Chapter 25 – Thoracic Flashcards
1
Q
What is the path of the azygos vein?
A
Runs along the right side and dumps into superior vena cava
2
Q
What is the path of the thoracic duct?
A
Runs along the right side, crosses midline and dumps into left subclavian vein at junction with IJ
3
Q
Which mainstem bronchi is longer?
A
Left
4
Q
Which pulmonary artery is longer?
A
Right
5
Q
Which nerve runs in anterior to hilum? Which runs posterior to hilum?
A
Anterior – phrenic; posterior – vagus
6
Q
What percentage of total lung volume is the right lung volume? What is the left lung volume?
A
55%; 45%
7
Q
What percent of the work is done by the diaphragm and quiet inspiration?
A
80%
8
Q
What are the accessory muscles of respiration?
A
Sternocleidomastoid, levators, serratus posterior, scalenes
9
Q
What is the function of type I pneumocyte? Type II pneumocytes?
A
Type I: gas exchange; type II: surfactant production
10
Q
What is the purpose of pores of Kahn?
A
Direct air exchange between alveoli
11
Q
How much pleural fluid is made in a day? Where is it cleared?
A
1-2 L produced by the parietal pleura, cleared by lymphatics in the visceral plural
12
Q
What FEV1 is needed before surgery?
A
Greater than 0.8 or 40% of predicted value
13
Q
What predicted DLCO is needed before surgery?
What is DLCO representative of?
A
Greater than 11 to 12 mL/min/mmHg CO, at least 50% of the predictive value
Represents carbon dioxide diffusion capacity
14
Q
What value of pCO2 or CO2 is needed prior to resection?
A
pCO2 greater than 45, CO2 less than 50
15
Q
Persistent air leak is most common after what operation?
A
Segmentectomy, wedge
16
Q
Symptoms of lung cancer?
A
Asymptomatic with findings on routine chest x-ray, pneumonia, pain, weight loss
17
Q
What is the most common cause of cancer related death in the United States?
A
Lung cancer
18
Q
What aspect of lung cancer has the strongest influence on survival?
A
Nodal involvement
19
Q
What is the single most common site of lung cancer metastasis?
A
Brain
20
Q
How does lung cancer recurrence present? What percent of recurrences are within the first three years?
A
Most commonly appears as disseminated metastases; 80%
21
Q
What is the overall five-year survival rate of lung cancer? With resection?
A
10%; 30%
22
Q
Which stages of lung cancer are resectable?
A
Stage I and II
23
Q
What is the most common lung cancer?
A
Adenocarcinoma
24
Q
What percent of lung cancer is non-small cell carcinoma?
A
80%
25
What type of non-small cell carcinoma is associated with more peripheral lesions and distant metastases?
Adenocarcinoma
26
What type of non-small cell carcinoma is associated with local recurrence and more central lesions?
Squamous cell carcinoma
27
What percent of lung cancer is small cell carcinoma?
20%
28
What is the overall five-year survival rate for small cell carcinoma?
Very poor, less than 5% are candidates for surgery; 50%
29
What paraneoplastic syndrome is associated with squamous cell carcinoma?
What two are associated with small cell carcinoma? Which is most common?
Squamous cell – PTH related peptide
Small cell – ACTH (most common), ADH
30
What is the most malignant lung tumor?
Mesothelioma
31
Chemotherapy used for non-small cell carcinoma stage II or higher?
Carboplatin, Taxol
32
What chemotherapy is used for small cell lung cancer?
Cisplatin, etoposide
33
What findings would prompt use of mediastinoscopy?
Centrally located tumors, patients with suspicious adenopathy, ipsilateral and contralateral mediastinal nodes
34
What is the Chamberlain procedure?
Assesses aortopulmonary window nodes; mediastinoscopy through left second rib cartilage
35
What is a Pancoast tumor?
Tumor invades apex of chest wall and patients have Horner's syndrome or ulnar nerve symptoms
36
Which cancers' 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
37
What are the characteristics of a carcinoid tumor?
Neuroendocrine tumor, central, 50% with symptoms
38
What is the five-year survival of a typical carcinoid? Atypical carcinoid?
90%, 60%
39
What bronchial adenomas are malignant?
Adenoid cystic adenoma, mucoepidermoid adenoma, mucous gland adenoma
40
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
41
What is the most common benign adult lung tumor?
Hamartomas
42
What do hamartoma lesions look like on chest CT?
Have calcifications, appear as popcorn lesion
43
Do hamartomas require resection?
No; repeat chest CT in six months to confirm diagnosis
44
What is the most common mediastinal tumor in adults and children?
Neurogenic
45
What is the most common site for mediastinal tumor?
Anterior
46
What tumors can be found in the anterior mediastinum?
Lots of "Ts":
* Thymoma
* Thyroid cancer
* paraThyroid adenoma
* T-cell lymphoma
* Teratoma
47
What is the number one anterior mediastinal mass in adults?
Thymoma
48
What tumors can be found in the middle mediastinum?
Lots of cysts:
* bronchiogenic cyst
* pericardial cyst
* enteric cyst
* lymphoma
49
What tumors can be found in the posterior mediastinum?
Enteric cyst, neurogenic tumor, lymphoma
50
What percent of thymomas are malignant? What percent have symptoms? What percent are associated with myasthenia gravis?
50%, 50%, 50%
51
What percent of patients with myasthenia gravis have thymomas?
10%
52
Treatment of thymomas?
All require resection, anti-cholinesterase medications, plasmapheresis, steroids
53
What is the most common type of lymphoma?
T cell non-Hodgkin's lymphoma
54
What type of Hodgkin's lymphoma is most common?
Nodular sclerosing
55
What is the treatment for lymphoma?
Chemo and radiation
56
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
57
Treatment for germ cell tumors?
Resection and chemotherapy with radiation for seminomas
58
What percent of nonseminoma tumors have elevated beta hCG and alpha-fetoprotein?
90%
59
Where are bronchiogenic cysts? What is their treatment?
Posterior to carina, resection
60
Where are pericardial cyst found? What is their treatment?
At right costophrenic angle, resection
61
What is the most common neurogenic tumor? Treatment?
Neurolemmoma, resection
62
Paragangliomas produce what?
Catecholamines
63
Nerve sheath tumors are associated with what syndrome?
Von Recklinghausen's
64
What percent of symptomatic mediastinal masses are malignant?
50%
65
What percent of asymptomatic mediastinal masses are benign?
90%
66
What are benign tumors of the trachea in adults? children?
Adults – papilloma, children – hemangioma
67
What are malignant tumors of the trachea?
Squamous cell carcinoma
68
What is the most common early complication after tracheal surgery? Late?
Laryngeal edema; granulation tissue formation
69
Where is post intubation stenosis?
At stoma site with tracheostomy, at cuff with ET tube
70
Where does a tracheostomy need to be placed so as not to risk tracheoinnominate fistula?
Between the first and second tracheal rings, not lower than third rings
71
Treatment for tracheoinnominate fistula?
* overinflated balloon or stick your finger in the tracheotomy and compress the innominate
* resect innominate and place graft
* use new tracheostomy site
72
Management of tracheoesophageal fistula?
Use large volume cuff below fistula, may need decompressing gastrostomy, tracheal resection, reanastomosis, sternohyoid flap
73
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
74
Treatment for lung abscess?
Antibiotic 95% successful, CT guided drain if that fails, surgery if drain fails or cannot rule out cancer
75
What causes empyemas?
Secondary to pneumonia and subsequent parapneumonic effusion (staph, strep)
76
Symptoms of empyema?
Pleuritic chest pain, fever, cough, SOB
77
What will the pleural fluid show in empyema?
WBCs \>500 cells/cc, bacteria, positive G stain
78
3 phases of empyema?
Exudative (1st week), fibroproliferative phase (2nd week), Organized phase (3rd week)
79
Treatment of empyema in the exudative phase?
Chest tube, abx
80
Treatment of empyema in fibroproliferative phase?
Chest tube, abx
81
Treatment of empyema in organized phase?
Likely decortication; fibrous peel around lung, Eloesser flap, chronic chest tube gradually pulled out
82
What is an Eloesser flap?
Direct opening to external environment
83
Chylothorax fluid characteristics?
Milky white; high lymphocytes and TAGs (\>110), Sudan red stains fat
84
What is the cause of chylothorax?
50% trauma/iatrogenic injury to thoracic duct, 50% tumor (lymphoma most common)
85
What level injury causes left sided chylothorax? Right sided?
Thoracic duct injury:
* Left: above T5-6
* Right: below T5-6
86
Treatment for chylothorax?
3-4wk conservative: CTb, octreotide, low-fat diet or TPN; if fails: surgery with ligation of thoracic duct on R. low in mediastinum
87
What is considered massive hemoptysis?
\>600cc/24h
88
What is the bleeding from in massive hemoptysis?
High pressure bronchial arteries
89
What is the most common etiology of massive hemoptysis?
Most commonly secondary to infection, mycetoma most common
90
Treatment of massive hemoptysis?
* place bleeding side down
* rigid bronch
* mainstem intubation to side opposite bleeding
* OR for lobectomy or pneumonectomy
* bronchial artery embolization if not good for OR
91
What is the recurrence risk of spontaneous pneumothorax after 1st? 2nd? 3rd?
1st: 20%, 2nd: 60%, 3rd: 80%
92
Treatment for spontaneous pneumothorax?
When is surgical intervention warranted?
Chest tube
Surgery for recurrence, large blebs on CT, air leak \>7d, nonreexpansion
93
What does surgery for spontaneous pneumothorax entail?
Thoracoscopy, apical blebectomy, mechanical pleurodesis
94
What are bronchiogenic cysts?
Abnormal lung tissue outside lung; did not get connected to bronchial system
95
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
96
Who is extralobar sequestration more common in?
Children; more likely to have systemic venous drainage
97
Who is intralobar sequestration more common in?
Adults; more likely to have pulmonary vein drainage
98
Treatment for sequestration?
Lobectomy
99
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: can be metastases or primary
100
What condition is most likely to cause arrest after blunt trauma due to impaired venous return?
Tension pneumothorax
101
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
102
What are bronchioliths usually caused by?
Secondary to infection
103
When does mediastinitis usually occur?
After cardiac surgery
104
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 from obstruction, need bronchoscopy to remove plug
Away: effusion, place chest tube
No shift: possibly contusion w/ trauma hx; CT to figure out
105
What are the characteristics of tuberculosis lung disease?
Long apices, calcifications, caseating granulomas
106
What is a Gohn complex?
Parenchymal lesions plus enlarged hilar lymph nodes
107
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
108
What is the treatment for recurrent pleural effusions?
Mechanical pleurodesis, talc pleurodesis for malignant effusions
109
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
110
What are AVMs? Where are they located in the lung?
Connections between the pulmonary arteries and pulmonary veins, usually in lower lobes
111
What are symptoms of AVMs? What is the treatment?
Hemoptysis, SOB, neurologic event; embolization
112
What is the most common benign chest wall tumor?
Osteochondroma
113
What is the most common malignant tumor of the chest wall?
Chondrosarcoma
