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ABSITE > 25 Thoracic > Flashcards

25 Thoracic Flashcards

1
Q

Course of the azygos vein

A

Right side

Dumps into SVC

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2
Q

Course of thoracic duct

A

Right side > crosses midline at T4-5 > dumps into L SCV at junction with IJV

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3
Q

Course of phrenic nerve in relation to the lung hilum

A

Anterior to the hilum

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4
Q

Course of vagus nerve in relation to the lung hilum

A

Posterior to the hilum

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5
Q

Function of type I pneumocytes

A

Gas exchange

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6
Q

Function of type II pneumocytes

A

surfactant production

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7
Q

Function of Pores of Kahn

A

Direct air exchange between alveoli

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8
Q

Pre-op requirements to allow for pneumonectomy?

A
  • Predicted post-op FEV1 > 0.8
    > If borderline, get V/Q scan to see how much the lung you are taking out actually contributes
  • Predicted post-op DLCO >10mL/min/mmHg CO
  • pCO2 <50, pO2 >50
  • VO2 max >10-12mL/min (max O2 consumption)
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9
Q

DCLO

A

Measures carbon monoxide diffusion and represents O2 exchange capacity

Depends on pulmonary capillary surface area, hemogloblin content, alveolar architecture

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10
Q

Common complications after lung resections?

A

Persistent air leak (segmentectomy/wedge)
Atelectasis (lobectomy)
Arrhythmias (pneumonectomy)

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11
Q

Most common site of lung cancer metastases?

A

Brain

Other: SCLN, other lung, bone, liver, adrenals

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12
Q

T-staging lung cancer?

A

T1: <3cm
T2: >3cm but >2cm away from carina
T3: Invasion of chest wall, pericardium, diaphragm or <2cm from carina
T4: Mediatinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion (unresectable)

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13
Q

N-staging lung cancer?

A

N1: ipsilateral hilum nodes
N2: ipsilateral mediastinal or subcarinal (unresectable)
N3: Contralateral mediastinal or suprclavicular (unresectable)

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14
Q

Non-small cell lung cancer

A

80% of lung CA
Central - SCC
Peripheral - AdenoCA (most common)

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15
Q

Small cell carcinoma

A

20% of lung CA
Neuroendocrine
Usually unresectable
Chemo-XRT

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16
Q

Paraneoplastic syndromes - PTH-related peptide?

A

Squamous cell lung CA

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17
Q

Paraneoplastic syndromes - ACTH?

A

Small cell lung CA (most common)

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18
Q

Paraneoplastic syndromes - ADH?

A

Small cell lung CA

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19
Q

Mesothelioma

A

Most malignant Lung CA
Aggressive local invasion, nodal invasion, distant mets
Risk: Asbestos exposure

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20
Q

Chemo for non-small cell lung CA?

A

For stage II or higher

Carboplatin, Taxol

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21
Q

Chemo for small cell lung CA?

A

Cisplatin, etoposide

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22
Q

Best single test for clinical assessment of T and N status in lung CA?

A

Chest and abdominal CT scan

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23
Q

Best single test for clinical assessment of M status in lung CA?

A

PET scan

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24
Q

Indications for Mediastinoscopy

A 
Centrally located lung CA
Suspicious adneopathy (>0.8cm or subcarinal >1.9cm) on chest CT
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25
Q

What can you assess with mediastinoscopy?

A 
Assess ipsilateral (N2) and contralateral (N3) mediastinal nodes
Does NOT assess aorto-pulmonary window nodes (left lung drainage)
If mediastinal nodes are positive - unresectable
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26
Q

Looking into middle mediastinum with mediastinoscopy - what do you see?

A

Left-side: RLN, esophagus, aorta, main pulmonary artery
Right-side: Azygous, SVC
Anterior: Innominate vein, innominate artery, right pulmonary artery

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27
Q

Chamberlain procedure

A

Anterior thoracotomy or parasternal mediastinotomy
Assesses enlarged AP window nodes (#5)
Go through left 2nd rib cartilage

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28
Q

Bronchoscopy

A

Good for centrally located nodes

Evaluate for airway invasion

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29
Q

Criteria for surgical intervention for lung cancer?

A

1) operable (appropriate FEV1/CLCO)

2) Resectable (No T4, N2, N3, or M disease)

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30
Q

Pancoast tumor

A

Tumor invades apex of chest wall
Can cause:
- Horner’s syndrome (ptosis, miosis, anhidrosis)
- Ulnar nerve symptoms

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31
Q

Features suggesting benign disease in lung coin lesions?

A

No growth in 2 years

Smooth contour

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32
Q

Bronchoalveolar CA

A

Can look like pnuemonia
Grows along alveolar walls
Multifocal

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33
Q

What metastases to the lung can be resected?

A 
Colon
Renal cell CA
Sarcoma
Melanoma
Ovarian
Endometrial CA
(If isolated and NOT associated with systemic disease
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34
Q

Carcinoids

A

Neuroendocrine tumor
Central
Tx: resection
Recurrence risk: positive nodes or tumors >3cm

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35
Q

Mucoepidermoid adenoma

Mucous gland adenoma

A

Malignant lung tumor
Slow growth, no mets
Resection

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36
Q

Adenoid cystic adenoma

A

From submucosal glands
Spreads via perineural lymphatics
Slow growing
Tx: resection, XRT (very sensitive)

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37
Q

Hamartoma

A

Most common benign adult lung tumor
Calcifications - popcorn lesions on CT
Does NOT require resection
Confirm dx with repeat CT in 5 months

38
Q

Most common mediastinal tumor in adults and children? Location?

A

Neurogenic tumors

Posterior mediastinum

39
Q

Mediastinal tumors: anterior

A

Thymus

  • Thymoma*
  • Thyroid CA and goiters
  • T-cell lymphoma
  • Teratoma (and other germ cell tumors)
  • ParaThyroid adenoma
40
Q

Mediastinal tumors: middle

A

Heart, trachea, ascending aorta

  • Bronchiogenic cyst
  • Pericardial cyst
  • Enteric cyst
  • Lymphoma
41
Q

Mediastinal tumors: posterior

A

Esophagus, descending aorta

  • Enteric cysts
  • Neurogenic tumor
  • Lymphoma
42
Q

Thymoma

A

Require resection
Thymus too big/refractory myasthenia gravis - resection
50% malignant
50% symptoms
50% myasthenia gravis
10% of patient with myasthenia gravis have a thymoma

43
Q

Myasthenia gravis

A

Fatigue, weaknes,s diplopia, ptosis
Antibodies to acetylcholine receptors
Tx: anticholinesterase inhibitor (neostigmine), steroids, plasmapheresis
80% have improvement with thyomectomy

44
Q

Mediastinal teratoma

A

Most common germ cell tumor in mediastinum
Can be benign or malignant
Tx: resection, chemotherapy

45
Q

Mediastinal seminoma

A

Most common malignant germ cell tumor in mediastinum
10% b-HCG positive
Should NOT have AFP
Tx: XRT (very sensitive), chemo for mets/bulky nodal disease, surgery for residual

46
Q

Mediastinal non-seminoma

A

90% have elevated b-HCG and AFP

Tx: Chemo (cisplatin, bleomycin, VP-16), surgery for residual disease

47
Q

Bronchiogenic cyst

A

Posterior to carina

Tx: resection

48
Q

Pericardial cyst

A

Right costophrnic angle

Benign - can leave alone

49
Q

Benign tumors of the trachea

A

Adults - papilloma

Children - hemangioma

50
Q

Malignant tumor of the trachea

A

Squamous cell caricnoma

51
Q

Most common late complication after tracheal surgery?

A

Granulation tissue formation

52
Q

Most common early complication after tracheal surgery?

A

Laryngeal edema

53
Q

Treatment of laryngeal edema?

A

Reintubation
Racemic epinephrine
Steroids

54
Q

Post-intubation stenosis

A

At stoma site with tracheostomy, at cuff site with ET tube
Tx:
Minor - Serial dilatation, bronchoscopic resection, laser ablation
Severe, recurrent - tracheal resection with end-to-end anastomosis

55
Q

Tracheo-innominate artery fistula

A

Occurs after tracheostomy
Rapid exsanguination
Tx:
- Place finger in tracheostomy hole and hold pressure
- Median sternotomy with ligation and resection of innominate artery
Avoid this complication by keeping tracheostomy above the 3rd tracheal ring

56
Q

Tracheo-esophageal fistula

A

Prolonged intubation
Place large-volume cuff endotracheal tube below fistula
May need decompresisng gastrostomy
Repair after patient is weaned form ventilator
Tx: tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea

57
Q

Lung abscess

A

Necrotic area - associated with aspiration
Superior segment of RLL
Tx: Abx alone, CT-guided drainage
Surgery if it fails or cannot r/o cancer (>6cm, failure to resolve after 6wks)
Chest CT can differentiate empyema from lung abscess

58
Q

Empyema

A

Secondary to pneumoia and subsequent parapneumonic effusion
Associated with esophageal, pulmonary or mediastinal surgery
Sx: pleuritic chest pain ,fever, cough, SOB
Pleural fluid: WBCs >500, bacteria and positive gram stain

59
Q

Exudative phase of empyema

A

1st week

Tx: chest tube, Abx

60
Q

Fibro-proliferative phase of empyema

A

2nd week

Tx: chest tube, abx, possibly VATS deloculation

61
Q

Organized phase of empyema

A

3rd week
Tx: decortication (remove fibrous peel)
Intra-pleural tPA (dissolve the peel)
Eloesser flap (open thoracic window) in frail/elderly

62
Q

Chylothorax

A

Increased lymphocytes, TAGs
Sudan red stain
Fluid is resistant to infection
Above T5-6 - left; below - right
Tx:
- Chest tube, octreotid, low-fat diet, TPN
- Traumatic - Ligation of thoracic duct on right side
- Malignant - Talc pleurodesis, chemo, XRT

63
Q

Massive hemoptysis

A 
>600cc/24hrs
Bronchial arteries
Tx:
- Bleeding side down
- Mainstem intubation to other side
- Rigid bronchoscopy
- Lobectomy/pneumonectomy
- Bronchial artery embolization
64
Q

Spontaneous pneumothorax

A

Recurrence: 1st - 20%, 2nd - 60%, 3rd - 80%
Tx: chest tube
Surgery - recurrence, air leak >7 days, non-reexpansion, high-risk profession, live in remote areas
Tx: thorascopy, apical blebectomy, mechanical pelurodesis

65
Q

Catamenial pnuemothorax

A

Temporal relation to menstruation

Endometrial implants

66
Q

Residual hemothorax despite 2 good chest tubes?

A

OR for thorascopic drainage

67
Q

Clotted hemothorax

A

Surgical drainage if: >25% lung, air-fluid levels, signs of infection
Do surgery within 1st week to avoid peel

68
Q

MCC broncholiths

A

infection

69
Q

MCC mediastinitis

A

Cardiac surgery

70
Q

Work up of whiteout on CXR?

A

Midline shift toward whiteout - collapse - bronchoscopy to remove plug
No shift - CT scan
Midline shift away from whiteout - effusion - chest tube

71
Q

Bronchiectasis

A

Acquired - infection, tumor, cystic fibrosis

No surgical intervention secondary to diffuse nature

72
Q

Tuberculosis

A

Lung apices
Get calcifications, caseating granulomas
Ghon complex = parenchymal lesion + enlarged hilar nodes
Tx: INH, rifampin, pyrazinamide

73
Q

Sarcoidosis

A

Non-caseating granulomas

Tx: steroids

74
Q 
Pleural fluid:
< 1000 WBC
Ph 7.45-7.55
Pleural fluid protein to serum ratio < 0.5
Pleural fluid LDH to serum ratio <0.6
A

Transudate

75
Q 
Pleural fluid:
> 1000 WBC
< 7.45
Pleural fluid protein to serum ratio > 0.5
Pleural fluid LDH to serum ratio > 0.6
A

Exudate

76
Q 
Pleural fluid:
> 1000 WBC, or >50,000 very specific
< 7.30
Pleural fluid protein to serum ratio > 0.5
Pleural fluid LDH to serum ratio > 0.6
A

Empyema

77
Q

Treatment for recurrent pleural effusion?

A

Mechanical pleurodesis

Malignant - talc

78
Q

Airway fire

A

Associated with laser

Tx: Stop gas, remove ET tube, reintubate for 24hrs, then do bronchoscopy

79
Q

Pulmonary AVMs

A

Connection between pulmonary arteries and pulmonary veins
Lower lobes
Associated with Osler-Weber-Rendu disease
Symptoms: hemoptysis, SOB, neurologic events
Tx: Embolization

80
Q

MC benign chest wall tumor

A

Osteochondroma

81
Q

MC malignant chest wall tumor

A

Chondrosarcoma

82
Q

R to L shunts cause?

A

Cyanosis

83
Q

Child who squat when having difficulty breathing?

A

Increases SVR and decreases R to L shunt

84
Q

Adverse effects of cyanosis?

A

Polycythemia, stroke, brain abscess, endocarditis

85
Q

Eisenmenger’s syndrome

A

Shift from L-R shunt to R-L shunt
Signs of increased pulmonary vascular resistance and pulmonary HTN
Irreversible

86
Q

L to R shunts cause?

A

CHF

Failure to thrive, tachycardia, tachypnea, hepatomegaly

87
Q

First sign of CHF in children?

A

Hepatomegaly

88
Q

L to R shunts - causes?

A

VSD, ASD, PDA

89
Q

R to L shunts - causes?

A

Tetrology of fallot

90
Q

Fetal connection between descending aorta and left pulmonary artery?

A

Ductus arteriosus

Shunts blood away from lungs in utero

91
Q

Fetal connection between portal vein and IVC?

A

Ductus venosum

Shunts blood away from liver in utero

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