all of chest Flashcards
treatment of chylothorax
start with NPO and TPN; if unresponsive after 5-7 days of conservative management then surgical ligation of thoracic duct; lymphoscintigraphy and thoracic duct embolization for patients who are poor surgical candidates
most common cause of nontraumatic chylothorax
lymphoma
treatment of retained hemothorax
first line tx is VATS; intrapleural fibrinolytics are recommended 2nd line (after surgery) or for patients if risk of surgery is too great
most common cause of chronic or fibrosing mediastinitis
Histoplasma, commonly causes mediastinal granuloma
true or false. aggressive blood glucose management both intraoperatively and posteroperatively has serious impact on rates of deep sternal wound infections and subsequent development of mediastinitis in both diabetic and nondiabetic patients
true
factors predictive on PFTs of ability to tolerate pneumonectomy/pulmonary resection
predicted posteroperative diffusion capacity of lungs for carbon monoxide (DLCO) > 60%; predicted postop FEV1 > 60%
patients who smoke should quit for at least _____ before lung surgery
4 weeks
patients with PPO FEV1 or DLCO <30% before lung surgery should undergo:
formal preop cardiopulmonary exercise testing with measurement of maximal oxygen consumption
confirmation of superior vena cava syndrome on CT scan:
nonopacification of the SVC inferior to the site of obstruction as well as opacification of collateral venous structures in the chest including the azygous and right intercostal veins
surgical treatment of primary lung cancers
anatomic lobectomy with lymph node staging
what populations should undergo annual low dose CT chest for lung cancer surveillance:
patients 55-80 with 30 pack year smoking history who currently smoke or quit within the past 15 years
cell findings consistent with exudative effusion
low glucose, low pH, high LDH; blood tinge is more suggestive of malignancy whereas empyema fluid is purulent
risk of recurrence of sponanteous pneumothorax without operative intervention:
60%
malignant pleural effusion denotes stage ____ lung cancer
IV; M1a disease present and resection is not recommended in most cases
triglyceride level above 110 in CT fluid is diagnostic for:
chylothorax
best approach for access to the heart
median sternotomy
left posterolateral thoracotomy allows access to what?
left ventricle, descending aorta, and distal esophagus
right posterolateral thoracotomy allows access to what?
trachea, bilateral mainstem bronchi, proximal/mid esophagus
treatment of malignant SVC syndrome:
often an oncologic emergency due to rapid progression; treat with high dose radiation and chemo initially
Lights criteria for exudative effusion:
anyone of these - effusion protein/serum protein ratio of >0.5, effusion LDH/serum LDH ratio >0.6; effusion LDH >2/3 the upper limit of normal range of serum LDH
true or false: mediastinal lymphadenopathy (N2 disease) in a tumor of the superior sulcus is not contraindication to surgical resection
false
symptoms of SVC syndrome
SOB, facial plethora & cyanosis, headache, papilledema, R UE edema, altered sensorium; 80% due to external compression from mediastinal tumor
to proceed with pneumonectomy, the contralateral lung needs what FEV1?
800cc (0.8L)
absolute contraindications to oncologic lung resection for lung cancer:
N2 (mediastinal) or N3 (contralateral supraclaviular) nodal disease
>50% vertebral body involvement
brachial plexus involvement above T1 nerve
invasion of esophagus or tracha
relative contraindications to oncologic lung rection for lung cancer:
N1 or N3 (ipsilateral supraclavicular) nodal disease
invasion of subclavian artery
<50% vertebral body involvement
intraforaminal extension
invasion of common carotid or vertebral artery
features of pancoast tumor:
superior sulcus tumor; usually NSCLC near the thoracic inlet at the apex of the lung; commonly invade chest wall including the first through third ribs and vertebrae
presentation of pancoast/superior sulcus tumor:
shoulder pain in c8 and t1 dermatomes, paresthesia and weakness in ulnar distribution, horner syndrome (ptosis, miosis, anhidrosis)
treatment of pancoast/superior sulcus tumor:
chemorads upfront followed by en bloc resection if resectable
most common benign tumor of the lung
hamartoma
radiologic features of hamartomas:
well-circumscribed nodule with popcorn calcification
most common tumors of posterior mediastinum:
neurogenic tumors
features of squamous cell carcinoma of the lung:
usually centrally located and associated with PTH-related peptide production
features of small cell lung cancer:
ADH and ACTH paraneoplastic syndromes
diagnostic test of choice for suspected TEF in adults:
bronchoscopy
true or false. in an upright patient, the lung apex will have the high V/Q ratio and the base will be low
true
conditions that cause low V/Q ratios
asthma, pulmonary edema
conditions that cause high V/Q ratios
PE and COPD
what does V/Q ratio of zero indicate
loss of ventilation; known as shunting
what does a V/Q ratio of infinity or undefined indicate
an area with ventilation but no perfusion, called dead space
PFT findings that are contraindications to lung resection?
DLCO<40%, postop FVC<1.5L
VO2 is a measure of ____. Optimal values are ___
measure of exercise tolerance; optimal values are >10-12 mL/min/kg
if preop FEV1<0.8L this study can be performed to see if patient can still tolerate a lobectomy
V/Q scan; can resect if resected lobe has minimal contribution to FEV1
type of pneumonia characterized by thick, bloody mucoid sputum
Klebsiella pneumonia (currant jelly sputum)
common VAP organisms include:
Pseudomonas, Staph aureus, H. flu, Strep pneumo, Enterobacter cloacae
True or false. Smaller chest tubes are not as effective as larger ones in evacuating blood from the pleural space.
False
Chest tube placement should be avoided if less than ____cc of blood is in the pleural space.
300cc
management of malignant chylothorax:
respond favorably to chemorads; duct ligation and embolization are usually ineffective
True or false. Pulmonary metastatectomy improves overall survival in sarcoma patients with isolated pulmonary mets.
True
Cause of spontaneous pneumomediastinum:
alveolar rupture with tracking along the bronchovascular bundle to the mediastinum
Symptoms and treatment of spontaneous pneumomediastinum:
chest pain, SOB, neck pain/crepitus; fever is uncommon
CT shows diffuse pneumomediastinum without pleural effusion or fluid collections
treat with pain control and observation
True or false. Surgical rib fracture fixation after blunt chest trauma reduces pulmonary morbidity, particularly incidence of pneumonia and duration of mechanical ventilation.
true
What is milrinone’s mechanism of action and what is it commonly used to treat?
phosphodiesterase type III inhibitor that causes increased contractility in cardiogenic shock and induces pulmonary vasodilation in pulmonary hypertension; improves right ventricular function and pulmonary hemodynamics
Normal aortic valve area:
3-4 cm squared
Which patients with aortic stenosis should have valve replacement?
those that are symptomatic or who have a valve area <1cm squared
What location is thoracentesis performed?
between the scapula and the mid axillary line (posterior axillary line), never below the 8th interspace; typically for large effusions it is performed 2-3 interspaces below the top margin of the effusion (as long as it is above 8); typically do in the sitting position leaning forward
Signs and symptoms of post-pericardiotomy syndrome/post cardiac injury syndrome?
fever, pleuritic chest pain 1-3 weeks after injury (surgery/CABG or trauma), pericardial friction rub, elevated wbc, elevated esr, elevated crp; diffuse ST segment elevation with PR depression, pericardial effusion on echo
Work up of post-pericardiotomy syndrome?
echo, EKG, labs and CXR
Tx of post-pericardiotomy syndrome?
NSAIDS
