Fiser Chapter 25. THORACIC Flashcards
1
Q
What runs along right side of SVC and dumps into it?
A
Azygous vein
2
Q
What runs along the right side, crosses midline at T4-T5, and dumps into the left subclavian vein at its junction with the IJ?
A
Thoracic duct
3
Q
What runs anterior to hilum and posterior to hilum?
A
Anterior to hilum: phrenic nerve
Posterior to hilum: vagus nerve
4
Q
Right and left lung volumes
A
Right 55%
Left 45%
5
Q
Muscle use in quiet inspiration
A
Diaphragm 80%, intercostals 20%
Greatest change in dimension is superior/inferior
6
Q
What are the accessory muscles?
A
SCM, levators, serratus poterior, scalens
7
Q
Type I and II pneumocytes
A
I: gas exchange
II: surfactant production
8
Q
Pores of Kahn
A
Direct air exchange between alveoli
9
Q
What is the minimum postop FEV1 needed before pneumonectomy?
A
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.
10
Q
What is tthe minimum postop DLVO needed?
A
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.
11
Q
What are minimum preop values of pCO2, pO2, and VOx max (max O2 consumption) before lung resection?
A
pCO2 < 50
pO2 > 60 at rest
VOx max > 10-12 mL/min/kg
12
Q
Most common cx after wedge resection / segmentectomy?
A
Persistent air leak
13
Q
Most common cx after lobectomy?
A
Atelectasis
14
Q
Most common cx after pneumonectomy?
A
Arrhythmias
15
Q
Cough, hemoptysis, atelectasis, PNA, pain, weight loss
A
Get CXR to look for lung cancer
16
Q
MCC cancer related death in US
A
Lung cancer
17
Q
Strongest influence on survival in lung ca?
A
Nodal involvement
18
Q
Mets in lung cancer?
A
- Brain most common
- Supraclavicular nodes, other lung, bone, liver, adrenals
19
Q
Lung cancer recurrence
A
Usually appears as disseminated mets
80% is within first 3 years
20
Q
Lung ca overall 5 year survival
A
10% -> 30% with resection for cure
21
Q
Lung ca resectability
A
Stage I and II resectable
Stage IIIa (T3N1M0) possibly resectable
22
Q
Lung ca types
A
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
23
Q
Suspect lung cancer and PET shows mediastinal lymphadenopathy (>1cm), what’s next step?
A
LN biopsy
24
Q
What is unresectable in lung cancer?
A
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)
25
Lung ca and hypercalcemia
PTHrP from squamous cell carcinoma
26
Lung ca and ACTH and ADH
Small cell Ca (ACTH most common paraneoplastic lung ca)
27
Most malignant lung tumor
Mesothelioma: aggressive local, nodal, and distance mets
28
Non-small cell Ca chemo (stage II or higher)
Carboplatin, taxol
29
Small cell lung Ca chemo
Cisplatin, Etoposide
30
XRT in Lung ca?
Yes
31
Single best test for clinical assessment of T and N status in lung ca?
CT chest and abdomen
32
Best test for M status in lung ca?
PET
33
Who gets mediastinoscopy?
Centrally located tumors and patients with suspicious adenopathy (>0.8cm or subcarinal >1.0 cm) on CT
34
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
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Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes
- Unresectable if MS nodes are positive
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Does NOT assess aortopulmonary window nodes (left lung drainage): Need Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy, through left 2nd rib cartilage, for these)
35
Who gets bronchoscopy?
Needed for centrally located tumors to check for aiway invasion
36
Who can get resection in lung ca?
- Must be operable (appropriate FEV1 and DLCO values) and resectable (up to T3, N1, M0)
37
Pancoast tumor
Horner's syndrome from tumor invading apex of chest wall and invasion of sympathetic chain (ptosis, miosis, anhirdosis) or ulnar nerve symptoms
38
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
39
Asbestos exposure increases lung Ca risk by how much?
90x
40
What lung cancer can look like pneumonia, grows along alveolar walls, and is multifocal?
Bronchoalveolar ca
41
Isolated lung mets can be resected in what diseases?
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CRC
RCC
Sarcoma
Melanoma
Ovarian
Endometrial
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42
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
43
Tx of lung carcinoid?
Resection, treat like cancer, outcome closely linked to histology (typical v atypical?)
44
Recurrence of carcinoid after resection?
Increase if positive nodes or >3cm
45
Bronchial adenomas types
Mucoepidermoid adenoma, mucous gland adenoma, adenoid cystic adenoma: all MALIGNANT
46
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
47
Most common benign adult lung tumor
Hamartomas
48
Popcorn lesion with calcifications on chest CT
Hamartoma
Does NOT require resection
Repeat chest CT in 6 months to confirm diagnosis
49
Most common mediastinal tumor in adults and kids
Neurogenic tumors, usually in posterior mediastinum
50
Most common site for mediastinal tumor
Anterior
51
Mediastinal masses
50% malignant
90% of asymptomatic are benign
52
Anterior mediastinal masses types
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Thymoma (most common)
Thyroid ca and goiters
T-cell lymphoma
Teratoma (and other germ cell tumors)
paraThyroid adenomas
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53
Middle mediastinum masses
Bronchiogenic cysts
Pericardial cysts
Enteric cysts
Lymphoma
54
Posterior mediasinum masses
Enteric cysts
Neurogenic tumors
Lymphoma
55
Thymoma treatment
Resect all!
Refractory MG or big thumus: resect
56
Thymomas
50% are malignant
50% have symptoms
50% have MG (but only 10% of patient with MG have thymomas)
57
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)
58
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)
59
Most common germ cell tumor in mediastinum; most common malignant germ cell tumor in mediastinum
Teratoma
Seminoma most common malignant GCT
60
Mediastinal mass and high HGB and AFP
Non-seminoma
61
Mediastinal cysts
Bronchiogenic (posterior to carina); resect
Pericardial (right costophrenic angle); leave alone
62
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
63
Tracheal tumor types
Papilloma
Hemangioma
Squamous cell carcinoma
64
Benign tracheal mass in adults and kids
Adults: papilloma
Kids: Hemangioma
65
Tracheal surgery complications (early and late)
Early: laryngeal edema; tx with reintubation, racemic epinephrine, steroids
Late: Granulation tissue
66
Post-intubation stenosis is usually where?
Tracheostomy: at stoma site
ETT: at cuff site
67
Tx of post-intubation stenosis
Serial dilatation, bronchoscopic resection, or laser ablation if minor
Tracheal resection end-end anastomosis if severe or recurrent
68
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
69
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
70
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)
71
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)
72
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)
73
Chylothorax location on R versus L
Above T5-6: Left
Below T5-6: Right
74
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
75
Massive hemoptysis
> 600 cc/24h
Usually from bronchial arteries (high pressure) not pulmonary arteries
Most commonly due to infection, death from asphyxiation
76
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
77
Spontaneous PTX most common what side?
Right
Tall, healthy, thin, young males
Results from rupture of bleb in apex of upper lobe
78
Recurrence risk of spontaneous PTX?
1st: 20%
2nd: 60%
3rd: 80%
79
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
80
Surgery for spontaneous PTX
Thoracoscopy, apical blebectomy, mechanmical pleurodesis
81
Tension PTX
More likely to cause arrest after BLUNT trauma; impaired venous return
82
Catamenial PTX
Temporal relation to menstruation, caused by endometrial implants in visceral lung pleura
83
Residual hemothorax despite 2 good chest tubes
OR for thoracoscopic drainage
84
Clotted hemothorax
Surgical drainage if >25% of lung, air-fluid levels, or signs of infection (fever, leukocytosis); surgery in 1st week to avoid peel
85
Broncholiths
Usually secondary toinfection
86
Mediastinitis
Usually after cardiac surgery
87
Whiteout on CXR, with midline shift toward whiteout
Collapse -> bronch to remove plug
88
Whiteout on CXR, with midline shift away from whiteout
Effusion -> place chest tube
89
Whiteout on CXR without shift
CT to find out wheter collapse or effusion
90
Bronchiectasis
Acquired from infection, tumor, or CF
Diffuse nature usually prevents surgery in most patients
91
TB
Lung apices, calcifications, caseating granulomas
Ghon complex: parenchymal lesion + enlarged hilar nodes
Tx: RIPE (Rifampin, INH, Pyrazinamide)
92
Non-caseating granulomas
Sarcoidosis
93
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
94
Pleural fluid analysis: WBC > 1,000, pH <7.45, pleural to serum protein > 0.5, pleural to serum LDH >0.6
Exudate
95
Pleural fluid analysis WBC > 50,000
Empyema
Also pH < 7.30 and light's criteria postivie
96
Recurrent pleural effusions tx
Mechanical pleurodesis
Talc pleurodesis for malignant (talc for tumor)
97
Airway fires
Usually associated with the laser
Tx: stop gas flow, remove ET tube, reintubate for 24hr, bronch
98
AVMs
Connections between pulm arteries and veins, usually in lower lobes, can occur with Osler-Weber-Rendu disease
Tx: Embolization
99
Hemoptysis, SOB, neurologic events
AVMs
100
Chest wall tumors
Benign: osteochondroma most commonly
Malignant: chondrosarcoma
