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ABSITE Dodie > Thoracic > Flashcards

Thoracic Flashcards

1
Q

What is the most important predictor of difficult intubation?

A

CXR: Gives body habitus, airway anomalies

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2
Q

How much anatomic dead space is in in the conducting airways

A

150cc

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3
Q

name the blood supply of of the trachea and lung

A

Upper 2/3 trachea = inferior thyroid arteries
Lower 1/3 trachea = bronchial arteries
lung parenchyma = bronchial arteries

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4
Q

Name structures found at the mediastinum

A

Azygous vein, thoracic duct, phrenic nerve, vagus nerve

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5
Q

Where does azygous vein empty?

A

SVC

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6
Q

Where does the thoracic duct crosses midline (runs along the right side)

A

T4-T5

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7
Q

Where does the thoracic duct empty?

A

Left Subclavian Vein

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8
Q

Define the accessory muscles

A

SCM, levators, serratus posterior, scalenes

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9
Q

Primary function of Type I pneumocytes

A

Gas Exchange (diffuse in alveoli)

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10
Q

Primary function of Type II pneumocytes

A

Surfactant production

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11
Q

What is surfactant?

A

Phosphotidylcholine. 80% phospholipid. Decreases alveolar surface tension, keeps alveoli open

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12
Q

What are pores of Kahn?

A

Direct air exchange between alveoli

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13
Q

What is the single best predictor of being able to wean off ventilator after pulmonary resection?

A

FEV1

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14
Q

What other pre-op values needed before pulm resection?

A
  1. DLCO >11-12ml/min/mmHg CO
  2. pCO2 60
  3. VO2 max >10 ml/kg/min
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15
Q

What is DLCO?

A

Carbon Monoxide Diffusion Capacity: Measures lung ability to transfer gases

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16
Q

what is the MCC of hypoxemia post pulm resection?

A

Atelectasis causing V/Q mismatch

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17
Q

what is the MCC of hypercarbia post pulm resection?

A

alveolar hypoventilation (poor minute ventilation)

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18
Q

what is MC nerve injury post pulm resection?

A

Brachial plexus injury on the dependent arm

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19
Q

What is the complication of segmentectomy/wedge

A

Persistent air leak

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20
Q

What is the MC Cx of lobectomy

A

Atelectasis

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21
Q

What complications can arise from pneumonectomy?

A

Arrhythmia, tracheoesophageal or bronchopleural resection, death, cardiac herniation, long bronchial stump syndrome, post-pneumonectomy syndrome

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22
Q

What is post-pneumonectomy syndrome?

A

mediastinal shift after right pneumonectomy. Complicated by main bronchial compression

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23
Q

What is sx of post-pneumonectomy syndrome?

A

Stridor

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24
Q

What is the first thing you do to manage a persistent air leak?

A

Check if CT is on suction. Check system. Repeat CXR

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25
Q

Besides checking chest tube, what else can you do for a persistent air leak?

A
  1. Place 2nd chest tube anteriorly
  2. Bronchoscopy
  3. Wait it out (7days for simple air leaks)
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26
Q

What is you last possible treatment for persistent air leak due to spontaneous PTX?

A
  1. Staple bleb

2. mechanical pleurodesis

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27
Q

What is you last possible treatment for persistent air leak due to post pulm resection?

A

mechanical pleurodesis

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28
Q

What is the MCC of atelectasis after lung resection

A
  1. Hypoxemia

2. Pulm shunting

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29
Q

What is the MCC of Adult Tracheo-esophageal fistula?

A
  1. Esophageal Ca

2. Post-op (pneumonectomy)

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30
Q

What is the primary cause of post-pneumonectomy pulm edema?

A
  1. inflammatory reaction
  2. vasc permeability
  3. Increase perfusion to remaining lung
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31
Q

MCC of empyema

A
  1. PNA

2. Post-thoracic Surgery

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32
Q

What are the 3 stages of empyema

A
  1. exudative (Tx: Ct and Abx)
  2. fibropurulent (Tx: CT and Abx)
  3. organizing (Tx: Decortication)
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33
Q

What alternative tx for organizing empyema besides decortication?

A

Eloesser flap: open thoracic window, direct opening to environment

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34
Q

What are sx of early post-op broncho-pleural flap?

A

massive air leak. resp compromise

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35
Q

What is the treatment for early post-op broncho-pleural flap?

A

tx: place intercostal muscle flap over bronchus

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36
Q

What is MCC of late post-op broncho-pleural fistula?

A

pressure from empyema

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37
Q

What is the treatment for late post-op broncho-pleural flap?

A
  1. Place CT
  2. place pt w/affected side down
  3. bronchoscopy
  4. abx
  5. re-expand lungs, decortication, claggett, high frequency ventilation
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38
Q

What is a claggett procedure

A

fills post-pneumonectomy space with permanent abx solution + intercostal muscle flap

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39
Q

MC benign adult lung tumor

A

Hamartoma

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40
Q

What percent of solitary pulmonary nodules are hamartomas?

A

10%

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41
Q

How does a hamartoma appear on CT?

A

popcorn lesion

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42
Q

Tx for Hamartoma

A

Do not require resection. Repeat CT in 3 months to confirm diagnosis

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43
Q

MC benign upper airway tumor in kids?

A

hemangioma

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44
Q

MC malignant upper airway tumor in kids?

A

carcinoid

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45
Q

MC benign upper airway tumor?

A

papilloma

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46
Q

MC malignant upper airway tumor?

A

SCCA

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47
Q

MC bronchial gland tumors

A

Carcinoids (90%)

1. Typical (90%) 2. Atypical (10%)

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48
Q

MC late Cx after tracheal surgery

A

granulation tissue formation

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49
Q

MC early Cx after tracheal surgery

A

laryngeal edema

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50
Q

What tx options for post-intubation stenosis?

A
  1. serial dilation
  2. tracheal resection
  3. If emergent, tracheostomy
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51
Q

MCC for tracheo-innominate artery fistula

A

Post-tracheostomy

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52
Q

How to treat tracheo-innominate artery fistula?

A

Surgical ligation + partial innominate artery resection. NO GRAFT. repair with strap muscle

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53
Q

How to avoid tracheo-innominate fistula during tracheostomy?

A

Tracheostomy at 3rd tracheal ring or above

54
Q

What is the Cx of having too high of a trach placement?

A

vocal cord problems

55
Q

Steps to control PA bleed

A
  1. Control airway (prevent asphyxiation)
  2. Pull Swan back
  3. Increase PEEP (tamponade)
  4. Bronch and mainstem intubate
  5. Lobectomy if bleeding persists
56
Q

MCC of massive hemoptysis

A
  1. TB
  2. Bronchiectesis
  3. Lung Abscess
57
Q

MCC of death w/massive hemoptysis

A

asphyxiation

58
Q

MC site of bleeding

A

bronchial aretries (high pressure)

59
Q

MCC of lung abscess

A

Aspiration PNA

60
Q

MC location fo lung abscess

A
  1. superior segment of RLL

2. post segment of RUL

61
Q

MC organism of lung abscess

62
Q

What parameters define an exudative effusion

A

protein >3
specific gravity > 1.016
LDH ratio >0.6

63
Q

What is the Tx of recurrent pleural effusions

A

VATS pleurodesis

64
Q

What is rate of recurrent spontaneous PTX

A
  1. 20% (after 1st)
  2. 60% (after 2nd)
  3. 80% (after 3rd)
65
Q

MC site of spont PTX

A

Upper lobe apex, right side

66
Q

What are Sxs of thoracic outlet syndrome

A

pain + paresthesias

motor weakness + atrophy

67
Q

MC anatomic abnormality causing thoracic outlet syndrome

A

cervical rib

68
Q

What is Tinsel’s test?

A

tapping reproduces symptoms (for thoracic outlet syndrome)

69
Q

What is Adson’s test?

A

decrease radial pulse with head turned ipsilateral side

70
Q

What are the 3 types of thorcic outlet syndrome?

A
  1. Neurogenic (MC)
  2. Arterial
  3. Venous
71
Q

What are Dx tools for Thoracic Outlet Syndrome

A
  1. CXR
  2. MRI
  3. Nerve conduction velocity (abnormal <60m/S)
72
Q

MC nerve distribution causing thoracic outlet syndrome

A

Ulnar nerve (C8-T1)

73
Q

what is sugcal treatment for neurogenic thoracic outlet syndrome?

A

1st rib resection (if physiotherapy, PT, OT does not work : persistant NCV <60m/S)

74
Q

What can cause an arterial thoracic outlet syndrome?

A

anterior scalene hypertrophy compression

75
Q

What is sx of venous thorcacic outlet syndrome

A

effort induced thrombosis of subclavian vein (baseball pitchers, excessive use of arm)
Arm acutely swollen and blue

76
Q

How to Dx venous thoracic outlet syndrome?

A

Duples U/S

77
Q

What defines a solitary pulmonary nodule?

A
  1. Single
  2. <3cm
  3. Surrounded by normal lung
  4. No adenopathy
  5. No pleural effusion
78
Q

How often do you monitor a solitary pulm nodule?

A

Serial CTs q3 mos x 4, then q6mos x 2

79
Q

What places a patient with solitary pulm nodule from an observation criteria to immediate or high risk

A

Age >45
previous smoker < 7 years ago
nodule > 1.5cm
scalloped shaped

80
Q

How to diagnosed immediate or high risk nodule?

A

Trans-pleural/Trans-bronchial needle Bx

VATS wedge resection

81
Q

MC lung lesion

82
Q

MC malignant tumor

A 
bronchogenic CA
#2 Mets
83
Q

What is pancoast syndrome?

A

T4-tumor invades apex of chest wall (superior sulcus)

84
Q

Syndrome involving tumor invasion of sympathetic chain?

A

Horner’s syndrome

85
Q

Besides ptosis, miosis and anhydrosis of Horner’s syndrome what other symptom can a patient experience?

A

Ulner Nerve Sxs

86
Q

MC type of lung Ca?

A

Adenocarcinoma

87
Q

What is the strongest influence on survival devoid of systemic mets

A

Nodal involvement

88
Q

Where is the MC site of lung Ca mets?

89
Q

What is the criteria used for lung resectrion?

A
  1. predicted post-op FEV-1 >800cc (>= 40% predicted)
  2. Pre-op DLCO > 10-12 ml/min/mmHg (>=50% predicted)
  3. pO2 >60mmHg (RA)
  4. pCO2 10-12 ml/min/kg
90
Q

What’s next step if work up of lung mass reveals mediastinal adenopathy (>1cm) or central mass?

A

Mediastinoscopy: Assess ipsilateral (N2), contralateral (N3) mediastinal nodes
If positive: unresectable

91
Q

What’s next step if work up reveals para-aortic or AP window adenopathy?

A
  1. Perform Chamberlain (through 2nd rib cartilage
    or
  2. VATS
92
Q

What’s next step if work up reveals supra-clavicular or scalene adenopathy?

A

FNA of node

93
Q

What is tx for Stages I and II?

A
  1. Formal lung resection (lobectomy or pneumonectomy
  2. Mediastinal lymph node dissection
  3. Adjuvant chemo - cardioplatine and paclitaxel
94
Q

What tx for stage IIIA ?

A

T3,N1M0-Resectable- neoadjuvant chemo-XRT

If N2, unresectable

95
Q

What is tx for stage IIIB?

A

T4 (usually unresectable) - neoadjuvant chemo-XRT

96
Q

What is tx for stage IV?

A

Palliative chemo-XRT

97
Q

What is the MCC of superior vena cava syndrome?

A

non-small cell lung Ca

98
Q

What is the MC benign cause of superior vena cava syndrome?

A

mediastinal fibrosis

99
Q

What is Tx of superior vena cava syndrome?

100
Q

What is the MC paraneoplastic syndrome?

A

small cell ACTH

101
Q

What is the most malignant thoracic tumor?

A

mesothelioma

102
Q

Where does small cell CA usually metastasize?

A

Mediastinum

103
Q

What is Tx for small cell lung Ca?

A

chemo: Cisplatin and etoposide

104
Q

What are symptoms of mediastinal mass

A

often asymptomatic, but can have resp insufficiency, chest pain and dysphagia

105
Q

What percent of mediastinal mass is malignant?

106
Q

MC site of mediastinal tumor?

A

Anterior mediastinum

107
Q

MC solitary mediastinal mass?

A

neurogenic (both adults and children)

108
Q

What type of thymoma has the worse prognosis?

A

Epithelial type

109
Q

What is MCC of mediastinal adenopathy?

110
Q

What is MC lymphoma in the mediastinum?

A

Non-Hodgkin’s lymphoma

111
Q

What is the MC germ cell tumor in mediastinum?

112
Q

What is the MC malignant germ cell tumor in mediastinum?

113
Q

What type of germ cell tumor has an elevated B-HCG and alpha-fetoprotein?

A

Non-seminoma

114
Q

How to treat non-seminoma tumor?

A

cisplatin-based chemo

115
Q

What chemo Rx used to treat seminoma and non-seminoma tumors?

A

cisplatin
bleomycin
etoposide

116
Q

MC neurogenic tumor?

A

neurolemma (Schwanomma, nerve sheath)

117
Q

What neurogenic tumor is associated with Von Recklinghausen’s disease

A

Neurofibroma (nerve sheath)

118
Q

Does chylous fluid have a higher risk of infection?

A

No. The fluid is resistant to infection

119
Q

What are the contents of chylous fluid

A

Increase lymphocytes and triglycerides

120
Q

Where is the most likely injury in a right sided chylothorax?

A

Below T5-6

121
Q

Where is the most likely injury in a left sided chylothorax?

A

Above T5-6

122
Q

what level does the thoracic duct crosses the mediastinum

123
Q

Catamenial PTX

A

Occurs in temporal relation to menstrual cycle. Endometrial implants to visceral lung pleura

124
Q

MCC of bronchiectasis?

A

cystic fibrosis

125
Q

Gohn complex

A

parenchymal lesion + enlarged hilar nodules

126
Q

Tx for Tuberculosis

A

INH, Rifampin, pyrazinamide, streptomycin, ethambutol

127
Q

MC site of pulmonary AVMs

A

lower lobes

128
Q

Treatment of pulm AVMs

A

embolization

129
Q

Sydrome associated with pulm AVMs

A

Osler-Weber-Rendu Syndrome (Sx of epistaxis)

130
Q

MC benign chest wall tumor

A

Osteochondroma

131
Q

MC malignant chest wall tumor

A

chondrosarcoma

ABSITE Dodie (3 decks)

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