Suspicious adneopathy (>0.8cm or subcarinal >1.9cm) on chest CT
25
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
```
26
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
27
Chamberlain procedure
Anterior thoracotomy or parasternal mediastinotomy
Assesses enlarged AP window nodes (#5)
Go through left 2nd rib cartilage
28
Bronchoscopy
Good for centrally located nodes
| Evaluate for airway invasion
29
Criteria for surgical intervention for lung cancer?
1) operable (appropriate FEV1/CLCO)
| 2) Resectable (No T4, N2, N3, or M disease)
30
Pancoast tumor
Tumor invades apex of chest wall
Can cause:
- Horner's syndrome (ptosis, miosis, anhidrosis)
- Ulnar nerve symptoms
31
Features suggesting benign disease in lung coin lesions?
No growth in 2 years
| Smooth contour
32
Bronchoalveolar CA
Can look like pnuemonia
Grows along alveolar walls
Multifocal
33
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
```
34
Carcinoids
Neuroendocrine tumor
Central
Tx: resection
Recurrence risk: positive nodes or tumors >3cm
35
Mucoepidermoid adenoma
| Mucous gland adenoma
Malignant lung tumor
Slow growth, no mets
Resection
36
Adenoid cystic adenoma
From submucosal glands
Spreads via perineural lymphatics
Slow growing
Tx: resection, XRT (very sensitive)
37
Hamartoma
Most common benign adult lung tumor
Calcifications - popcorn lesions on CT
Does NOT require resection
Confirm dx with repeat CT in 5 months
38
Most common mediastinal tumor in adults and children? Location?
Neurogenic tumors
| Posterior mediastinum
39
Mediastinal tumors: anterior
Thymus
- Thymoma*
- Thyroid CA and goiters
- T-cell lymphoma
- Teratoma (and other germ cell tumors)
- ParaThyroid adenoma
40
Mediastinal tumors: middle
Heart, trachea, ascending aorta
- Bronchiogenic cyst
- Pericardial cyst
- Enteric cyst
- Lymphoma
41
Mediastinal tumors: posterior
Esophagus, descending aorta
- Enteric cysts
- Neurogenic tumor
- Lymphoma
42
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
43
Myasthenia gravis
Fatigue, weaknes,s diplopia, ptosis
Antibodies to acetylcholine receptors
Tx: anticholinesterase inhibitor (neostigmine), steroids, plasmapheresis
80% have improvement with thyomectomy
44
Mediastinal teratoma
Most common germ cell tumor in mediastinum
Can be benign or malignant
Tx: resection, chemotherapy
45
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
46
Mediastinal non-seminoma
90% have elevated b-HCG and AFP
| Tx: Chemo (cisplatin, bleomycin, VP-16), surgery for residual disease
47
Bronchiogenic cyst
Posterior to carina
| Tx: resection
48
Pericardial cyst
Right costophrnic angle
| Benign - can leave alone
49
Benign tumors of the trachea
Adults - papilloma
| Children - hemangioma
50
Malignant tumor of the trachea
Squamous cell caricnoma
51
Most common late complication after tracheal surgery?
Granulation tissue formation
52
Most common early complication after tracheal surgery?
Laryngeal edema
53
Treatment of laryngeal edema?
Reintubation
Racemic epinephrine
Steroids
54
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
55
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
56
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
57
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
58
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
59
Exudative phase of empyema
1st week
| Tx: chest tube, Abx
60
Fibro-proliferative phase of empyema
2nd week
| Tx: chest tube, abx, possibly VATS deloculation
61
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
62
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
63
Massive hemoptysis
```
>600cc/24hrs
Bronchial arteries
Tx:
- Bleeding side down
- Mainstem intubation to other side
- Rigid bronchoscopy
- Lobectomy/pneumonectomy
- Bronchial artery embolization
```
64
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
65
Catamenial pnuemothorax
Temporal relation to menstruation
| Endometrial implants
66
Residual hemothorax despite 2 good chest tubes?
OR for thorascopic drainage
67
Clotted hemothorax
Surgical drainage if: >25% lung, air-fluid levels, signs of infection
Do surgery within 1st week to avoid peel
68
MCC broncholiths
infection
69
MCC mediastinitis
Cardiac surgery
70
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
71
Bronchiectasis
Acquired - infection, tumor, cystic fibrosis
| No surgical intervention secondary to diffuse nature
72
Tuberculosis
Lung apices
Get calcifications, caseating granulomas
Ghon complex = parenchymal lesion + enlarged hilar nodes
Tx: INH, rifampin, pyrazinamide
73
Sarcoidosis
Non-caseating granulomas
| Tx: steroids
74
```
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
75
```
Pleural fluid:
> 1000 WBC
< 7.45
Pleural fluid protein to serum ratio > 0.5
Pleural fluid LDH to serum ratio > 0.6
```
Exudate
76
```
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
77
Treatment for recurrent pleural effusion?
Mechanical pleurodesis
| Malignant - talc
78
Airway fire
Associated with laser
| Tx: Stop gas, remove ET tube, reintubate for 24hrs, then do bronchoscopy
79
Pulmonary AVMs
Connection between pulmonary arteries and pulmonary veins
Lower lobes
Associated with Osler-Weber-Rendu disease
Symptoms: hemoptysis, SOB, neurologic events
Tx: Embolization
80
MC benign chest wall tumor
Osteochondroma
81
MC malignant chest wall tumor
Chondrosarcoma
82
R to L shunts cause?
Cyanosis
83
Child who squat when having difficulty breathing?
Increases SVR and decreases R to L shunt
84
Adverse effects of cyanosis?
Polycythemia, stroke, brain abscess, endocarditis
85
Eisenmenger's syndrome
Shift from L-R shunt to R-L shunt
Signs of increased pulmonary vascular resistance and pulmonary HTN
Irreversible
86
L to R shunts cause?
CHF
| Failure to thrive, tachycardia, tachypnea, hepatomegaly
87
First sign of CHF in children?
Hepatomegaly
88
L to R shunts - causes?
VSD, ASD, PDA
89
R to L shunts - causes?
Tetrology of fallot
90
Fetal connection between descending aorta and left pulmonary artery?
Ductus arteriosus
| Shunts blood away from lungs in utero
91
Fetal connection between portal vein and IVC?
Ductus venosum
| Shunts blood away from liver in utero
