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ABSITE > Fiser Chapter 25. THORACIC > Flashcards

Fiser Chapter 25. THORACIC Flashcards

1
Q

What runs along right side of SVC and dumps into it?

A

Azygous vein

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2
Q

What runs along the right side, crosses midline at T4-T5, and dumps into the left subclavian vein at its junction with the IJ?

A

Thoracic duct

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3
Q

What runs anterior to hilum and posterior to hilum?

A

Anterior to hilum: phrenic nerve

Posterior to hilum: vagus nerve

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4
Q

Right and left lung volumes

A

Right 55%

Left 45%

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5
Q

Muscle use in quiet inspiration

A

Diaphragm 80%, intercostals 20%

Greatest change in dimension is superior/inferior

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6
Q

What are the accessory muscles?

A

SCM, levators, serratus poterior, scalens

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7
Q

Type I and II pneumocytes

A

I: gas exchange

II: surfactant production

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8
Q

Pores of Kahn

A

Direct air exchange between alveoli

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9
Q

What is the minimum postop FEV1 needed before pneumonectomy?

A

FEV1 > 0.8 (or >40% of predicted postop value)

If too close, get a qualitative VQ scan to see contribution of that portionof lung to overall FEV1. If low, may still be able to resect.

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10
Q

What is tthe minimum postop DLVO needed?

A

10 mL/min/mmHg CO (or >40% of predicted postop value)

Measures CO diffusion and represents OXYGEN EXCHANGE CAPACITY. Depends on pulmonary capillary surface area, hemoglobin content, and alveolar architecture.

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11
Q

What are minimum preop values of pCO2, pO2, and VOx max (max O2 consumption) before lung resection?

A

pCO2 < 50

pO2 > 60 at rest

VOx max > 10-12 mL/min/kg

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12
Q

Most common cx after wedge resection / segmentectomy?

A

Persistent air leak

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13
Q

Most common cx after lobectomy?

A

Atelectasis

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14
Q

Most common cx after pneumonectomy?

A

Arrhythmias

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15
Q

Cough, hemoptysis, atelectasis, PNA, pain, weight loss

A

Get CXR to look for lung cancer

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16
Q

MCC cancer related death in US

A

Lung cancer

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17
Q

Strongest influence on survival in lung ca?

A

Nodal involvement

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18
Q

Mets in lung cancer?

A
  • Brain most common

- Supraclavicular nodes, other lung, bone, liver, adrenals

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19
Q

Lung cancer recurrence

A

Usually appears as disseminated mets

80% is within first 3 years

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20
Q

Lung ca overall 5 year survival

A

10% -> 30% with resection for cure

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21
Q

Lung ca resectability

A

Stage I and II resectable

Stage IIIa (T3N1M0) possibly resectable

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22
Q

Lung ca types

A

Non-small cell carcinoma (80%): squamous cell (central), adeno (peripheral and most common)

Small cell carcinoma (20%): neuroendocrine in origin, usually unresectable at time of diagnosis (<5% candidates for surgery), overall <5% 5 year survival; T1N0M0 has a 50% 5yr survival, most get just chemoradiation

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23
Q

Suspect lung cancer and PET shows mediastinal lymphadenopathy (>1cm), what’s next step?

A

LN biopsy

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24
Q

What is unresectable in lung cancer?

A

T4 (mediastinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion)

Nodes positive

Distant mets

-Can still resect if invading chest wall, pericardium, diaphgram, phrenic nerve, or <2cm away from carina)

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25
Q

Lung ca and hypercalcemia

A

PTHrP from squamous cell carcinoma

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26
Q

Lung ca and ACTH and ADH

A

Small cell Ca (ACTH most common paraneoplastic lung ca)

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27
Q

Most malignant lung tumor

A

Mesothelioma: aggressive local, nodal, and distance mets

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28
Q

Non-small cell Ca chemo (stage II or higher)

A

Carboplatin, taxol

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29
Q

Small cell lung Ca chemo

A

Cisplatin, Etoposide

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30
Q

XRT in Lung ca?

A

Yes

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31
Q

Single best test for clinical assessment of T and N status in lung ca?

A

CT chest and abdomen

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32
Q

Best test for M status in lung ca?

A

PET

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33
Q

Who gets mediastinoscopy?

A

Centrally located tumors and patients with suspicious adenopathy (>0.8cm or subcarinal >1.0 cm) on CT

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34
Q

Mediastinoscopy assesses what nodes?

A

Looks into middle mediastinum

  • Left structures are RLN, esophagus, aorta, PA
  • Right structures are azygous and SV
  • Anterior structures are innominate vein and artery and Right PA
Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes
- Unresectable if MS nodes are positive

Does NOT assess aortopulmonary window nodes (left lung drainage): Need Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy, through left 2nd rib cartilage, for these)

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35
Q

Who gets bronchoscopy?

A

Needed for centrally located tumors to check for aiway invasion

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36
Q

Who can get resection in lung ca?

A
  • Must be operable (appropriate FEV1 and DLCO values) and resectable (up to T3, N1, M0)
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37
Q

Pancoast tumor

A

Horner’s syndrome from tumor invading apex of chest wall and invasion of sympathetic chain (ptosis, miosis, anhirdosis) or ulnar nerve symptoms

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38
Q

Coin lesions

A

10% are malignant

Under 50yo, 5% malignant

Over 50yo, 50% malignant

Likely benign if no growth in 2 years and smooth contour

If suspicious, need either guided biopsy or wedge resection

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39
Q

Asbestos exposure increases lung Ca risk by how much?

A

90x

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40
Q

What lung cancer can look like pneumonia, grows along alveolar walls, and is multifocal?

A

Bronchoalveolar ca

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41
Q

Isolated lung mets can be resected in what diseases?

A 
CRC
RCC
Sarcoma
Melanoma
Ovarian
Endometrial
42
Q

Carcinoid tumor

A

Neuroendocrine, usually central

5% have mets at diagnosis

50% have symptoms (cough, hemoptysis)

Typical: 90% 5 year survival
Atypical: 60% 5 year survival

43
Q

Tx of lung carcinoid?

A

Resection, treat like cancer, outcome closely linked to histology (typical v atypical?)

44
Q

Recurrence of carcinoid after resection?

A

Increase if positive nodes or >3cm

45
Q

Bronchial adenomas types

A

Mucoepidermoid adenoma, mucous gland adenoma, adenoid cystic adenoma: all MALIGNANT

46
Q

Mucoepidermoid adenoma and mucous gland adenoma versus adenoid cystic adenoma

A

Mucoepidermoid adenoma and mucous gland ademoa: slow growth, no mets, resect!

Adenoid cystic adenoma: from submucosal glands, spreads along perineural lymphatics, well beyond endoluminal component, very XRT SENSITIVE; slow growing, can get 10yr survival with incomplete resection; Tx is resection, if unresectable, XRT can provide good palliation

47
Q

Most common benign adult lung tumor

A

Hamartomas

48
Q

Popcorn lesion with calcifications on chest CT

A

Hamartoma

Does NOT require resection

Repeat chest CT in 6 months to confirm diagnosis

49
Q

Most common mediastinal tumor in adults and kids

A

Neurogenic tumors, usually in posterior mediastinum

50
Q

Most common site for mediastinal tumor

A

Anterior

51
Q

Mediastinal masses

A

50% malignant

90% of asymptomatic are benign

52
Q

Anterior mediastinal masses types

A 
Thymoma (most common)
Thyroid ca and goiters
T-cell lymphoma
Teratoma (and other germ cell tumors)
paraThyroid adenomas
53
Q

Middle mediastinum masses

A

Bronchiogenic cysts
Pericardial cysts
Enteric cysts
Lymphoma

54
Q

Posterior mediasinum masses

A

Enteric cysts
Neurogenic tumors
Lymphoma

55
Q

Thymoma treatment

A

Resect all!

Refractory MG or big thumus: resect

56
Q

Thymomas

A

50% are malignant
50% have symptoms
50% have MG (but only 10% of patient with MG have thymomas)

57
Q

Fatigue, weakness, diplopia, ptosis, Ab to Ach receptors

A

MG

Tx: Neostigmine (acetylcholinesterase inhibitors); steroids; plasmapheresis; thomectomy (80% get improvement, including patients who do not have thymomas)

58
Q

Mediastinal germ cell tumors

A

Need to biopsy (mediastinoscopy)

Teratoma: most common germ cell tumor in mediastinum, can be benign or malignant, resect with possible chemo

Seminoma: most common malignant GCT in mediastinum; 10% are beta-HCG positive but No AFP; Tx with XRT (very sensitive); chemo reserved for mets or bulky node disease; surgery for residual disease after that

Non-seminoma: 90% have elevated beta-HCG and AFP; tx chemo (cisplatin, bleomycin, VP-16)

59
Q

Most common germ cell tumor in mediastinum; most common malignant germ cell tumor in mediastinum

A

Teratoma

Seminoma most common malignant GCT

60
Q

Mediastinal mass and high HGB and AFP

A

Non-seminoma

61
Q

Mediastinal cysts

A

Bronchiogenic (posterior to carina); resect

Pericardial (right costophrenic angle); leave alone

62
Q

Neurogenic mediastinal tumors

A

Pain, neurologic deficit; tx is resection

10% have intra-spinal involvement thatrequires simultaenous spinal surgery

Neurolemmmoma (schwannoma) most common

Paraganglioma: can produces CAs, associated with von Recklinghausen’s disease; can also get neuroblastomas and neurofibromas

63
Q

Tracheal tumor types

A

Papilloma
Hemangioma
Squamous cell carcinoma

64
Q

Benign tracheal mass in adults and kids

A

Adults: papilloma
Kids: Hemangioma

65
Q

Tracheal surgery complications (early and late)

A

Early: laryngeal edema; tx with reintubation, racemic epinephrine, steroids

Late: Granulation tissue

66
Q

Post-intubation stenosis is usually where?

A

Tracheostomy: at stoma site

ETT: at cuff site

67
Q

Tx of post-intubation stenosis

A

Serial dilatation, bronchoscopic resection, or laser ablation if minor

Tracheal resection end-end anastomosis if severe or recurrent

68
Q

Tracheo-innominate artery fistula

A

Can have rapid exsanguination if occurs after tracheostomy

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 3rd tracheal ring

69
Q

Tracheo-esophageal fistula

A

Usually occurs with prolonged intubation

Place large-volume cuff endotracheal tube BELOW fistula

May need decompressing gastrostomy

Attempt repair after patient weaned from vent

Tx: tracheal resection, reanastomosis, close hole in esophagus, STERNOHYOID flap between esophagus anf trachea

70
Q

Lung abscess cause, location, dx, and tx

A

Aspiration

RLL superior segment

Chest CT to differentiate empyeme from abscess

Antibiotics 95% successful; CT drainage if fails; surgery if that fails or if c/f cancer (>6cm, failure to resolve after 6 weeks)

71
Q

Lung empyema cause, symptoms, dx, phases, tx

A

Pneumonia and subsequent parapneumonic effusion (staph, strep); also can be due to esophageal, pulmonary, or mediastinal surgery

Pleuritic chest pain, fever, cough, SOB

Pleural fluid WBC > 500 cells/cc, bacteria, and positive gram stain

Week 1 Exudative phase: tx with chest tube and abx

Week 2 Fibroproliferative phase: tx with chest tube, abx, possible VATS deloculation

Week 3 Organized phase: fibrous peel around lung, likely need decort; some are using intrapleural tPA to try and dissolve peel; may need Eloesser flap (open thoracic window - direct opening to external environment - in frail/elderly)

72
Q

Milky white fluid, a lot of lymphocytes and TGs > 110 ml/uL, sudan red stains fat

A

Chylothorax: fluid is resistant to infection

half due to trauma or iatrogenic

half due to tumor (lymphoma most common due to tumor burden in lymphatics)

73
Q

Chylothorax location on R versus L

A

Above T5-6: Left

Below T5-6: Right

74
Q

Tx of chylothorax

A

2-3 weeks of chest tube, octreotide, low-fat diet or TPN

If fails and if due to trauma or iarogenic, need THORACID DUCT LIGATION on Right side low in mediastinum (80% successful)

If malignant, need talc pleurodesis and possible chemoXRT

75
Q

Massive hemoptysis

A

> 600 cc/24h

Usually from bronchial arteries (high pressure) not pulmonary arteries

Most commonly due to infection, death from asphyxiation

76
Q

Tx of massive hemoptysis

A

Place bleeding side down

Mainstem intubation to side opposite bleeding to prevent drowning in blood

Rigid bronchoscopy to identify site and possibly control bleeding

May need lobectomy or pneumonectomy to control

Bronchial artery embolization if not suitable for surgery

77
Q

Spontaneous PTX most common what side?

A

Right

Tall, healthy, thin, young males

Results from rupture of bleb in apex of upper lobe

78
Q

Recurrence risk of spontaneous PTX?

A

1st: 20%
2nd: 60%
3rd: 80%

79
Q

Tx of spontaneous PTX

A

Chest tube

Surgery if recurrence, air leak >7 days, non-reexpansion, high risk job (pilot, diver, mountain climber) or if from remote area

80
Q

Surgery for spontaneous PTX

A

Thoracoscopy, apical blebectomy, mechanmical pleurodesis

81
Q

Tension PTX

A

More likely to cause arrest after BLUNT trauma; impaired venous return

82
Q

Catamenial PTX

A

Temporal relation to menstruation, caused by endometrial implants in visceral lung pleura

83
Q

Residual hemothorax despite 2 good chest tubes

A

OR for thoracoscopic drainage

84
Q

Clotted hemothorax

A

Surgical drainage if >25% of lung, air-fluid levels, or signs of infection (fever, leukocytosis); surgery in 1st week to avoid peel

85
Q

Broncholiths

A

Usually secondary toinfection

86
Q

Mediastinitis

A

Usually after cardiac surgery

87
Q

Whiteout on CXR, with midline shift toward whiteout

A

Collapse -> bronch to remove plug

88
Q

Whiteout on CXR, with midline shift away from whiteout

A

Effusion -> place chest tube

89
Q

Whiteout on CXR without shift

A

CT to find out wheter collapse or effusion

90
Q

Bronchiectasis

A

Acquired from infection, tumor, or CF

Diffuse nature usually prevents surgery in most patients

91
Q

TB

A

Lung apices, calcifications, caseating granulomas

Ghon complex: parenchymal lesion + enlarged hilar nodes

Tx: RIPE (Rifampin, INH, Pyrazinamide)

92
Q

Non-caseating granulomas

A

Sarcoidosis

93
Q

Pleural fluid analysis: WBC < 1,000, pH 7.45-7.55, pleural to serum protein ratio <0.5, pleural to serum LDH ration <0.6

A

Transudate

94
Q

Pleural fluid analysis: WBC > 1,000, pH <7.45, pleural to serum protein > 0.5, pleural to serum LDH >0.6

A

Exudate

95
Q

Pleural fluid analysis WBC > 50,000

A

Empyema

Also pH < 7.30 and light’s criteria postivie

96
Q

Recurrent pleural effusions tx

A

Mechanical pleurodesis

Talc pleurodesis for malignant (talc for tumor)

97
Q

Airway fires

A

Usually associated with the laser

Tx: stop gas flow, remove ET tube, reintubate for 24hr, bronch

98
Q

AVMs

A

Connections between pulm arteries and veins, usually in lower lobes, can occur with Osler-Weber-Rendu disease

Tx: Embolization

99
Q

Hemoptysis, SOB, neurologic events

A

AVMs

100
Q

Chest wall tumors

A

Benign: osteochondroma most commonly

Malignant: chondrosarcoma

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