Chapter 25: Thoracic Flashcards Preview

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Flashcards in Chapter 25: Thoracic Deck (166):
1

Runs along the right side and dumps into the SVC

Azygous vein

2

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

Thoracic duct

3

Nerve runs anterior to hilum

Phrenic nerve

4

Nerve runs posterior to hilum

Vagus nerve

5

Right lung volume

55% (3 lobes: RUL, RML, RLL)

6

Left lung volume

45% (2 lobes: LUL and LLL and lingula)

7

Muscles involved in quite inspiration

Diaphragm 80%
Intercostals 20%

8

Greatest change in dimension when breathing

Anterior and posterior

9

Accessory muscles of inspiration

SCM, levators, serratus posterior, scalenes

10

Function: type 1 pneumocytes

Gas exchange

11

Function: type 2 pneumocytes

Surfactant production

12

Function: pores of Kahn

direct air exchange between alveoli

13

Predicted postop requirements:
FEV1
DLCO

- FEV1 > 0.8 (or >40% of the predicted post value)
- DLCO > 10mL/min/mmHg CO (or > 40% of the predicted post value)

14

What if predicted postop FEV1 is not > 0.8 but is close?

If it is close -> get qualitative V/Q scan to see contribution of that portion of the lung to overall FEV1 -> if low, may still be able to resect

15

- Measures carbon monoxide diffusion and represents oxygen exchange capacity
- This value depends on pulmonary capillary surface area, hemoglobin content, and alveolar architecture.

DLCO

16

pre op pCO2, pO2, VO2 max that say no resection

pCO2 > 50 at rest
pO2

17

MC after segmentectomy / wedge

Persistent air leak

18

MC after lobectomy

Atelectasis

19

MC after pneumonectomy

Arrhythmias

20

Symptoms: can be asymptomatic with finding on routine CXR; cough, hemoptysis, atelectasis, PNA, pain, weight loss

Lung cancer

21

MCC cancer-related death in the United States

Lung cancer

22

Strongest influence on survival in lung cancer

Nodal involvement

23

Lung cancer: single most common site of metastasis

Brain
- Can also go to supraclavicular nodes, other lung, bone, liver, and adrenals

24

Usually appears as disseminated metastasis

Recurrence
- 80% of recurrences are within the 1st three years

25

Overall 5-year survival rate lung cancer

10% 5-year survival rate
- 30% with resection for cure

26

What lung cancer is resectable?

Stage 1 and 2 disease resectable; T3,N1,M0 (stage3a) possibly resectable

27

MC procedure for lung cancer

Lobectomy or pneumonectomy; sample suspicious nodes

28

80% of lung cancer

Non-small cell carcinoma

29

Lung cancer: usually more central

Squamous cell carcinoma

30

Lung cancer: usually more peripheral

Adenocarcinoma

31

MC lung cancer

Adenocarcinoma (not squamous)

32

TNM staging system for lung cancer

T: 1 (3cm but >2cm away from carina) 3(invasion of chest wall, pericardium, diaphragm or

33

- 20% of lung cancer; neuroendocrine in origin
- usually unresectable at time of diagnosis (

Small cell carcinoma

34

Overall 5 year survival rate of small cell carcinoma

35

Small cell carcinoma: 5 year survival rate T1, N0, M0

50%

36

Most treatment for small cell carcinoma

Just get chemo-XRT

37

Paraneoplastic syndrome: squamous cell CA

PTH-related peptide

38

Paraneoplastic syndrome: small cell CA

ACTH and ADH

39

Most common paraneoplastic syndrome

Small cell ACTH

40

- Most malignant lung tumor
- Aggressive local invasion, nodal invasion, and distant metastases common at the time of diagnosis.

Mesothelioma

41

What is mesothelioma related to?

Asbestos exposure

42

Non-small cell CA chemotherapy (stage 2 or higher)

Carboplatin, Taxol

43

Small cell lung CA chemotherapy

Cisplatin, etoposide

44

Can XRT be used for lung CA?

Yes

45

Single best test for clinical assessment of T and N status for lung cancer

Chest and abdominal CT scan

46

Best test for M status in lung cancer?

PET scan

47

Use for centrally located tumors and patients with suspicious adenopathy (> 0.8 cm or subcarinal > 1.0 cm) on chest CT

Mediastinoscopy

48

What does mediastinoscopy assess?

- Does not assess aorto-pulmonary (AP) window nodes (left lung drainage)
- Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes

49

Treatment if mediastinal nodes are positive

Tumor is unresectable

50

Looking into middle mediastinum with mediastinoscopy:
- Left-side structures
- Right side structures
- Anterior

Left-side: RLN, esophagus, aorta, main pulmonary artery (PA)
Right-side: azygous and SVC
Anterior: innominate vein, innominate artery, right PA

51

assesses enlarged AP window nodes; go thru left 2nd rib cage

Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy)

52

Needed for centrally located tumors to check for airway invasion

Bronchoscopy

53

For lung CA, patients need to be...

1) operable (FEV1/DLCO)
2) resectable (can't have T4, N2, N3, or M disease)

54

Tumor invades apex of chest wall and patients have Horner's syndrome (invasion of sympathetic chain - ptosis miosis, anhidrosis) or ulnar nerve symptoms

Pancoast tumor

55

- Overall, 10% are malignant.
- Age 50 -> >50% malignant
- No growth in 2 years, and smooth contour suggests benign disease

coin lesion

56

Management of suspicious coin lesion

if suspicious, will need either guided biopsy or wedge resection

57

Increased lung CA risk 90x

Asbestos exposure

58

Can look like pneumonia; grows along alveolar walls; multifocal

Bronchoalveolar cancer

59

Management: metastases to the lung -> if isolated and not associated with any other systemic disease

May be resected for colon, renal cell CA, sarcoma, melanoma, ovarian, and endometrial CA

60

Neuroendocrine tumor, usually central
- 5% have metastases at time of diagnosis; 50% have symptoms (cough, hemoptysis)

Carcinoids

61

5-year Survival rate: typical carcinoid

90%

62

5-year Survival rate: atypical carcinoid

60%

63

Tx: carcinoid

Resection, treat like cancer, outcome closely linked to histology

64

Malignant bronchial adenomas

Mucoepidermoid adenoma, mucous gland adenoma, and adenoid cystic adenoma

65

Type - bronchial adenomas
- Slow growth, no metastases
- Tx: resection

Mucoepidermoid adenoma, and mucous gland adenoma

66

- From submucosal glands; spreads along perineural lymphatics, well beyond endoluminal component; very XRT sensitive
- Slow growing; can get 10-year survival with incomplete resection
- Tx: resection; if unresectable, XRT can provide good palliation

Adenoid cystic adenoma

67

- Most common benign adult lung tumor
- Have calcifications and can appear as a popcorn lesion on chest CT
- diagnosis can be made with CT

Hamartomas

68

Tx: hamartomas

- Do not require resection.
- Repeat chest CT in 6 months to confirm diagnosis

69

Most are asymptomatic, can present with chest pain, cough, dyspnea

Mediastinal tumors in adults

70

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

Neurogenic tumors

71

% of symptomatic mediastinal masses that are malignant

50%

72

% of asymptomatic mediastinal masses are benign

90%

73

Most common site for mediastinal tumors

Anterior (thymus)

74

Tumors in the anterior mediastinum

- Thymoma
- Thyroid CA and goiters
- T-cell lymphoma
- Teratoma (and other germ cell tumors)
- Parathyroid adenomas

75

Structures in the middle mediastinum

Heart
Trachea
Ascending aorta

76

Pathology in the middle mediastinum

Bronchogenic cysts
Pericardial cysts
Enteric cysts
Lymphoma

77

Structures in the posterior mediastinum

Esophagus
Descending aorta

78

Pathology in the posterior mediastinum

Enteric cysts
Neurogenic tumors
Lymphoma

79

Structures in mediastinum

- Anterior: thymus
- Middle: heart, trachea, ascending aorta
- Posterior: esophagus, descending aorta

80

Treatment: thymoma

All thymomas require resection

81

Thymus too big or associated with refractory myasthenia gravis

Resection

82

__% of thymomas are malignant

50%

83

__% of patients with thymomas have symptoms

50%

84

__% of patients with thymomas have myasthenia gravis

50%

85

__% of patients myasthenia gravis have thymomas

10%

86

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

Myasthenia gravis

87

Tx: myasthenia gravis

Anticholinesterase inhibitors (neostigmine); steroids, plasmapheresis

88

Myasthenia gravis: __% of patients get improvement with thymectomy, including patients who do not have thymomas

80%

89

Need to biopsy (often done with mediastinoscopy)

Germ cell tumors

90

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

Teratoma

91

Most common malignant germ cell tumor in mediastinum

Seminoma

92

- 10% are beta-hcg positive, should not have AFP
- Tx: XRT (extremely sensitive); chemotherapy reserved only for metastases or bulky nodal disease; surgery for residual disease after that

Seminoma

93

90% have elevated beta-hcg and AFP
-TX: chemo (cisplatin, bleomycin, VP-16); surgery for residual disease

Non-seminoma

94

Cysts: usually posterior to carina.
- Tx: resection

Bronchiogenic cyst

95

Cysts: usually at right costophrenic angle.
- Tx: can leave alone (benign)

Pericardial cyst

96

Have pain, neurologic deficit.
- Tx: resection
- 10% have intra-spinal involvement that requires simultaneous spinal surgery

Neurogenic tumors

97

Most common neurogenic tumor

Neurolemmoma (schwannoma)

98

Neurogenic tumors: can produce catecholamines, associated with von Recklinghausen's disease

Paraganglioma

99

What is associated with neurogenic tumors?

Neuroblastomas and neurofibromas

100

Trachea: benign tumors
Adult?
Children?

Adults - papilloma
Children - hemangioma

101

Trachea malignancy

Squamous cell carcionma

102

Most common late complication after tracheal surgery

Granulation tissue formation

103

Most common early complication after tracheal surgery

Laryngeal edema

104

Tx: laryngeal edema after tracheal surgery

Reintubation, racemic epinephrine, steroids

105

Where does post-intubation stenosis occur:
- with tracheostomy
- with ET tube

- Tracheostomy: at stoma site
- ETT: cuff site

106

Tx: post-intubation stenosis

- Serial dilatation, bronchoscopic resection, or laser ablation if minor
- Tracheal resection with end-to-end anastomosis if severe or if it keeps recurring

107

Occurs after tracheostomy, can have rapid exsanguination

Tracheo-innominate artery fistula

108

Tx: tracheo-innominate artery fistula

Place finger in tracheostomy hole and hold pressure -> median sternotomy with ligation and resection of innominate artery

109

How do you avoid trachea-innominate artery fistula?

This complication is avoided by keeping tracheostomy above the 3rd tracheal ring.

110

- Usually occurs with prolonged intubation
- Place large-volume cuff ETT below
- May need decompressing gastrostomy
- Attempt repair after the patient is weaned from ventilator

Tracheo-esophageal fisutla

111

Tx: tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea

Tracheo-esophageal fistula

112

Necrotic area; most commonly associated with aspiration
- MC'ly in the superior segment of the RLL

Lung abscess

113

Tx: lung abscess

Antibiotics alonge (95% successful); CT-guided drainage if that fails.
- Surgery if above fails or cannot rule out cancer (>6cm, failure to resolve after 6 weeks)

114

What can help you differentiate empyema from lung abscess?

Chest CT

115

What are the causes of empyema?

Usually secondary to pneumonia and subsequent parapneumonic effusion (Staph, strep)
- Can also be due to esophageal, pulmonary or mediastinal surgery

116

Symptoms: pleuritic chest pain, fever, cough, SOB
- Pleural fluid often has WBCs > 500 cells/cc, bacteria, and a positive gram stain

Empyema

117

What are the three phases of empyema?

1st week: exudative phase
2nd week: fibroproliferative phase
3rd week: organized week

118

Tx: exudative phase of empyema

1st week: chest tube, antiobiotics

119

Tx: fibro-proliferative phase of empyema

2nd week: chest tube, antibiotics; possible VATS (video-assisted thoracoscopic surgery) deloculation

120

Tx: organized phase

3rd week: likely need decortication; fibrous peel occurs around lung.
- Some are using intra-pleural tPA to try and dissolve the peel
- May need Eloesser flap (open thoracic window - direct opening to external environment) in frail / elderly

121

Open thoracic window - direct opening to external environment

Eloesser flap

122

Milky white fluid; has increased lymphocytes and TAGs (>110 mL/uL)
- fluid is resistant to infection

Chylothorax

123

What stain would you used for chylothorax?

Sudan red stains fat

124

Chylothorax: % secondary to trauma or iatrogenic injury

50%

125

Chylothorax: % secondary to tumor (lymphoma most common, due to tumor burden in the lymphatics)

50%

126

Results in left-sided chylothorax

Injury above T5-T6

127

Results in right-sided chylothorax

Injury below T5-T6

128

Tx: chylothorax

2-3 weeks of conservative therapy (chest tube, octreotide, low-fat diet or TPN)

129

If conservative therapy fails and chylothorax secondary to trauma or iatrogenic injury?

Need ligation of thoracic duct on right side low in mediastinum (80% successful)

130

Treatment for malignant causes of chylothorax

Need talc pleurodesis and possible chemo and/or XRT (less successful than above)

131

Define massive hemoptysis

> 600 cc/hr

132

What usually causes bleeding from massive hemoptysis?

Bleeding usually from high-pressure bronchial arteries

133

What is massive hemoptysis most commonly secondary to?

Infection

134

What causes death in massive hemoptysis?

Asphyxiation

135

Tx: massive hemoptysis

Place bleeding side down; mainstem intubation to side opposite of 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

136

Tall, healthy, thin, young males; more common on the right

Spontaneous pneumothorax

137

Recurrence risk after 1st pneumothorax, 2nd pneumothorax, 3rd pneumothorax

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

138

What causes spontaneous pneumothorax?

Results from rupture of a bleb usually in the apex of the upper lobe of the lung

139

Tx: spontaneous pneumothorax

chest tube

140

Indications for surgery in spontaneous pneumothorax

Recurrence, air leak > 7 days, non-reexpansion, high-risk profession (airline pilot, diver, mountain climber), or patients who live in remote areas

141

Surgery options for spontaneous pneumothorax

Thorascoscopy, apical blebectomy, and mechanical pleurodesis

142

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

Tension pneumothorax

143

Pneumothorax: occurs in temporal relation to menstruation

Catamenial pneumothorax

144

What causes catamenial pneumothorax?

Caused by endometrial implants in the visceral lung pleura

145

Residual hemothorax despite 2 good chest tubes

OR for thoracoscopic drainage

146

Indications for surgery for clotted hemothorax

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

147

Causes of broncholiths

Usually secondary to infection

148

Cause of mediastinitis

Usually occurs after cardiac surgery

149

Whiteout on CXR: midline shift toward whiteout

Most likely collapse: need bronchoscopy to remove plug

150

Whiteout on CXR: no shift

CT scan to figure it out

151

Whiteout on CXR: midline shift away from whiteout

Most likely effusion -> place chest tube

152

What causes bronchiectasis?

Acquired from infection, tumor, cystic fibrosis
- Diffuse nature prevents surgery in most patients

153

Lung apices, get calcifications, caseating granulomas
- Tx: INH, rifampin, pyrazinamide

Tuberculosis

154

What makes up a Ghon complex?

Parenchymal lesion + enlarged hilar nodes

155

Has non-caveating granulomas

Sarcoidosis

156

Transudate:
WBC
pH
Pleural fluid protein to serum
Pleural fluid LDH to serum

WBC:

157

Exudate:
WBC
pH
Pleural fluid protein to serum
Pleural fluid LDH to serum

WBC: > 1,000
pH: 7.45
Protein: > 0.5
LDH: > 0.6

158

Empyema:
WBC
pH
Pleural fluid protein to serum
Pleural fluid LDH to serum

WBC: > 1,000, > 50,000 most specific
pH: 0.5
LDH: > 0.6

159

Can be treated with mechanical pleurodesis

Recurrent pleural effusions

160

What is talc pleurodesis used for?

Malignant pleural effusions

161

What are airway fires associated with?

Usually associated with the laser

162

Tx: airway fires

Stop gas flow, remove ETT, re-intubate for 24 hours, bronchoscopy

163

Connections between the pulmonary arteries and pulmonary veins; usually in lower lobes; can occur with Osler-Weber-Rendu disease

AVMs

164

Symptoms: hemoptysis, SOB, neurologic events

Tx: embolization

AVMs

165

Chest wall tumors: MC benign

Osteochondroma

166

Chest wall tumors: MC malignant

Chondrosarcoma