Mediastinum and pleura

Question 1

components of anterior mediastinum

Answer 1

Thymus Gland, Substernal thyroid and parathyroid tissue, Lymphatic vessels and nodes, Connective Tissue

Question 2

components of middle mediastinum

Answer 2

Heart, Pericardium, Aortic arch and great vessels, Innominate veins and SVC, Trachea and major bronchi
Hila, Lymph nodes, Phrenic and upper vagus nerves, Connective tissueHeart, Pericardium, Aortic arch and great vessels, Innominate veins and SVC, Trachea and major bronchi
Hila, Lymph nodes, Phrenic and upper vagus nerves, Connective tissueHeart, Pericardium, Aortic arch and great vessels, Innominate veins and SVC, Trachea and major bronchi
Hila, Lymph nodes, Phrenic and upper vagus nerves, Connective tissue

Question 3

components of posterior mediastinum

Answer 3

Esophagus, Descending aorta, Azygous and hemiazygous veins, Thoracic duct, Lymph nodes, Vagus nerves (lower portion), Sympathetic chains, Connective tissue

Question 4

Symtoms of mediastinal mass

Answer 4

compression/invasion of adjacent structures, fever, anorexia, weight loss, endocrin symptoms, auto immune (thymus related)

Question 5

compare mediastinal masses in adults vs children

Answer 5

adults are usually anterior, wheras children are usually posterior masses

Question 6

list Anterior mediastinal masses

Answer 6

Thymoma (thymic neoplasm), Teratoma (germ cell tumor), Terrible Lymphoma, Thyroid tissue neoplasm, plus mesenchymal neoplasm, diaphragmatic hernia and primary carcinoma

Question 7

List middle mediastinal masses

Answer 7

Lymphadenopathy, developmental cysts, etc

Question 8

List posterior mediastinal masses

Answer 8

Neurinomas (peripheral nerve)

Question 9

What diagnostic tests are used to diagnose mediastinal mass

Answer 9

CXR to determine compartment, CT chest to differentiate btw cysts and solid lesions, fatty structures, lymphadenopathy vs vascular. CBC, needle aspiration, surgical (mediastinoscopy), Beta-HCG, alpha fetoprotein

Question 10

Complications of mediastinal masses

Answer 10

Tracheal Obstruction, SVC Syndrome , Vascular invasion with hemorrhage , Esophageal Rupture

Question 11

What condition is often associated with thymomas

Answer 11

paraneoplastic syndromes such as lupus, polymyositis, myocarditis, Sjogrens, and sarcoidosis

Question 12

What is the pleura

Answer 12

•Two single-cell thick, continuous membranes that line the outer surface of the lung, inner surface of the thoracic cavity and meet at the hilar root of lung.

Question 13

What is a pneumothorax and list the potential causes

Answer 13

Air in the pleural space. Causes: spontaneous (primary occurs in absence of underlying disease or secondary occurs as complication of underlying disease) or traumatic (iatrogenic from medical treatment/procedure or non iatrogenic)

Question 14

Causes of primary spontaneous pneumothorax

Answer 14

rupture of subpleural emphysematous blebs which are common in the lung apices in patients who smoke, have a family history or in tall thin males. Other risk factors include narrowed airways and missing bronchi.

Question 15

List causes of secondary spontaneous pneumothorax

Answer 15

inherited disease (folliculin gene defect), COPD, PCP, MTb, necrotizing pneumonia, cystic fibrosis, interstitial lung disease, pneumoconiosis, lung cancer

Question 16

Causes of non iatrogenic traumatic pneumothorax

Answer 16

penetrating or blunt tauma to chest (increases alveolar pressure from chest compression)

Question 17

List causes of iatrogenic and non-iatrogenic traumatic pneumothorax

Answer 17

Placement of central lines, barotrauma (intubation, mechanical ventilation)

Question 18

Clinical presentation of pneumothorax

Answer 18

Acute onset chest pain, Dyspnea , Cough, Anxiety , Cyanosis, Respiratory distress

Question 19

Physical exam of pneumothorax

Answer 19

Hyper resonant chest percussion , Decreased / absent breath sounds , Decreased fremitus, Chest wall trauma, Decreased rib space

Question 20

Lab findings in spontaneous pneumothorax

Answer 20

hypoxia, increased A-a gradient, respiratory alkalosis

Question 21

CXR of pneumothorax

Answer 21

Pleural line, increased hemithorax volume, tracheal/mediastinal shift towards contralateral hemothorax or depression of ipsilateral hemidiaphragm

Question 22

Treatment of pneumothorax

Answer 22

Observation, Supplemental oxygen (100%), Simple aspiration, Tube thoracostomy (chest tube), Pleurodesis, open thoracotomy

Question 23

Prevention of pneumothorax after initial pneumothorax

Answer 23

Sclerosis of pleural space using chemical or surgical technique to prevent recurrenc. Chemical agents include talc and tetracycline, but talc can be associated with ARDS and chronic pleural fibrosis/ restrictive disease. Video assisted thoracoscopic surgery and open thoracotomy is most effective approach but high mortality.

Question 24

What is a tension pneumothorax

Answer 24

Medical emergency. Intrapleural pressure exceeds atmospheric pressure throughout expiration and often during inspiration. Causes hemodynamic compromise by decreasing venous return and limiting cardiac output

Question 25

Symptoms of tension pneumothorax

Answer 25

Tachycardia, hypotension, Respiratory distress, cyanosis, profuse diaphoresis

Question 26

Treatment of tension pneumothorax

Answer 26

DO NOT wait for CXR results. Emergently insert an 18 gauge angiocath in the second intercostal space along the midclavicular line and attach IV tubing to the end which is placed in a cup of saline. Place tube thoracostomy if pneumothorax confirmed

Question 27

Pleural effusion definition

Answer 27

Normal fluid is 0.2-0.3 mL/kg. Pleural effusion results when the rate of pleural fluid formation exceeds drainage. Associated with both localized pleural disorders and systemic conditions that affect the pleura.

Question 28

Clinical presentation of pleural effusion

Answer 28

Dyspnea, Pleuritic chest pain, Dry cough, Symptoms associated with underlying cause, Decreased breath sounds, dullness to percussion, decreased tactile and vocal fremitus on examination

Question 29

Pleural effusion CXR findings

Answer 29

meniscus sign and dense opacity

Question 30

Types of pleural effusions

Answer 30

Transudative effusions result from alteration in hydrostatic forces that affect fluid formation (non-protein rich). Exudative effusions are due to alterations in permeability of the pleura or rate of fluid removal (protein rich).

Question 31

Diagnostic procedure for pleural effusion

Answer 31

Thoracentesis- collect fluid from the effusion and assess for transudate vs exudate

Question 32

Trasudate vs exudate

Answer 32

Transudate: LDH plasma/LDH serum < 0.6 and Protein plasma/Protien serum < 0.5. Exudate: LDH pl/LDH ser > 0.6 or Protpl/Protser > 0.5 or LDHpl > 0.667 upper limit normal for serum

Question 33

Pleural fluid analysis

Answer 33

LDH (+ serum), Total protein (+ serum), pH, glucose, CBC, gram stain, culture, AFB/fungal stains and culture, cytology

Question 34

Conditions that cuase transudative pleural effusion

Answer 34

Congestive heart failure, cirrhosis with ascites, nephrotic syndrome, peritoneal dialysis, myxedema. Etc

Question 35

Conditions that cause exudative pleural effusion

Answer 35

infection, cancer, PE, Asbestos, sarcoidosis, uremia, etc

Question 36

Pleural abnormalities

Answer 36

Pleural Thickening, Pleural Plaques, Pleural Tumors

Question 37

Describe pleural tumors

Answer 37

Most are malignant and most are metastatic (from lung, breast, lymphoma, GI or GU)

Question 38

Describe pleural plaques

Answer 38

Develop from chronic inflammation and asbestos (20-30 yrs after exposure)

Question 39

Describe pleural thickening etiology

Answer 39

Inflammation following infection, Hemorrhage, Prior treatment for effusion/ptx, Occupational exposure (i.e. asbestos), Trauma, Neoplasm. Begins as inflammation and fibrosis along visceral pleura with secondary response of parietal pleura