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BTK Book Review > Thoracic > Flashcards

Thoracic Flashcards

1
Q

What is a good way to remember the lymph node stations?

A

single digits are mediastinal and double digits are hilar

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2
Q

Describe the course of the thoracic duct.

A
  • from the cistern chyli at L2
  • closing T5 from right to left
  • emptying into the junction of the L internal jugular and subclavian veins
  • you fund the “duck” between the two “goose” (azygoose and esophagoose)
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3
Q

What is the final destination of the azygos vein?

A

the SVC

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4
Q

Where do the phrenic and vagus nerves run in relation to the hilum of the lung?

A
  • the phrenic anteriorly

- the vagus posteriorly

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5
Q

What are the anatomic boundaries of the mediastinum?

A
  • sternum anteriorly
  • vertebrae posteriorly
  • pleurae laterally
  • thoracic inlet superiorly
  • diaphragm inferiorly
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6
Q

What are the functions of type I and type II pneumocytes?

A
  • type I are for gas exchange

- type II make surfactant

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7
Q

What are the pores of Kahn?

A

pores in the alveoli that enable direct air exchange

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8
Q

What are light’s criteria?

A

exudative if one or more of the following is true

  • pleural to serum protein ratio > 0.5
  • pleural to serum LDH ratio > 0.6
  • pleural LDH > ⅔ normal limit of serum
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9
Q

What is the best predictor of post-op complications for patients undergoing lobectomy? What else is predictive?

A
  • FEV1 < 80% is the best predictor

- DLCO < 10mL/min/mm (40%) predicted

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10
Q

How are PFTs used peri-operatively for patients undergoing lobectomy?

A
  • the best predictor of post-op complications is an FEV1 < 80% predicted
  • if borderline, can use a V/Q scan to show contribution of the diseased lung
  • DLCO < 40% predicted is predictive of peri-operative risk
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11
Q

If a patient is planned to undergo lobectomy but has an FEV1 close to 80%, what can be used to better assess the risk for post-op complication?

A

a V/Q scan can show the contribution to pulmonary function that the diseased lobe makes

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12
Q

What size must a pleural effusion be to be visible on CXR?

A

at least 300cc

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13
Q

How is retained hemothorax managed?

A

with a chest tube followed by VATS/thoracotomy for washout

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14
Q

What is the treatment for empyema?

A

decortication

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15
Q

How is a chylothorax diagnosed?

A
  • appears white and milky
  • has a triglyceride level > 110 with lymphocyte predominance
  • sudan red stains fat and will therefore be positive
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16
Q

What are the most common etiologies for chylothorax?

A
  • half are due to malignancy, particularly lymphoma

- the other half are traumatic or iatrogenic with symptoms beginning after oral intake begins

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17
Q

How is chylothorax treated?

A
  • first line is conservative management with a low-fat, medium-chain fatty acid diet (avoidance of long chains) or bowel rest with TPN, can also add octreotide
  • If this fails or the etiology is traumatic, then the next step is ligation of the thoracic duct in the lower right mediastinum versus talc pleurodesis
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18
Q

What is the difference between a primary and secondary pneumothorax?

A

secondary are due to an underlying medical condition

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19
Q

What are the features of tension pneumothorax?

A
  • absent breath sounds
  • hypotension and tachycardia
  • labored breathing and tachypnea
  • chest pain and dyspnea
  • prominent neck veins
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20
Q

What are the indications for operative intervention for pneumothorax?

A
  • persistent air leak (>4 days) is an indication for VATS pleurodesis
  • second recurrence of primary pneumothorax is an indication for blebectomy
  • first occurrence of primary pneumothorax in a high risk professional (scuba diver, pilot)
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21
Q

If a patient has recurrent spontaneous pneumothorax and they go to the OR for blebectomy but blebs aren’t seen, what should you do?

A

an apical wedge resection

22
Q

For stable patients with primary or secondary pneumothorax, what size pneumothorax is an indication for a tube?

A
  • primary greater than 3 cm at the apex or 2 cm at the hilum

- secondary in all cases, regardless of size

23
Q

How do you diagnose and manage acute mediastinal infection?

A
  • diagnose with CT chest
  • manage with source control and antibiotics
  • sternal debridement if etiology is posted sternotomy
  • cervical drain if it is a descending cervical infection
  • VATS to drain mediastinum into pleural space if secondary to lower mediastinal infection
24
Q

What is the most common cause of mediastinal adenopathy?

A

lymphoma

25
Q

What is the most common type of mediastinal tumor in adults and children?

A

neurogenic, found in the posterior mediastinum

26
Q

What is the most common site for a mediastinal tumor?

A

anterior

27
Q

What is the differential for an anterior mediastinal mass?

A
  • think “terrible T’s”

- thymoma, teratoma, (ectopic) thyroid, terrible lymphoma

28
Q

What is the relationship/associations between thymomas and myasthenia gravis?

A
  • 50% are malignant
  • 50% are symptomatic
  • 50% have myasthenia gravis
  • 10% of MG patients have thymoma
  • 80% of MG patients improve with thymectomy
29
Q

Describe the diagnosis, etiology, and treatment of chylothorax.

A
  • diagnosis is made based on finding white, milky fluid with a triglyceride level greater than 110 that stains with Sudan red (stains fat)
  • half are due to malignancy, the other half to traumatic or iatrogenic injury of the thoracic duct
  • treat with avoidance of long-chain fatty acids versus bowel rest and TPN, octreotide is second line
  • operative intervention indicated for traumatic injury or failure of conservative management: ligation of thoracic duct in low right mediastinum versus talc pleurodesis
30
Q

What is the most common cause of SVC syndrome?

A

malignancy is most common, particularly small cell

31
Q

What is the treatment for SVC syndrome?

A

position patient to reduce edema, steroids, anticoagulation, emergent radiation if extreme

32
Q

What is the only real indication for emergent radiation therapy?

A

very extreme SVC syndrome secondary to malignancy

33
Q

What is the recommendation for lung cancer screening?

A

annual low dose CT for 3 years in those 55-80 with a greater than 30 pack year history who have quit in the last 15 years

34
Q

What is the strongest prognostic indicator for patients with lung cancer?

A

nodal involvement

35
Q

What is the most common site of lung cancer metastasis?

A

brain (also goes to supraclavicular nodes, contralateral lung, bone, liver, adrenal)

36
Q

How should pulmonary nodules be followed or evaluated?

A
  • should be followed for two years
  • if low risk of cancer, serial CT at 3, 6, 12, 24 months
  • if med risk of cancer, PET/CT and biopsy
  • if high risk of cancer, VATS biopsy with frozen and resection if malignant
37
Q

How long should solitary pulmonary nodules be watched if no growth is seen?

A

two years

38
Q

What is the most common type of lung cancer?

A

non-small cell

39
Q

Which lung cancers are more central?

A
  • squamous and small cell

- adenocarcinoma is more peripheral

40
Q

What are the common paraneoplastic syndromes associated with lung cancer?

A
  • squamous with PTHrP causing hypercalcemia

- small cell with ACTH and ADH secretion

41
Q

Describe TNM staging for lung cancer.

A
  • T1 is < 3 cm
  • T2 is 3-5 cm
  • T3 is 5-7 cm or invading chest wall or pericardium
  • T4 is >7 cm or invading mediastinum
  • N1: ipsilateral peribronchial or hilar nodal involvement
  • N2: ipsilateral mediastinal or subcarinal node involvement
  • N3: contralateral nodal involvement
  • M1: nodules in contralateral lung, malignant pleural effusion, malignant pericardial effusion, distant metastasis
42
Q

How is lung cancer treated?

A
  • stage I: resection or definitive radiation if not a surgical candidate
  • stage II: resection or definitive radiation if not a surgical candidate
  • locally advanced stage III: resection after neoadjuvant chemoRT
  • stage III with T4 or N3: chemo radiation
  • stage IV: palliative resection or radiation
43
Q

When can you do VATS versus open resection of a lung cancer?

A

VATS okay for tumor < 5cm, peripheral disease, and no regional lymphadenopathy or local invasion

44
Q

What surveillance is recommended for lung cancer?

A
  • stage I/II: CT chest every 6 months for 3 years then annual noncon CT chest
  • stage III/IV: CT chest every 3-6 months for 3 years, then every 6 months, then every year
45
Q

What volume of blood from a chest tube following trauma indicates a need for thoracotomy?

A

> 1500cc initially or >200cc every hour for 3 hours

46
Q

How is a tracheoinnominate fistula managed?

A
  • temporize with overinflation of the cuff or anterior pressure with a finger through the tracheostomy opening
  • definitive treatment with sternotomy and ligation of innominate artery
47
Q

How can you prevent development of a tracheoinnominate fistula?

A

place it between the 2nd and 3rd tracheal ring

48
Q

Where are bronchiogenic cysts found and how are they managed?

A

found posterior to the carina and require surgical resection

49
Q

What is the most likely diagnosis for a popcorn lesion in the lung with calcifications?

A

a benign hamartoma, repeat CT chest in 6 months

50
Q

What are the most common lung tumors, benign and malignant, in children?

A
  • benign: hemangioma

- malignant: carcinoid

51
Q

What type of lung cancer mimics pneumonia?

A

bronchoalveolar cancer, which grows along the alveolar walls and is usually multifocal

BTK Book Review (13 decks)

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