Thoracic Flashcards
(131 cards)
1
Q
What is the most important predictor of difficult intubation?
A
CXR: Gives body habitus, airway anomalies
2
Q
How much anatomic dead space is in in the conducting airways
A
150cc
3
Q
name the blood supply of of the trachea and lung
A
Upper 2/3 trachea = inferior thyroid arteries
Lower 1/3 trachea = bronchial arteries
lung parenchyma = bronchial arteries
4
Q
Name structures found at the mediastinum
A
Azygous vein, thoracic duct, phrenic nerve, vagus nerve
5
Q
Where does azygous vein empty?
A
SVC
6
Q
Where does the thoracic duct crosses midline (runs along the right side)
A
T4-T5
7
Q
Where does the thoracic duct empty?
A
Left Subclavian Vein
8
Q
Define the accessory muscles
A
SCM, levators, serratus posterior, scalenes
9
Q
Primary function of Type I pneumocytes
A
Gas Exchange (diffuse in alveoli)
10
Q
Primary function of Type II pneumocytes
A
Surfactant production
11
Q
What is surfactant?
A
Phosphotidylcholine. 80% phospholipid. Decreases alveolar surface tension, keeps alveoli open
12
Q
What are pores of Kahn?
A
Direct air exchange between alveoli
13
Q
What is the single best predictor of being able to wean off ventilator after pulmonary resection?
A
FEV1
14
Q
What other pre-op values needed before pulm resection?
A
- DLCO >11-12ml/min/mmHg CO
- pCO2 60
- VO2 max >10 ml/kg/min
15
Q
What is DLCO?
A
Carbon Monoxide Diffusion Capacity: Measures lung ability to transfer gases
16
Q
what is the MCC of hypoxemia post pulm resection?
A
Atelectasis causing V/Q mismatch
17
Q
what is the MCC of hypercarbia post pulm resection?
A
alveolar hypoventilation (poor minute ventilation)
18
Q
what is MC nerve injury post pulm resection?
A
Brachial plexus injury on the dependent arm
19
Q
What is the complication of segmentectomy/wedge
A
Persistent air leak
20
Q
What is the MC Cx of lobectomy
A
Atelectasis
21
Q
What complications can arise from pneumonectomy?
A
Arrhythmia, tracheoesophageal or bronchopleural resection, death, cardiac herniation, long bronchial stump syndrome, post-pneumonectomy syndrome
22
Q
What is post-pneumonectomy syndrome?
A
mediastinal shift after right pneumonectomy. Complicated by main bronchial compression
23
Q
What is sx of post-pneumonectomy syndrome?
A
Stridor
24
Q
What is the first thing you do to manage a persistent air leak?
A
Check if CT is on suction. Check system. Repeat CXR
25
Besides checking chest tube, what else can you do for a persistent air leak?
1. Place 2nd chest tube anteriorly
2. Bronchoscopy
3. Wait it out (7days for simple air leaks)
26
What is you last possible treatment for persistent air leak due to spontaneous PTX?
1. Staple bleb
| 2. mechanical pleurodesis
27
What is you last possible treatment for persistent air leak due to post pulm resection?
mechanical pleurodesis
28
What is the MCC of atelectasis after lung resection
1. Hypoxemia
| 2. Pulm shunting
29
What is the MCC of Adult Tracheo-esophageal fistula?
1. Esophageal Ca
| 2. Post-op (pneumonectomy)
30
What is the primary cause of post-pneumonectomy pulm edema?
1. inflammatory reaction
2. vasc permeability
3. Increase perfusion to remaining lung
31
MCC of empyema
1. PNA
| 2. Post-thoracic Surgery
32
What are the 3 stages of empyema
1. exudative (Tx: Ct and Abx)
2. fibropurulent (Tx: CT and Abx)
3. organizing (Tx: Decortication)
33
What alternative tx for organizing empyema besides decortication?
Eloesser flap: open thoracic window, direct opening to environment
34
What are sx of early post-op broncho-pleural flap?
massive air leak. resp compromise
35
What is the treatment for early post-op broncho-pleural flap?
tx: place intercostal muscle flap over bronchus
36
What is MCC of late post-op broncho-pleural fistula?
pressure from empyema
37
What is the treatment for late post-op broncho-pleural flap?
1. Place CT
2. place pt w/affected side down
3. bronchoscopy
4. abx
5. re-expand lungs, decortication, claggett, high frequency ventilation
38
What is a claggett procedure
fills post-pneumonectomy space with permanent abx solution + intercostal muscle flap
39
MC benign adult lung tumor
Hamartoma
40
What percent of solitary pulmonary nodules are hamartomas?
10%
41
How does a hamartoma appear on CT?
popcorn lesion
42
Tx for Hamartoma
Do not require resection. Repeat CT in 3 months to confirm diagnosis
43
MC benign upper airway tumor in kids?
hemangioma
44
MC malignant upper airway tumor in kids?
carcinoid
45
MC benign upper airway tumor?
papilloma
46
MC malignant upper airway tumor?
SCCA
47
MC bronchial gland tumors
Carcinoids (90%)
| 1. Typical (90%) 2. Atypical (10%)
48
MC late Cx after tracheal surgery
granulation tissue formation
49
MC early Cx after tracheal surgery
laryngeal edema
50
What tx options for post-intubation stenosis?
1. serial dilation
2. tracheal resection
3. If emergent, tracheostomy
51
MCC for tracheo-innominate artery fistula
Post-tracheostomy
52
How to treat tracheo-innominate artery fistula?
Surgical ligation + partial innominate artery resection. NO GRAFT. repair with strap muscle
53
How to avoid tracheo-innominate fistula during tracheostomy?
Tracheostomy at 3rd tracheal ring or above
54
What is the Cx of having too high of a trach placement?
vocal cord problems
55
Steps to control PA bleed
1. Control airway (prevent asphyxiation)
2. Pull Swan back
3. Increase PEEP (tamponade)
4. Bronch and mainstem intubate
5. Lobectomy if bleeding persists
56
MCC of massive hemoptysis
1. TB
2. Bronchiectesis
3. Lung Abscess
57
MCC of death w/massive hemoptysis
asphyxiation
58
MC site of bleeding
bronchial aretries (high pressure)
59
MCC of lung abscess
Aspiration PNA
60
MC location fo lung abscess
1. superior segment of RLL
| 2. post segment of RUL
61
MC organism of lung abscess
S. aureus
62
What parameters define an exudative effusion
protein >3
specific gravity > 1.016
LDH ratio >0.6
63
What is the Tx of recurrent pleural effusions
VATS pleurodesis
64
What is rate of recurrent spontaneous PTX
1. 20% (after 1st)
2. 60% (after 2nd)
3. 80% (after 3rd)
65
MC site of spont PTX
Upper lobe apex, right side
66
What are Sxs of thoracic outlet syndrome
pain + paresthesias
| motor weakness + atrophy
67
MC anatomic abnormality causing thoracic outlet syndrome
cervical rib
68
What is Tinsel's test?
tapping reproduces symptoms (for thoracic outlet syndrome)
69
What is Adson's test?
decrease radial pulse with head turned ipsilateral side
70
What are the 3 types of thorcic outlet syndrome?
1. Neurogenic (MC)
2. Arterial
3. Venous
71
What are Dx tools for Thoracic Outlet Syndrome
1. CXR
2. MRI
3. Nerve conduction velocity (abnormal <60m/S)
72
MC nerve distribution causing thoracic outlet syndrome
Ulnar nerve (C8-T1)
73
what is sugcal treatment for neurogenic thoracic outlet syndrome?
1st rib resection (if physiotherapy, PT, OT does not work : persistant NCV <60m/S)
74
What can cause an arterial thoracic outlet syndrome?
anterior scalene hypertrophy compression
75
What is sx of venous thorcacic outlet syndrome
effort induced thrombosis of subclavian vein (baseball pitchers, excessive use of arm)
Arm acutely swollen and blue
76
How to Dx venous thoracic outlet syndrome?
Duples U/S
77
What defines a solitary pulmonary nodule?
1. Single
2. <3cm
3. Surrounded by normal lung
4. No adenopathy
5. No pleural effusion
78
How often do you monitor a solitary pulm nodule?
Serial CTs q3 mos x 4, then q6mos x 2
79
What places a patient with solitary pulm nodule from an observation criteria to immediate or high risk
Age >45
previous smoker < 7 years ago
nodule > 1.5cm
scalloped shaped
80
How to diagnosed immediate or high risk nodule?
Trans-pleural/Trans-bronchial needle Bx
| VATS wedge resection
81
MC lung lesion
granuloma
82
MC malignant tumor
```
bronchogenic CA
#2 Mets
```
83
What is pancoast syndrome?
T4-tumor invades apex of chest wall (superior sulcus)
84
Syndrome involving tumor invasion of sympathetic chain?
Horner's syndrome
85
Besides ptosis, miosis and anhydrosis of Horner's syndrome what other symptom can a patient experience?
Ulner Nerve Sxs
86
MC type of lung Ca?
Adenocarcinoma
87
What is the strongest influence on survival devoid of systemic mets
Nodal involvement
88
Where is the MC site of lung Ca mets?
brain
89
What is the criteria used for lung resectrion?
1. predicted post-op FEV-1 >800cc (>= 40% predicted)
2. Pre-op DLCO > 10-12 ml/min/mmHg (>=50% predicted)
3. pO2 >60mmHg (RA)
4. pCO2 10-12 ml/min/kg
90
What's next step if work up of lung mass reveals mediastinal adenopathy (>1cm) or central mass?
Mediastinoscopy: Assess ipsilateral (N2), contralateral (N3) mediastinal nodes
If positive: unresectable
91
What's next step if work up reveals para-aortic or AP window adenopathy?
1. Perform Chamberlain (through 2nd rib cartilage
or
2. VATS
92
What's next step if work up reveals supra-clavicular or scalene adenopathy?
FNA of node
93
What is tx for Stages I and II?
1. Formal lung resection (lobectomy or pneumonectomy
2. Mediastinal lymph node dissection
3. Adjuvant chemo - cardioplatine and paclitaxel
94
What tx for stage IIIA ?
T3,N1M0-Resectable- neoadjuvant chemo-XRT
| If N2, unresectable
95
What is tx for stage IIIB?
T4 (usually unresectable) - neoadjuvant chemo-XRT
96
What is tx for stage IV?
Palliative chemo-XRT
97
What is the MCC of superior vena cava syndrome?
non-small cell lung Ca
98
What is the MC benign cause of superior vena cava syndrome?
mediastinal fibrosis
99
What is Tx of superior vena cava syndrome?
XRT
100
What is the MC paraneoplastic syndrome?
small cell ACTH
101
What is the most malignant thoracic tumor?
mesothelioma
102
Where does small cell CA usually metastasize?
Mediastinum
103
What is Tx for small cell lung Ca?
chemo: Cisplatin and etoposide
104
What are symptoms of mediastinal mass
often asymptomatic, but can have resp insufficiency, chest pain and dysphagia
105
What percent of mediastinal mass is malignant?
25%
106
MC site of mediastinal tumor?
Anterior mediastinum
107
MC solitary mediastinal mass?
neurogenic (both adults and children)
108
What type of thymoma has the worse prognosis?
Epithelial type
109
What is MCC of mediastinal adenopathy?
Lymphoma
110
What is MC lymphoma in the mediastinum?
Non-Hodgkin's lymphoma
111
What is the MC germ cell tumor in mediastinum?
Teratoma
112
What is the MC malignant germ cell tumor in mediastinum?
Seminoma
113
What type of germ cell tumor has an elevated B-HCG and alpha-fetoprotein?
Non-seminoma
114
How to treat non-seminoma tumor?
cisplatin-based chemo
115
What chemo Rx used to treat seminoma and non-seminoma tumors?
cisplatin
bleomycin
etoposide
116
MC neurogenic tumor?
neurolemma (Schwanomma, nerve sheath)
117
What neurogenic tumor is associated with Von Recklinghausen's disease
Neurofibroma (nerve sheath)
118
Does chylous fluid have a higher risk of infection?
No. The fluid is resistant to infection
119
What are the contents of chylous fluid
Increase lymphocytes and triglycerides
120
Where is the most likely injury in a right sided chylothorax?
Below T5-6
121
Where is the most likely injury in a left sided chylothorax?
Above T5-6
122
what level does the thoracic duct crosses the mediastinum
T5-6
123
Catamenial PTX
Occurs in temporal relation to menstrual cycle. Endometrial implants to visceral lung pleura
124
MCC of bronchiectasis?
cystic fibrosis
125
Gohn complex
parenchymal lesion + enlarged hilar nodules
126
Tx for Tuberculosis
INH, Rifampin, pyrazinamide, streptomycin, ethambutol
127
MC site of pulmonary AVMs
lower lobes
128
Treatment of pulm AVMs
embolization
129
Sydrome associated with pulm AVMs
Osler-Weber-Rendu Syndrome (Sx of epistaxis)
130
MC benign chest wall tumor
Osteochondroma
131
MC malignant chest wall tumor
chondrosarcoma
