Chapter 25 – Thoracic Flashcards
What is the path of the azygos vein?
Runs along the right side and dumps into superior vena cava
What is the path of the thoracic duct?
Runs along the right side, crosses midline and dumps into left subclavian vein at junction with IJ
Which mainstem bronchi is longer?
Left
Which pulmonary artery is longer?
Right
Which nerve runs in anterior to hilum? Which runs posterior to hilum?
Anterior – phrenic; posterior – vagus
What is the right lung volume? What is the left lung volume?
55%; 45%
What percent of the work is done by the diaphragm and quiet inspiration?
80%
What are the accessory muscles of respiration?
Sternocleidomastoid, levators, serratus posterior, scalenes
What is the function of type I pneumocyte? Type II pneumocytes?
Type I: gas exchange; type II: surfactant production
What is the purpose of pores of Kahn?
Direct air exchange between alveoli
How much pleural fluid is made in a day? Where is it cleared?
1-2 L produced by the parietal pleura, cleared by lymphatics in the visceral plural
What FEV1 is needed before surgery?
Greater than 0.8 or 40% of predicted value
What predicted DLCO is needed before surgery?
Greater than 11 to 12 mL/min/mmHg CO, at least 50% of the predictive value; represents carbon dioxide diffusion capacity
What value of pCO2 or CO2 is needed prior to resection?
pCO2 greater than 45, CO2 less than 50
Persistent air leak is most common after what operation?
Segmentectomy, wedge
Symptoms of lung cancer?
Asymptomatic with findings on routine chest x-ray, pneumonia, pain, weight loss
What is the most common cause of cancer related death in the United States?
Lung cancer
What aspect of lung cancer has the strongest influence on survival?
Nodal involvement
What is the single most common site of lung cancer metastasis?
Brain
How does recurrence present? What percent of recurrences are within the first three years?
Most commonly appears as disseminated metastases; 80%
What is the overall five-year survival rate of lung cancer? With resection?
10%; 30%
Which stages of one cancer are resectable?
Stage I and II
What is the most common lung cancer?
Adenocarcinoma
What percent of lung cancer is non-small cell carcinoma?
80%
What type of non-small cell carcinoma is associated with more peripheral lesions and distant metastases?
Adenocarcinoma
What type of non-small cell carcinoma is associated with local recurrence and more central lesions?
Squamous cell carcinoma
What percent of lung cancer is small cell carcinoma?
20%
What is the overall five-year survival rate for small cell carcinoma?
Very poor, less than 5% are candidates for surgery; 50%
What paraneoplastic syndrome is associated with squamous cell carcinoma? Small cell carcinoma? Which is most common?
Squamous cell – PTH related peptide; small cell – ACTH (most common), ADH
What is the most malignant lung tumor?
Mesothelioma
Chemotherapy used for non-small cell carcinoma stage II or higher?
Carboplatin, Taxol
What chemotherapy is used for small cell lung cancer?
Cisplatin, etoposide
What is mediastinoscopy used for?
Centrally located tumors, patients with suspicious adenopathy, ipsilateral and contralateral mediastinal nodes
What is the Chamberlain procedure?
Assesses aortopulmonary window nodes; go through left second rib cartilage
What is a Pancoast tumor?
Tumor invades apex of chest wall and patients have Horner’s syndrome or ulnar nerve symptoms
What mets to the lung may be resected if isolated and not associated with any other systemic disease?
Colon, renal cell cancer, sarcoma, melanoma, ovarian or endometrial cancer
What are the characteristics of a carcinoid tumor?
Neuroendocrine tumor, central, 50% with symptoms
What is the five-year survival of a typical carcinoid? Atypical carcinoid?
90%, 60%
What bronchial adenomas are malignant?
Adenoid cystic adenoma, mucoepidermoid adenoma, mucous gland adenoma
What is the spread of adenoid cystic adenoma?
Spread along perineural lymphatics, beyond endoluminal compartment; slow-growing, can get 10 year survival with incomplete resection
What is the most common benign adult lung tumor?
Hamartomas
What do hamartoma lesions look like on chest CT?
Have calcifications, appear as popcorn lesion
Do hamartomas require resection?
No; repeat chest CT in six months to confirm diagnosis
What is the most common mediastinal tumor in adults and children?
Neurogenic
What is the most common site for mediastinal tumor?
Anterior
What tumors can be found in the anterior mediastinum?
Thymoma, thyroid cancer, T-cell lymphoma, teratoma, parathyroid adenoma
What is the number one anterior mediastinal mass in adults?
Thymoma
What tumors can be found in the middle mediastinum?
Bronchiogenic cyst, pericardial cyst, enteric cyst, lymphoma
What tumors can be found in the posterior mediastinum?
Enteric cyst, neurogenic tumor, lymphoma
What percent of thymomas are malignant? What percent have symptoms? What percent are associated with myasthenia gravis?
50%, 50%, 50%
What percent of patients with myasthenia gravis have thymomas?
10%
Treatment of thymomas?
All require resection, anti-cholinesterase medications, plasmapheresis, steroids
What is the most common type of lymphoma?
T cell non-Hodgkin’s lymphoma
What type of Hodgkin’s lymphoma is most common?
Nodular sclerosing
What is the treatment for lymphoma?
Chemo and radiation
What is the most common germ cell tumor in the mediastinum? What is the most common malignant germ cell tumor in the mediastinum?
Teratoma, seminoma
Treatment for germ cell tumors?
Resection and chemotherapy with radiation for seminomas
What percent of nonseminoma tumors have elevated beta hCG and alpha-fetoprotein?
90%
Where are bronchiogenic cysts? What is their treatment?
Posterior to carina, resection
Where are pericardial cyst found? What is their treatment?
At right costophrenic angle, resection
What is the most common neurogenic tumor? Treatment?
Neurolemmoma, resection
Paragangliomas produce what?
Catecholamines
Nerve sheath tumors are associated with what syndrome?
Von Recklinghausen’s
What percent of symptomatic mediastinal masses are malignant?
50%
What percent of asymptomatic mediastinal masses are benign?
90%
What are benign tumors of the trachea in adults? children?
Adults – papilloma, children – hemangioma
What are malignant tumors of the trachea?
Squamous cell carcinoma
What is the most common early complication after tracheal surgery? Late?
Laryngeal edema; granulation tissue formation
Where is post intubation stenosis?
At stoma site with tracheostomy, at cuff with ET tube
Where does a tracheostomy need to be placed so as not to risk tracheoinnominate fistula?
Between the first and second tracheal rings, not greater than third rings
Treatment for tracheoinnominate fistula?
Overinflated balloon or stick your finger in the hole and depressed innominate artery; resect innominate and place graft; use new tracheostomy site
Management of tracheoesophageal fistula?
Use large volume cuff below fistula, may need decompressing gastrostomy, tracheal resection, reanastomosis, sternohyoid flap
Long abscesses are most commonly associated with what? What segment of the long are they most commonly in?
Aspiration; posterior segment of RUL and superior segment of RLL
Treatment for lung abscess?
Antibiotic 95% successful, CT guided drain if that fails, surgery if drain fails or cannot rule out cancer
What causes empyemas?
Secondary to pneumonia and subsequent parapneumonic effusion (staph, strep)
Symptoms of empyema?
Pleuritic chest pain, fever, cough, SOB
What will the pleural fluid show in empyema?
WBCs >500 cells/cc, bacteria, positive G stain
3 phases of empyema?
Exudative (1st week), fibroproliferative phase (2nd week), Organized phase (3rd week)
Treatment of empyema in the exudative phase?
Chest tube, abx
Treatment of empyema in fibroproliferative phase?
Chest tube, abx
Treatment of empyema in organized phase?
Likely decortication; fibrous peel around lung, Eloesser flap, chronic chest tube gradually pulled out
What is an Eloesser flap?
Direct opening to external environment
Chylothorax fluid characteristics?
Milky white; high lymphocytes and TAGs (>110), Sudan red stains fat
What is the cause of chylothorax?
50% trauma/iatrogenic injury, 50% tumor (lymphoma most common)
What level injury causes left sided chylothorax? Right sided?
Left: above T5-6; Right: below T5-6
Treatment for chylothorax?
3-4wk conservative: CT, octreotide, low-fat diet or TPN; if fails: surgery with ligation of thoracic duct on R. low in mediastinum
What is considered massive hemotysis?
> 600cc/24h
What is the bleeding from in massive hemotysis?
High pressure bronchial arteries
What causes massive hemoptysis?
Most commonly secondary to infection, mycetoma most common
Treatment of massive hemoptysis?
Place bleeding side down; rigid bronch; mainstem intubation to side opposite bleeding; to OR for lobectomy or pneumonectomy; bronchial artery embolization if not good for OR
What is the recurrence risk of spontaneous pneumothorax after 1st? 2nd? 3rd?
1st: 20%, 2nd: 60%, 3rd: 80%
Treatment for spontaneous pneumothorax?
Chest tube; surgery for recurrence, large blebs on CT, air leak >7d, nonreexpansion
What does surgery for spontaneous pneumothorax entail?
Thoracoscopy, apical blebectomy, mechanical pleurodesis
What are bronchiogenic cysts?
Abnormal lung tissue outside lung; did not get connected to bronchial system
Where does sequestered lung tissue get its blood supply?
From anomalous systemic arteries, usually off of thoracic aorta; can also come from abdominal aorta through inferior pulmonary ligament
Who is extralobar sequestration more common in?
Children; more likely to have systemic venous drainage
Who is intralobar sequestration more common in?
Adults; more likely to have pulmonary vein drainage
Treatment for sequestration?
Lobectomy
What is the etiology of a solitary pulmonary nodule with history of previous sarcoma/melanoma? Head, neck, breast? GI, GU?
Sarcoma/melanoma: more likely metastases; head, neck, breast: more likely primary lung cancer; G.I./GU: metastases or primary
What condition is most likely to cause arrest after blunt trauma due to impaired venous return?
Tension pneumothorax
What is a catamenial pneumothorax and what is it caused by?
Occurs in temporal relation to menstruation, caused by endometrial implants in the visceral lung pleura
What are bronchioliths usually caused by?
Secondary to infection
When does mediastinitis usually occur?
After cardiac surgery
What causes white out on chest x-ray with midline shift toward white out? Midline shift away from white out? No shift?
Toward whiteout: collapse, need bronchoscopy to remove plug; away: effusion, place chest tube; no shift: CT scan to figure out
What are the characteristics of tuberculosis lung disease?
Long apices, calcifications, caseating granulomas
What is a Gohn complex?
Parenchymal lesions plus enlarged hilar lymph nodes
What are characteristics of exudative effusions on cytology?
Protein greater than 3, SG greater than 1.016, LDH ratio (plural fluid to serum) greater than 0.6, low glucose
What is the treatment for recurrent pleural effusions?
Mechanical pleurodesis, talc pleurodesis for malignant effusions
What are airway fires usually caused by? What is the treatment?
Associated with the laser; stop gas flow, remove ET tube, re-intubate for 24 hours, bronchoscopy
What are AVMs? Where are they located in the lung?
Connections between the pulmonary arteries and pulmonary veins, usually in lower lobes
What are symptoms of AVMs? What is the treatment?
Hemoptysis, SOB, neurologic event; embolization
What is the most common benign chest wall tumor?
Osteochondroma
What is the most common malignant tumor of the chest wall?
Chondrosarcoma
