Thoracic Flashcards
Where does the azygous vein dump?
The azygous vein on the right dumps into the superior vena cava.
Where does the thoracic duct travel?
The thoracic duct travels on the right, crosses midline at T4-T5, and dumps into the subclavian vein.
Thoracic duct goes right to left at T4-T5
What is the location of the phrenic nerve?
The phrenic nerve is located anterior to the hilum.
What is the location of the vagus nerve?
The vagus nerve is located posterior to the hilum.
What is the function of Type I pneumocytes?
Type I pneumocytes are responsible for gas exchange.
What is the function of Type II pneumocytes?
Type II pneumocytes produce surfactant and can replicate.
What is the most common chest wall tumor?
The most common chest wall tumor is osteochondroma.
What is the most common malignant chest wall tumor?
The most common malignant chest wall tumor is chondrosarcoma.
What are the risk factors for post-operative pulmonary complications?
Risk factors: Age >50, COPD, CHF, ASA > 2, albumin < 3.5, OSA, pulm HTN, smoking, incisions closer to diaphragm
Stop smoking, even if just 1 week prior to surgery (previously thought this would thicken secretions debunked)
Pre-operative albumin of <3.0 is the single greatest laboratory predictor of adverse pulmonary events post-surgery
Nasogastric tubes increases the risk of PNA and atelectasis
What happens to FRC with PEEP?
PEEP increases FRC.
TV= amount of air moved during a normal breath
VC= amount of air moved from maximal inspiration to maximal expiration
RV= amount of air remaining in lung after maximal expiration
ERV: amount of air that can be exhaled after normal expiration
FRC= volume of air remaining in lungs after normal expiration
How does obesity affect FRC, TLC, and VC?
FRC, TLC, and VC decrease with increasing obesity.
What characterizes restrictive lung disease?
Restrictive lung disease decreases TLC, RV, FEV1, and FVC, with FEV1/FVC normal or increased.
What characterizes obstructive lung disease?
Obstructive lung disease increases TLC, RV, and decreases FEV1 and FVC, with a low FEV1/FVC ratio.
What is the effect of age on lung function?
- increased FRC (ERV & RV) and residual volume. Decreased vital capacity. Total lung capacity is preserved
- DLCO decreases with age
- overall lung compliance is decreased
What is the mandatory pre-operative test before lung resection?
First check pre-operative FEV1 and DLCO, if both > 80% proceed to surgery. If either <80% then need predicted post-operative lung function below
If the predicted post-operative of residual lung function FEV1 and DLCP is > 60% = low risk, proceed with lobectomy
If either predicted post-operative functions are between 30-60%: exercise screening test (stair climbing, walking 400 meters) should be performed: if screening satisfactory low risk, proceed with lobectomy
If either predicted post-operative functions are < 30%: then need formal cardiopulmonary testing
-V/Q scan to see contribution of diseased lung to overall FEV1= best predictor pulmonary complications and being able to wean off the ventilator
DLCO: measures carbon monoxide diffusion & represents oxygen exchange capacity; depends on pulmonary capillary surface area, hemoglobin content alveolar architecture
What is the most common complication following lobectomy?
- Persistent air leak – wedge/segmentectomy
- Atelectasis – lobectomy = MC complication following lung surgery
- Arrhythmias – pneumonectomy
- Broncho pleural fistula – pneumonectomy
What is the biggest prognostic indicator for lung cancer?
Biggest prognostic indicator for lung CA – nodal status
TNM Staging
T1: less than 3
T2: 3 - 5 cm but greater than 2 cm from carina
T3 tumors (all potentially resectable) – 5-7 cm in size, chest wall, pericardium, phrenic nerve, parietal pleura
T4 tumors (non-resectable)- > 7 cm, DIAPHRAGM, mediastinum, heart, great vessels, carina, trachea, esophagus, vertebra, recurrent laryngeal nerve
-N1 nodes (resectable) – hilar, intra-lobar, lobar
-N2 (NOT resectable) - ipsilateral mediastinal, subcarinal, aortopulmonary window
-N3 (NOT resectable) – contralateral mediastinal, supraclavicular
M1: distant metastasis
Considered (non-resectable)
- Pleural effusion, heart, great vessel, recurrent laryngeal, carina, trachea,
- Mediastinal node involvement, esophagus, vertebra
- Bilateral lung involvement
- Any extra-thoracic mets
- > 7 cm
What is the most common lung cancer type?
Adenocarcinoma is the most common lung cancer, typically found in non-smokers.
Adenocarcinoma
Adenocarcinoma – MC lung cancer. NON SMOKER!! More peripheral!
Squamous
-More central (squamous in the anus) (keratin pearls)
- Secretes PTHrp
Small cell
Small cell: Chemo-XRT
- Central
- Secretes ADH and ACTH -> cushings
Lung cancer work up
Lung CA:
Sequential steps in order:
1. CT chest
2. PET scan
3. If peripheral tumor, no N2/N3 nodes light up proceed to resection with mediastinal LN harvest
3. If central tumor, CT shows LN > 0.8 cm or PET lights up of N2 or N3 nodes
4. Then you need mediastinal staging #1 endobronchial US with transbronchial FNA or transesophageal US with FNA
* EBUS can access aortopulmonary window, but not para-aortic and subaortic station 5 and 6 Here you need anterior mediastinotomy (chamberlain procedure) or VATS
* If EBUS is inconclusive or sampling is negative Cervical mediastinoscopy was the gold standard
5. PFT before surgery
- CT chest and Abd Best for T and N status
- PET Scan – indicated in all lung CA!! best for M status
- Bronchoscopy needed for centrally located tumors to check for airway invasion (patient presents with symptoms of airway obstruction
- Mediastinoscopy Needed for:
* Centrally located tumors
* suspicious adenopathy on chest CT >0.8 cm or subcarinal > 1.0cm
* Positive PET
- Mediastinoscopy:
* Assesses ipsilateral N2 and contralateral N3 mediastinal nodes
* If any mediastinal nodes are positive = unresectable
* Does not assess aortopulmonary window Need Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy, left 2nd rib cartilage) (if positive unresectable)
* VATS and Endobronchial US guided transbronchial needle aspiration are alternatives for chamberlain procedure
Pre-op PFT are mandatory before lung resection
Surgery: Requires at least lobectomy
Lung cancer chemotherapy
Best indicator for Neoadjuvant chemo-XRT in lung CA – T3 superior sulcus tumor (apical or Pancoast tumor) to downstage to make resectable
Adjuvant chemo– standard following resection of NSCLC (adeno, broncho, squamous) (all stages)
XRT decreases local recurrence
NSCLC - cisplatin and etoposide
Small cell - cisplatin and etoposide
Pancoast tumor
Lung cancer that invades the thoracic inlet (first rib, brachial plexus, subclavian)
They CAN present with Horner’s or SVC syndrome
Pancoast tumors need neoadjuvant chemo-rad then surgery
SVC syndrome
MC is small cell lung CA. Also caused by central lines
Surgery to resect CA is contraindicated with SVC syndrome
Tx: Endovascular stent for all!! Radiation is no longer supported as treatment
Lung cancer screening
Screening CT chest, need all 3:
- 55-80 y/o
- 30 pack year history
- Currently smoking or quit < 15 years ago
Pulmonary nodule
Pulmonary nodule - Must be < 3 cm to be called nodule
- MC lesion is granuloma (laminated calcification): No further work up
- MC tumor is hamartoma (popcorn calcification) (cartilage and fat): Diagnoses made with repeat CT in 3 months
- If > 3 cm go straight to resection
- < 8 mm less likely to be malignant follow with CT
- > 8 mm: low risk = CT, moderate risk = CT/PET, high risk = biopsy
- High risk smoker, age > 50
Upper airway tumor (trachea and main bronchus)
Children – 90% benign. MC benign hemangioma. MC malignant Carcinoid
Adults – 90% malignant. MC benign papilloma, MC malignant squamous cell CA
For all 3 below Bronchial gland tumors resection with 1 cm margin and post op XRT
1. Carcinoid – 90% of all bronchial gland tumors in adults
- Typical 90% - 5% mets. Pink, purple, friable mucosa. 5YS 95%
- Atypical 10% - 50% mets, necrosis, 5YS 50%
2. Adenoid cystic
- Mucosa intact, predilection for perineural invasion
- Very responsive to XRT, avoid taking vital structures
- Post op XRT after resection.
3. Mucoepidermoid
Malignant pleural effusion
Malignant pleural effusion TALC pleurodesis. Contraindication to this is non-re-expansion of the lung
- If you can’t get lung up indwelling pleural catheter
Empyemas
2/2 PNA & paraneumonic effusion (staph, strep); also 2/2 surgery
Pleuritic chest pain, fever, SOB, cough
All empyemas are infected by definition and is a form of complicated parapneumonic effusion and need drainage by CT or surgery
- > 500 WBC, pH <7.2, glucose <40, bacteria = Need chest tube
Parapneumonic effusion
- Uncomplicated = no infection, no loculations. Normal pH, normal glucose. Abx only, no drainage
-Complicated – pH < 7.2, glucose < 40 (key), + gram stain = ALL need drainage
-Exudative – Day 1-5 - 2/2 to lung infection. Sterile, NOT INFECTED pleural fluid: Tx: Just abx unless infected then Chest tube
-Fibrinopurulent - After day 5 – ALL INFECTED: Drainage of fluid is mandatory. Tx: chest tubes + tPA and DNase, If does not resolve after 72 hours VATS deloculation
-Organized – after 3 - 4 weeks – Lung trapped, thick fibrinous peel; lung won’t expand; VATS decortication/deloculation
- If lung won’t expand : VATS Decortication/deloculation.
-If elderly or frail: Eloesser flap (open thoracic window)
Bronchopleural fistula
High frequency ventilation can assist with closure
Symptoms include tracheal secretions resembling saliva or gastric distension if intubated.
How is tracheoesophageal fistula diagnosed?
Bronchoscopy
Chylothorax
Chylothorax >110 Triglycerides. MCC is iatrogenic. MC non-iatrogenic = lymphoma.
Treatment:
- FIRST thing to do is: Conservative X 2 weeks.
1st: high protein, low fat with medium chain fatty acids: FOR BOTH LYMPHOMA AND IATROGENIC
-if this fails next step is: NPO, TPN without lipids, and octreotide
- if above fails do lymphoscintigrophy to find leak if iatrogenic
- If traumatic or iatrogenic, >1 L/day X5 days predicts failure
-VATS ligation of thoracic duct on right side low in mediastinum OR can embolize thoracic duct if patient is too sick to operate - Malignant chylothorax Difference here is you must do thoracentesis, and conservative measures as above, treat the cancer, NEVER OPERATE FOR THESE. if this fails will need talc pleurodesis
- pleuroperitoneal shunting usually not recommended
Chylous ascites
MCC is lymphoma. Can be caused by trauma, surgery (especially in the retroperitoneum in the para-aortic area, especially after AAA repair), cirrhosis or TB
Triglycerides > 110
- Steps are the same as above
- Peritoneovenous shunting are usually NOT recommended
- If conservative management fails then ligate cysterna chyli, right side of aorta just below right renal artery
No surgical repair while intubated; try to extubate first.
Massive hemoptysis
Massive hemoptysis = > 600 cc/24 hours. MC from bronchial arteries. MCC TB. Treatment bleeding side down, double lumen ETT
1st step is to do a rigid bronchoscopy with cautery (do this to locate the bleed too). Tx: bronchial artery embolization has best chance to stop the bleed
Pulmonary AVM
MC lower lobes. Hemoptysis. Associated with osler weber rendu. Tx: embolization
Tracheoinnominate fistula
- MC after tracheostomy.
-Patients have a sentinel bleed followed by massive hemoptysis.
-Best thing to do first is place an ETT distal to bleeding site (Secure airway). Also can try to hyperinflate the trach cuff, can try Utley Manuever, finger in distal trachea with anterior pressure
Go to OR immediately for bronchoscopy but prep for median sternotomy first. - After airway control and control of bleed median sternotomy and resect innominate artery. NO GRAFT. Repair trachea
Tracheal esophageal fistula
Tracheoesophageal fistula – MC from hyperinflated ETT.
Sx: tracheal secretions that look like saliva or gastric distension if intubated
Dx: bronchoscopy
Tx: remove tracheostomy (if present) place ETT with cuff below fistula.
- No surgical repair while intubated. Try to extubate 1st. If unable then below
- If intubated Start PPI, place ETT balloon distal to fistula, Remove NGT, and place decompressive PEG. Wait until extubated for repair
- If unable to extubate or poor surgical candidate esophageal stent as bridge to surgery or definitive tx
- If malignant TEF esophageal stent and +/- tracheal stent
Surgery only when extubated. Only for BENIGN causes. No cancer.
- Primary surgical treatment is tracheal resection with primary anastomosis. Closure of esophagus. Use muscle flaps.
- If small < 5 mm , can argue no need for resection and primarily close all.
Tracheal stenosis
MCC is prolonged intubation, also tracheostomy too high 1-2 ring or cricothyroidotomy.
- Symptoms present about 5 weeks after extubation
- Dx: Bronchoscopy.
- Treatment tracheal resection and anastomosis
- Bronchoscopic laser ablation and dilation does not work for tracheal stenosis caused by intubation.
Thoracic outlet syndrome
Phrenic nerve (runs over anterior scalene),
Anterior to posterior anatomical location of structures: clavicle, subclavian vein, Phrenic nerve, Anterior Scalene, Subclavian artery, brachial plexus, middle scalene, spinal accessory
Surgery for thoracic outlet syndrome (all 3 below): 1st rib resection, divide anterior/middle scalene. Cervical rib resection (if present),
Neurogenic TOS – MC TYPE. medial forearm and 4-5th fingers (MC ulnar affected). Dx: CXR look for cervical rib. Nerve conduction velocity < 60. Tx: Physiotherapy X 3 months. If that fails and NCV < 60 then OR above
Paget von schrotter – Dx Duplex US.
-Effor induced thrombosis of subclavian vein (e.g. baseball pitchers): acutely painful, swollen, blue limb
- If acute and symptomatic 1st give full dose heparin, then only if acute (<2 weeks) Catheter thrombolytic. (If > 2 weeks don’t do thrombolytic). Then surgical repair (above) during same hospitalization or DC with AC and elective surgery
Arterial TOS – Dx: angiogram. Tx: surgery above AND usually interposition bypass graft (artery usually too damaged for repair OR an aneurysm is present)
- compression 2/2 anterior scalene hypertrophy (weight lifters); absent radial pulse with head turned to ipsilateral side= adson’s test
- If there is acute thrombosis:
* Threatened limb: open balloon thrombectomy via brachial artery
* Non-threatened limb: catheter directed thrombolytics
* Both will need 1st rib resection and bypass during same admission
Mediastinal masses
To Diagnose these: Core needle biopsy (avoid FNA) 1st, if unsuccessful and in anterior, the best method is Chamberlain procedure.
Can also use VATS to bx
Incision and removal of anterior mediastinal masses median sternotomy
MC site for mediastinal tumors in adults and children – Anterior
Anterior (The T’s) – MC here is thymoma, thyroid CA and goiter, Terrible Hodgkin’s and B-cell lymphoma, germ cell tumor (teratoma, seminoma, non-seminoma)
Middle - (Heart, trachea, and ascending aorta) MC here is lymphadenopathy (lymphoma, infection, mets), bronchogenic pericardia and enteric cysts
- Bronchogenic and enteric cysts should be resected to confirm dx. Leave pericardial cysts alone
Posterior - (esophagus, descending aorta) MC here is neurogenic tumor (Neurofibroma, neuroganglioma, neuroblastoma), lymphoma, benign cyst
MCC of mediastinal adenopathy lymphoma. NHL MC.
Teratoma – Benign if markers negative. Malignant if high AFP and BHCG. Tx: Resection and chemo if malignant.
Bronchogenic and enteric cysts can get infected resection
Pericardial cyst Leave alone, no CA risk
Neurogenic tumors MC in paravertebral sulcus. Tx: resection. Neurolemma is MC (Shwannoma benign nerve sheathe tumor).
Mediastinal masses in children
Anterior - Thyroid CA, lymphoma = #1 anterior mass in children, teratoma
Middle – T cell lymphoma, teratoma, cardiogenic or bronchogenic cyst
Posterior – T cell lymphoma, neuroblastoma, neurogenic tumor
Thymomas
- All thymomas need resection (median sternotomy)
- MC neoplasm in anterior mediastinum in adults
- Thymus too big or any associated with myasthenia gravis resection
- Children never get thymomas
- 50% are malignant. 50% symptomatic.
- 50% of patients with thymoma have myasthenia. 10% of myasthenia have thymoma.
- Thymectomy improves/resolves symptoms in 90% of myasthenia gravis WITHOUT a thymoma and only 25% WITH a thymoma
Myasthenia Gravis
Dx: EMG, shows Jitter
Tx: Pyridostigmine
Indication for thymectomy: thymoma or severe disease
Need to give post op steroids to avoid Addisonian crisis
Fetus ductus arteriosus, foramen ovale
2 umbilical arteries – from fetus to the placenta. Carries deoxygenated blood
1 umbilical vein – from placenta to fetus. Carries oxygenated blood
High O2 content causes ductus arteriosus to close after birth (connection between descending aorta and left pulmonary artery= blood shunted away from lungs in utero)
Lowered pulmonary vascular resistance causes foramen ovale to close after birth (shunts blood away from lungs)
L -> R shunt
VSD, ASD, PDA: L -> R shunt. Causes CHF
Increasing heart rate, tachypnea, hepatomegaly, pulmonary edema
Cardiac blood supply
Left main coronary artery branches into LAD and circumflex.
Right coronary artery MC has posterior descending artery. Less commonly PDA comes off of left circumflex.
Left internal mammary artery (LIMA) to left anterior descending is best conduit for CABG 90% 20-year patency
Indications for CABG
Indications for CABG:
1. Left main (>50%)
2. 3 vessel disease
3. LAD (>70%) + circumflex disease
Aortic stenosis
Valve area < 1 cm squared = severe. This is when symptoms start
- Worst prognostic indicator is CHF, not syncope
Indications for surgery: Severe with any symptoms or asymptomatic with < 0.6 cm valve area
Cardiac tumors
MC cardiac tumor and MC benign tumor – myxoma, MC located in the left atrium (mobile lesions can cause obstruction of the AV valve; dx best= echo; also histological exam of distal embolus)
MC primary malignancy – angiosarcoma
MC mets to heart – lung CA
MC pediatric cardiac tumor – rhabdomyoma (obstructive sx most common presentation, may exhibit spontaneous regression, carry association with tuberous sclerosis)
Broncho-pulmonary Carcinoid
90% non-functional
PET DOTATE to localize, or octreotide scan
Tx: resection with 1 cm margin and post op XRT
90% of all bronchial gland tumors in adults
- Typical 90% - 5% mets. Pink, purple, friable mucosa. 5YS 95%
- Atypical 10% - 50% mets, necrosis, 5YS 50%
Treatment: lobectomy
