L6 cardiothorasci surgery

List common postoperative pulmonary complications.

List common postoperative pulmonary complications.

Atelectasis

Bronchopneumonia

Bronchitis

Lung abscess

Adult respiratory distress syndrome (ARDS)

Respiratory failure

Mendelson's syndrome

Pulmonary embolism

What are the risk factors for pulmonary complications in the postoperative period?

Age (infants, elderly)

Male sex

Smoking

Chronic respiratory conditions (COPD, asthma, tuberculosis)

Postoperative pain

Deep vein thrombosis (DVT)

Pulmonary embolism

Septicemia

Paralytic ileus

Anesthetic complications

Aspiration problems

Obesity

What are the clinical manifestations of postoperative atelectasis?

Fever and unexplained tachycardia (within 48 hours)

Dyspnea

Cyanosis and chest pain (massive cases)

Chest X-ray: homogeneous wedge-shaped opacity

1. The most common pulmonary complications after surgery include ________, ________, and ________.

Postoperative atelectasis typically manifests within ________ hours after surgery, presenting with fever, tachycardia, and dyspnea.

3. Risk factors for postoperative pulmonary complications include ________, ________, and conditions like ________ or ________.

Atelectasis, bronchopneumonia, bronchitis.

: 48.

Smoking, advanced age, COPD, asthma.

1. Which of the following is NOT a common pulmonary complication during the postoperative period?

A. Atelectasis

B. Bronchopneumonia

C. Pulmonary hypertension

D. ARDS

: C. Pulmonary hypertension

. What is the main radiological finding in postoperative atelectasis?

A. Bilateral pleural effusion

B. Homogeneous wedge-shaped opacity

C. Pulmonary nodules

D. Pneumothorax

B. Homogeneous wedge-shaped opacity

Which of the following is a predisposing factor for postoperative atelectasis?

A. Hyperthyroidism

B. Old age and morbid obesity

C. Hypocalcemia

D. Upper respiratory tract infections

B. Old age and morbid obesity

What is Mendelson's syndrome, and what causes it?

Definition: Chemical pneumonitis caused by aspiration during anesthesia (abolished laryngeal reflexes).

Causes:

Aspiration of gastric juice, blood, bile, or water.

Common in patients with a full stomach, intestinal obstruction, or pregnancy during anesthesia.

What are the key clinical features of Mendelson's syndrome?

Hypoxia signs (cyanosis, dyspnea, fever).

Pulmonary wheeze, crepitant rales, rhonchi.

Tachycardia with low blood pressure.

Onset: 2–5 hours post-anesthesia

What investigations and treatments are used for Mendelson's syndrome?

Arterial blood gas analysis (severe hypoxia).

Treatment:

Prophylaxis: Nasogastric tube, fasting, metoclopramide, H2 blockers.

Treatment: Bronchoscopic aspiration, steroids, bronchodilators, antibiotics.

1. Mendelson's syndrome is caused by ________ during anesthesia due to abolished ________ reflexes.

Common clinical features of Mendelson's syndrome include ________, ________, and ________ 2–5 hours post-anesthesia.

Preventive measures for high-risk patients include ________, ________, and the use of ________ medications.

Aspiration, laryngeal.

Cyanosis, dyspnea, tachycardia.

Nasogastric tube, fasting, H2-blockers.

Which of the following patients is at the highest risk of Mendelson's syndrome?

A. A patient with severe COPD undergoing thoracic surgery.

B. A pregnant patient undergoing emergency surgery with a full stomach.

C. A patient with postoperative ileus.

D. A patient on long-term mechanical ventilation.

B. A pregnant patient undergoing emergency surgery with a full stomach.

What is the most common clinical sign of Mendelson’s syndrome?

A. Pleuritic chest pain

B. Fever and hypoxia

C. Hemoptysis

D. Petechial rash

B. Fever and hypoxia

3. What is the gold standard investigation for confirming severe hypoxia in Mendelson's syndrome?

A. Chest X-ray

B. Arterial blood gas (ABG) analysis

C. Pulmonary angiography

D. Sputum culture

B. Arterial blood gas (ABG) analysis

What are the main causes of ARDS?

Severe sepsis

End-stage hypovolemic shock

Major trauma

Major burns

Acute pancreatitis

Iatrogenic cause

Iatrogenic causes: of RDS

Non-filtered blood transfusion

Over-transfusion of fluids

Use of oxygen >50%

Massive doses of steroids

Prolonged use of heart-lung machine

What is the pathogenesis of ARDS?

Over-release of inflammatory mediators (TNF, IL-2, IL-6, PAF).

Endothelial damage and surfactant loss.

Increased capillary permeability and lung tissue edema.

Impaired oxygen diffusion, leading to defective ventilation-perfusion.

What investigations and findings are key in diagnosing ARDS?

Arterial blood gases (ABGs): Rising PaCO2 and falling PaO2.

Chest X-ray: Bilateral pulmonary infiltrations.

ARDS is a critical condition that results from severe ________, ________, or ________.

In ARDS, inflammatory mediators like ________ and ________ cause endothelial damage and increase capillary ________.

The primary diagnostic features of ARDS are ________ on ABGs and ________ on chest X-ray.

Sepsis, trauma, hypovolemic shock.

TNF, IL-6, permeability.

Rising PaCO2, bilateral pulmonary infiltrations

Which of the following inflammatory mediators is NOT involved in ARDS pathogenesis?

A. Tumor necrosis factor (TNF)

B. Interleukin-6 (IL-6)

C. Platelet activating factor (PAF)

D. Prostaglandin E2 (PGE2)

D. Prostaglandin E2 (PGE2)

Which of the following treatments is NOT typically used in ARDS management?

A. Oxygen therapy

B. Corticosteroids for inflammatory suppression

C. Immediate thoracotomy

D. Mechanical ventilation in severe cases

Answer: C. Immediate thoracotomy

What are the common causes of pulmonary embolism (PE)?

Lower limb deep vein thrombosis (DVT): Most common cause (15%)

Pelvic vein DVT

Upper limb DVT (30%)

What are the clinical features of PE?

Chest pain, cough, hemoptysis, and dyspnea

Unexplained dyspnea and heart failure in hospitalized patients

If associated with DVT: fever, calf pain, tenderness, and positive Homan’s sign

What is the gold standard investigation for pulmonary embolism?

Pulmonary angiography.

Describe the treatment options for pulmonary embolism.

Thrombolysis with streptokinase

Heparin or low-molecular-weight heparin (LMWH)

Surgical clot removal in some cases

Inferior vena cava (IVC) filter placement in recurrent DVT

1. Pulmonary embolism is commonly caused by ________ DVT, but can also arise from ________ or ________ vein DVT.

. The gold standard diagnostic tool for pulmonary embolism is ________, while ________ is used for initial assessment in many cases.

Patients with recurrent DVT may require ________ placement alongside anticoagulation therapy.

: Lower limb, pelvic, upper limb.

Pulmonary angiography, CT angiogram

Inferior vena cava (IVC) filter.

Which of the following is the most common source of pulmonary embolism?

A. Pelvic vein thrombosis

B. Upper limb vein thrombosis

C. Lower limb deep vein thrombosis (DVT)

D. Subclavian vein thrombosis

Answer: C. Lower limb deep vein thrombosis (DVT)

Which clinical feature is LEAST likely to be seen in pulmonary embolism?

A. Dyspnea

B. Chest pain

C. Bilateral leg swelling

D. Hemoptysis

C. Bilateral leg swelling

What is the first-line imaging study for a suspected PE in hemodynamically stable patients?

A. Chest X-ray

B. CT angiogram of the thorax

C. Pulmonary angiography

D. Ventilation-perfusion (V/Q) scan

: B. CT angiogram of the thorax

Differential diagnosis of pE

Congestive heart failure, Pneumonia, Myocardial infarction

ECG and Echocardiography in PE

differentiate it from myocardial infarction (in 40% of cases, there are large P wave, right axis deviation, inverted T wave and sinus tachycardia)

What are the classifications of hemoptysis?

Massive: >600 mL/24 hours (medical emergency; 30-50% mortality rate)

Non-massive: <600 mL/24 hours

List common causes of true hemoptysis

Larynx/Trachea: Foreign body, carcinoma

Bronchus: Tumors, bronchiectasis, foreign body

Lung: Tuberculosis (TB), pneumonia, lung abscess, pulmonary embolism, aspergilloma

Cardiac: Mitral stenosis, left ventricular failure

What is spurious hemoptysis, and what are its causes?

Definition: Blood from the nose, mouth, or pharynx, mistakenly thought to be from the lungs.

Causes: Nosebleeds, gingivitis, oral tumors, dental trauma, scurvy, hypertensive spontaneous bleeding.

Blood from the proximal bronchi or trachea is usually ……………….

 Blood from the distal bronchioles and alveoli is often …………………..

bright red. It may be frank blood or mixed with mucus and debris, particularly from a tumour.

pink and mixed with frothy sputum (e.g. pulmonary oedema

The most common causes of hemoptysis include ________, ________, and ________.

Infection (e.g., pneumonia), bronchitis

What is the classification of hemoptysis based on volume?

A. Mild (<100 mL/24 hours) and Severe (>600 mL/24 hours)

B. Non-massive (<600 mL/24 hours) and Massive (>600 mL/24 hours)

C. Acute (<24 hours) and Chronic (>24 hours)

D. Localized (<500 mL/24 hours) and Diffuse (>500 mL/24 hours)

Answer: B. Non-massive (<600 mL/24 hours) and Massive (>600 mL/24 hours)

Which of the following features is MOST characteristic of hemoptysis caused by pulmonary edema?

A. Bright red blood mixed with clots

B. Frothy pink sputum

C. Blood-streaked sputum with mucus

D. Dark red blood with debris

Answer: B. Frothy pink sputum

In hemoptysis due to lung malignancy, massive bleeding is MOST commonly caused by:

A. Tumor invasion of the pulmonary artery.

B. Inflammatory rupture of bronchial vessels.

C. Secondary infection in the tumor site.

D. Bronchial artery thrombosis.

Tumor invasion of the pulmonary artery

Which of the following investigations is MOST appropriate for confirming the site of bleeding in hemoptysis?

A. Sputum culture and sensitivity

B. Bronchoscopy

C. Chest X-ray

D. Arterial blood gas analysis

B. Bronchoscopy

What is the primary imaging modality used to identify the underlying cause of hemoptysis in cases of pulmonary embolism?

A. Ventilation-perfusion (V/Q) scan

B. CT pulmonary angiography

C. MRI of the chest

D. Duplex ultrasound of the lower limbs

B. CT pulmonary angiography

Which cardiac condition is listed in the document as a cause of true hemoptysis?

A. Mitral stenosis

B. Aortic stenosis

C. Right ventricular hypertrophy

D. Patent ductus arteriosus

Answer: A. Mitral stenosis

What clinical feature in a patient with hemoptysis would MOST strongly indicate spurious hemoptysis?

A. Blood mixed with mucus

B. Bright red blood originating from the pharynx or nose

C. Frothy blood-stained sputum

D. Coughing blood with chest pain

Answer: B. Bright red blood originating from the pharynx or nose

What is the recommended position for a patient with massive hemoptysis to prevent aspiration?

A. Supine with legs elevated

B. Prone position

C. Lateral decubitus with the bleeding lung down

D. Sitting upright with oxygen therapy

Lateral decubitus with the bleeding lung down

According to the document, what is the FIRST step in managing life-threatening hemoptysis?

A. Administer intravenous antibiotics.

B. Perform a bronchoscopy to identify the bleeding site.

C. Intubate the patient with lung isolation.

D. Obtain a detailed patient history and physical examination.

Answer: C. Intubate the patient with lung isolation.

Which of the following is NOT a cause of spurious hemoptysis mentioned in the document?

A. Gingivitis

B. Vitamin C deficiency (scurvy)

C. Pulmonary infarction

D. Nasal tumors

Answer: C. Pulmonary infarction

What is the main treatment for localized bleeding in hemoptysis that cannot be controlled conservatively?

A. Bronchial artery embolization

B. Systemic corticosteroids

C. Pulmonary artery thrombolysis

D. Prolonged oxygen therapy

Answer: A. Bronchial artery embolization

Which of the following investigations is considered GENERAL in the workup of hemoptysis?

A. Sputum cytology for malignancy

B. Clotting profile and complete blood count (CBC)

C. Bronchoscopy for direct visualization

D. CT angiography for vascular causes

B. Clotting profile and complete blood count (CBC)

What is the mortality rate associated with massive hemoptysis as stated in the document?

A. 20-30%

B. 30-50%

C. 50-70%

D. >70%

Answer: B. 30-50%

What clinical feature would MOST strongly suggest bronchiectasis as the underlying cause of hemoptysis?

A. Sudden onset hemoptysis with pleuritic chest pain

B. Chronic cough with large amounts of purulent sputum

C. Hemoptysis following strenuous physical activity

D. Hemoptysis with a cavitary lesion on X-ray

Answer: B. Chronic cough with large amounts of purulent sputum

When was the first truly successful single lung transplantation performed?

What are the indications for lung transplantation?

1983, in Toront

End-stage parenchymal diseases

Pulmonary vascular diseases

Not typically indicated for malignancies

The overall survival rate after lung transplantation at 5 years is approximately ________.

50%.

What is the primary limitation in performing lung transplantations?

A. Rejection risk

B. Lack of donor lungs

C. High surgical cost

D. Advanced technology requirements

Answer: B. Lack of donor lungs

What is the main contraindication for lung transplantation?

A. Pulmonary vascular disease

B. End-stage COPD

C. Pulmonary malignancies

D. Severe bronchiectasis

C. Pulmonary malignancies

What is the average length of the adult trachea, and how many cartilaginous rings does it have?

Average length: 11 cm; 18–22 cartilaginous rings.

What are the common types of congenital tracheal lesions?

Tracheoesophageal fistula (most common)

Congenital stenosis: web-like diaphragms, tracheomalacia, absence of membranous trachea

What is the most common tracheal injury, and what causes it?

Ischemic necrosis at the tube cuff site due to tracheal intubation.

1. What is the primary blood supply to the trachea?

A. Superior thyroid artery

B. Inferior thyroid artery and bronchial arteries

C. Pulmonary artery

D. Subclavian artery

B. Inferior thyroid artery and bronchial arteries

Which congenital lesion is most commonly associated with the trachea?

A. Tracheomalacia

B. Tracheoesophageal fistula

C. Bronchial stenosis

D. Absence of membranous trachea

Answer: B. Tracheoesophageal fistula

Primary tracheal neoplasms are uncommon; more than 80 % are malignant.  Bronchoscopy is an essential part of the evaluation.  TTT: Up to one-half of the trachea can be resected and reconstructed with an end-to-end anastomosis. Airway stents and laser ablation are used for palliation

What is Bochdalek hernia, and where is it most commonly located?

congenital diaphragmatic hernia.

95% left-sided.

What are the clinical features of congenital diaphragmatic hernia (CDH)?

Respiratory distress

Scaphoid abdomen

Mediastinal shift (pseudodextrocardia)

What is the treatment for eventration of the diaphragm?

Diaphragmatic plication through laparotomy.

What is the primary feature of eventration of the diaphragm?

A. Complete herniation of abdominal contents

B. Weakening or atrophy of diaphragm muscles

C. Absence of the diaphragm

D. Posterior diaphragmatic rupture

B. Weakening or atrophy of diaphragm muscles

Which anomaly is NOT associated with congenital diaphragmatic hernia?

A. GIT anomalies

B. Cardiac anomalies

C. CNS anomalies

D. Thyroid anomalies

D. Thyroid anomalies

Which of the following is NOT a feature of congenital diaphragmatic hernia (CDH)?

A. Scaphoid abdomen

B. Mediastinal shift

C. Respiratory distress in neonates

D. Presence of a hernial sac in 80% of cases

Answer: D. Presence of a hernial sac in 80% of cases (only 20% have a sac).

Bochdalek hernia is MOST commonly associated with which other anomalies?

A. Skeletal anomalies

B. Cardiac, CNS, and gastrointestinal anomalies

C. Renal and liver anomalies

D. None of the above

Answer: B. Cardiac, CNS, and gastrointestinal anomalies

Which of the following types of oesophageal hiatus hernias is MOST common?

A. Sliding hernia

B. Paraesophageal hernia

C. Mixed hernia

D. Diaphragmatic hernia

Answer: A. Sliding hernia

Which of the following is a characteristic feature of paraesophageal hiatus hernia?

A. The gastroesophageal junction remains in its normal position.

B. The hernia is always congenital.

C. It rarely causes complications like strangulation.

D. It is the most common type of hiatus hernia.

A. The gastroesophageal junction remains in its normal position.

Eventration of the diaphragm is defined as:

A. Complete rupture of the diaphragm leading to abdominal content herniation.

B. Weakening or atrophy of the diaphragm with thin fibrous tissue formation.

C. Absence of the diaphragm due to congenital defect.

D. Enlargement of the diaphragm due to neoplasia.

B. Weakening or atrophy of the diaphragm with thin fibrous tissue formatio

Which of the following is NOT a cause of acquired eventration of the diaphragm?

A. Phrenic nerve palsy

B. Iatrogenic injury

C. Autoimmune neuropathy

D. Congenital weakness of the diaphragm

D. Congenital weakness of the diaphragm (this is a congenital cause, not acquired)

What is the most common presentation of eventration of the diaphragm in children?

A. Respiratory distress

B. Severe cyanosis

C. Recurrent lower respiratory infections

D. Persistent abdominal pain

Answer: C. Recurrent lower respiratory infections

What is the imaging modality of choice to differentiate diaphragmatic eventration from hernia?

A. Chest X-ray

B. CT scan

C. Ultrasound

D. MR

Answer: D. MRI

Which of the following conditions can cause phrenic nerve palsy leading to diaphragmatic eventration?

A. Viral infections like polio

B. Severe asthma attacks

C. Gastroesophageal reflux disease (GERD)

D. Persistent pneumothorax

Answer: A. Viral infections like polio

Which of the following treatments is considered definitive for diaphragmatic eventration?

A. Ventilation support with CPAP

B. Diaphragmatic plication through laparotomy

C. Long-term corticosteroid therapy

D. Bronchial artery embolization

B. Diaphragmatic plication through laparotomy

The diaphragm is innervated by which nerve?

A. Vagus nerve

B. Phrenic nerve

C. Intercostal nerves

D. Hypoglossal nerve

Answer: B. Phrenic nerve

What are the primary imaging findings in diaphragmatic eventration?

A. Elevation of the diaphragm with mediastinal shift

B. Flattening of the diaphragm with lung collapse

C. Visible herniation of abdominal organs into the thoracic cavity

D. Calcification along the diaphragmatic border

Answer: A. Elevation of the diaphragm with mediastinal shift

15. Which of the following diaphragmatic abnormalities is associated with autoimmune neuropathy?

A. Oesophageal hiatus hernia

B. Eventration of the diaphragm

C. Bochdalek hernia

D. Diaphragmatic rupture

B. Eventration of the diaphragm