Fiser ABSITE Ch. 25 Thoracic Flashcards
What is the position of the phrenic nerve and vagus nerve in the hilum?
■ Phrenic nerve - runs anterior to hilum
■ Vagus nerve - runs posterior to hilum
What percentage of total lung volume is from the right lung?
55%
What percentage of quiet inspiration is from the diaphragm? and the intercostals?
80%, 20%
Which pneumocytes produce surfactant?
Type II
What structures direct air exchange between alveoli?
Pores of Kahn
How much pleural fluid is produced per day?
1-2 L
Which layer of the pleura produces pleural fluid and which layer has the lymphatics that clear the fluid?
parietal pleura produces pleural fluid cleared by lymphatics in the visceral pleura
What is the most common single site of lung CA mets?
brain
What is the overall 5 year survival rate for lung CA? and with resection?
10%, 30%
What is the most common type of lung CA?
adenocarcinoma
Local recurrence is increased with which type of lung CA? and distant metastases?
local recurrence, distant metastases
What percentage of pts with small carcinoma are surgical candidates?
Less than 5% (most get just chemo and XRT)
What is the most common paraneoplastic syndrome?
Small cell ACTH
What is the most malignant lung tumor?
mesothelioma
Name two chemotherapy agents used for small cell lung CA
cisplatin, etopside
What is the name of the procedure used to assess aortopulmonary window nodes; goes through left 2nd rib cartilage?
Chamberlain procedure
In addition to Horner’s syndrome, what other nerve can have sx with Pancoast tumor?
ulnar
Coin lesions are overall 5-10% malignant. Age 50?
Less than 5%, 50%
What type of tumor is carcinoids? what is the tx?
neuroendocrine, tx: resection; treat like CA
Name the lung mass:
• Submucosal glands; spread along perineural lymphatics, well beyond endoluminal component; XRT sensitive • Slow growing; can get 10-year survival with incomplete resection • Tx: resection; if unresectable, XRT can provide good palliation
Adenoid cystic adenoma, Thyroid CA and goiters, T-cell lymphoma, Teratoma, Parathyroid adenomas
What is the tx for all thymomas?
resection
What is the tx for mediastinal teratoma? and seminoma?
resection and chemo for teratoma; seminoma is very XRT sensitive, chemo for positive nodes or residual disease; surgery for residual disease after that
90% of nonseminoma mediastinal germ cell tumor have elevations in what two markers? and what is the tx?
beta-HCG and alpha-fetoprotein
Tx: cisplatin-based chemo and XRT; surgery for residual disease
Benign tumor of the trachea seen in adults? and in children? malignant is usually what?
adults papilloma; children hemangioma; malignant squamous cell carcinoma
What is the most common late complication after tracheal surgery? and early complication?
late - granulation tissue formation
early - laryngeal edema
Postintubation stenosis - at stoma site with tracheostomy, at cuff site with ET tube
May be able to treat with ___ or ___ May need resection with end-to-end anastomosis if severe.
serial dilatation or with laser
Tracheostomy - needs to be between the 1st and 2nd tracheal rings not >3 rings → risk what?
tracheoinnominate fistula
What is the tx for tracheoinnominate fistula?
overinflate balloon to plug hole or stick your finger in hole and depress innominate artery. Resect innominate and place graft. Leave trachea alone. Use new tracheostomy site
■ Tracheoesophageal fistula: • Use large-volume cuff below fistula • May need decompressing gastrostomy • Tx: tracheal resection, reanastomosis, ___ flap
sternohyoid
Lung abscess are most commonly associated with what?
aspiration
Tx for lung abscess is abx which are 95% successful, what next if abx fails? and if that fails?
CT guided drainage
surgery if fails or cannot rule out CA (>6 cm, failure to resolve after 6 weeks)
What are the three phases of empyema seen in 1-3 weeks respectively?
Exudative phase - 1st week
Fibroproliferative phase - 2nd week
Organized phase - 3rd week
What is the tx of empyema during the 1st and 2nd weeks? and 3rd week (3 options)?
abx and chest tube in 1st and 2nd week
3rd week - Tx: likely need decortication; fibrous peel occurs around lung • May need Eloesser flap (direct opening to external environment) for chronic unresolving empyema • Can also place a chronic chest tube that is gradually pulled out
50% of chylothorax is secondary to what cause? and the other 50%
50% secondary to tumor, 50% secondary to trauma or iatrogenic injury
What is the most common tumor to cause chylothorax?
lymphoma due to tumor burden on lymphatics
The thoracic duct runs along the right side and dumps into the left sublavian vein at junction with internal jugular. Where does it cross? Why is this location significant in chylothorax?
T4-5; Injury above T5-6 results in left-sided chylothorax ■ Injury below T5-6 results in right-sided chylothorax
Tx for chylothorax is 3-4 weeks of conservative therapy * chest tube, octreotide, low-fat diet or TPN). What if that fails for chylothorax secondary to trauma or iatrogenic injury? and for malignant cases?
If that fails, surgery with ligation of thoracic duct on right side low in mediastinum (80% successful) if chylothorax secondary to trauma or iatrogenic injury
For malignant causes of chylothorax, can perform mechanical or talc pleurodesis (less successful than above)
What stain can be used to stain fat in chylothorax?
sudan red stain
Does the milky white fluid in chylothorax that is high in lymphocytes and TAGs get infected?
chylothorax is fluid resistant to infection
Massive hemoptysis (>600 cc/24 h), bleeding is from high pressure bronchial arteries. Most commonly secondary to infection. What type is most common?
mycetoma (fungal)
What is the tx for massive hemoptysis (>600cc in 24 hrs)?
place bleeding side down if know; rigid bronchoscopy to identify site; mainstem intubation to side opposite of bleeding to prevent drowning in blood; to OR for lobectomy or pneumonectomy; brochial artery embolization if not suitable for surgery
Spontaneous pneumothorax seen in tall, healthy, thin, young males. Recurrence risk after 1st pneumothorax is what percent? after 2nd? after 3rd?
20%, 60%, 80%
Which side is spontaneous pnuemothorax most common?
right
What is the tx for spontaneous pneumothorax?
chest tube
When is surgery indicated for spontaneous pneumothorax?
recurrence, large blebs on CT scan, air leak >7 days, nonreexpansion.
Also need surgery for high-risk profession (airline pilot, diver, mountain climber) or pts who live in remote areas
What is the most common cysts of the mediastinum and their usual location?
bronchiogenic cysts, usually posterior to the carina
What type of pneumothorax occurs in temporal relation to menstruation. Caused by endometrial implants in visceral lung pleura?
catamenial pneumothorax
Residual hemothorax despite 2 good chest tubes. What next?
OR for thorascopic drainage
Clotted hemothorax - surgical drainage if >25% of lung, air-fluid levels, or signs of infection; surgery in 1st week to avoid what?
avoid peel
Whiteout on CXR:
Midline shift toward whiteout is most likely collapse. Needs what tx?
No shift - do CT to figure it out
Midline shift away from whiteout likely effusion. Needs what tx?
collapse needs bronchoscopy to remove plug
effusion needs chest tube
Bronchiectasis is acquired from infection, tumor or what other condition?
cystic fibrosis
Noncaseating granulomas are seen in what lung condition?
sarcoidosis
What is the pleural fluid protein to serum ratio seen in an exudate? and the pleural fluid LDH to serum ratio seen in exudate?
> 0.5
> 0.6
Recurrent pleural effusions can be treated with what?
mechanical pleurodesis (talc pleurodesis for malignant pleural effusions)
Airway fires are usually associated with the laser. What is the tx?
stop gas flow, remove ET tube, reintubate for 24 hrs; bronchoscopy
AVMs, connections between the pulmonary arteries and pulmonary veins; usually occurs in the lower lobes and in pts with what disease?
Osler-Weber-Rendu disease
What is the tx for AVMs in the lung?
embolization
What is the most common benign chest wall tumor? and malignant?
benign - osteochondroma
malignant - chondrosarcoma
