Thoracic - TCAR
Blood supply upper 2/3 of trachea - answer inferior thyroid arteries
Blood supply lower 2/3 of trachea - answer bronchial arteries
Blood supply lung parenchyma - answer bronchial arteries
Pathway of azygous vein in the thorax - answer runs along R side and dumps into
superior vena cava
Pathway of thoracic duct in the chest - answer runs along R side, crosses midline at T4-
T5, goes into L neck and dumps into L subclavian vein at junction with LIJ
Pathway of phrenic nerve in thorax - answer runs anterior to hilum
Pathway of vagus nerve in thorax - answer runs posterior to hilum
What fissures exist in the lungs? - answer Major oblique separates RLL from middle and
upper lobe
Minor separates upper from middle lobe
Muscle used in quiet respiration - answer Diaphragm 80%, intercostals 20%
Accessory muscles of respiration – answer SCM
Legators
Serratus posterior
Scalenes
Main surface active agent in surfactant - answer phosphatidylcholine
Alveolar, arterial, and venous pressures in lung zones in upright person - answer Zone
I: PA > Pa > Pv
Zone II: Pa > PA > Pv
Zone III: Pa > Pv > PA
Normal pulmonary artery pressure - answer25/10 (mean 15)
What predicted value is needed for pulmonary resection? - answerPredicted postop
FEV1 > 0.8L (>40% predicted)
,What can be done if the predicted postop FEV1 is close to 0.8 (40% predicted)? -
answerObtain a V/Q scan and see how much that segment actually contributes
Single best predictor of being able to wean off ventilator after pulmonary resection -
answerFEV1
Minimum DLCO for lung resection - answer>11-12 ml/min/mmHg CO (>50% predicted
value)
What six things effect DLCO? - answerPulmonary capillary surface area
Hgb
Alveolar architecture
Dead space
Low CO
Pulmonary HTN
What pCO2 is necessary for lung resection? - answer<45 at rest
What pO2 is necessary for lung resection? - answer>60 at rest, not on O2
What VO2max is needed for lung resection? - answer>10 ml/kg/min (maximum o2
consumption)
Overall PFTs required for pulmonary resection - answerFEV1 >0.8L (>40% predicted)
DLCO >11-12 ml/min/mmHg CO (>50% predicted, or 40% postop)
pCO2 <45 at rest
pO2 >60 at rest, not on O2
VO2 >10 ml/kg/min
MCC of hypoxemia after pulmonary resection - answerV/Q mismatch from atelectasis
(shunt)
MCC of hypercarbia after pulmonary resection - answeralveolar hypoventilation (poor
minute ventilation RR x TV)
MC nerve injury after pulmonary resection - answerbrachial plexus injuries
How can common peroneal nerve injuries be avoided durin pulmonary resection? -
answerflex dependent leg
Most common resection resulting in persistent air leak - answersegmentectomy/wedge
MC resection resulting in atelectasis - answerlobectomy
MC resection resulting in arrhythmias - answerpneumonectomy (R MC)
, MC resection resulting in postop TEF - answerpneumonectomy (R MC)
MC resection resulting in postop bronchopleural fistula - answerpneumonectomy (R
MC)
MC resection resulting in mortality - answerpneumonectomy (R MC)
What is post-pneumonectomy syndrome? - answerMC after R pneumonectomy
mediastinal shift causing main bronchial compression
How is post-pneumonectomy syndrome treated? - answerSilicone issue expanders on
pneumonectomy side to shift mediastinum back
What should be expected with hypotension, cyanosis, tachycardia, and displaced heart
on CXR after R pneumnoectomy? - answerCardiac herniation through pericardium
Treatment and prevention of cardiac herniation after R pneumonectomy -
answerPericarial Gortex patch
What should be expected with pooled secretions, recurrent infection, or bronchial stump
blowout after L pneumonectomy? - answerLong bronchial stump syndrome
How is long bronchial stump syndrome treated? - answerShorten bronchus and cover
with flap
Mortality with wedge? lobectomy? pneumonectomy? - answerwedge - 1%
lobectomy - 3%
pneumonectomy - 6% (R>L)
Treatment of persistent air leak in CT - answerCheck system
2nd CT anteriorly
Bronch (foreign body, BPF, mucous plug)
CT chest
Wait 7 days then mechanical pleurodesis
Treatment of atelectasis resistant to usual measures - answerBronch to look for mucous
plugging
Increase TV if already vented
MCC of adult TEF - answerEsophageal cancer eroding into trachea
Treatment of adult TEF caused by esophageal cancer erosion - answerStent
esophagus
Treatment of postop adult TEF - answerRepair esophagus primarily
Close hole in trachea or bronchus
Blood supply upper 2/3 of trachea - answer inferior thyroid arteries
Blood supply lower 2/3 of trachea - answer bronchial arteries
Blood supply lung parenchyma - answer bronchial arteries
Pathway of azygous vein in the thorax - answer runs along R side and dumps into
superior vena cava
Pathway of thoracic duct in the chest - answer runs along R side, crosses midline at T4-
T5, goes into L neck and dumps into L subclavian vein at junction with LIJ
Pathway of phrenic nerve in thorax - answer runs anterior to hilum
Pathway of vagus nerve in thorax - answer runs posterior to hilum
What fissures exist in the lungs? - answer Major oblique separates RLL from middle and
upper lobe
Minor separates upper from middle lobe
Muscle used in quiet respiration - answer Diaphragm 80%, intercostals 20%
Accessory muscles of respiration – answer SCM
Legators
Serratus posterior
Scalenes
Main surface active agent in surfactant - answer phosphatidylcholine
Alveolar, arterial, and venous pressures in lung zones in upright person - answer Zone
I: PA > Pa > Pv
Zone II: Pa > PA > Pv
Zone III: Pa > Pv > PA
Normal pulmonary artery pressure - answer25/10 (mean 15)
What predicted value is needed for pulmonary resection? - answerPredicted postop
FEV1 > 0.8L (>40% predicted)
,What can be done if the predicted postop FEV1 is close to 0.8 (40% predicted)? -
answerObtain a V/Q scan and see how much that segment actually contributes
Single best predictor of being able to wean off ventilator after pulmonary resection -
answerFEV1
Minimum DLCO for lung resection - answer>11-12 ml/min/mmHg CO (>50% predicted
value)
What six things effect DLCO? - answerPulmonary capillary surface area
Hgb
Alveolar architecture
Dead space
Low CO
Pulmonary HTN
What pCO2 is necessary for lung resection? - answer<45 at rest
What pO2 is necessary for lung resection? - answer>60 at rest, not on O2
What VO2max is needed for lung resection? - answer>10 ml/kg/min (maximum o2
consumption)
Overall PFTs required for pulmonary resection - answerFEV1 >0.8L (>40% predicted)
DLCO >11-12 ml/min/mmHg CO (>50% predicted, or 40% postop)
pCO2 <45 at rest
pO2 >60 at rest, not on O2
VO2 >10 ml/kg/min
MCC of hypoxemia after pulmonary resection - answerV/Q mismatch from atelectasis
(shunt)
MCC of hypercarbia after pulmonary resection - answeralveolar hypoventilation (poor
minute ventilation RR x TV)
MC nerve injury after pulmonary resection - answerbrachial plexus injuries
How can common peroneal nerve injuries be avoided durin pulmonary resection? -
answerflex dependent leg
Most common resection resulting in persistent air leak - answersegmentectomy/wedge
MC resection resulting in atelectasis - answerlobectomy
MC resection resulting in arrhythmias - answerpneumonectomy (R MC)
, MC resection resulting in postop TEF - answerpneumonectomy (R MC)
MC resection resulting in postop bronchopleural fistula - answerpneumonectomy (R
MC)
MC resection resulting in mortality - answerpneumonectomy (R MC)
What is post-pneumonectomy syndrome? - answerMC after R pneumonectomy
mediastinal shift causing main bronchial compression
How is post-pneumonectomy syndrome treated? - answerSilicone issue expanders on
pneumonectomy side to shift mediastinum back
What should be expected with hypotension, cyanosis, tachycardia, and displaced heart
on CXR after R pneumnoectomy? - answerCardiac herniation through pericardium
Treatment and prevention of cardiac herniation after R pneumonectomy -
answerPericarial Gortex patch
What should be expected with pooled secretions, recurrent infection, or bronchial stump
blowout after L pneumonectomy? - answerLong bronchial stump syndrome
How is long bronchial stump syndrome treated? - answerShorten bronchus and cover
with flap
Mortality with wedge? lobectomy? pneumonectomy? - answerwedge - 1%
lobectomy - 3%
pneumonectomy - 6% (R>L)
Treatment of persistent air leak in CT - answerCheck system
2nd CT anteriorly
Bronch (foreign body, BPF, mucous plug)
CT chest
Wait 7 days then mechanical pleurodesis
Treatment of atelectasis resistant to usual measures - answerBronch to look for mucous
plugging
Increase TV if already vented
MCC of adult TEF - answerEsophageal cancer eroding into trachea
Treatment of adult TEF caused by esophageal cancer erosion - answerStent
esophagus
Treatment of postop adult TEF - answerRepair esophagus primarily
Close hole in trachea or bronchus
