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ABTS - Thoracic Surgery Notecards IA > Thoracic Infections and Hemoptysis > Flashcards

Thoracic Infections and Hemoptysis Flashcards

1
Q

Indications for surgery for M. tuberculosis infection

A
  • Massive hemoptysis
  • BPF
  • Broncial stenosis
  • Entrapped lung
  • Failure of medical therapy
  • Persistent cavitary diease
  • Destroyed lung of lobe
  • Rule out malignancy
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2
Q

Prior to sugery for M. tuberculosis, patients should have what profile

A
  • Combination drug therapy for 3 months
  • Sputum cultures ideally should be negative
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3
Q

First line medical therapy for M. tuberculosis

A
  • INH and Rifampin (6 total months)
    • INH+Rifampin+Pyrazinamide+Ethambutol (first 2 months)
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4
Q

Increases need for surgery for those with M. tuberculosis

A

Multi-drug resistant TB (MDR-TB)

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5
Q

Pericardial complication of TB

A

Pericardial effusion or constrictive pericarditis

(pericardial bx diagnostic, high level of adenosine deaminase (ADA) test in pericardial fluid suggestive)

The adenosine deaminase (ADA) test is not a diagnostic test, but it may be used along with other tests such as pleural fluid analysis, acid-fast bacillus (AFB) smear and culture, and/or tuberculosis molecular testing to help determine whether a person has a Mycobacterium tuberculosis infection (tuberculosis or TB) of the lining of the lungs (pleurae).

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6
Q

Tx of TB related pericardial effusion

A

Antibiotics

Pericardial drainage

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7
Q

Tx of TB related constrictive pericarditis

A

Antibiotics

Pericardectomy

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8
Q

Pleural TB associated with _

A

Lymphocyte-rich pleural effusion

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9
Q

Dx of pleural TB

A

Pleural biopsy (fluid culture may result in no growth)

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10
Q

Tx of pleural TB

A
  • Tube thoracostomy (large effusion)
  • Decortication (trapped lung or empyema)
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11
Q

May form in cavitary lung lesions after TB infection

A

Aspergillomas

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12
Q

Uncommon endobronchial compication that may result from TB infecton

A

Endobroncial stenosis (scarring) or obstruction (extrinsic compression from lymph nodes)

Tx (endobronchial stenosis): inhaled corticosteroids (I&D of lymph nodes if steroids unsuccessful, not lymph node excision)

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13
Q

Most common (organisms) of Non-tuberculous mycobacterial infection (NTM)

A

Mycobacterium avium and intracellulare (M avium complex)

Other organisms:

M. chelonae

M. abscessus

M. fortuitum

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14
Q

Non-tuberculous mycobacterial infection (NTM) infections most common in what patient populations

A

Disease lungs

Women

Caucasians

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15
Q

T/F

Non-tuberculous mycobacterial infection (NTM) are more resistentant to drug therpy than MTB infecitons

A

True

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16
Q

The surgical treatment approach to Nontuberculous Mycobacteria (NTM) Infections

A
  • Pts with localized disease more amenable to surgical therapy
    • Consider surgery in course of treatment
  • Extrapleural dissection preferential
    • d/t dense adhesions between parietal and visceral pleura
  • All grossly infected tissue should be removed
  • Tissue flaps used to reduce bronchial stump complications
  • Continue anti-tubercular medications x 12-24 hrs postoperatively
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17
Q

Complications associated with surgical resections for mycobacterial infections

A

High rate of BPF

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18
Q

Overall classification scheme of lung abscesses

A

Primary vs. secondary lung abscess

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19
Q

Most common overall etiology of lung abscesses

A

Aspiration

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20
Q

Atypical bacterium that classically causes multiple abscesses throughout the body, including the lungs

A

Actinomyces

(PCN sensitive)

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21
Q

Most accurate diagnostic modality for lung abscesses

A

High resolution CT

(cavity with air-fluid level)

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22
Q

First line treatment for lung abscesses

A

Prolonged antibiotic therapy (directed by cultures)

Lack of response to antibiotic therapy is bronchoscopy (r/o obstructive process)

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23
Q

Sampling of lung abscess most accurately performed by what technique

A

CT-guided or bronchoscopic FNA

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24
Q

Indications for external drainage of lung abscesses (as an adjunct to Abx)

A
  • Failure of medical managment
    * symptoms lasts more than 12 weeks with appropriate therapy
  • Giant abscess (>8 cm in diameter)
  • Contralateral contamination
  • Rupture
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25
Q

Indications for surgery for lung abscesses

A
  • Empyema
  • BPF
  • Major hemoptysis
  • Suspicion of cancer
  • Failure of non-operative therapy
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26
Q

7 major mycotic lung infections

A
  • Histoplasmosis
  • Coccidiomycosis
  • Blastomycosis
  • Cryptococcus
  • Mucormycosis
  • Aspergillosis
  • Pneumocystis
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27
Q

Mycotic infection associated with bat and/or bird feces** and **Mississippi Valley

A

Histoplasmosis

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28
Q

Presentation of Histoplasmosis

A
  • Self-limited, flu-like illness (often do not require treatment)
  • Disseminated histoplasmosis (immunocompromised)
    • Tx: amphotericin
  • Granulomas (non-caseating, sometimes calcified)
    • can compress or erode into trachobronchial tree
      • Obstruction or hemoptysis
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29
Q

Rare complication of histoplasmosis resulting in progressive compression of mediastinal structures (SVC, esophagus, etc)

A

Fibrosing mediastinitis

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30
Q

Can mimic TB

A

Chronic cavitary histoplasmosis

(Dx: isolation of organisms in culture)

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31
Q

Mycotic infection associated wtih dimorphic fungus found in soil in the Southwest US, Mexico, Central America

A

Coccidiomycosis (“Valley fever”)

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32
Q

Characteristics of Coccidiomycosis

A
  • Self resolved infecton in immunocompetent patient
  • Erythema nodosum (positive prognostic sign of cell-mediated immunity)
  • Chronic infection = cavitary lesion
  • Cavitations located peripherally, may rupture into pleural space
    • Effusion
    • Ptx
    • BPF
    • Empyema
33
Q

Surgical indications for coccidiomycosis

A
  • Treatment of complications
    • Effusion
    • Ptx
    • BPF
    • Empyema
  • Differentiate Coccidioides nodules from cancer
34
Q

Mycotic infection found in Southeastern and Central US

A

Blastomycosis

  • Types:
    • Pulmonary blastomycosis
    • Cutaneous blastomycosis
      • Multiple ulcerated skin nodules
    • Disseminated blastomycosis
35
Q

Dx:

wide-based budding yeast with double refractile walls

A

Blastomycosis

36
Q

Treatment of Blastomycosis

A
  • Antifungals
    • Although spontaneous remission can occur, it is recommended that all patients with mild or moderate disease be treated to avoid dissemination and recurrence.
      • _Itraconazole i_s the treatment of choice for all forms of the disease, except in severe, life-threatening cases.
      • Amphotericin B is used in severe and life-threatening diseases at a high dose of 0.7 to 1 mg/kg/day to a total dose of 1.5 to 2 grams. Liposomal amphotericin B at a dose of 3 to 5 mg/kg per day can alternatively be used for severe infection and is preferred for CNS blastomycosis and treatment in pregnant women.
  • Surgery: rule out malignancy
37
Q

Mycotic infection characterized by encapsulated yeast round in soil

A

Cryptococcus

38
Q

Mycotic infection with tendency to invade meninges (especially in immunocomprimised)

A

Cryptococcus

39
Q

Microscopic appearance:

capsule with narrow budding

A

Cryptococcus

40
Q

Next step in diagnosis and treatment after pathology demonstrates Cryptococcus in lung mass

A

CSF analysis (r/o meningitis)

Amphotericin

41
Q

Omnipresent yeast found in soil that thrives in acidic, hyperglycemic enviornments

A

Mucormycosis

(DKA patients susceptible)

42
Q

Risk factors for Mucormycosis

A
  • Diabetic ketoacidosis (uncontrolled hyperglycemia)
  • Corticosteroid use (immunosuppressed)
  • Neutropenia
43
Q

Mycotic infection that causes infarction of tissue and is associated with PA rupture and hemoptysis, and invasion of chest wall and mediastinal structures

A

Mucormycosis

44
Q

Typical presentation of Mucormycosis

A

PNA refractory to antibacterial therapy

45
Q

Microscopic appearance:

broad aseptate hyphae with right-angled, finger-like projections)

https://upload.wikimedia.org/wikipedia/commons/thumb/2/29/Zygomycosis%2C_mucormycosis_2.jpg/440px-Zygomycosis%2C_mucormycosis_2.jpg

A

Mucormycosis

46
Q

Treatment principles of Mucormycosis

A
  • Correction of DKA
  • Reversal of immunosuppression
  • GM-CSF (if neutropenia)
  • Amphotericin
  • Rapid and aggressive surgical resection
47
Q

Mycotic infection that typically affects immunocompromised patients or those with structural lung disease

A

Aspergillosis

48
Q

Types of aspergillus infection

A
  • Aspergilloma
  • Invasive pulmonary aspergillosis
  • Allergic bronchopulmonary aspergillosis (asthma, cystic fibrosis)
    • Esosinophilia and IgE elevation
49
Q

Cross-sectional imaging charactistics of aspergillosis

A

Fungus ball within thick-walled cavity sometimes surrounded by a crescent of air (Monod’s sign)

50
Q

Monod’s sign

A

The Monod sign simply describes gas that surrounds a mycetoma (most commonly an aspergilloma) in a pre-existing pulmonary cavity.

It should not be confused with the air crescent sign which is seen in recovering angioinvasive aspergillosis. The air crescent sign heralds improvement in the condition.

https://www.google.com/url?sa=i&url=https%3A%2F%2Fepos.myesr.org%2Fposterimage%2Fesr%2Fecr2014%2F121234%2Fmediagallery%2F541315&psig=AOvVaw1m_qXVLr5AxMNW2LD53G3a&ust=1684261983795000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCPiU7Pv69_4CFQAAAAAdAAAAABAJ

51
Q

Diagnostic stains used to visualize Aspergillosis

A
  1. Gomori methenamine silver stain
  2. Calcofluor White Stain
52
Q

Can be visualized in sputum with polarizing light microscopy to diagnose Aspergillosis

A

Birefringent calcium oxalate crystals

53
Q

Component of Aspergillosis cell wall that can be measured in serum or BAL fluid

A

Galactomannan

54
Q

Most common symptoms of aspergillosis

A

Hemoptysis

Tx: bronchial artery embolization (recurrence of bleeding 50%)

Rebleeding = surgical resection

55
Q

True of False

Antifungal therapy is helpful for treatment of aspergilloma

A

False:

Antifungal therpy is not helpful for treatment of aspergilloma

  • Asymptomatic aspergilloma: should not be treated (most resolve)
  • Symptomatic aspergilloma (i.e. hemoptysis): bronchial artery embolization/resection
56
Q

Complication of invasive pulmonary aspergilosis

A

Necrotizing bronchopneumonia refractory to antibacterial therapy

(Immunocompromised patients)

57
Q

Treatment of invasive pulmonary aspergilosis

A
  1. Antifungal therapy (high mortality rate)
  2. Surgery reserved when diagnosis questionable or for patient with resectable disease
58
Q

Opportunistic mycotic infection limited to immunocompromised patients (commonly found in lungs of healthy individuals)

A

Pneumocystis

(i.e. Pneumocystis PNA [PCP])

59
Q

Treatment of choice for PCP

A

Bactrim

60
Q
  1. Most common cause of massive hemoptysis
  2. Most common cause of death d/t massive hemoptysis
A
  • MCC
    • bronchiectasis
    • cancer
    • TB
    • Mycetoma
  • MCC death: asphyxiation
61
Q

Initial treatment priorities for massive hemoptysis

A
  • Stabilization of airway (mainstem intubate non-bleeding side)
  • Resuscitation
  • Position in lateral decubitus position (bleeding side down)
  • Anti-tussive
  • Avoid bronchodilators
  • Bronchoscopy (evacuate blood, selective intubation)
    • Balloon occlusion if possible
62
Q

Bronchoscopic measures to control bleeding with massive hemoptysis

A
  • Ice-cold saline lavage
  • Epinepherine lavage
  • Directed cautery
  • Application of pro-coagulants (fibrin, thrombin)
  • Balloon tamponade
63
Q

Most common source of hemoptysis

A

Bronchial arteries (~ 95%)

Justification for bronchial artery embolizaiton (BAE)

64
Q

Embolizaiton techniques utilized for hemoptysis

A
  • Bronchial Artery Embolization (BAE)
    • ~ 95% of hemoptysis due to broncial artery bleeding
  • PA angiography with vaso-occlsion or endovascular stenting
    • if PA bleeding
65
Q

Risk of early re-bleeding after Bronchial Artery Embolization (BAE)

A

~30%

Thus, semi-elective surgical resection usually desired after Bronchial Artery Embolization (BAE)

66
Q

Treatment of choice for massive hemoptysis if Bronchial Artery Embolization (BAE) fails or patient too unstable

A

Emergent surgical resection (lobectomy)

67
Q

Signs of pneumonia on auscultation of the chest?

A

On physical examination, most patients have audible crackles on auscultation. Signs of consolidation include decreased or bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony.

68
Q

if clinical presentation is classic for pneumonia, but chest x-ray is normal. What should you do next?

A

On the other-hand if clinical presentation is classic for pneumonia, but chest x-ray is normal, clarification with chest CT should be done as the chest x-ray may be a false negative. Chest CT has a higher sensitivity and specificity than chest x-ray for detecting pneumonia

69
Q

Important risk factors in The Pneumonia Severity Index (PSI)

A
  • Age > 50 years
  • Co-existing conditions: Cancer, Heart Failure, Cerbrovascular disease, Renal Disease, Liver Disease
  • Physical examination abnormalities:
    • Altered mental status
    • pulse ≥ 125/minute
    • respiratory rate ≥ 30/minute
    • Systolic blood pressure < 90 mm Hg
    • Temperature < 350C or ≥400C
70
Q

Indications for intervention for lung abscesses include:

A

Indications for intervention for lung abscesses include:
* failure of medical therapy
* size larger than 4 to 6 cm in diameter
* necrotizing infection with multiple abscesses
* complications (hemoptysis and rupture into pleural space)
* high degree of suspicion for cancer

Surgical intervention in such cases is usually a lobectomy or pneumonectomy.

71
Q

Interventions for lung abscess in those that are poor surgical candidates?

A
  1. For those who are poor operative candidates, percutaneous and endoscopic drainage have been described.
    2. Care has to be taken in percutaneous procedures to avoid soilage of the pleural space.
  2. Endoscopic drainage is achieved under bronchoscopic visualization with a catheter placed into the abscess.
    4. The catheter is then left in place until the cavity has drained.
72
Q

Empyema Management

  1. Early
  2. Fibrinopurulent stage
  3. Organized stage
A

Patients with early empyema should be treated with drainage, patients in the fibrinopurulent stage can be treated with VATS or possibly fibrinolytics, and patients in the organized stage need a decortication to remove the rind and fully re-expand the lung.

73
Q

Treatment of CAP

A

The vast majority of CAP is treated on an outpatient basis for five days, and empiric antibiotics (a macrolide or fluoroquinolone) are effective in >95% cases

74
Q

Empiric antibiotic choice for Hospital acquired pneumonia:

A
  • No risk factors for MDR: Piperacillin-tazobactam 4.5 g IV every six hours, or Cefepime 2 g IV every 8 hours, or Levofloxacin 750 mg IV daily
  • For MDR suspicion:
    • One of the following – Piperacillin-tazobactam 4.5 g IV every six hours, cefepime 2 g IV every 8 hours, Ceftazidime 2 g IV every 8 hours, Imipenem 500 mg IV every 6 hours, Meropenem 1 g IV every 8 hours, Aztreonam 2 g IV every 8 hours\
    • Plus an aminoglycoside (amikacin, gentamicin or tobramycin IV)
    • Plus one of the following – Linezolid, Vancomycin or Telavancin
75
Q

Prevention of Ventillator associated pneumonia (VAP)

A
  • Avoidance of intubation and mechanical ventilation with the use of non-invasive positive pressure ventilation for able patients:
    * especially in immunocompromised patients
    * those with acute exacerbations of chronic obstructive pulmonary disease (COPD)
    * those with pulmonary edema
  • Elevation of head of bed (300 to 450)
  • Daily sedation interruption and assessment of readiness to extubate
  • Use of subglottic secretion drainage
  • Avoidance of scheduled ventilator circuit changes
76
Q

The most common organisms causing aspiration pneumonia and lung abscesses are:

A

The most common organisms causing aspiration pneumonia and lung abscesses are oral anaerobes

77
Q

Simple parapneumonic effusions have characteristic features:

A
  1. pH >7.2
  2. LDH < 1000 iu/L,
  3. Glucose >2.2 mmol/L
  4. no organisms in culture or gram stain.
78
Q

characteristic biochemical and microbiological features of complicated pleural effusions:

A

pH< 7.2, glucose < 2.2 mmol/L, LDH >1000 iu/L and possible positive gram stain and/or bacterial culture.

ABTS - Thoracic Surgery Notecards IA (48 decks)

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