Board Review Questions Flashcards
1
Q
What are the WHO 2013 guidelines features for malignant Solitary Fibrous tumors?
A
hypercellularity
high mitotic activity (>4 mitoses/10hpf)
cytologic atypia
tumor necrosis or infiltrative margins
2
Q
Solitary Fibrous Tumors are associated with which stains?
A
Positive CD34 and STAT 6
Negative SOX10,pankeratin and calretinin .
3
Q
How do Solitary Fibrous Tumors cause hypoglycemia?
A
Secretion of insulin like growth factor from the tumor
4
Q
What is the mechanism of metastasis for Solitary Fibrous Tumors?
A
Hematogenous Spread
5
Q
What is the treatment of choice for a solitary fibrous tumor?
A
Surgical consultation
6
Q
What is the first line therapy for malignant mesothelioma?
A
platinum base chemotherapy with pemetrexed
7
Q
What is the mean adult male and female tracheal diameter?
A
Male 19mm and Female 16mm
8
Q
What is the etiology for the primary sensation of dyspnea in central airway obstruction?
A
increased effort required to obtain the normal velocity of air delivered to and from the lungs
9
Q
At what tracheal diameter have studies shown that a health adult may have symptoms of exertional dyspnea?
A
8mm
10
Q
At what tracheal diameter have studies shown that a health adult may have symptoms of resting dyspnea and hypercapnia?
A
6mm
11
Q
At what tracheal diameter have studies shown that a health adult may have stridor?
A
5mm
12
Q
What can be used for local anesthesia in a patient who is allergic to lidocaine?
A
Procaine
13
Q
What class of medications does lidocaine belong to?
A
amide
14
Q
What class of medications does Procaine belong too?
A
esther
15
Q
What is the onset of action of Procaine?
A
five to ten minutes
16
Q
What is the onset of action and duration of anesthesia of procainamide?
A
onset of action is five to ten minutes and duration of anesthesia is 1.5 hours
17
Q
What is the maximal dose of procaine 1%?
A
500mg (50ml)
18
Q
What is the anesthetic duration of a 1% diphenhydramine injection?
A
five minute and can last between fifteen minutes and three hours for about 80% of people
19
Q
What are the pulmonary complications of Granulomatosis Polyangiitis (Wegners)?
A
pulmonary nodules, bronchial stenosis, alveolar hemorrhage and infection related to treatment
20
Q
What are the characteristic findings in Tracheobronchopathia osteochondroplastica?
A
Submucosal nodules containing combinations of cartilaginous, osseous, and calcified acellular protein matrix
Posterior membe
Sparing
21
Q
What percent of patients with GPA(Wegners) have subglottic stenosis?
A
22%
22
Q
What is the treatment for subglottic stenosis due to GPA(wegners)?
A
NO STENT-combination of intralesional injection of corticosteroids, balloon dilatation and radial incisions.
23
Q
What amount of chyle production is predicative of successful conservative management?
A
<500ml/day
24
Q
When to remove a broncholith?
A
If it is symptomatic
25
What are the three classifications of broncholiths?
intraluminal, extraluminal and mixed
26
How do you diagnosis Pulmonary Alveolar Proteinosis (PAP)
Presence of alveolar filling with material that stains positive with Periodic Acid-Shift (PAS) testing. CT imaging of crazy paving on CT.
Most cases are related to anti-GM-CSF antibodies and blood test may potentially avert the need for bronchoscopic diagnosis or support PAS stain results.
27
What are the indications for whole lung lavage?
worsening dyspnea, hypoxemia (at rest or with exercise), and worsening imaging findings
28
What is the effect of cigarette smoking on the number of whole lung lavages
Increases the number of whole lung lavage required
29
What is Argon Plasma Coagulation?
A non-contact thermal ablative therapy where argon gas flow is used to care electric charge to the nearest airway surface.
30
Can APC be used for tumor de-bulking?
No it has a lack of vaporization effect,
31
What is the required fraction of inspired oxygen to avoid airway fires?
less than 40% inspired oxygen
32
What is the required fraction of inspired oxygen to avoid airway fires?
less than 40% inspired oxygen
33
How far should the APC probe be held away from the target lesion? How deep is the APC thermal injury ?
1-5mm from the target lesion and 2-3mm of depth for thermal injury. Continuous bleeding may affect tissue coagulation.
34
What is the penetration depth, tissue effect and common settings for the Nd-YAG laser?
6-10mm, Charring coagulation and vaporization, 30-60 watts and 0.4 second pulses or continuous mode
35
What is the penetration depth, tissue effect and common settings for APC?
2-3mm, coagulation, 20-40 watts and 0.4L/min - 1.2 L/min
36
What is the penetration depth, tissue effect and common settings for Electrocautery Probe?
3-4mm, coagulation fulgaration and vaporization, 20-40watts
37
How do you position who has had a systemic gas/venous air embolism?
Durant's maneuver place the patient in the left lateral decubitus position and Trendelenburg
38
When there is a lack of tissue effect when using electrocautery what steps for troubleshooting should be taken?
check the ground pad connection,
probe connection,
probe contact with mucosa and that secretions are not dissipating the circuit.
39
What is the photosensitizing agent used in photodynamic therapy?
porfimer sodium
40
How long does it take for there to be selective uptake of the photosensitizing agent?
48-72hours
41
What is the wavelength of the nonthermal laser used to activate PDT?
630nm
42
What are the two types of destructive effects of cryotherapy?
Cellular Injury and Vascular Injury
43
Which type of cryotherapy injury is delayed cellular or vascular?
cellular injury is immediate and vascular injury is delayed
44
What is the effective killing zone surrounding the cryoprobe?
5-8mm
45
What is the mechanism of vascular injury during cyrotherapy?
During the initial freezing the tissues respond with vasoconstriction that ceases with freezing is complete. During thawing the circulation returns with compensatory vasodilatation. However the endothelial damage from cryotherapy results in increased permeability of the capillary walls, edema, platelet aggregation and microthrombus formation. Progressive circulatory stagnation results over the ensuing hours. These effects culminate in tissue necrosis. This is why cryo-debulking requires follow up bronchoscopy clean up of the necrotic tumor tissue in 7 to 10 days.
46
How long will the the skin of a patient who has received photodynamic therapy remain sensitive?
Thirty days
47
What is the risk of concurrent PDT and radiation therapy and how much time should be in between the two treatment modalities ?
PDT and radiation should be separated 4 weeks apart due to concerns of excessive inflammation
48
What are the contraindications to photodynamic therapy?
Porphyria,
Preexisting tracheoesophageal or bronchoesophageal fistulae
Tumor eroding into a major blood vessel
Severe acute respiratory distress caused by an obstructing lesion with an immediate need to reestablish airway patency.
Patients with hepatic or renal impairment may have delayed clearance of the drug and will require photosensitivity precautions for longer periods.
Porfimer sodium is a category C drug for pregnancy
49
What is the most common type of tracheal stenosis complication that may occur after tracheostomy?
A-frame stenosis
50
Which type of stent have been shown to have reduced migration?
Hourglass silicone stents
51
What type of stents are used on benign disease?
silicone
52
Which type of stents have the highest inner/outer diameter ratio and highest radial expansion force?
Self expanding metallic stents
53
What is the most common complication of hourglass stents?
mucus plugging
54
Pulmonary neuroendocrine tumors account for what percentage of primary lung cancers?
25%
55
What is the most common type of pulmonary neuroendocrine tumor?
small cell
56
What is the incidence of atypical carcinoid?
0.2%
57
What percent of atypical carcinoid involves the regional nodes and what percent involves distant metastasis?
regional nodes are involved in 50% of patients and distant mets can be seen in 20% of patients.
58
What is the primary treatment and management for stage I typical carcinoid?
Surgery is the primary treatment with survival rates greater than 90%.
Surveillance bronchoscopy every six months for the first 2 years and then annually is recommended if bronchoscopy is the only optiom
59
What is the recommended scheduled surveillance bronchoscopy for patient who underwent bronchoscopic treatment for atypical carcinoid according to the 2013 ACCP guidelines?
Surveillance bronchoscopy should be done at 1,2, and 3 months and thereafter at three month intervals during the first year. Then every six months until five years.
60
Which factors were associated with high failures of bronchoscopic intervention for central airway obstruction?
ASA>3
Renal Failure
primary left main disease
tracheoesophageal fistula
61
What is the downside to lobar stenting?
smaller improvements in quality of life
62
What is the most common type primary tracheal tumor?
Squamous cell
63
What is the second most common type primary tracheal tumor?
adenoid cystic carcinoma
64
What are the majority of tracheal tumors caused by?
endotracheal mets
65
At what what endoluminal diameter is therapeutic bronchoscopy considered successful?
When the post intervention endoluminal diameter is at least 50% of the airway
66
What features of central airway obstruction favor technical success?
pure endobronchial disease or extrinsic compression
67
What features of central airway obstruction favor technical failure?
left mainstem obstruction
mucosal infiltration
68
What are the three categories of malignant central airway obstruction?
extraluminal or extrinsic
intraluminal or intrinsic
mixed
69
How do you may pure extraluminal compression?
airway stent
70
How to do you mange purely endoluminal disease?
mechanical debridement with or without thermal ablation. Rare need for stenting
71
What factors are predictive of having lung re-expansion?
less than four weeks of atelectasis
presence of heterogeneous enhancement indicating absence of necrosis
72
What is the overall mortality due to procedures for patients with known malignant central airway obstruction?
7.8% though as low as 3.9% in Acquire and overall mortality up to 14.8%
73
What are the risk factors associated with death at 30 days with malignant central airway obstruction?
ECOG score>1
ASA >3
present of endoluminal or mixed obstructions
placement of an airway stent
74
What percent of foreign bodies can be retrieved with a net, forceps or saline with a cryoprobe?
90%
75
What is the mechanism of iron pill aspiration injury in the airway?
free radical formaltion
76
What are the stain is used to differentiate iron pill injury from neoplasm?
prussian blue
77
What patients were selected as candidates for the AIR-2 Trial?
Adult patients who have had symptomatic asthma despite high-dose ICS and long-acting beta agonist use?
78
What were the findings of the Air 2 trial?
AQLQ: 79% of patients in the BT group and 64% of patients in the sham group achieved a clinically meaningful improvement in the asthma quality of life (AQL), as measured in the AQLQ score change from baseline ≥0.5.
Reduction of severe exacerbations: There was a 32% of reduction in severe exacerbations requiring systemic corticosteroids per patient/year in the BT group
Emergency room (ER) visits and time lost from work: When the BT and sham group were compared; there was an 84% reduction in ERs visits for respiratory symptoms and 66% reduction in time lost from work/school/other daily activities due to asthma, favoring the BT group.
Severe exacerbations (decrease of both event rates and patients with severe exacerbations, 48% and 44%, respectively), when compared with the 12 months sham group prior to BT treatment.
ER visits for respiratory symptoms (88% average decrease) over 5 years in the ratio ER lists for respiratory symptoms compared with 1 year prior to BT treatment.
79
Which patients may have a potential survival benefit for lung volume reduction?
Those with upper lobe predominant emphysema and low exercise capacity
80
Which patients were shown to have a high risk for lung volume reduction surgery?
FEV1 less than 20 percent predicted
DLCO less than 20 percent predicted
maximum exercise capacity of 25w for women and 40w for men
81
What is the selection criteria for Bronchoscopic lung volume reduction?
Severe COPD Gold stage 3-4 with FEV1 20-50%,
RV greater than equal to 150%,
total lung capacity greater than or equal to 100%, 6 minute walk greater than 150 feet, 100m
DLCO >20%,
PA pressure <50 on echo
PACO2 < 50-60mm Hg at room air
PaO2 > 45mm Hg at room air sea level
82
What is common condition that is associated with and can worsen Excessive Dynamic Airway Collapse?
GERD
83
What is the most common form of post intubation tracheal stenosis?
web like
84
What is the benefit of rapid onsite cytology evaluation in EBUS TBNA?
it can decrease the number of sites to be sampled
85
What is the bleeding risk of transbronchial lung biopsy on Plavix?
89%
However, lymph node biopsy limited to assessment can be performed with relative safety
86
What mutation is crizotnib(xalkori) used to treat?
Alk rearrangements
87
What is the target of pembroluzimab?
PDL-1 check point inhitior
88
What is the mutation that Osimertnib used to treat?
T790M
89
What is the first-line chemotherapy advance non-small cell lung cancer?
platinum-based doublet chemotherapy
90
What is the criteria for lung cancer screening?
Adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years
91
What is the pleural fluid to serum albumin ratio for a pseudo-exiduate?
serum albumin level minus pleural effusion albumin level >1.2
92
What is lights criteria?
Satisfying any ONE criterium means it is exudative:
Pleural Total Protein/Serum Total Protein ratio > 0.5
Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6
Pleural lactate dehydrogenase level > 2/3 upper limit of the laboratory's reference range of serum lactate dehydrogenase.
93
What were the outcomes of the ASAP Trial (Standard (every other day drainage) vs Aggressive (daily drainage) ) ?
Pleurodesis rates were higher in the daily drainage group. 54 days compared to 70 days. There was no significant difference in the rate of adverse events ,quality of life or patient satisfaction.
AMPLE 2 trial aggressive vs symptomatic guided drainage had similar results
94
What were the outcomes of the AMPLE - Trial (effect of an indwelling pleural catheter vs talc pleurodesis)?
IPC (indwelling pleural catheter) group had less days in the hospital and less same sided invasive pleural interventions
No significant number of differences in dyspnea improvement or quality of life
95
What are the components of the LENT score?
Pleural LDH, ECOG score, serum neutrophil to lymphocyte ratio, and tumor type
Low median survival 319 days
Moderate median survival 130 days
High median survival 19 days
96
What are the variables in the Promise Score?
hemoglobin, c reactive protein (CRP), white blood cell count, ECOG score, cancer type, Pleural fluid TIMP and previous chemo or radiation therapy.
97
Do EBUS and Mediastinoscopy have similar safety and accuracy?
yes
98
How many aspirations per lymph node station are optimal for sample adequacy and diagnosis?
3 passes per lymph node had 100% adequacy and 95% sensitivity.
99
Does sample adequacy and diagnosis improve with suction for EBUS-TBNA?
There is no difference between suction and no suction regarding to sample adequacy, sample quality, diagnostic yield for malignancy or any other condition.
100
Does using rapid on site cytologic evaluation (ROSE) for EBUS TBNA improve yield for the procedure?
No significant difference in accuracy or sensitivity. No difference in procedure time. Less passes possible possible in the ROSE group and feedback helps reduce additional procedures in the ROSE group.
101
Does ROSE(rapid onsite cytological examination) during EBUS TBNA have a good concordance rate with final pathological staging for lung cancer?
Yes The concordance rate for lung cancer stage by ROSE during EBUS -TBNA and pathological staging of lung cancer was 94%. There were no false positives by ROSE and there were 5.7% dalse negative.
Nakajima 2013
102
Is EBUS TBNA better over conventional TBNA for sarcoidosis?
EBUS is better and EBUS andTransbronchial lung biopsies is the best
Gupta 2014 chest
103
Can you safely perform EBUS -TBNA on Plavix?
Yes if it it is urgent
104
Does using a larger gauge needle for EBUS TBNA improve yield ?
no but you do get more tissue
105
What is the highest risk factor for occult N2 and N3 disease in those with clinical N2 disease?
Adenocarcinoma histology
106
In patients with clinical 1B disease what is the false negative rate?
greater than 10%
107
What are the characteristics for occult N2 disease?
central tumors, >3cm, SUV >4 and adenocarcinoma histology
108
Which patients should undergo pre-operative mediastinal staging?
Tumor >3cm, centrally located tumor inner 1/3 or N1 disease on non-invasive imaging
109
What are the ideal conditions for bronchoscopy ablative modalities for endoluminal or mixed lesions in non-surgical candidates?
less than 4 cm in length, patent distal airways, visible distal lung parenchyma and life expectancy that exceeds 4 weeks.
110
What are examples of immediate effect therapies?
mechanical debulking, heat based electro cautery, snare, apc and cryoextraction debulking
111
What are examples of delayed effect therapies?
PDT, brachytherapy, mitomycin c or kenalog
112
What is a benefit of ND YAG laser compared to mechanical debulking?
The median time between the 1st and 2nd treatment was 100 days vs 29 days
113
What features are associated with unsuccessful use of a neodymium-doped yttrium aluminium garnet laser?
significant extrinsic compression, long segment obstruction and obstruction of a lobar bronchus
114
Which type of stent produce the lowest levels of stress on the trachea?
Silicone stents produce the lowest stress due to weak contact between the stent and trachea. This may explain the propensity for migration.
covered metal stent exert less force that uncovered metal stents
115
Among stented patients what is a risk for decreased survival?
Lower respiratory tract infections
116
What are the indications of Montgomery T tube placement?
For stenotic segments greater than six centimeters long term T tube placement is recommended
117
What is the definition of a solitary pulmonary nodule?
A well-circumscribed opacity less than or equal to 30mm and not associated with hilar enlargement, pleural effusion or atelectasis.
118
For a incidentally found lung nodule <6mm what is the recommended follow up?
Low risk: No follow up
High risk: optional CT chest 12 months
119
What high risk characteristics in the Fleischner Society Guidelines?
older age, heavy smoking, irregular or spiculated margins, and upper lobe location.
120
What is the recommend follow up for an incidental solid pulmonary nodule <6mm?
Low Risk: No follow up
High Risk: Optional CT chest 12months
121
What is the recommended follow up for an incidental solid nodule 6-8mm?
Low Risk: CT chest 6-12 months and then consider CT at 18-24 months
High-risk patients: CT at 6-12 months, then CT at 18-24 months
122
What is the recommended follow up for an incidental solid nodule > 8mm?
Low-risk and high-risk patients: consider CT at 3 months, PET-CT, or tissue sampling
123
What is the recommend follow up for multiple incidental solid pulmonary nodule <6mm?
low-risk patients: no routine follow-up required
high-risk patients: optional CT at 12 months
124
What is the recommend follow up for multiple incidental solid pulmonary nodule >6mm?
low-risk patients: CT at 3-6 months, then consider CT at 18-24 months
high-risk patients: CT at 3-6 months, then CT at 18-24 months
125
What is the recommend follow up for a subsolid (part solid) or ground glass nodule < 6mm?
low-risk patients: No routine follow up
high-risk patients: No routine follow up
126
What is the recommend follow up for a ground glass nodule > 6mm?
CT at 6-12 months, then if persistent, CT every 2 years until 5 years
127
What is the recommend follow up for a part solid ground glass nodule > 6mm?
CT at 3-6 months, then if persistent and solid component remains <6 mm, annual CT until 5 years
128
Which features on HCRT were noted to be less malignant for nodules?
bronchus sign or if they were lobulated, smooth polygonal margins
129
Wh ich features on HCRT were noted to be indicative of likely malignant for nodules?
spiculated or ragged margins, pleural retraction and vessel sign
130
What are independent risk factors of malignancy?
older age
current or past smoker
history of extra-thoracic cancer
+5 years prior
nodule diameter
spiculation upper lobe location
female sex
emphysema
family history of lung cancer
131
What is the relative risk reduction in the rate of death from lung cancer when comparing X-ray to LDCT
20%
132
What are strong contraindications to bronchial thermoplasty?
known coagulopathy
presence of implantable electronic device such as pacemaker defibrillator
active respiratory infection
asthma exacerbation of changing dose of systemic steroids within 14 days prior to treatment
133
What type of stents are used in post lung transplant patient's who have undergone dehiscence due to infections?
Uncovered self expanding stents for drainage and to avoid colonization. The stents should be removed in 4-6 weeks to prevent granulation
134
What are the characteristics of post intubation tracheal stenosis?
Mid tracheal simple web like scarring
usually circumferential
135
Which is the one type of tissue that is not cryosensitive and why ?
cartilage because it has low water content
136
What are the risk of PDT in central airway lesions?
necrosis post treatment can cause airway obstruction
137
What is the goal of airway re-cannulization?
Provide at least a 50% patent airway
stent is best extrinsic compression and second line treatment
138
At what flow rates are systemic air embolism associated with APC?
greater than 1 L/min
139
How long do the effects of bronchohermoplasty last?
at least 10 years
140
What has been shown to enhance the local and distal spread of recurrent respiratory papillomatosis?
tracheostomy
All bronchoscopic interventions have the potential to aerosolize viral particles either initial or on follow up.
no systemic therapy has been shown to control the disease
141
What is the best noninvasive treatment for upper airway and tracheal obstruction?
Heliox- 70/30-this is the quickest way to optimize flow dynamics. helium is approximately 1/10 the density of air and enhances laminar flow thereby decreasing the pressure drop required to flow and reducing work
142
What are clues on CT scan of potential viable lung?
atelectatic lung rather than tumor mass including homogenously enhancing and vascularized lung with ipsilateral volume loss
143
What are the three innovative bronchoscopy modalities for the treatment of chronic bronchitis?
bronchial rheoplasty
targeted lung denervation
metered cryospray
144
What are contraindications to bronchial rheoplasty?
presence of a permanent pacemaker
145
What are contraindications to targeted lung denervation?
gastroparesis
146
What are the bronchoscopic findings of sarcoidosis?
Mucosal airway abnormalities, mediastinal and hilar lymph adenopahy and history of non-necrotizing (non-caseating) granulomas that do no react with PAS or AFB stains.
147
What is the sensitivity of EBUS-TBNA in diagnosing sarcoidosis?
80% sensitivity with increased odds endobronchial/transbronchial sampling in the proper context
148
What is confoacal microscopy and what is its depth of penetration?
Confocal microscopy is a an optical imaging technique which increases optical resolution and contrast by adding a spatial pinhole at the the confocal plane lens to eliminate out-of-focus light and allows the reconstruction of three-dimensional structures of cellular and subcellular microstructures at a depth of 100-300 micrometers
149
What is optical coherence tomography and what is its depth of penetration?
OCT utilizes near-infrared light transit time and to provides a macroscopic optical cross-sectional view of hollow organs which provides excellent special resolution with a depth of 3mm.
150
What is the maximum depth of radial ebus?
4-5cm penetration and frequency of 20-30Mhz
151
Bronchoscopy provides higher yield in allogenic hematopoietic stem cell transplants or autologous hematopoietic stem cell transplants
allogenic hematopoietic stem cell transplants
152
What is the method of choice for diagnosing low grade neuroendocrine tumors?
Forceps or excisional biopsy
153
What is the stain commonly used for ROSE- rapid onsite specimen evaluation>
ENA Romanowsky Diff Quik staining
154
Do EBUS yields differ between General Anesthesia and Moderate sedation?
No
155
Which of the follow sonographic features are independent factors for nodal metastases?
round shape
distinct margin
heterogeneous echogenicity
presence of coagulation necrosis sign
156
What is the minimum number of passes to obtain enough EBUS tissue for molecular testing?
4
157
What is diagnostic yield of transbronchial biopsy in ICU patients?
63%
158
What percent of cases in the ICU does transbronchial biopsy change management?
49%
159
What is the rate of pneumothorax and bleeding of transbronchial biopsy in ICU patients?
10%
160
What is the treatment for catamenial pneumothorax in a young and healthy patient?
VATS with pleural biopsy and pleurodesis
161
What are the specific indications for endobronchial valves in persistent air leak?
Grade 1 leak lasting at least 7 days or grade 2 leak lasting 5 days
162
What did the Coffee Trial show?
For pleural biopsy cryo had a larger sample size than forceps biopsy but the diagnostic yield was similar.
163
What did the MINT trial show?
rigid pleura scope had larger biopsy but lower diagnostic yield and more pain
164
What is the recommended antibiotic coverage for a community acquired empyema?
ceftriaxone, flagyl and azithromycin
165
What did the TIME1 trial show?
NSAIDS resulted in noninferior in pleurodesis rates
Smaller chest reduced pain scores and were noninferior for pleurodesis
166
For primary spontaneous pneumothorax according to the ACCP guidelines in which patients should a definitive thoracoscopic treatment approach be reserved for?
Persistent air leaks, individuals with high risk occupations such as diving or flying, or recurrence of a second pneumothorax.
BTS recommend surgical evaluation of patients with bilateral synchronous pneumothorax
167
What is a duropleural fistula?
A connection between the dural membrane and the parietal pleura. Develops following spinal cord injury or neurosurgery.
DDx CT myelogram, MRI or pleural beta 2 transferrin
Tx surgical
168
What is the empyema risk of a TIPC?
10-20%
169
What are ultrasound features of nodal metastasis?
round shape, distinct margin, heterogeneous echogenicity and the presence of coagulation necrosis sign
170
What is the pathogenic mechanism that best explains cicatricial bronchial stenosis or a hurricane or corckscrew like mucosal pattern?
Exuberant deposition of collagen and extracellular matrix by TGFB mediated activation of myofibbroblasts
171
What is the pathogenic mechanism that best describes invasive squamous carcinoma which is irregular, raised, erythematous, edematous and sometimes polypoid or necrotic?
mucosal and submucosal infiltration by a CK-5 and p40 stain positive carcinoma
172
What are contraindications to mediastinoscopy?
tracheostomy and severe cervical arthritis
173
Which has the worst prognosis?
multinodal PN2 disease
single PN1/N2
Single station pN1
Single N2
multinodal N1
multinodal PN2 disease has the worst prognosis and single station PN1 has the best prognosis
174
What are contraindications to rigid bronchoscopy in the non trached patient?
inability to achieve neck extension due to cervical Mets, recent trauma or ankylosing spondylitis
other limiting factors include small mouth or overbite
175
What is the risk of pneumothorax post Endobronchial Valve Placement?
up to 1/3 of patients may develop a post op pneumothorax
The risk of pneumothorax is highest in the first three days
the occurrence of pneumothorax doesn't alter the outcomes of the valves
176
How do you manage benign airway stenosis in lung transplant patient?
Dilatation and silicone stent placement
177
Which HPV strains are associated with recurrent respiratory papillomatosis?
HPV 6 and 11
178
What are the treatment options for recurrent respiratory papillomatosis?
Surgical or endoscopic resection and intralesional applications of cidofovir and bevacizumab
179
What are maneuvers that can be used to mitigate the risk for pneumothorax during the administration of cryospray?
deflating the endotracheal tube cuff
disconnecting the endotracheal tube bronchoscope adapter
disconnecting the rigid bronchoscope from the ventilator
use of low-flow settings
180
What is the overall incidence of anastomotic airway complications following lung transplantation?
2-33%
181
What is one way of reducing the risk of airway complications in lung transplant patients?
Dividing the donor bronchus closer to the lobar carina (shorter donor bronchus)
182
At what temperature does irreversible tissue injury begin?
40 degrees Celsius
183
At what temperature dues tissue coagulation start?
70 degrees Celsius
184
At what temperature does tissue carbonization and vaporization start?
200 degrees Celsius
185
What did the AIR 2 trial NOT show?
Improvement in morning peak flow, rescue medication use and FEV1
186
What is the classification of tracheobronchial injuries? (4 levels 1-3b)
Level 1: Mucosal or submucosal injury without mediastinal emphysema or esophageal injury
Level 2: Lesion extending to the muscular wall with subcutaneous or mediastinal emphysema without esophageal injury or mediastinitis
Level 3a: Complete laceration with esophageal or mediastinal soft tissue herniation without esophageal injury or mediastinitis
Level 3b: Any laceration with esophageal injury or mediastinitis.
187
What is the first line treatment for Tracheoesophageal Fistula?
Placement of an esophageal stent unless the lesion is too high
188
What is the definition of early stage central airway cancer?
Radiographically occult squamous cell carcinoma less than 2cm in surface area, with clear visible margins appearing superficial endoscopically and without invasion beyond the bronchial cartilage assessed either by pathologic assessment or by imaging such as radial probe EBUS.
189
What are the treatment modalities for endobronchial tumor and what is the one risk.
PDT, Brachytherapy, electrocautery, cryotherapy and Nd-YAG have similar outcomes.
ND-Yag increase risk of airway perforations.
Patients should under go bronchoscopic evaluation post treatment every 3-6months
190
What is a risk of cryo-debulking?
Moderate bleeding (4-25%) defined as the need for ablative therapy or cold saline to achieve hemostasis
191
What is the treatment of Persistent Air leak (>3 days) after placement of endobronchial valves?
Removal of 1-2 valves
192
When is the Chartis system optional to use
When patients have >95% fissure integrity
193
What is the benefit of a tunneled pleural catheter over a chest tube pleurodesis with talc?
Fewer days in the hospital
194
According to the Bayman et al trial what is the incidence of chest wall mets in mesothelioma at 12months with radiation?
8.1% and 10.1% with no radiation
195
What is the definition of a hemothorax?
Bloody pleural effusion in which the pleural fluid hematocrit is at least 50% of the serum
196
When is a surgical approach indicated in acute traumatic hemothorax?
Initial drainage greater than 1500mL or drainage of more than 200ml per hour for 4 hours
in non surgical patients lytic therapy maybe used
197
What is the rate of catheter blockage in Tunneled Intrapleural Catheters?
<5% of patient
198
What is the diagnostic yield from pleural fluid cytology?
~60%-Medical thoracoscopy has a 95% yield
199
What is a cardiac contraindication to bronchoscopy?
Acute MI is considered a contraindication to
bronchoscopy within 4–6 weeks
200
What is overdiagnosis bias?
Occurs when cancers are diagnosed in individuals
who would not have presented with clinical
symptoms during their natural lifetime had they
not been screened
201
What is overdiagnosis bias?
Occurs when cancers are diagnosed in individuals
who would not have presented with clinical
symptoms during their natural lifetime had they
not been screened
202
What is lead time bias?
• Measuring survival rates may give the
impression that screening increased
survival time.
• In reality patient would have still died
at the same time point.
• Difficult to account for as knowing
onset of tumor is not possible
• RCTs can address this by comparing
age matched mortality rates in patients
who are screened compared to a
control group of unscreened
individuals
203
What is length time bias?
• An overestimation of survival due to relative excessive cases that are asymptomatic slowly progressing while fast progressing cases are detected after giving symptoms.
• This bias makes it seem
that screening and early
intervention improves
outcomes.
• In reality, screening in
tumors with inherently
better prognosis.
• This can be addressed
through RCTs in which
there is a screening
group and a control
group that is not
screened (NELSON Trial).
204
What is the treatment and 5 year survival for Stage 1 Lung Cancer?
Surgery (if non operable radiation)
5 year survival 68-90%
205
What is the treatment and 5 year survival for Stage 2 Lung Cancer?
Surgery With
Adjuvant
Chemotherapy
5 year survival 50-60%
206
What is the treatment and 5 year survival for Stage 3 Lung Cancer?
Chemotherapy with radiation
therapy (surgery in some IIIA)
Adjuvant Immunotherapy
or Targeted therapy
5 year survival 13-35%
207
What is the treatment and 5 year survival for Stage 4 Lung Cancer?
Chemotherapy Targeted
Therapy Immunotherapy
Supportive Care
5 year survival 0-10%
208
In patients with a solid, indeterminate nodule that measures > 8 mm in diameter,
surgical diagnosis is suggested when: (4 itms)
1.When the clinical probability of malignancy is high (> 65%)
2.When the nodule is intensely hypermetabolic by PET
3.When nonsurgical biopsy is suspicious for malignancy
4.When a fully informed patient prefers undergoing a definitive
diagnostic procedure
209
If CT-PET negative in the mediastinum,
tissue confirmation is recommended
prior to surgery for the following 3 reasons?
• Central tumor, usually in contact with the
mediastinum (A central tumor was defined as
existing within the proximal one-third of the
hemithorax, and a peripheral tumor was defined as
existing outside the proximal one-third of the
hemithorax.)
• There is suspicion for N1 disease
• Tumor size is > 3 cm
210
When is invasive mediastinal staging required?
Patients with extensive mediastinal infiltration of tumor and no distant metastases, it is
suggested that radiographic (CT) assessment of the mediastinal stage is usually sufficient
without invasive confirmation (Grade 2C)
• Patients with discrete mediastinal lymph node enlargement (and no distant metastases)
with or without PET uptake in mediastinal nodes, invasive staging of the mediastinum is
recommended over staging by imaging alone (Grade 1C) .
• In patients with PET activity in a mediastinal lymph node and normal appearing nodes by
CT (and no distant metastases), invasive staging of the mediastinum is recommended over
staging by imaging alone (Grade 1C)
• Intermediate suspicion of N2,3 involvement, ie, a radiographically normal mediastinum (by
CT and PET) and a central tumor or N1 lymph node enlargement (and no distant
metastases), invasive staging of the mediastinum is recommended over staging by imaging
alone (Grade 1C)
• For patients with a peripheral clinical stage IA tumor (negative nodal involvement by CT
and PET), invasive preoperative evaluation of the mediastinal nodes is not required (Grade
2B)
211
What are the four features that make up the Canada Lymph node score?
margins(well defined or indistinct), central hilar structure, central necrosis and size greater than 10mm -if three of four present then high odds of malignancy
212
What are lidocaine toxicity symptoms?
CNS symptoms such as metallic taste, perioral numbness light headedness and dizziness. occasional seizure activity. Arrhythmia and cardiac arrest can occur in rare case.
213
What is the treatment for lidocaine toxicity?
Lipid emulsion infusion
214
Which of the following risk factors are associated with increased risk of airway complications in lung transplant recipients?
Duration of the donor's mechanical ventilation prior to organ recovery, Height mismatch between the donor and recipient, type of surgical anastomosis, and post operative broncho pneumonitis
215
What type of patients most commonly have EGFR mutations?
Asian females that do not smoke
216
In the presence of a KRAS mutation is EGFR and ALK testing necessary?
No
217
When using volume doubling time to predict malignancy a <20 days is related to what?
infectious/inflammatory etiologies
218
When using volume doubling time to predict malignancy 20-400 days is related to what?
malignancy
219
When using volume doubling time to predict malignancy >400 days is related to what?
benign etiology, although remember 3-4% NSCLC might have VDT>400
(e.g. lepidic growth adenocarcinoma, sarcoid).
220
A >15 HU change during a dynamic contrast CT will do what?
will increase the probability of malignancy
221
Should molecular markers/ancillary testing of EBUS-TBNA
samples should be done for patients with low stage malignancy
(stages I and II)?
NO
222
What is the most common predictor of conversion (VATS to thoracotomy)?
Delay in surgical intervention
223
What is the triglyceride range for chylothorax?
>110 indeterminate range (50-110mg/dL) and need chylomicrons for indeterminate
224
What are CO2 lasers best used for?
High cutting effect, for which is used mainly tomake incisions in abnormal tissues found in the airways.
225
What are Nd:YAG lasers best used for?
Nd:YAG laser has the highest coagulation effect and is one of the
most common lasers used for debulking of endobronchial lesions
226
Based on currently available evidence, the least likely to be associated
with post transplant airway complications is:
A) Immunosuppression
B) Surgical technique
C) Chronic rejection
D) Donor and recipient characteristic
C) Chronic rejection
227
What was the exclusion criteria for bronchothermoplasty for the Air 2 Trial?
Life threatening asthma requiring intubation
o 3 or more hospitalizations in the past 1 year for asthma
o 4 or more pulses of oral corticosteroids in past 1 year
o 3 or more respiratory tract infections in the past 1 year
o Emphysema
o Pacemaker or defibrillator present
o Inability to tolerate bronchoscopy or medications for procedure
228
What patients is bronchothermoplasty an option for?
Age 18 or older
o Severe asthma
o FEV1 > 60%; Methacholine PC20 <8 mg/ml
o Stable maintenance medications for 4 weeks prior
o Oral corticosteroids if less than 10 mg/day; Leukotriene inhibitors ok, omalizumab
if on for greater than 1 year prior to procedure
o Non smoker with less than 10 pack year history
229
What positioning during bronchoscopy has a higher risk of complication?
Sitting
230
How long after bronchoscopy should the patient be monitored?
2 hours
231
What factors are predictors of hypoxemia during bronchoscopy?
FEV1 and Peak flow
232
Hypoxemia during bronchoscopy is associated with what cardiac changes?
increase in cardiac index, blood pressure, heart rate and cardiac workload
233
What percent of patients demonstrate EKG changes during bronchoscopy?
15%
234
What percent of patients over the age of 60 develop cardiac strain?
21%
235
When is acute MI considered a contraindication to bronchoscopy?
within 4-6weeks (not revascularized pts)
236
What patients should undergo anticoagulation screening before bronchoscopy?
those on anticoagulation therapy
evidence of liver disease
history of bleeding
family history of bleeding
active bleeding or recent transfusion
237
Which type of patients have increased risk of bleeding with transbronchial biopsies?
Lung transplant patients
238
Do renal patients have increased bleeding risk with bronchoscopy?
yes and perform post dialysis or give DDVAP
239
How many days should hold plavix prior to transbronchial or endobronchial lung biopsy?
5-7 days
240
When is a chest xray required post transbronchial biopsy?
If the patient is symptomatic
241
What are the pulmonary physiologic changes of pregnancy?
increased respiratory drive (due to progesterone)
Tidal Volume increase 30-35%
Minute Ventilation increases by almost 50% (respiratory alkalosis
242
What are the pulmonary physiologic changes of pregnancy?
increased respiratory drive (due to progesterone)
Tidal Volume increase 30-35%
Minute Ventilation increases by almost 50% (respiratory alkalosis
243
In the pregnant when is bronchoscopy ideally the safest?
After 28 weeks of pregnancy
244
In the lactating patient which medications are likely safe?
Lidocaine and fentanyl safe
albuterol probably safe
Versed unknown
245
What are non malignant causes of central airway obstruction?
• Congenital
• Trauma
• Iatrogenic
• Mechanical, thermal,
chemical
• Foreign body reactions
•Inflammatory disease
•Anastomotic reaction
•Infectious disease
• Collapse- TBM and EDAC
• Distortion and slings
•Idiopathic
• GERD
246
What is the definition of a simple stricture?
• Confined to 1 cartilage ring
• No malacia or chondritis
247
What is the definition of a complex stricture?
• Length > 1cm
• Typically complicated by cartilage damage
• Includes dynamic changes
248
What factors are associated with more anastomotic complications of tracheal resection?
• Lesions > 4cm, close to glottis associated with more anastomotic complications
• Cases can resect up to 1⁄2 of length of proximal and
mid-trachea, with aid of laryngeal release
249
What population is associated with Idiopathic subglottic stenosis?
Population: women 30-40s
History: GERD
Investigation should exclude sarcoid and GPA
250
What are the histological features of Idiopathic subglottic stenosis?
Normal perichondrium
Submucosal fibrosis with mucous gland obstruction is
common
251
What is the best long-term treatment for idiopathic subglottic stenosis?
Surgery-for slowly recurrent fibrosis and patients who are not a surgical candidate repeat bronchoscopy is consideration
252
What percent of cases of Relapsing Polychondritis have airway involvement?
20% have airway involvement which includes TBM, airway and subglottic stenosis
253
The recurrence rate of carcinoid tumor with surgery is
significantly lower than with
endoscopic treatment
True or False
False
254
What are the four morphological patterns of a tracheal bronchus?
P
255
What is the prevalence of a tracheal bronchus?
1) displaced (most common)- there is no right upper lobe bronchus and the tracheal bronchus aerates the right upper lobe
2) rudimentary -tracheal bronchus ends in a blind pouch
3)supernumerary-tracheal bronchus exists with normal right upper lobe anatomy
4)anomalous- the tracheal bronchus arises proximal to the origin of the upper lobe bronchus. (post pre-eprterial (right (is above)) and hyparterial (left(left is below))
256
What is the prevalence of a tracheal bronchus?
0.1%-2%
257
True or False
Acquired resistance to first generation EGFR inhibitors such as erlotinib frequently occurs through secondary mutations in the EGFR kinase domain such as the T790M substitution?
True
258
What time frame do early airway complications after lung transplant occur?
within the first three months
usually consist pf necrosis or dehiscence
259
What time frame do late airway complications after lung transplant occur?
after three months and usually consist of stenosis or malacia
260
Which of the following patterns of calcification is associated with malignancy?
eccentric
261
Which of the following patterns of calcification is associated with malignancy?
eccentric
262
What is the tumor stain for small cell carcinoma?
The tumor cells stain with synaptophysin and show a strong diffuse positivity for ki-67
263
What is the recommended total dose of topical lidocaine that should not be exceeded?
7mg/kg when used with lidocaine and 4.5mg/kg when used alone
264
What is the recommended total dose of topical lidocaine that should not be exceeded?
7mg/kg when used with lidocaine and 4.5mg/kg when used alone
265
Who was excluded from the air flow 2 trial?
o Who is specifically excluded?
o Life threatening asthma requiring intubation
o 3 or more hospitalizations in the past 1 year for asthma
o 4 or more pulses of oral corticosteroids in past 1 year
o 3 or more respiratory tract infections in the past 1 year
o Emphysema
o Pacemaker or defibrillator present
o Inability to tolerate bronchoscopy or medications for procedure
