Ir -- Chest

Front 1

1. What are some causes of massive hemoptysis?
2. What is the definition of massive hemoptysis?
3. What vessel is the most common source of hemoptysis?
4. What systemic vessel other than the bronchial arteries commonly supply the lungs?
5. At what level from the aorta do the bronchial arteries originate? How many branches are present?
6. What is used for embolization and why?
7. When doing bronchial artery embolization, what is important to identify and stay away from?

Back 1

1. Bronchogenic CA, bronchial adenoma (variety of tumors arising within the bronchi), TB, Aspergilloma, CF, bronchiectasis.
2. 300-600mL of blood/day
3. Bronchial artery. Less common sources of bleeding include the pulmonary arteries and systemic arterial collaterals.
4. Internal mammary artery
5. Bronchial arteries most commonly arise at the level of the left mainstem bronchus, usually at T5-T6. Although there are a lot of variation, the most common variant is 2 left bronchial arteries and 1 right bronchial artery. Active extravasation is rarely identified. Tortuous, enlarged BA and hypervascularity are typically the only findings.
6. PVA is used. Coils are not used b/c they produce proximal occlusion, precluding repeat embolization should hemoptysis recur. Immediate recurrence after BAE may indicate bleeding from aberrant bronchial arteries or systemic arteries.
7. Spinal artery. Branches of the spinal artery may arise from bronchial and intercostal arteries.

Front 2

1. What is an indication of an percutaneous chest tube?
2. How do you place a percutaneous thoracostomy tube?
3. When inserting the needle, should you go above or below the rib?
4. How do you manage a catheter placed for empyema drainage? What do you do if drainage stops?

Back 2

1. Pneumothorax and percutaneous drainage of empyema.
2. Under imaging guidance, a needle is inserted in the collection and contrast is injected to confirm proper positining. Over a guidewire, the tract is dilated and a catheter is placed and attached to negative pressure.
3. Above the rib. The neurovascular bundles courses below the rib.
4. When the collection resolves, the catheter can be pulled incremently to allow tract to close. If drainage stops, the catheter may be occluded in which case a new catheter can be placed or the collection may be loculated in which case fibrinolytic agents can be given.

Front 3

What are the congenital abnormalities of the SVC?

Back 3

Dupilcated and left sided SVC:
- high association with congenital heart disease.
- left SVC drains into the right atrium via the coronary sinus.
- occasionally associated with anomalous pulmonary venous return.

Front 4

1. What is catheter pinch off syndrome?
2. If fractured catheter goes unrecognized what is the consequence?

Back 4

1. Catheter pinch off syndrome occurs with medially inserted SUBCLAVIAN vein catheters due to compression between the clavicle and the first rib.
2. Chronic fragments may become endothelialized into the right heart or pulmonary artery.

Front 5

1. What is the most common congenital aortic arch abnormality?
2. What kind of sx is it associated with?

Back 5

1. Aberrant right subclavian artery
2. Usually asymptomatic. However, aneurysm of an aberrant right subclavian artery at its aortic origin (diverticulum of kommerell) is associated with compressive symptoms giving rise to dysphagia.

Front 6

1. What is the risk of pneumothorax after a lung biopsy? What percentage of pts require a chest tube placement?
2. How do you place a chest tube for pneumothorax drainage?
3. What do you do if the pneumothorax keeps expanding despite chest tube placement?
4. What are the risk factors that increase the likelihood of pneumothorax?

Back 6

1. The incidence of PTX after lung biopsy is 20%. However, only 3-5% of pts require chest tube placement.
2. The chest tube is placed in the 2nd intercostal space in the mid axillary line. The tube is connected to a one way valve.
3. Evaluate the tube as it may be kinked or clogged. You may have to connect the tube to water seal and suction. Alternatively, the patient may have a persistent air leak for which thoracic surgery consult would be needed.
4. Emphysema, deep lesions, smaller lesion, lesions abutting the fissures, greater number of needle passes, traversing more than one pleural surface.

Front 7

What are the etiologies of carotid artery aneurysm?

Back 7

- Kawasaki disease: seen in kids.
- Mycotic aneurysm

Front 8

Pulmonary angiogram

Back 8

- If the pt has a left bundle branch block, he needs transcutaneous pacing.
- Pulmonary Hypertension
Mild = PA sys 30 – 40 mm Hg
Moderate = PA sys 40 – 70 mm Hg
Severe = PA sys > 70 mm Hg