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oral boards > benign/infxs thoracic > Flashcards

benign/infxs thoracic Flashcards

1
Q

immediate CT output threshold to go straight to OR for thoracotomy

A

1500mL

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2
Q

ongoing CT output threshold to go to the OR for thoracotomy

A

300mL/h x3h

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3
Q

“ideal” hyperhidrosis sympathectomy candidate characteristics

A
  • onset of hyperhidrosis at early age (usu <16yo)
  • young at time of surgery (usu <25yo)
  • approp BMI (<28)
  • no sweating during sleep
  • relatively healthy (no other significant comorbidities)
  • no bradycardia (resting HR<55bpm) – trial of low-dose β-blocker to simulate effects of surgery? (TSRA)
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4
Q

sympathectomy level for craniofacial hyperhidrosis

A

R3 top (STS expert consensus)
resect nerve segment at top of rib 3 (or do not do; TSRA = “T2”)

“For palmar hyperhidrosis, the optimal operation is an R3 interruption (cauterizing or clipping the sympathetic chain on top of the third rib) because it yields the driest hands; however, an R4 interruption is also reasonable. The patient should be aware of the differences and the slightly higher risk of CH with an R3 but the risk of moister hands with an R4. For those who are willing to accept a higher risk of CH because they want their hands to be completely dry, it is suggested that two interruptions in the sympathetic chain are made, at R3 and R4.
An R4 and R5 sympathetic chain interruption should be used for palmar-axillary, palmar-axillary-plantar, or axillary hyperhidrosis alone. An R5 interruption alone is also a viable option for patients who have axillary hyperhidrosis only. Finally, an R3 interruption is suggested for patients with craniofacial hyperhidrosis without blushing. An R2 and R3 procedure may be performed for these patients, but it may lead to a higher incidence of CH, and it increases the risk of Horner’s syndrome, especially on the left side.”

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5
Q

nomenclature for hyperhidrosis sympathectomy

A

perform interruption only at top of rib; refer to interruption level by rib rather than ganglion/vertebral level; include surgical method of interruption

e.g. If the chain is clipped on top of the fifth rib, the abbreviation for the operative note would be “clipped R5, top.”
If the chain is cauterized on the top and bottom of the fourth rib, the operative note would be “cauterized, top R4, bottom R4.”

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6
Q

sympathectomy level for axillary hyperhidrosis

A

R4 top + R5 top (STS expert consensus)
resect nerve overlying rib from top of 4th rib to top of 5th rib

“For palmar hyperhidrosis, the optimal operation is an R3 interruption (cauterizing or clipping the sympathetic chain on top of the third rib) because it yields the driest hands; however, an R4 interruption is also reasonable. The patient should be aware of the differences and the slightly higher risk of CH with an R3 but the risk of moister hands with an R4. For those who are willing to accept a higher risk of CH because they want their hands to be completely dry, it is suggested that two interruptions in the sympathetic chain are made, at R3 and R4.
An R4 and R5 sympathetic chain interruption should be used for palmar-axillary, palmar-axillary-plantar, or axillary hyperhidrosis alone. An R5 interruption alone is also a viable option for patients who have axillary hyperhidrosis only. Finally, an R3 interruption is suggested for patients with craniofacial hyperhidrosis without blushing. An R2 and R3 procedure may be performed for these patients, but it may lead to a higher incidence of CH, and it increases the risk of Horner’s syndrome, especially on the left side.”

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7
Q

sympathectomy level for palmar+plantar hyperhidrosis

A

R4 top + R5 top (STS expert consensus)
resect nerve overlying rib from top of 4th rib to top of 5th rib

“For palmar hyperhidrosis, the optimal operation is an R3 interruption (cauterizing or clipping the sympathetic chain on top of the third rib) because it yields the driest hands; however, an R4 interruption is also reasonable. The patient should be aware of the differences and the slightly higher risk of CH with an R3 but the risk of moister hands with an R4. For those who are willing to accept a higher risk of CH because they want their hands to be completely dry, it is suggested that two interruptions in the sympathetic chain are made, at R3 and R4.
An R4 and R5 sympathetic chain interruption should be used for palmar-axillary, palmar-axillary-plantar, or axillary hyperhidrosis alone. An R5 interruption alone is also a viable option for patients who have axillary hyperhidrosis only. Finally, an R3 interruption is suggested for patients with craniofacial hyperhidrosis without blushing. An R2 and R3 procedure may be performed for these patients, but it may lead to a higher incidence of CH, and it increases the risk of Horner’s syndrome, especially on the left side.”

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8
Q

sympathectomy level for palmar hyperhidrosis

A

R3 top > R4 top or R3+R4 top (STS expert consensus)
resect nerve overlying rib 3, from top of rib to bottom edge of rib

“For palmar hyperhidrosis, the optimal operation is an R3 interruption (cauterizing or clipping the sympathetic chain on top of the third rib) because it yields the driest hands; however, an R4 interruption is also reasonable. The patient should be aware of the differences and the slightly higher risk of CH with an R3 but the risk of moister hands with an R4. For those who are willing to accept a higher risk of CH because they want their hands to be completely dry, it is suggested that two interruptions in the sympathetic chain are made, at R3 and R4.
An R4 and R5 sympathetic chain interruption should be used for palmar-axillary, palmar-axillary-plantar, or axillary hyperhidrosis alone. An R5 interruption alone is also a viable option for patients who have axillary hyperhidrosis only. Finally, an R3 interruption is suggested for patients with craniofacial hyperhidrosis without blushing. An R2 and R3 procedure may be performed for these patients, but it may lead to a higher incidence of CH, and it increases the risk of Horner’s syndrome, especially on the left side.”

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9
Q

medical therapy for hyperhidrosis

A
  • aluminum-based antiperspirants
  • anticholinergics (glycopyrrolate, oxybutinin) – but side effects often limiting
  • iontophoresis
  • Botox
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10
Q

key differentiating sx features between 1° & 2° hyperhidrosis

A

in 1° (versus 2°):
- NO sweating during sleep
- earlier age of onset/in childhood
- bilateral, symmetric, focal distribution

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11
Q

International Hyperhidrosis Society guideline dx criteria

A

ABCDEFG:
AGE OF ONSET: childhood/adolescence
BILATERAL, symmetric, focal (face/palms/axilla/feet)
CESSATION DURING SLEEP
DURATION: x≥6mo
EPISODES: ≥2x/w
FAMILY: hx in 25%-50% (TSRA) / 2/3 (IHS)
GETS IN THE WAY: ￬QoL

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12
Q

Where can you miss nerve fibers during sympathectomy leading to persistent hyperhidrosis?

A

accessory fibers run lateral to sympathetic chain, called nerves of Kuntz ⇒ continue interruption ~2cm lateral on inside of the rib to denude periosteum

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13
Q

Where are the sympathetic ganglia located in relation to the ribs/vertebra?

A

@ the underside of / within the intercostal space below their respective rib/vertebra

(e.g. the T3 ganglion will be below the lower border of rib 3, in the 3rd intercostal space)

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14
Q

mgmt of invasive pulmonary mucormycosis

A

surgical debridement + amphotericin B

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15
Q

benefits of rib plating

A
  • “as early as 24-72h post-inj” ⇒ ￬inflamm,HTX,empyema
  • in flail chest on vent ⇒ ￬vent days,ICU days,hosp costs
  • in ≥65yo ⇒ ￬rib fx M&M, ￪resp mechanics, earlier return to fxn
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16
Q

definition of flail segment (rib fxs)

A

≥2 contiguos ribs fx in 2+ places

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17
Q

relative indication(s) for rib plating

A
  • ≥3 displaced rib fxs
  • flail segment
  • failure of med mgmt / to liberate from vent
  • concomitant thoracic surg
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18
Q

Haller index

A

transv ÷ AP thoracic inner diameter

transverse thoracic distance
(lateral rib to rib inner surface)
-—————————-
anterior-posterior thoracic distance
(post sternal table to ant vert body)

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19
Q

Haller index threshold for pectus excavatum rx

A

≥3.25

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20
Q

How long do Nuss bars stay implanted in adult pectus pts?

A

≥3y

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21
Q

pathophysiologic cause of dyspnea in pectus

A

restricted RV filling

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22
Q

Do PFTs improve after pectus rx?

A

NO

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23
Q

Does cardiopulmonary capacity (e.g. measured on CPET) improve after pectus rx?

A

YES

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24
Q

Light’s criteria

A

any 1 of these 3 criteria = exudative effusion:
- pleural fluid : serum protein ratio > 0.5
- pleural fluid : serum LDH ratio > 0.6
- pleural fluid LDH > 2/3 upper nl (for serum)

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25
Q

pleural effusion fluid test indicating TB infxn

A

￪ADA (adenosine deaminase)

SESATS: “Adenosine deaminase (ADA) is an enzyme that is essential to the proper functioning of lymphocytes and correlates with the burden of mycobacterial antigens in the pleural space. The sensitivity of ADA in diagnosing tubercular pleural effusions is high, but it can also be elevated in empyema, rheumatoid, and lymphomatous effusions. If the prevalence of the disease is high in the local population, then an elevated ADA can be used to diagnose tuberculosis, but there will be a significant number of false negatives. However, if the prevalence is low, then false positives become more likely, and a low ADA level can be used to rule out tuberculosis.”

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26
Q

best confirmatory test for suspected tuberculous (TB) pleural effusion

A

pleural bx (80% yield)

27
Q

mgmt of TB pleural effusions

A

TB medical tx
(only drain for sxs)

SESATS: “Most tuberculous effusions will resolve spontaneously and do not require chest tube drainage; pleural drainage should be used selectively to relieve symptoms.”

28
Q

LVRS criteria

A

NETT criteria:
- heterogeneous (esp upper lobe-predominant) emphysema on CT & V/Q
- ≤70yo
- FEV1=20-45%
- DLCO≤20%
- RV (resid vol)>150% (air-trapping)
- pCO2<60 (rest, RA)
- pO2>45 (rest, RA)
- 6MWT>140m
- unloaded bike ≥3min
- ⊕pulm rehab x6-10w
- ⊖pHTN
- ∅cig x6mo
tx: resxn of 20-35% of each lung

29
Q

NETT outcomes

A
  • ∅∆OS despite higher early postop mortality
  • cont progressive decline in lung fxn & QoL in both surg & med groups,
    with LVRS pts returning to baseline by μ=2y
30
Q

lung transplant listing criteria for COPD

A
  • FEV1<20%
  • DLCO<20%
  • BODE (body mass, airflow obstruction, degree of dyspnea, exercise tolerance) score > 7
  • hosp for COPD exac with pCO2>50
  • pHTN

(SESATS)

31
Q

site of compression in vTOS

A

subclv vein between clavicle & 1st rib (± further posterior compression from anterior scalene muscle hypertrophy)
(different from nTOS/aTOS)

32
Q

site of compression in nTOS

A

brachial plexus in the posterior scalene triangle ???
(same as aTOS; different from vTOS)

33
Q

key maneuvers in 1st rib resxn for vTOS

A
  • debridement of subclavius tendon @ costoclavicular joint
  • venolysis
34
Q

site of compression in aTOS

A

brachial plexus in the posterior scalene triangle ???
(same as nTOS; different from vTOS)

35
Q

most reliable indicator of GEJ location

A

proximal extent of gastric rugae/folds

36
Q

mgmt of pleural fluid infxn in setting of PleurX

A

cont volume-based periodic fluid drainage + cx-approp abx x3w(σ) ⇒ 90% success without catheter removal
(incidence=2-12%)

(SESATS)

37
Q

MIST2

A

tPA + DNAse ⇒ ￬surgery (4% v 16%),LOS,AEs

38
Q

effect of DNAse alone in MIST2

A

⇒ ￪surgery (39% v 16%)

39
Q

therapeutic bronch size

A

2.8mm channel = 6.2-6.5mm shaft
(need at least 7.0 ETT to fit & still ventilate, ideally 7.5)

40
Q

ETT sizing

A

inner diameter in mm, in 0.5mm increments
(usu ♀ 7.0-7.5 / ♂ 7.5-8.5)

41
Q

smaller bronch size

A

2.2mm channel = 5.0mm shaft
(need at least 6.0 ETT)

42
Q

lung transplant listing criteria for CF

A
  • FEV1<30% OR rapid ￬
  • ￪ O2 req
  • ￪CO2
  • exac req ICU adm
  • ￪ freq exac
  • refrx/recurrent PTX
  • pHTN
  • NO resistant infxns/colonization (e.g. Burkholderia cepacia complex)

(SESATS)

43
Q

3 most common indications for lung transplant

A
  1. COPD (31%)
  2. ILD (26%)
  3. CF (15%)
44
Q

TB tx

A

RIPE x9mo
= rifampin + isoniazid (INH) + pyrazinamide + ethambutol

45
Q

mgmt of aspergilloma

A

resxn

SESATS: “Definitive treatment for an aspergilloma is surgical resection. However, surgery is associated with considerable risk. The disease is rarely confined to the cavitary lesion observed on radiographs, and usually the adjacent lung and pleura are involved and the fibrosis is extensive. Surgical mortality approaches 8% and morbidity is 25%. Postoperatively, patients are at risk of empyema, bronchopleural fistula development, and bleeding.”

46
Q

round lesion within a cavitary lung lesion in an immigrant pt

A

mycetoma (fungal ball, usu Aspergilloma, within a TB cavitary lesion)

47
Q

mgmt of mycetoma

A
  1. r/o active TB
  2. if +TB, RIPE x9mo + amphotericin???
  3. resxn
48
Q

clinical requirements for consideration of diaphragmatic pacing

A
  • intact lower motor neurons (e.g. injuries above C3 ideal since C3/4/5 innervate diaphragm)
  • >3mo from injury (to allow for any return of fxn)
49
Q

stages of empyema

A

I: exudative = early (days) = fluid ± pus
II: fibrinopurulent = late (weeks) = pus + loculations
III: organizing = v late (months) = rind/trapping, scarring

50
Q

pleural fluid indication(s) for tube thoracostomy drainage per AATS empyema guidelines

A
  • pus
  • ⊕Gram stain/cx
  • pH<7.2
  • LDH>1000
  • Glc<40
  • loculations
    (all signs of stage 2: fibrinopurulent)
51
Q

empiric abx for CAP + empyema

A

Unasyn
OR ceftrx/Flagyl

52
Q

empiric abx for HAP + empyema

A

vanc/cef/Flagyl
cef = cefepime or ceftazidime (“pime & dime Pseudomonas”)
(+ MRSA & Pseudomonas coverage)

53
Q

relative indication(s) for transthoracic drainage (in add’n to or instead of transcervical) in descending mediastinitis

A

extension below carina or into pleural space

54
Q

CT findings of focal, calcified mediastinal lesions ± compression of hilar airways/vessels, R>L

A

fibrosing mediastinitis
a/w Histoplasma capsulatum infxn hx
(endemic in OH & MS river valleys)

SESATS:
42yo previously healthy never-smoker p/w progressive dyspnea & fatigue
CT shows “mixed-attenuation densities t/o mediastinum (CT image shows L hilar mass) with associated areas of calcification and extrinsic compression of the main pulmonary vessels”
“Fibrosing mediastinitis, sometimes referred to as sclerosing mediastinitis, is a rare condition characterized by the development of a progressive fibroinflammatory process within the mediastinum. The proliferation of fibrotic tissue frequently results in compression of adjacent mediastinal vascular structures as well as the airways, resulting in associated symptoms. Due to the progressive nature of the inflammatory process, fibrosing mediastinitis is associated with significant morbidity and disease-related mortality associated with progressive cardiopulmonary dysfunction.
The diagnosis of fibrosing mediastinitis can typically be made radiographically. Classic findings on chest CT include focal, calcified lesions in the mediastinum. Compression of the hilar airways and vasculature is common, with the most significant disease classically seen on the right side of the chest. Surgical biopsy is rarely indicated and is reserved for situations where the imaging findings are equivocal and a malignant diagnosis is felt to be likely.”

55
Q

mgmt of fibrosing mediastinitis

A

palliation of airway/vascular obstruction (stents)

SESATS:
“While the exact pathophysiology of fibrosing mediastinitis remains unclear, prior infection with Histoplasma capsulatum is frequently associated with the development of the condition. Fibrosing mediastinitis is widely believed to be driven by a form of rare hypersensitivity immune reaction to infection with the organism, particularly in areas such as the the Ohio and Mississippi river valleys where the disease is endemic. Unfortunately, antimicrobial treatment for histoplasma is rarely helpful once mediastinal fibrosis develops. Biopsies obtained from a subset of patients with fibrosing mediastinitis associated with histoplasma infection also have demonstrated infiltration by IgG4 plasma cells. Other IgG4-related disease has been shown to respond well to glucocorticoid treatment, though this has been met with limited success in fibrosing mediastinitis, with the lone exception of patients with the idiopathic immune-mediated variant of the disease. For the majority of patients, treatment is palliative and seeks to relieve the obstruction caused by airway and vascular compression in the mediastinum. Surgical options are typically limited, and endovascular stent placement is the intervention of choice.”

56
Q

profuse frothy secretions after lung transplant

A

esp if unilateral
PV anastomotic stenosis/obstr
also can p/w ￪pulm cap pressures, persistent pulm edema, lobar/unilateral consolidation
(dx with TEE, can visualize well except L IPV)

57
Q

initial intubation of high-grade tracheal obstruction

A
  1. sedated (non-paralyzed) flex bronch with local @ cords
  2. ideally pass ETT with bronch guidance
  3. exchange for rigid bronch only if needed

SESATS: “Bronchoscopic examination is essential for both diagnostic and therapeutic purposes. Diagnostic goals include a more precise assessment of the extent of endobronchial tumor extension as well as biopsy for histologic characterization. Therapeutic goals include relief of the obstruction by debulking any endobronchial component of tumor and possibly via stenting.
Rigid bronchoscopy is the most appropriate technique for safe examination of the tumor as well as relieving the critical narrowing of the trachea. Paralytic administration is generally avoided until after the stenosis or stricture has been traversed by the rigid bronchoscope. Inhalational and intravenous induction strategies that maintain spontaneous breathing while mitigating patient resistance and coughing as the scope is introduced is important. Sevoflurane is considered to be the least irritating of the commonly used inhalational agents and ideal for induction. Fiberoptic intubation is often used for mild or moderate tracheal strictures but should be avoided for critical airways and especially in the presence of friable tumor because crossing the obstruction with a flexible scope is not ensured and bleeding and complete obstruction are possible.”

58
Q

ulnar nerve conduction velocity (UNCV) normal limit & threshold mandating immediate surgery for nTOS

A

nl: >85
OR: <55

59
Q

minimum duration of PT before TOS surgery

A

4w

60
Q

nerve that passes through middle scalene muscle

A

long thoracic
⇝ serratus anterior
(transection ⇒ winged scapula)

61
Q

nerve that passes through middle scalene muscle

A

long thoracic
⇝ serratus anterior
(transection ⇒ winged scapula)

62
Q

key structures to resect/divide in TOS

A
  • anterior scalene muscle (below phrenic nerve / at insertion onto 1st rib)
  • middle scalene muscle (below long thoracic nerve / at insertion onto 1st rib)
  • 1st rib esp head/neck
  • subclavius muscle (venous)
  • costoclavicular ligament (venous)
  • cervical rib (if present)
63
Q

supraclavicular TOS approach incision

A

1-2cm (~1 fingerbreadth) above the clavicle,
from 1cm medial to lateral border of SCM laterally for 5-6cm

oral boards (15 decks)

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