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06 - absite > Chapter 25: Thoracic > Flashcards

Chapter 25: Thoracic Flashcards

1
Q

Runs along the right side and dumps into the SVC

A

Azygous vein

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2
Q

Runs along the right side, crosses midline at T4-T5, and dumps into left subclavian vein at junction with internal jugular vein

A

Thoracic duct

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3
Q

Nerve runs anterior to hilum

A

Phrenic nerve

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4
Q

Nerve runs posterior to hilum

A

Vagus nerve

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5
Q

Right lung volume

A

55% (3 lobes: RUL, RML, RLL)

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6
Q

Left lung volume

A

45% (2 lobes: LUL and LLL and lingula)

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7
Q

Muscles involved in quite inspiration

A

Diaphragm 80%

Intercostals 20%

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8
Q

Greatest change in dimension when breathing

A

Anterior and posterior

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9
Q

Accessory muscles of inspiration

A

SCM, levators, serratus posterior, scalenes

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10
Q

Function: type 1 pneumocytes

A

Gas exchange

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11
Q

Function: type 2 pneumocytes

A

Surfactant production

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12
Q

Function: pores of Kahn

A

direct air exchange between alveoli

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13
Q

Predicted postop requirements:
FEV1
DLCO

A
  • FEV1 > 0.8 (or >40% of the predicted post value)

- DLCO > 10mL/min/mmHg CO (or > 40% of the predicted post value)

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14
Q

What if predicted postop FEV1 is not > 0.8 but is close?

A

If it is close -> get qualitative V/Q scan to see contribution of that portion of the lung to overall FEV1 -> if low, may still be able to resect

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15
Q
  • Measures carbon monoxide diffusion and represents oxygen exchange capacity
  • This value depends on pulmonary capillary surface area, hemoglobin content, and alveolar architecture.
A

DLCO

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16
Q

pre op pCO2, pO2, VO2 max that say no resection

A

pCO2 > 50 at rest

pO2

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17
Q

MC after segmentectomy / wedge

A

Persistent air leak

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18
Q

MC after lobectomy

A

Atelectasis

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19
Q

MC after pneumonectomy

A

Arrhythmias

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20
Q

Symptoms: can be asymptomatic with finding on routine CXR; cough, hemoptysis, atelectasis, PNA, pain, weight loss

A

Lung cancer

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21
Q

MCC cancer-related death in the United States

A

Lung cancer

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22
Q

Strongest influence on survival in lung cancer

A

Nodal involvement

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23
Q

Lung cancer: single most common site of metastasis

A

Brain

- Can also go to supraclavicular nodes, other lung, bone, liver, and adrenals

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24
Q

Usually appears as disseminated metastasis

A

Recurrence

- 80% of recurrences are within the 1st three years

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25
Q

Overall 5-year survival rate lung cancer

A

10% 5-year survival rate

- 30% with resection for cure

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26
Q

What lung cancer is resectable?

A

Stage 1 and 2 disease resectable; T3,N1,M0 (stage3a) possibly resectable

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27
Q

MC procedure for lung cancer

A

Lobectomy or pneumonectomy; sample suspicious nodes

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28
Q

80% of lung cancer

A

Non-small cell carcinoma

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29
Q

Lung cancer: usually more central

A

Squamous cell carcinoma

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30
Q

Lung cancer: usually more peripheral

A

Adenocarcinoma

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31
Q

MC lung cancer

A

Adenocarcinoma (not squamous)

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32
Q

TNM staging system for lung cancer

A

T: 1 (3cm but >2cm away from carina) 3(invasion of chest wall, pericardium, diaphragm or

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33
Q
  • 20% of lung cancer; neuroendocrine in origin

- usually unresectable at time of diagnosis (

A

Small cell carcinoma

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34
Q

Overall 5 year survival rate of small cell carcinoma

A
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35
Q

Small cell carcinoma: 5 year survival rate T1, N0, M0

A

50%

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36
Q

Most treatment for small cell carcinoma

A

Just get chemo-XRT

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37
Q

Paraneoplastic syndrome: squamous cell CA

A

PTH-related peptide

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38
Q

Paraneoplastic syndrome: small cell CA

A

ACTH and ADH

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39
Q

Most common paraneoplastic syndrome

A

Small cell ACTH

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40
Q
  • Most malignant lung tumor

- Aggressive local invasion, nodal invasion, and distant metastases common at the time of diagnosis.

A

Mesothelioma

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41
Q

What is mesothelioma related to?

A

Asbestos exposure

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42
Q

Non-small cell CA chemotherapy (stage 2 or higher)

A

Carboplatin, Taxol

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43
Q

Small cell lung CA chemotherapy

A

Cisplatin, etoposide

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44
Q

Can XRT be used for lung CA?

A

Yes

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45
Q

Single best test for clinical assessment of T and N status for lung cancer

A

Chest and abdominal CT scan

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46
Q

Best test for M status in lung cancer?

A

PET scan

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47
Q

Use for centrally located tumors and patients with suspicious adenopathy (> 0.8 cm or subcarinal > 1.0 cm) on chest CT

A

Mediastinoscopy

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48
Q

What does mediastinoscopy assess?

A
  • Does not assess aorto-pulmonary (AP) window nodes (left lung drainage)
  • Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes
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49
Q

Treatment if mediastinal nodes are positive

A

Tumor is unresectable

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50
Q

Looking into middle mediastinum with mediastinoscopy:

  • Left-side structures
  • Right side structures
  • Anterior
A

Left-side: RLN, esophagus, aorta, main pulmonary artery (PA)
Right-side: azygous and SVC
Anterior: innominate vein, innominate artery, right PA

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51
Q

assesses enlarged AP window nodes; go thru left 2nd rib cage

A

Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy)

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52
Q

Needed for centrally located tumors to check for airway invasion

A

Bronchoscopy

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53
Q

For lung CA, patients need to be…

A

1) operable (FEV1/DLCO)

2) resectable (can’t have T4, N2, N3, or M disease)

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54
Q

Tumor invades apex of chest wall and patients have Horner’s syndrome (invasion of sympathetic chain - ptosis miosis, anhidrosis) or ulnar nerve symptoms

A

Pancoast tumor

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55
Q
  • Overall, 10% are malignant.
  • Age 50 -> >50% malignant
  • No growth in 2 years, and smooth contour suggests benign disease
A

coin lesion

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56
Q

Management of suspicious coin lesion

A

if suspicious, will need either guided biopsy or wedge resection

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57
Q

Increased lung CA risk 90x

A

Asbestos exposure

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58
Q

Can look like pneumonia; grows along alveolar walls; multifocal

A

Bronchoalveolar cancer

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59
Q

Management: metastases to the lung -> if isolated and not associated with any other systemic disease

A

May be resected for colon, renal cell CA, sarcoma, melanoma, ovarian, and endometrial CA

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60
Q

Neuroendocrine tumor, usually central

- 5% have metastases at time of diagnosis; 50% have symptoms (cough, hemoptysis)

A

Carcinoids

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61
Q

5-year Survival rate: typical carcinoid

A

90%

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62
Q

5-year Survival rate: atypical carcinoid

A

60%

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63
Q

Tx: carcinoid

A

Resection, treat like cancer, outcome closely linked to histology

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64
Q

Malignant bronchial adenomas

A

Mucoepidermoid adenoma, mucous gland adenoma, and adenoid cystic adenoma

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65
Q

Type - bronchial adenomas

  • Slow growth, no metastases
  • Tx: resection
A

Mucoepidermoid adenoma, and mucous gland adenoma

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66
Q
  • From submucosal glands; spreads along perineural lymphatics, well beyond endoluminal component; very XRT sensitive
  • Slow growing; can get 10-year survival with incomplete resection
  • Tx: resection; if unresectable, XRT can provide good palliation
A

Adenoid cystic adenoma

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67
Q
  • Most common benign adult lung tumor
  • Have calcifications and can appear as a popcorn lesion on chest CT
  • diagnosis can be made with CT
A

Hamartomas

68
Q

Tx: hamartomas

A
  • Do not require resection.

- Repeat chest CT in 6 months to confirm diagnosis

69
Q

Most are asymptomatic, can present with chest pain, cough, dyspnea

A

Mediastinal tumors in adults

70
Q

Most common mediastinal tumor in adults and children, usually in posterior mediastinum

A

Neurogenic tumors

71
Q

% of symptomatic mediastinal masses that are malignant

72
Q

% of asymptomatic mediastinal masses are benign

73
Q

Most common site for mediastinal tumors

A

Anterior (thymus)

74
Q

Tumors in the anterior mediastinum

A
  • Thymoma
  • Thyroid CA and goiters
  • T-cell lymphoma
  • Teratoma (and other germ cell tumors)
  • Parathyroid adenomas
75
Q

Structures in the middle mediastinum

A

Heart
Trachea
Ascending aorta

76
Q

Pathology in the middle mediastinum

A

Bronchogenic cysts
Pericardial cysts
Enteric cysts
Lymphoma

77
Q

Structures in the posterior mediastinum

A

Esophagus

Descending aorta

78
Q

Pathology in the posterior mediastinum

A

Enteric cysts
Neurogenic tumors
Lymphoma

79
Q

Structures in mediastinum

A
  • Anterior: thymus
  • Middle: heart, trachea, ascending aorta
  • Posterior: esophagus, descending aorta
80
Q

Treatment: thymoma

A

All thymomas require resection

81
Q

Thymus too big or associated with refractory myasthenia gravis

82
Q

__% of thymomas are malignant

83
Q

__% of patients with thymomas have symptoms

84
Q

__% of patients with thymomas have myasthenia gravis

85
Q

__% of patients myasthenia gravis have thymomas

86
Q

Fatigue, weakness, diplopia, ptosis, antibodies to acetylcholine receptors

A

Myasthenia gravis

87
Q

Tx: myasthenia gravis

A

Anticholinesterase inhibitors (neostigmine); steroids, plasmapheresis

88
Q

Myasthenia gravis: __% of patients get improvement with thymectomy, including patients who do not have thymomas

89
Q

Need to biopsy (often done with mediastinoscopy)

A

Germ cell tumors

90
Q

Most common germ cell tumor in mediastinum

  • Can be benign or malignant
  • Tx: resection, possible chemotherapy
91
Q

Most common malignant germ cell tumor in mediastinum

92
Q
  • 10% are beta-hcg positive, should not have AFP
  • Tx: XRT (extremely sensitive); chemotherapy reserved only for metastases or bulky nodal disease; surgery for residual disease after that
93
Q

90% have elevated beta-hcg and AFP

-TX: chemo (cisplatin, bleomycin, VP-16); surgery for residual disease

A

Non-seminoma

94
Q

Cysts: usually posterior to carina.

- Tx: resection

A

Bronchiogenic cyst

95
Q

Cysts: usually at right costophrenic angle.

- Tx: can leave alone (benign)

A

Pericardial cyst

96
Q

Have pain, neurologic deficit.

  • Tx: resection
  • 10% have intra-spinal involvement that requires simultaneous spinal surgery
A

Neurogenic tumors

97
Q

Most common neurogenic tumor

A

Neurolemmoma (schwannoma)

98
Q

Neurogenic tumors: can produce catecholamines, associated with von Recklinghausen’s disease

A

Paraganglioma

99
Q

What is associated with neurogenic tumors?

A

Neuroblastomas and neurofibromas

100
Q

Trachea: benign tumors
Adult?
Children?

A

Adults - papilloma

Children - hemangioma

101
Q

Trachea malignancy

A

Squamous cell carcionma

102
Q

Most common late complication after tracheal surgery

A

Granulation tissue formation

103
Q

Most common early complication after tracheal surgery

A

Laryngeal edema

104
Q

Tx: laryngeal edema after tracheal surgery

A

Reintubation, racemic epinephrine, steroids

105
Q

Where does post-intubation stenosis occur:

  • with tracheostomy
  • with ET tube
A
  • Tracheostomy: at stoma site

- ETT: cuff site

106
Q

Tx: post-intubation stenosis

A
  • Serial dilatation, bronchoscopic resection, or laser ablation if minor
  • Tracheal resection with end-to-end anastomosis if severe or if it keeps recurring
107
Q

Occurs after tracheostomy, can have rapid exsanguination

A

Tracheo-innominate artery fistula

108
Q

Tx: tracheo-innominate artery fistula

A

Place finger in tracheostomy hole and hold pressure -> median sternotomy with ligation and resection of innominate artery

109
Q

How do you avoid trachea-innominate artery fistula?

A

This complication is avoided by keeping tracheostomy above the 3rd tracheal ring.

110
Q
  • Usually occurs with prolonged intubation
  • Place large-volume cuff ETT below
  • May need decompressing gastrostomy
  • Attempt repair after the patient is weaned from ventilator
A

Tracheo-esophageal fisutla

111
Q

Tx: tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea

A

Tracheo-esophageal fistula

112
Q

Necrotic area; most commonly associated with aspiration

- MC’ly in the superior segment of the RLL

A

Lung abscess

113
Q

Tx: lung abscess

A 
Antibiotics alonge (95% successful); CT-guided drainage if that fails.
- Surgery if above fails or cannot rule out cancer (>6cm, failure to resolve after 6 weeks)
114
Q

What can help you differentiate empyema from lung abscess?

115
Q

What are the causes of empyema?

A

Usually secondary to pneumonia and subsequent parapneumonic effusion (Staph, strep)
- Can also be due to esophageal, pulmonary or mediastinal surgery

116
Q

Symptoms: pleuritic chest pain, fever, cough, SOB

- Pleural fluid often has WBCs > 500 cells/cc, bacteria, and a positive gram stain

117
Q

What are the three phases of empyema?

A

1st week: exudative phase
2nd week: fibroproliferative phase
3rd week: organized week

118
Q

Tx: exudative phase of empyema

A

1st week: chest tube, antiobiotics

119
Q

Tx: fibro-proliferative phase of empyema

A

2nd week: chest tube, antibiotics; possible VATS (video-assisted thoracoscopic surgery) deloculation

120
Q

Tx: organized phase

A

3rd week: likely need decortication; fibrous peel occurs around lung.

  • Some are using intra-pleural tPA to try and dissolve the peel
  • May need Eloesser flap (open thoracic window - direct opening to external environment) in frail / elderly
121
Q

Open thoracic window - direct opening to external environment

A

Eloesser flap

122
Q

Milky white fluid; has increased lymphocytes and TAGs (>110 mL/uL)
- fluid is resistant to infection

A

Chylothorax

123
Q

What stain would you used for chylothorax?

A

Sudan red stains fat

124
Q

Chylothorax: % secondary to trauma or iatrogenic injury

125
Q

Chylothorax: % secondary to tumor (lymphoma most common, due to tumor burden in the lymphatics)

126
Q

Results in left-sided chylothorax

A

Injury above T5-T6

127
Q

Results in right-sided chylothorax

A

Injury below T5-T6

128
Q

Tx: chylothorax

A

2-3 weeks of conservative therapy (chest tube, octreotide, low-fat diet or TPN)

129
Q

If conservative therapy fails and chylothorax secondary to trauma or iatrogenic injury?

A

Need ligation of thoracic duct on right side low in mediastinum (80% successful)

130
Q

Treatment for malignant causes of chylothorax

A

Need talc pleurodesis and possible chemo and/or XRT (less successful than above)

131
Q

Define massive hemoptysis

A

> 600 cc/hr

132
Q

What usually causes bleeding from massive hemoptysis?

A

Bleeding usually from high-pressure bronchial arteries

133
Q

What is massive hemoptysis most commonly secondary to?

134
Q

What causes death in massive hemoptysis?

A

Asphyxiation

135
Q

Tx: massive hemoptysis

A

Place bleeding side down; mainstem intubation to side opposite of bleeding to prevent drowning in blood; rigid bronchoscopy to identify site and possibly control bleeding; may need lobectomy or pneumonectomy to control; bronchial artery embolization if not suitable for surgery

136
Q

Tall, healthy, thin, young males; more common on the right

A

Spontaneous pneumothorax

137
Q

Recurrence risk after 1st pneumothorax, 2nd pneumothorax, 3rd pneumothorax

A

1st: 20%
2nd: 60%
3rd: 80%

138
Q

What causes spontaneous pneumothorax?

A

Results from rupture of a bleb usually in the apex of the upper lobe of the lung

139
Q

Tx: spontaneous pneumothorax

A

chest tube

140
Q

Indications for surgery in spontaneous pneumothorax

A

Recurrence, air leak > 7 days, non-reexpansion, high-risk profession (airline pilot, diver, mountain climber), or patients who live in remote areas

141
Q

Surgery options for spontaneous pneumothorax

A

Thorascoscopy, apical blebectomy, and mechanical pleurodesis

142
Q

Most likely to cause arrest after blunt trauma; impaired venous return

A

Tension pneumothorax

143
Q

Pneumothorax: occurs in temporal relation to menstruation

A

Catamenial pneumothorax

144
Q

What causes catamenial pneumothorax?

A

Caused by endometrial implants in the visceral lung pleura

145
Q

Residual hemothorax despite 2 good chest tubes

A

OR for thoracoscopic drainage

146
Q

Indications for surgery for clotted hemothorax

A

Surgical drainage if > 25% of lung, air-fluid levels, or signs of infection (fever, leukocytosis); surgery in 1st week to avoid peel

147
Q

Causes of broncholiths

A

Usually secondary to infection

148
Q

Cause of mediastinitis

A

Usually occurs after cardiac surgery

149
Q

Whiteout on CXR: midline shift toward whiteout

A

Most likely collapse: need bronchoscopy to remove plug

150
Q

Whiteout on CXR: no shift

A

CT scan to figure it out

151
Q

Whiteout on CXR: midline shift away from whiteout

A

Most likely effusion -> place chest tube

152
Q

What causes bronchiectasis?

A

Acquired from infection, tumor, cystic fibrosis

- Diffuse nature prevents surgery in most patients

153
Q

Lung apices, get calcifications, caseating granulomas

- Tx: INH, rifampin, pyrazinamide

A

Tuberculosis

154
Q

What makes up a Ghon complex?

A

Parenchymal lesion + enlarged hilar nodes

155
Q

Has non-caveating granulomas

A

Sarcoidosis

156
Q 
Transudate:
WBC
pH
Pleural fluid protein to serum
Pleural fluid LDH to serum
157
Q 
Exudate:
WBC
pH
Pleural fluid protein to serum
Pleural fluid LDH to serum
A

WBC: > 1,000
pH: 7.45
Protein: > 0.5
LDH: > 0.6

158
Q 
Empyema:
WBC
pH
Pleural fluid protein to serum
Pleural fluid LDH to serum
A

WBC: > 1,000, > 50,000 most specific
pH: 0.5
LDH: > 0.6

159
Q

Can be treated with mechanical pleurodesis

A

Recurrent pleural effusions

160
Q

What is talc pleurodesis used for?

A

Malignant pleural effusions

161
Q

What are airway fires associated with?

A

Usually associated with the laser

162
Q

Tx: airway fires

A

Stop gas flow, remove ETT, re-intubate for 24 hours, bronchoscopy

163
Q

Connections between the pulmonary arteries and pulmonary veins; usually in lower lobes; can occur with Osler-Weber-Rendu disease

164
Q

Symptoms: hemoptysis, SOB, neurologic events

Tx: embolization

165
Q

Chest wall tumors: MC benign

A

Osteochondroma

166
Q

Chest wall tumors: MC malignant

A

Chondrosarcoma

06 - absite (44 decks)

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