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SA Surgery Final > Lower Respiratory Tract Surgery > Flashcards

Lower Respiratory Tract Surgery Flashcards

1
Q

Green LO what does the respiratory pattern look like in animals with pleural disease?

A
  • Restrictive pattern
  • Shallow breathing
  • Tachypneic
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2
Q

Green LO What information can pulse-oximetry provide?

A
  • Hemoglobin saturation of the blood and thus indirectly provides quantitative information about oxygenation
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3
Q

Green LO What diagnostic do you perform first in animals with SEVERE dyspnea suspected to stem from pleural disease?

A
  • Thoracocentesis
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4
Q

Green LO What diagnostic do you perform first in animals with MILD dyspnea suspected to stem from pleural disease?

A
  • DV thoracic radiograph first
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5
Q

Green LO Is surgery usually the treatment of choice for thoracic wall trauma?

A
  • NO or at least rarely
  • Assess for respiratory dysfunction
  • If respiratory dysfunction, they need critical care
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6
Q

Where does inspiratory noise or effort localize for respiration?

A
  • Upper airway
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7
Q

Where does expiratory effort localize for respiration?

A
  • Lower airway
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8
Q

Where does a restrictive breathing pattern localize (i.e. rapid and shallow breathing)?

A
  • Chest wall/pleural cavity
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9
Q

Green LO What are common findings on PE (including auscultation) of patients with pneumothorax?

A
  • Muffled lung sounds all over
  • Reverberating upper airway sounds
  • Restrictive breathing pattern
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10
Q

Green LO If the animal is severely dyspneic, in which order do you perform diagnostics?

A
  • Oxygenation and thoracocentesis first!

- Then radiographs

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11
Q

Green LO What are common findings on PE (including auscultation) of patients with pleural effusion?

A
  • Muffled sounds (lung +/- heart) ventrally

- Harsh lung sounds dorsally

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12
Q

Clicker Question Which of the following statements is incorrect in regards to placement of a large bore chest tube?

A. Prepare the tube by making additional holes in it

B. Make skin incision ventrally in the 10th and 11th intercostal space (ICS)

C. Advance the tube subcutaneously for 3-4 ICS before introducing it into the chest.

D. Attach the tube with purse-string and Chinese finger trap sutures

A

B. Make skin incision ventrally in the 10th and 11th ICS

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13
Q

Green LO Know how to perform an “air” needle thoracocentesis to remove pleural effusion.

A
  • Palpate the costochondral junction
  • Go in the 6th, 7th, or 8th intercostal space in the distal third - close to the costochondral junction
  • IV catheter, extension tubing or needle helpful (or butterfly catheter), and 3 way stopcock
  • GO at a 45 degree angle so that the bevel follows the outline of the chest wall
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14
Q

Green LO Know how to perform an “air” chest tube placement using a large bore tube.

A
  • Could do open with a thoracotomy; otherwise closed
  • Dog size; 14F to 20F (up to 36F)
  • If pleural disease, go bigger due to higher viscosity
  • Make at least 5 holes, and the last one over the radiopaque line
  • Skin incision in the dorsal 1/3 of the chest wall (regardless of fluid or air; this will be around 9-11 ICS)
  • Advance the tube 2-4 intercostal spaces cranial (or pull the skin to overlay the chosen IC space; this will be around 7-9 ICS)
  • Vertical direction - push tube and stylet through the muscle and pleura OR use big hemostatic forcep to guide the tube into the thoracic cavity
  • Remove the trochar before advancing into the chest
  • Secure the tube with a Pursestring around the exit site and Chinese finger trap (alternate between crossing suture behind the tube and tying a surgeon’s throw or square knot on top of the tube
  • Protect and cover the tube with a stockinette
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15
Q

Blue LO Where in relation to the rib are the intercostal vessels and nerve located?

A
  • Caudally
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16
Q

Green LO Know how to perform an “air” chest tube with a small-bore wire-guided tube.

A
  • Clip and prepare the lateral thorax for aseptic surgery.
  • Make a small skin incision in the dorsal one-third of the lateral thoracic wall at the 9th or 10th intercostal space.
  • Tunnel the introducer catheter to the 7th or 8th intercostal space and insert it at the cranial aspect of the rib into the thoracic cavity.
  • Advance the introducer into the thorax over the stylet and thread a J-wire through the catheter.
  • Advance the wire in a cranioventral direction until resistance is encountered.
  • Remove the catheter over the guide wire, leaving the guide wire in place.
  • Insert a small-bore catheter into the thoracic cavity over the guide wire.
  • Gentle aspirate the drain to assess accurate placement.
  • Secure the drain to the skin through the suture holes on the catheter
  • If the tube cannot be fully inserted into the thoracic cavity, secure the external portion of the tube to the skin using a Chinese-Finger Trap.
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17
Q

Treatment for an open (penetrating) thoracic wall trauma?

A
  • Cover with anything (even a towel)
  • Evacuate (thoracocentesis or chest tube)
  • Clean and cover with sterile dressing
  • REFER
  • Surgical debride and explore WHEN STABILIZED!
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18
Q

Blue LO How does a flail chest occur?

A
  • Multiple fractured ribs –> free segment –> paradoxical respiration
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19
Q

Blue LO How much is the flail segment believed to contribute to respiratory insufficiency?

A

NOT SO

  • Hypoventilation is mainly 2° to pulmonary contusion, NOT a flail chest
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20
Q

Appearance of flail chest

A
  • Paradoxical respiration

- As the patient inhales, you see the flail chest segment go in (relative though)

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21
Q

Blue LO How do you initially stabilize a flail rib segment?

A
  • Lay with the affected side down
  • O2 and cardiovascular support
  • Analgesia
  • Check for and treat significant pneumothorax
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22
Q

Blue LO How can you stabilize a flail chest segment?

A
  • External stabilizer or internal fixation
  • You can use tongue depressors or a plastic splinting material
  • Stabilize and do radiographs to know where the segments are
  • Two sutures per segment with a huge tapered needle circumcostally
  • Anchor with two sutures on the intact ribs
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23
Q

Blue LO In which situations do rib fractures need to be stabilized?

A
  • Hypoventilation
  • Or extreme somatic pain
  • The vast majority don’t need repair
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24
Q

How sensitive are radiographs at identifying pulmonary contusions immediately after trauma?

A
  • Can lag behind radiographically

- Can take 24 hours

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25
Q

What do you need to do in all poly-trauma trauma cases (e.g. HBC) regarding diagnosis of trauma to thoracic structures?

A
  • Radiographs to look for pulmonary contusions (may take 24 hours) or diaphragmatic hernia
  • ECG to look for delayed onset cardiac arrhythmias
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26
Q

Green LO What are common findings on PE of acute DH?

A
  • Often in shock if recent
  • Pale or cyanotic mm, tachypnea, tachycardia, and/or oliguria
  • Cardiac arrythmias common
  • GI, respiratory, or CVS systems
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27
Q

Green LO What is the most common cause of diaphragmatic hernia (DH) in dogs and cats?

A
  • Trauma
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28
Q

Green LO What are the clinical signs of a chronic DH?

A
  • Varying levels of respiratory distress
  • Most animals with chronic diaphragmatic hernia are not dyspneic at the time of diagnosis
  • GI signs like anorexia and vomiting
  • Sometimes very mild (fracture? chest rads first!)
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29
Q

Diagnosis of diaphragmatic hernia

A
  • +/- history of trauma
  • Emergency tx (thoracocentesis and oxygen)
  • Radiographs
  • Thoracic ultrasound
  • Barium GI contrast
  • Intra-peritoneal contrast (shouldn’t travel into chest if diaphragm intract
  • False negs possible
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30
Q

Emergency treatment for acquired diaphragmatic hernia

A
  • O2, elevate front, place a stomach tube (orogastric tube often; NG tube possible)
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31
Q

Blue LO When should surgery be pursued in most DH patients?

A
  • After the patient is stable

- ~12-24 hour delay in okay

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32
Q

Blue LO What findings indicate that surgery should be performed immediately?

A
  • Stomach within the chest –> can dilate –> severe respiratory distress
  • Unable to stabilize or deteriorating
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33
Q

What should you do if a patient with a diaphragmatic hernia is decompensating rapidly?

A
  • PASS A STOMACH TUBE to decompress the stomach
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34
Q

Diaphragmatic hernia surgery steps

A
  • Reposition organs
  • Do a complete abdominal explore to look for other injuries
  • Replace the herniated abdominal contents back into the abdomen
  • Repair defect in the diaphragm
  • Thoracocentesis/chest tube
  • Re-expand chronic DH slowly
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35
Q

What if the organs won’t go through the rent in the diaphragm?

A
  • Extend the rent!
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36
Q

What can cause reexpansion pulmonary edema?

A
  • Chronic diaphragmatic hernia
37
Q

Appearance and pathophysiology of reexpansion pulmonary edema

A
  • Distress within hours post-op
  • Volutrauma, barotrauma, and atelectotrauma causing free radical formation (anaerobic metabolism more than aerobic metabolism)
  • Fatal in animals
38
Q

How should you deal with reexpansion pulmonary edema?

A
  • Re-expand slowly and gradually
  • Keep ventilation pressure low (<15 cm H2O)
  • PEEP ventilation in severe cases
39
Q

Prognosis for acute diaphragmatic hernia

A
  • Good if stable (>85%)

- Pulmonary pathology will worsen prognosis

40
Q

Prognosis for chronic diaphragmatic hernia

A
  • Fair - related to duraiton of disease
  • Reinflation of lungs –> re-expansion edema
  • Reposition of organs (liver/pancreas) –> change in blood vessel position –> ischemia
41
Q

What causes peritoneal pericardial diaphragmatic hernia (congenital)?

A
  • Failure of septum transversum to form
42
Q

Clinical signs of PPDH

A
  • None (incidental finding)

- Acute onset of GI, cardiac, or respiratory signs

43
Q

Clicker question

Which is the most common type of pneumothorax in small animals?

A. Primary spontaneous pneumothorax

B. Secondary spontaneous pneumothorax

C. Traumatic closed pneumothorax

D. Traumatic open pneumothorax

A

C. Traumatic closed pneumothorax

44
Q

Green LO How do you initially treat pneumothorax?

A
  • Medical management

- Thoracocentesis and oxygen

45
Q

Green LO What do you do if your initial treatment is inadequate?

A
  • Tube thoracostomy and intermittent suctioning
  • Consider continuous suctioning
  • If nothing is owrking, consider surgery (lobectomy +/- pleurodesis)
46
Q

How common relatively is traumatic vs spontaneous pneumothorax?

A
  • Traumatic from blunt trauma or penetrating trauma is usually MUCH MORE COMMON
47
Q

Green LO If air accumulates rapidly, what can you do?

A
  • Relieve the pressure!
  • Large bore thoracocentesis or open the chest
  • Oxygen and thoracocentesis
  • If you haven’t yet differentiated from a diaphragmatic hernia, you may also need to place a stomach tube
48
Q

Green LO How often does traumatic pneumothorax require surgical treatment?

A
  • Almost never

- Most often medical treatment

49
Q

Green LO How often does spontaneous pneumothorax require surgical treatment?

A
  • Usually they do
50
Q

Examples of secondary spontaneous pneumothorax

A
  • Underlying pulmonary disease like abscess, migrating plant material, etc.
51
Q

Examples of primary spontaneous pneumothorax (RARE)

A
  • Ruptured bullae or bleb
  • Idiopathic
  • ONLY SURGERY HELPS
  • Usually large breed
52
Q

What is a tension pneumothorax?

A
  • One-way valve in the lower airway/lung meaning that air escapes into the chest on inspiration
53
Q

What happens during expiration with a tension pneumothorax?

A
  • Valve closes and air is caught in the pleura space –> intrathoracic pressure increases
54
Q

Which intrathoracic structures are impacted by tension pneumothorax and how?

A
  • Lungs (reduced ventilation)

- Venous vessels (no cardiac return)

55
Q

How can traumatic pneumothorax be classified?

A
  • Open (free communication between the pleural space and external environment) or closed (air accumulates due to leakage from pulmonary parenchyma)
56
Q

Green LO How does a tension pneumothorax form?

A
  • When a flap of tissue acts as a one-way valve so that there is a continuous influx of air into the pleural cavity on inspiration that does not return to the lung on expiration
57
Q

Green LO How does a spontaneous pneumothorax form?

A
  • Result of air leakage from the lung but without trauma as a precipitating cause
58
Q

Green LO What type and class is the most common pneumothorax?

A
  • Closed traumatic pneumothorax
59
Q

How do closed traumatic pneumothoraxes usually occur?

A
  • Often result of blunt trauma that causes parenchymal pulmonary damage to the lung and a closed pneumothorax
60
Q

Green LO Which type of spontaneous pneumothorax is most common in dogs?

A
  • Secondary spontaneous pneumothorax is more common
  • SUbpleural blebs are associated with diffuse emphysema or other pulmonary lesions
  • Underlying pulmonary disease
  • This is vs a primary spontaneous pneumothorax which is secondary to a ruptured bullae or bleb and is idiopathic.
61
Q

Green LO Why is it important to differentiate traumatic and spontaneous pneumothorax?

A
  • It is important to differentiate them because the treatment is drastically different
  • Traumatic tend to be treated medically; spontaneous tend to be treated surgically
62
Q

Green LO Which diagnostic modality is less definitive for presence of pleural effusion? Which modality is definitive for type of pleural effusion?

A
  • Definitive modality is thoracocentesis

- Maybe radiographs are less definitive?

63
Q

Green LO Considering etiologies, how likely is surgical treatment required to resolve pleural effusion in animals with pure transudate, modified transudate, hemorrhage, chylous effusion, and septic exudate?

A
  • Pure transudate: Never
  • Hemorrhage: Seldom
  • Chylous effusion: Very common
  • Septic effusion: Commonly
64
Q

What should be performed on a fluid analysis?

A
  • specific gravity
  • Total protein
  • Nucleated cell count
  • Differential cell count (degenerated PMN? Bacteria? Fat droplets, i.e. chylomicrons? Clears with centrifuging?)
65
Q

Fluid analysis for exudate:

PCV
TNCC
DiffCC
TP

A
  • No PCV
  • TNCC: >5000/µL
  • Diff: PMN
  • TP: >3 g/dL
66
Q

Fluid analysis for hemorrhage

PCV
TNCC
DiffCC
TP

A
  • PCV >8%
67
Q

Fluid analysis for modified transudate

PCV
TNCC
DiffCC
TP

A
  • TNCC: <5000/µL
  • MN for diff
  • TP: <3.5 g/dL
68
Q

Fluid analysis for pure transudate:

PCV
TNCC
DiffCC
TP

A
  • No PCV
  • TNCC: <1000/µL
  • DiffCC: MN
  • TP: <3 g/dL
69
Q

Fluid analysis for chyle

PCV
TNCC
DiffCC
TP

A
  • No PCV
  • TNCC 400 - <10,000
  • MN or PMN
  • TP > 2.5 g/dL
  • If you suspect chyle do a triglyceride analysis of effusion and serum
70
Q

How do you diagnose chylous effusion if suspected?

A
  • Triglyceride analysis of effusion and serum
71
Q

Is hemothorax by itself often surgical?

A
  • No unless there’s a mass or a lung lobe torsion
  • Otherwise underlying disorders are usually coagulation disorders, trauma which don’t require surgery unless they’re not responding to appropriate medical management
72
Q

What is the infection route of pyothorax often?

A
  • Usually unknown
73
Q

Green LO What are the most commonly cultured agents from pyothorax in dogs?

A
  • Gram-negative bacteria like E. coli, Klebsiella, and Pseudomonas are more common in dogs than cats
  • In general, obligate and facultative anaerobic bacteria are the most common
74
Q

Green LO What are the most commonly cultured agents from pyothorax in cats?

A
  • Pasteurella is the most common aerobic agent in cats
75
Q

Which bacteria are most commonly associated with migrating foreign bodies?

A
  • Filamentous rods

- Actinomyces

76
Q

Green LO What is fluid analysis usually showing in pyothorax?

A
  • I think an exudate
  • TNCC > 5000 cells/µL
  • TP >3 g/dL
  • Diff is PMNs
77
Q

Green LO How should pyothorax be managed?

A
  • Medically ideally initially
  • Thoracocentesis with gram stain and culture and sensitivity
  • Bilateral chest tubes: drain and lavage with warm isotonic fluid with heparin added
  • Antibiotics: empirically until C&S results (Ampi or amoxicillin and enrofloxacin are often reasonable until C/S)
  • Antibiotics should be continued for a minimum of 4-6 weeks
78
Q

Green LO How does antibiotic selection differ between actinomyces and nocardis?

A
  • Nocardia: TMS, amikacin

- Actinomyces: Ampicillin, Clindamycin, Doxycyline,Chloramphenicol, Amoxicillin

79
Q

Black LO WHen is surgery indicated in animals with pyothorax?

A
  • If pulmonary mass lesion diagnosed: abscess, torsion, foreign body
  • If not responding to medical management within 3-4 days (fluid should look serosanguinous after this)
80
Q

What are the goals of surgical management of pyothorax?

A
  • Breakdown of adhesions, resection of mass lesions (lung lobectomy)
81
Q

Clicker Of the options listed, which is not considered an indication for surgery in an animal with pyothorax?

A. Concurrent lung FB
B. Concurrent lung abscess
C. Concurrent lung lobe torsion
D. No response to 2 days of medical management

A

D. No response to 2 days of medical management

82
Q

Hydrothorax - when to do surgery?

A
  • Rarely!
  • Sometimes for diagnostic purposes for diffuse neoplastic lesions
  • Thoracoscopy is advantagenous
  • Pure transudate is seldom neoplasia
83
Q

Where does chyle form and go?

A
  • It is intestinal lymph
  • It comes from the intestines
  • Hooks up with the systemic lymphatics to the thoracic duct
84
Q

Why do animals get chylothorax (3 mechanisms), and which is most common?

A
  1. Increased right atrial pressure
  2. Increased cranial vena cava pressure (granulomas or mass)
  3. Leaking from the terminal thoracic duct (MOST common)
85
Q

What can cause chylothorax, and what is the most common cause?

A
  • Non-idiopathic causes are neoplasia, heartworm, trauma, CVC thrombus, pericardial disease, right heart disease
  • Idiopathic is most common
86
Q

What is the treatment for chylothorax, and when is it surgical?

A
  • Idiopathic chylothorax requires surgical treatment

- Or if medical treatment is unsuccessful for a non-idiopathic cause

87
Q

Medical management for chylothorax

A
  • Remember that idiopathic chylothorax requires surgical treatment
  • Thoracocentesis (not chest tubes)
  • Low fat diet
  • Fat soluble vitamins
  • Rutin (Benzopyrone which increases macrophage activity)
  • Surgery if medical treatment is unsuccessful
88
Q

Surgical management of chylothorax details (black*

A
  • Thoracic duct ligation and pericardectomy
  • Omentalization
  • Thoracoscopy is best
  • You can do Pleuralport systems for failed surgical treatments

SA Surgery Final (19 decks)

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