Fiser Chapter 25. THORACIC Flashcards
What runs along right side of SVC and dumps into it?
Azygous vein
What runs along the right side, crosses midline at T4-T5, and dumps into the left subclavian vein at its junction with the IJ?
Thoracic duct
What runs anterior to hilum and posterior to hilum?
Anterior to hilum: phrenic nerve
Posterior to hilum: vagus nerve
Right and left lung volumes
Right 55%
Left 45%
Muscle use in quiet inspiration
Diaphragm 80%, intercostals 20%
Greatest change in dimension is superior/inferior
What are the accessory muscles?
SCM, levators, serratus poterior, scalens
Type I and II pneumocytes
I: gas exchange
II: surfactant production
Pores of Kahn
Direct air exchange between alveoli
What is the minimum postop FEV1 needed before pneumonectomy?
FEV1 > 0.8 (or >40% of predicted postop value)
If too close, get a qualitative VQ scan to see contribution of that portionof lung to overall FEV1. If low, may still be able to resect.
What is tthe minimum postop DLVO needed?
10 mL/min/mmHg CO (or >40% of predicted postop value)
Measures CO diffusion and represents OXYGEN EXCHANGE CAPACITY. Depends on pulmonary capillary surface area, hemoglobin content, and alveolar architecture.
What are minimum preop values of pCO2, pO2, and VOx max (max O2 consumption) before lung resection?
pCO2 < 50
pO2 > 60 at rest
VOx max > 10-12 mL/min/kg
Most common cx after wedge resection / segmentectomy?
Persistent air leak
Most common cx after lobectomy?
Atelectasis
Most common cx after pneumonectomy?
Arrhythmias
Cough, hemoptysis, atelectasis, PNA, pain, weight loss
Get CXR to look for lung cancer
MCC cancer related death in US
Lung cancer
Strongest influence on survival in lung ca?
Nodal involvement
Mets in lung cancer?
- Brain most common
- Supraclavicular nodes, other lung, bone, liver, adrenals
Lung cancer recurrence
Usually appears as disseminated mets
80% is within first 3 years
Lung ca overall 5 year survival
10% -> 30% with resection for cure
Lung ca resectability
Stage I and II resectable
Stage IIIa (T3N1M0) possibly resectable
Lung ca types
Non-small cell carcinoma (80%): squamous cell (central), adeno (peripheral and most common)
Small cell carcinoma (20%): neuroendocrine in origin, usually unresectable at time of diagnosis (<5% candidates for surgery), overall <5% 5 year survival; T1N0M0 has a 50% 5yr survival, most get just chemoradiation
Suspect lung cancer and PET shows mediastinal lymphadenopathy (>1cm), what’s next step?
LN biopsy
What is unresectable in lung cancer?
T4 (mediastinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion)
Nodes positive
Distant mets
-Can still resect if invading chest wall, pericardium, diaphgram, phrenic nerve, or <2cm away from carina)
Lung ca and hypercalcemia
PTHrP from squamous cell carcinoma
Lung ca and ACTH and ADH
Small cell Ca (ACTH most common paraneoplastic lung ca)
Most malignant lung tumor
Mesothelioma: aggressive local, nodal, and distance mets
Non-small cell Ca chemo (stage II or higher)
Carboplatin, taxol
Small cell lung Ca chemo
Cisplatin, Etoposide
XRT in Lung ca?
Yes
Single best test for clinical assessment of T and N status in lung ca?
CT chest and abdomen
Best test for M status in lung ca?
PET
Who gets mediastinoscopy?
Centrally located tumors and patients with suspicious adenopathy (>0.8cm or subcarinal >1.0 cm) on CT
Mediastinoscopy assesses what nodes?
Looks into middle mediastinum
- Left structures are RLN, esophagus, aorta, PA
- Right structures are azygous and SV
- Anterior structures are innominate vein and artery and Right PA
Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes - Unresectable if MS nodes are positive
Does NOT assess aortopulmonary window nodes (left lung drainage): Need Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy, through left 2nd rib cartilage, for these)
Who gets bronchoscopy?
Needed for centrally located tumors to check for aiway invasion
Who can get resection in lung ca?
- Must be operable (appropriate FEV1 and DLCO values) and resectable (up to T3, N1, M0)
Pancoast tumor
Horner’s syndrome from tumor invading apex of chest wall and invasion of sympathetic chain (ptosis, miosis, anhirdosis) or ulnar nerve symptoms
Coin lesions
10% are malignant
Under 50yo, 5% malignant
Over 50yo, 50% malignant
Likely benign if no growth in 2 years and smooth contour
If suspicious, need either guided biopsy or wedge resection
Asbestos exposure increases lung Ca risk by how much?
90x
What lung cancer can look like pneumonia, grows along alveolar walls, and is multifocal?
Bronchoalveolar ca
Isolated lung mets can be resected in what diseases?
CRC RCC Sarcoma Melanoma Ovarian Endometrial
Carcinoid tumor
Neuroendocrine, usually central
5% have mets at diagnosis
50% have symptoms (cough, hemoptysis)
Typical: 90% 5 year survival
Atypical: 60% 5 year survival
Tx of lung carcinoid?
Resection, treat like cancer, outcome closely linked to histology (typical v atypical?)
Recurrence of carcinoid after resection?
Increase if positive nodes or >3cm
Bronchial adenomas types
Mucoepidermoid adenoma, mucous gland adenoma, adenoid cystic adenoma: all MALIGNANT
Mucoepidermoid adenoma and mucous gland adenoma versus adenoid cystic adenoma
Mucoepidermoid adenoma and mucous gland ademoa: slow growth, no mets, resect!
Adenoid cystic adenoma: from submucosal glands, spreads along perineural lymphatics, well beyond endoluminal component, very XRT SENSITIVE; slow growing, can get 10yr survival with incomplete resection; Tx is resection, if unresectable, XRT can provide good palliation
Most common benign adult lung tumor
Hamartomas
Popcorn lesion with calcifications on chest CT
Hamartoma
Does NOT require resection
Repeat chest CT in 6 months to confirm diagnosis
Most common mediastinal tumor in adults and kids
Neurogenic tumors, usually in posterior mediastinum
Most common site for mediastinal tumor
Anterior
Mediastinal masses
50% malignant
90% of asymptomatic are benign
Anterior mediastinal masses types
Thymoma (most common) Thyroid ca and goiters T-cell lymphoma Teratoma (and other germ cell tumors) paraThyroid adenomas
Middle mediastinum masses
Bronchiogenic cysts
Pericardial cysts
Enteric cysts
Lymphoma
Posterior mediasinum masses
Enteric cysts
Neurogenic tumors
Lymphoma
Thymoma treatment
Resect all!
Refractory MG or big thumus: resect
Thymomas
50% are malignant
50% have symptoms
50% have MG (but only 10% of patient with MG have thymomas)
Fatigue, weakness, diplopia, ptosis, Ab to Ach receptors
MG
Tx: Neostigmine (acetylcholinesterase inhibitors); steroids; plasmapheresis; thomectomy (80% get improvement, including patients who do not have thymomas)
Mediastinal germ cell tumors
Need to biopsy (mediastinoscopy)
Teratoma: most common germ cell tumor in mediastinum, can be benign or malignant, resect with possible chemo
Seminoma: most common malignant GCT in mediastinum; 10% are beta-HCG positive but No AFP; Tx with XRT (very sensitive); chemo reserved for mets or bulky node disease; surgery for residual disease after that
Non-seminoma: 90% have elevated beta-HCG and AFP; tx chemo (cisplatin, bleomycin, VP-16)
Most common germ cell tumor in mediastinum; most common malignant germ cell tumor in mediastinum
Teratoma
Seminoma most common malignant GCT
Mediastinal mass and high HGB and AFP
Non-seminoma
Mediastinal cysts
Bronchiogenic (posterior to carina); resect
Pericardial (right costophrenic angle); leave alone
Neurogenic mediastinal tumors
Pain, neurologic deficit; tx is resection
10% have intra-spinal involvement thatrequires simultaenous spinal surgery
Neurolemmmoma (schwannoma) most common
Paraganglioma: can produces CAs, associated with von Recklinghausen’s disease; can also get neuroblastomas and neurofibromas
Tracheal tumor types
Papilloma
Hemangioma
Squamous cell carcinoma
Benign tracheal mass in adults and kids
Adults: papilloma
Kids: Hemangioma
Tracheal surgery complications (early and late)
Early: laryngeal edema; tx with reintubation, racemic epinephrine, steroids
Late: Granulation tissue
Post-intubation stenosis is usually where?
Tracheostomy: at stoma site
ETT: at cuff site
Tx of post-intubation stenosis
Serial dilatation, bronchoscopic resection, or laser ablation if minor
Tracheal resection end-end anastomosis if severe or recurrent
Tracheo-innominate artery fistula
Can have rapid exsanguination if occurs after tracheostomy
Tx: Place finger in tracheostomy hole and hold pressure -> MEDIAN STERNOTOMY with LIGATION AND RESECTION OF INNOMINATE ARTERY
Avoid this complication by keeping tracheostomy above 3rd tracheal ring
Tracheo-esophageal fistula
Usually occurs with prolonged intubation
Place large-volume cuff endotracheal tube BELOW fistula
May need decompressing gastrostomy
Attempt repair after patient weaned from vent
Tx: tracheal resection, reanastomosis, close hole in esophagus, STERNOHYOID flap between esophagus anf trachea
Lung abscess cause, location, dx, and tx
Aspiration
RLL superior segment
Chest CT to differentiate empyeme from abscess
Antibiotics 95% successful; CT drainage if fails; surgery if that fails or if c/f cancer (>6cm, failure to resolve after 6 weeks)
Lung empyema cause, symptoms, dx, phases, tx
Pneumonia and subsequent parapneumonic effusion (staph, strep); also can be due to esophageal, pulmonary, or mediastinal surgery
Pleuritic chest pain, fever, cough, SOB
Pleural fluid WBC > 500 cells/cc, bacteria, and positive gram stain
Week 1 Exudative phase: tx with chest tube and abx
Week 2 Fibroproliferative phase: tx with chest tube, abx, possible VATS deloculation
Week 3 Organized phase: fibrous peel around lung, likely need decort; some are using intrapleural tPA to try and dissolve peel; may need Eloesser flap (open thoracic window - direct opening to external environment - in frail/elderly)
Milky white fluid, a lot of lymphocytes and TGs > 110 ml/uL, sudan red stains fat
Chylothorax: fluid is resistant to infection
half due to trauma or iatrogenic
half due to tumor (lymphoma most common due to tumor burden in lymphatics)
Chylothorax location on R versus L
Above T5-6: Left
Below T5-6: Right
Tx of chylothorax
2-3 weeks of chest tube, octreotide, low-fat diet or TPN
If fails and if due to trauma or iarogenic, need THORACID DUCT LIGATION on Right side low in mediastinum (80% successful)
If malignant, need talc pleurodesis and possible chemoXRT
Massive hemoptysis
> 600 cc/24h
Usually from bronchial arteries (high pressure) not pulmonary arteries
Most commonly due to infection, death from asphyxiation
Tx of massive hemoptysis
Place bleeding side down
Mainstem intubation to side opposite 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
Spontaneous PTX most common what side?
Right
Tall, healthy, thin, young males
Results from rupture of bleb in apex of upper lobe
Recurrence risk of spontaneous PTX?
1st: 20%
2nd: 60%
3rd: 80%
Tx of spontaneous PTX
Chest tube
Surgery if recurrence, air leak >7 days, non-reexpansion, high risk job (pilot, diver, mountain climber) or if from remote area
Surgery for spontaneous PTX
Thoracoscopy, apical blebectomy, mechanmical pleurodesis
Tension PTX
More likely to cause arrest after BLUNT trauma; impaired venous return
Catamenial PTX
Temporal relation to menstruation, caused by endometrial implants in visceral lung pleura
Residual hemothorax despite 2 good chest tubes
OR for thoracoscopic drainage
Clotted hemothorax
Surgical drainage if >25% of lung, air-fluid levels, or signs of infection (fever, leukocytosis); surgery in 1st week to avoid peel
Broncholiths
Usually secondary toinfection
Mediastinitis
Usually after cardiac surgery
Whiteout on CXR, with midline shift toward whiteout
Collapse -> bronch to remove plug
Whiteout on CXR, with midline shift away from whiteout
Effusion -> place chest tube
Whiteout on CXR without shift
CT to find out wheter collapse or effusion
Bronchiectasis
Acquired from infection, tumor, or CF
Diffuse nature usually prevents surgery in most patients
TB
Lung apices, calcifications, caseating granulomas
Ghon complex: parenchymal lesion + enlarged hilar nodes
Tx: RIPE (Rifampin, INH, Pyrazinamide)
Non-caseating granulomas
Sarcoidosis
Pleural fluid analysis: WBC < 1,000, pH 7.45-7.55, pleural to serum protein ratio <0.5, pleural to serum LDH ration <0.6
Transudate
Pleural fluid analysis: WBC > 1,000, pH <7.45, pleural to serum protein > 0.5, pleural to serum LDH >0.6
Exudate
Pleural fluid analysis WBC > 50,000
Empyema
Also pH < 7.30 and light’s criteria postivie
Recurrent pleural effusions tx
Mechanical pleurodesis
Talc pleurodesis for malignant (talc for tumor)
Airway fires
Usually associated with the laser
Tx: stop gas flow, remove ET tube, reintubate for 24hr, bronch
AVMs
Connections between pulm arteries and veins, usually in lower lobes, can occur with Osler-Weber-Rendu disease
Tx: Embolization
Hemoptysis, SOB, neurologic events
AVMs
Chest wall tumors
Benign: osteochondroma most commonly
Malignant: chondrosarcoma
