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Thoracic > Thoracic > Flashcards

Thoracic Flashcards

1
Q

Azygos vein

A

runs along right side and dumps into SVC

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2
Q

Thoracic duct

A

runs along right side, crosses midline, and dumps into left subclavian vein at junction with internal jugular vein; crosses at T4-T5

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3
Q

Mainstem bronchus

A

left longer than right

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4
Q

Pulmonary artery

A

right longer than left before 1st branch

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5
Q

Phrenic nerve

A

runs anterior to hilum

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6
Q

Vagus nerve

A

runs posterior to hilum

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7
Q

Lung volume

A
  • right lung 55% 3 lobes (RUL, RML, RLL)

* left lung 45% 2 lobes (LUL and LLL and lingula)

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8
Q

Quiet inspiration

A
  • diaphragm 80%, intercostals 20%
  • greatest change in dimension superior / inferior
  • accessory muscles - sternocleidomastoid muscle, levators, serratus posterior, scalenes
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9
Q

Type 1 pneumocytes

A

gas exchange

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10
Q

Type 2 pneumocytes

A

surfactant production

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11
Q

Pores of Kahn

A

direct air exchange between alveoli

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12
Q

Pleural fluid

A

1-2 L / day; parietal pleura produces pleural fluid cleared by lymphatics in visceral pleura

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13
Q

Pulmonary Function Tests

A
  • need predicted postop FEV1 > 0.8 (or at least 40% of predicted value)
  • if close, get qualitative V/Q scan to see contribution of that portion of lung to overall FEV1; if low may still be able to resect
  • need predicted postop DLCO > 11-12 mL/min/mm Hg CO (at least 50% of predicted value); this represents CO diffusion capacity; this value is based on pulmonary capillary surface area, Hgb content, and alveolar architecture
  • need predicted postop FVC > 1.5L
  • no resection if pre op pCO2 > 45 or pO2 < 50 at rest
  • no resection if preop VO2 max < 10 mL/min/kg
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14
Q

Persistent air leak

A

most common after segmentectomy / wedge

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15
Q

Atelectasis and arrhythmias

A

common problems after lobectomy or pneumonectomy

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16
Q

Lung cancer

A
  • most common cause of cancer related death in US
  • nodal involvement has strongest influence on survival
  • Brain single most common site of mets
  • can also go to supraclavicular nodes, other lung, bone, liver, and adrenals
  • Recurrence most commonly appears as disseminated mets (brain most common)
  • 80% recurrences are within the 1st 3 yrs
  • over 5y survival rate 10%; 30% with resection
  • stage I and II resectable; T3N1M0 (IIIa) possibly resectable
  • adenocarcinoma most common lung ca
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17
Q

Non small cell carcinoma

A
  • 80% of lung ca
  • squamous cell ca usually more central
  • adenocarcinoma usually more peripheral
  • local recurrence increased with squamous cell ca
  • distant mets increased with adenoca
  • chemo stage II or higher - carboplatin, taxol
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18
Q

TNM staging for lung cancer

A

T1: < 3cm
T2: > 3cm but > 2cm away from carina
T3: invasion of chest wall, pericardium, diaphragm or < 2cm from carina
T4: mediastinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion (all indicate unresectable)
N1: ipsilateral hilum nodes
N2: ipsilateral mediastinal nodes (unresectable)
N3: contralateral mediastinal or supraclavicular nodes (unresectable)
M1: distant mets

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19
Q

Small cell carcinoma

A
  • 20% lung CA neuroendocrine in orign
  • usually unresectable at time of dx (<5% candidates for surgery)
  • overall 5-yr survival rate; very poor px
  • stage T1, N0, M0 5 year survival rate - 50%
  • most get chemo and XRT
  • chemo - cisplatin, etoposide
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20
Q

Squamous cell CA paraneoplastic syndrome

A

PTH-related peptide

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21
Q

Small Cell CA paraneoplastic syndrome

A

ACTH, ADH

*ACTH most common paraneoplastic syndrome

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22
Q

mesothelioma

A

most malignant lung tumor

  • aggressive local invasion, nodal invasion, and distant mets common at the time of dx
  • asbestos exposure
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23
Q

Mediastinoscopy

A
  • use for centrally located tumors and pts with suspicious adenopathy > 0.8cm or subcarinal > 1.0cm on chest ct
  • does not assess aortopulmonary window nodes (left lung drainage)
  • assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes
  • if positive, tumor unresectable
  • looking into middle mediastinum with mediastinoscopy:
  • left sided structures - RLN, esophagus, aorta, main PA
  • right sided structures - azygous & SVC
  • anterior structures - innominate vein, innominate artery, right PA
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24
Q

Chamberlain procedure

A

assesses aortopulmonary window nodes; go through left 2nd rib cartilage

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25
Q

Bronchoscopy

A

needed for centrally located tumors

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26
Q

Pancoast tumor

A

tumor invades apex of chest wall and patients have Horner’s syndrome (invasion of sympathetic chain –> ptosis, miosis, anhidrosis) or ulnar nerve symptoms

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27
Q

Coin lesion

A

overall 5-10% are malignant

  • age < 50 –> < 5% malignant
  • age > 50 –> > 50% malignant
  • no growth in 2 years, smooth contour suggests benign disease
  • core needle biopsy frequently nondiagnostic
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28
Q

Asbestos exposure

A

increases lung CA risk 90x

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29
Q

Bronchioalveolar CA

A

can look like PNA; grows along alevolar walls, multifocal

30
Q

Mets to lung

A

if isolated and not associated with any other systemic disease, may be resected for colon, renal cell CA, sarcoma, melanoma, ovarian, or endometrial CA

31
Q

Carcinoids

A

neuroendocrine tumor, usually central

  • 5% have mets at time of dx; 50% have symptoms
  • typical carcinoid - 90% 5 year survival rate *atypical carcinoid - 60% 5 year survival
  • tx: resection; treat like cancer
  • outcome closely linked to histology; recurrence increased with positive nodes or tumors > 3cm
32
Q

Malignant bronchial adenomas

A

adenoid cystic adenoma, mucoepidermoid adenoma, mucous gland adenoma

  • slow growth, no mets
  • tx: resection
33
Q

Adenoid cystic adenoma

A
  • submucosal glands; spread along perineural lymphatics, well beyond endoluminal component; XRT sensitive
  • slow growing; can get 10 year survival with incomplete resection
  • tx: resection; if unresectable XRT can provide good palliation
34
Q

Hamartomas

A
  • most common benign adult lung tumor
  • have calcifications and can appear as a popcorn lesion on chest CT
  • dx can be made with CT
  • do not require resection
  • repeat Chest CT in 6 months to confirm diagnosis
35
Q

Neurogenic tumors

A

most common mediastinal tumor in adults and children, usually posterior mediastinum

36
Q

Anterior mediastinal tumors (thymus)

A
  • most common site for mediastinal tumor
  • thymoma (#1 in adults)
  • thyroid cancer and goiters
  • T cell lymphoma
  • teratoma (germ cell tumors)
  • parathyroid adenomas
37
Q

Middle mediastinal tumors (heart, trachea, ascending aort)

A
  • bronchogenic cysts
  • pericardial cysts
  • enteric cysts
  • lymphoma
38
Q

Posterior mediastinal tumors (esophagus, descending aorta)

A
  • enteric cysts
  • neurogenic tumors
  • lymphoma
39
Q

Thymoma

A
  • all thymomas require resection
  • thymus too big or associated with refractory myasthenia gravis –> resection
  • 50% of thymomas are malignant
  • 50% of patients have symptoms
  • 50% pts have myasthenia gravis
  • 10% pts with myasthenia gravis have thymomas
40
Q

Myasthenia gravis

A

fatigue, weakness, diplopia, ptosis, antibodies to acetylcholine receptors

  • tx: anticholinesterase medications, plasmapheresis, steroids
  • 80% get improvement with thymectomy, including patients who do not have thymomas
41
Q

Lymphoma

A
  • T cell most common (non-Hodgkins) - lymphoblastic variant most common
  • Hodgkin’s lymphoma - nodular sclerosing most common
  • Tx: chemo and XRT
42
Q

Germ cell tumors

A
  • need to biopsy (usually via mediastinoscopy)
  • teratoma –> most common germ cell tumor in mediastinum; tx: resection and chemo
  • seminoma –> most common malignant germ cell tumor in mediastinum; tx: XRT (extremely sensitive); chemo for positive nodes or residual disease; surgery for residual disease after that
  • nonseminoma –> 90% have elevated beta-HCG and AFP; tx: cisplatin based chemo and XRT; surgery for residual disease
43
Q

Cysts

A
  • bronchogenic - posterior to carina; tx: resection

* pericardial - at right costophrenic angle; tx: resection

44
Q

Neurogenic tumors

A

have pain, neurologic deficit; tx: resection

  • 10% have intraspinal involvement that requires simultaneous spinal surgery
  • neurolemmoma - most common
  • paraganglioma - produce catecholamines
  • nerve sheath - assoc with von Recklinghausen’s disease
  • can also get neuroblastomas and neurofibromas
45
Q

mediastinal mass

A

50% of symptomatic mediastinal masses are malignant

90% of asymptomatic mediastinal masses are benign

46
Q

Trachea tumors

A

benign adults papilloma, children hemangioma

malignant squamous cell ca

47
Q

most common late complication after tracheal surgery

A

granulation tissue formation

48
Q

most common early complication after tracheal surgery

A

laryngeal edema

*tx: reintubate, racemic epinephrine, steroids

49
Q

Postintubation stenosis

A

at stoma site with tracheostomy; at cuff with ET tube

  • may be able to treat with serial dilation or with laser
  • may need resection with end-to-end anastomosis if severe
50
Q

Tracheoinnominate fistula

A

trach - needs to be between 1st and 2nd tracheal rings not > 3 ring - risk of TIF
*tx: overinflate balloon to plug hole or stick finger in hole and depress innominate artery; resect innominate and place graft; leave trachea alone; use new trach site

51
Q

lung abscess

A

necrotic area; most common assoc with aspiration
most commonly posterior segment of RUL and superior segment of RLL
*tx: abx 95% successful; CT guided drainage if fails
*surgery if this fails or cannot r/o cancer (>6cm, failure to resolve after 6 weeks)
*chest ct can help differentiate empyema from lung abscess

52
Q

Empyema

A
  • usually 2/2 PNA and subsequent parapneumonic effusion (staph, strep)
  • can also be due to esophageal, pulm or mediastinal surgery
  • pleuritic chest pain, fever, cough, SOB
  • pleural fluid often has WBCs > 500cells/cc, bacteria, +gram stain
  • exudative phase (1st week) - tx: chest tube, abx
  • fibroproliferative phase (2nd week) - tx: chest tube, abx
  • organized phase (3rd week) - tx: likely need decortication; fibrous peel occurs around lung
  • may need Eloesser flap (direct opening to external environment) for chronic unresolving empyema
53
Q

Chylothorax

A
  • fluid mikly white; has increase lymphocytes and TAGs (>110mL/uL); Sudan red stains fat
  • fluid resistant to infection
  • 50% 2/2 trauma or iatrogenic injury
  • 50% 2/2 tumor (lymphoma most common, due to tumor burden in lymphatics)
  • injury above T5-6 results in left sided chylothorax
  • injury below T5-6 results in right sided chylothorax
  • 3-4 weeks of conservative therapy (chest tube, octreotide, low fat diet or TPN)
  • if that fails surgery with ligation of thoracic duct on right side low in mediastinum (80% successful) if chylothorax 2/2 trauma or iatrogenic injury
  • for malignant causes of chylothorax can perform mechanical or talc pleurodesis
54
Q

Massive hemoptysis

A

> 600 cc / 24h

  • bleeding is from high pressure bronchial arteries
  • most commonly 2/2 infection, mycetoma most common
  • death due to asphyxiation
  • tx: place bleeding side down if known: rigid bronch to identify site; mainstem intubation to side opposite of bleeding to prevent drowning in blood; to OR for lobectomy or pneumonectomy; bronchial artery embolization if not suitable for surgery
55
Q

Spontaneous pneumothorax

A

tall, healthy, thin, young males

  • recurrence risk after 1st pneumothorax 20%, after 2nd pneumothorax 60%, after 3rd pneumothorax 80%
  • results from rupture of a bleb in apex of upper lobe of lung; can occur in superior segment of lower lobe
  • more common right
  • tx: chest tube
  • surgery for recurrence, large blebs on CT scan, air leak > 7 days, nonreexpansion
  • also need surgery for high risk profession (airline pilot, diver, mountain climber) or patient who lives in remote areas
  • VATS, apical blebectomy, mechanical pleurodesis
56
Q

Sequestration

A
  • lung tissue in lung not connected to bronchial tree
  • receives blood supply from anomalous systemic arteries –> usually off thoracic aorta (can also come from abdominal aorta through inferior pulmonary ligament)
  • venous blood supply is either pulmonary vein or systemic veins
  • extrolobar - more common in children; more likely to have systemic venous drainage
  • intralobar - more common in adults; more likely to have pulmonary vein drainage
    tx: lobectomy
57
Q

Solitary pulmonary nodule with h/o previous cancer

A
  • sarcoma / melanoma –> nodule more likely mets
  • head / neck / breast –> nodule more likely primary lung CA
  • GI / GU –> mets or primary
  • in case of primary cancer with a resectable lung mets, take out primary 1st, then mets
58
Q

Tension pneumothorax

A

most likely to cause arrest after blunt trauma; impaired venous return

59
Q

Catamenial pneumothorax

A

occurs in temporal relation to menstruation

*caused by endometrial implants in visceral lung pleura

60
Q

Residual hemothorax despite 2 good chest tubes

A

OR for VATs drainage

61
Q

Broncholiths

A

usually 2/2 infection

62
Q

Mediastinitis

A

usually after cardiac surgery

63
Q

White out on chest xray

A
  • midline shift toward whiteout - most likely collapse –> need bronch to remove plug
  • no shift –> CT scan
  • midline shift away from whiteout - most likely effusion –> place chest tube
64
Q

Bronchiectasis

A

acquired from infection, tumor, cystic fibrosis

65
Q

TB

A

lung apices; get calcifications, caseating granulomas

  • Ghon complex –> parenchymal lesion + enlarged hilar nodes
  • tx: rifampin, INH, pyrazinamide
66
Q

Sarcoidosis

A

has noncaseating granulomas

67
Q

Effusions

A 
exudative:
protein > 3
specific gravity > 1.016
LDH ratio (pleural fluid: serum) >0.6 
decreased glucose 
pH < 7.45
wbc > 1,000
68
Q

Recurrent pleural effusions

A

can be treated with mechanical pleurodesis

*talc pleurodesis for malignant pleural effusions

69
Q

Airway fires

A

usually assoc with laser

*tx: stop gas flow, remove ET tube, reintubate for 24 hours, bronch

70
Q

Chest wall tumors

A

benign osteochondroma

malignant chondrosarcoma

Thoracic (1 decks)

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