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107 Basics ofMechanical Ventilation forthePracticing Surgeon
363
– ARDS (tx—low TV, high PEEP)
– Pneumothorax (tx—chest tube)
• High peak and low plateau pressures
– Secretions (tx—suction, chest PT)
– Obstructed ETT, kinked tubing or ETT
– Bronchospasm (tx—β2 agonists, steroids, IV mg, Epi)
• Sudden hypotension in patient with inverse I/E ratio
or high respiratory rate
– Intrinsic PEEP (auto-PEEP)
Auto-PEEP is the alveolar pressure applied from an
incomplete exhalation (breath stacking).
Auto-PEEP can be determined by an end-expiratory
pause on the ventilator or the Exp wave does not go
back to 0.
Auto-PEEP=if total PEEP is >PEEP set.
Auto-PEEP can cause increased intrathoracic pressure resulting in hypotension.
Treatment—Increasing expiratory time or briey
disconnecting the ventilator can relieve auto-PEEP.
Clean Kills
• Missing pneumothorax
• Not conrming ETT placement
• No BIS or train of four monitoring with paralytics
• Failure to call for ECMO consult
• Extubating with no cuff leak
Summary
Acute respiratory distress syndrome (ARDS) is a lifethreatening condition characterized by poor oxygenation
and noncompliant or “stiff” lungs. The disorder is associated with capillary endothelial injury and diffuse alveolar damage causing hypoxia. The main goal for treatment
in these patients is to prevent further acute lung injury,
maintain oxygenation, and treat the underlying cause.
Mechanical ventilation remains the most important
aspect of managing patients with ARDS. An in-depth
knowledge of lung protective ventilation, optimal PEEP
strategies, rescue modes of ventilation, and adjunct treatments are essential for the management of ARDS.
Bonus Information
Basic Ventilator Modes
Most ventilators can be set to achieve spontaneous breathing,
volume-targeted ventilation, pressure-targeted ventilation, or
some combination.
Volume Control Ventilation
• Termed volume-limited, volume-control, volume-assist,
or volume-targeted.
• Most common mode used in adults.
• Vent is set to reach a determined volume regardless of the
pressure required.
• The clinician sets the desired TV, RR, FiO
, and PEEP.
2
Pressure Control Ventilation
• “Pressure” is the ventilator’s targeted parameter.
• Set to reach a determined pressure regardless of the volume generated.
• Volume delivered is determined by the compliance of the
patient’s respiratory system, airway resistance, inspiratory time, and the pressure target.
• The clinician sets the desired PEEP, respiratory rate, FiO2,
inspiratory pressure, I/E ratio, and trigger mode.
• One problem with PCV is that the volume received by the
patient is variable and therefore the minute ventilation can
be variable. The patient may, therefore, be subject to
unpredictable or wide swings in pCO
and pH.
2
• This mode is typically used when a patient is awake, or
when a patient has a high peak pressure and you are willing to accept some permissive hypercapnia in order to
avoid barotrauma.
Pressure Support Ventilation (PSV)
• Patient-generated breaths.
• Clinician sets FiO2, inspiratory pressure, and PEEP.
• Patient dictates the RR.
• TV is dictated by the PS given, patient effort, and
compliance.
• Backup apnea rate (dangerous in hypoventilating sedated
patients).
Airway Pressure Release Ventilation (APRV)
• APRV is a rescue mode of ventilation that is at the extreme
end of reverse I/E.
• The tidal volume is delivered and the lungs held in ination for a prolonged period of time (typically 5–6s) in
order to facilitate increased time of oxygen contact at the
alveolar-arterial membrane and increased diffusion of
oxygen into the bloodstream.
• The pressure is then released to allow a short period of
ventilation, typically 0.5s, or a time in which the PEEP
will not go to zero.
• Initial settings are stated in time high (T-high), time low
(T-low), pressure high (P-high), and pressure low (P-low).
Often starting is set to T-high of 5.5 and T-low of 0.5,
P-high of whatever the patient’s plateau pressure is, and
P-low of 0. Adjustments are then made based on blood
gas analysis.
• Weaning APRV is accomplished by “dropping and
stretching”—decreasing the P-high and increasing the
364
F. J. DiRoma and S. Bonne
T-high by a proportional amount, so as to maintain the
minute ventilation. Once a patient is at a P-high of 20,
they should be breathing over the P-high enough on their
own to adequately ventilate and clear carbon dioxide and
can be simply placed on pressure support of 20 and
weaned from there.
Bibliography
Chapter 12: Surgical complications; Respiratory complications. In:
Sabiston textbook of surgery: the biological basis of modern surgical practice, 21st ed.
Diamond M, Peniston HL, Sanghavi DK, etal. Acute respiratory dis-
tress syndrome. [Updated 2024 Jan 31]. In: StatPearls. Treasure
Island: StatPearls Publishing; 2024.
Extracorporeal Membrane Oxygenation
VictoriaSharp andAnnHutchison
108
Concept
Most questions will be related to common indications for use
and criteria for initiating therapy. Extracorporeal membrane
oxygenation (ECMO) is a form of life support used to support patients with respiratory or cardiac failure by providing
oxygenation, removing carbon dioxide, and/or providing circulatory support. Venovenous (V-V) and venoarterial (V-A)
are the two most common congurations.
Venovenous ECMO is indicated in severe, acute, and
potentially reversible hypoxemic respiratory failure. The
most common etiology is acute respiratory distress syndrome (ARDS). Other indications include primary graft dysfunction after lung transplantation, diffuse alveolar
hemorrhage, and pulmonary embolism with preserved cardiac function. V-V ECMO should only be considered after
optimizing conventional management strategies such as lung
protective ventilation, neuromuscular blockade, and prone
positioning. Inclusion criteria are based on PaO2/FiO2 ratios
and acid-base status (P/F<80mmHg for >6h, <50 mgHg for
>3h, or pH <7.25 with PaCO2>60mmHg for >6h with RR
at 35/min and settings adjusted to keep plateau pressure<32mmHg). There are many relative contraindications
but only two absolute contraindications: severe irreversible
noncardiac organ failure or non-survivable condition (severe
anoxic brain injury, end-stage malignancy) or lack of a transition off of ECMO, known as “the bridge to nowhere.”
Venoarterial ECMO indications include etiologies associated with acute cardiac failure as a bridge to recovery in
reversible conditions, as well as a bridge to transplant or
coronary artery stenting/bypass. This most commonly
includes refractory cardiogenic shock, which can stem from
myocardial infarction, acute decompensated heart failure
from underlying cardiomyopathy, refractory ventricular
V. Sharp (*)
Acute Care Surgery, Ypsilanti, MI, USA
e-mail: Victoria_sharp@ihacares.com
A. Hutchison
Surgical Critical Care, Little Rock, AR, USA
arrhythmias, cardiotoxic drug intoxication, peripartum cardiomyopathy, or pulmonary embolism. Criteria for initiating
V-A ECMO are based on the Society for Cardiovascular
Angiography and Interventions classication (Stages A–E).
Contraindications are similar to those of V-V ECMO but also
include severe aortic insufciency and aortic dissection.
While the goals of V-V and V-A ECMO are different
(respiratory support versus circulatory support), the management principles are similar. Cannula sites are chosen based
on specic patient factors. Oxygenation (V-V) and circulatory (V-A) support is dictated by the ow rate through the
circuit. CO2 removal is controlled by the sweep gas (increase
sweep, increase clearance of CO2). Special considerations
for V-A ECMO include the need for a distal reperfusion catheter for the arterial cannula as well as the presence of dual
circulation (competitive ow within the aorta between the
anterograde native cardiac output and the retrograde ECMO
reinfusion ow).
Way Question May BeAsked?
1. “You are called to the bedside of a 57-year-old patient
who underwent ventral hernia repair earlier in the day.
Per nursing report, the patient had been nauseous while
drinking clear liquids and subsequently vomited. There
was immediate concern for aspiration. On exam the
patient is tachypneic and tachycardic; there are rhonchi
present bilaterally as well as accessory muscle use. Vitals
are notable for respirations of 30 breaths/min, heart rate
of 120 beats/min, blood pressure of 125/73, and oxygen
saturation of 83% on non-rebreather.”
2. “A 63-year-old male presents to the emergency depart-
ment with complaints of difculty breathing, feeling
faint, and a racing heart. His history is signicant for
recent admission following a motor vehicle accident during which he suffered a femur fracture that was repaired
as well as three rib fractures. He was discharged 2 days
prior to presentation and reports he has not been walking
much due to the pain in his ribs. On exam he is tachy-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_108
365
366
V. Sharp and A. Hutchison
pneic, tachycardic, and hypotensive to 83/53. There are
tenderness to the left chest wall, unilateral edema of the
left lower extremity, and jugular venous distention.”
How toAnswer?
History
• History of the events leading up to the presentation.
• Thorough history including chronic conditions and their
severity.
• Particularly note history of cardiac conditions and signicant peripheral vascular disease if concerned for cardiogenic shock.
• Recent decompensation of any chronic conditions (i.e.,
asthma or COPD exacerbation).
• Medication history including use of cardiac medications
or blood thinning agents.
Physical Examination
• Check vital signs.
• Pulmonary exam.
• Cardiac exam.
• Peripheral pulses.
• Evaluate for evidence of hypoxia or decreased perfusion
including altered mental status and delayed capillary
rell.
Diagnostic Tests
• Lab values including CBC, BMP, Mg, Phos, lactic acid,
troponin, BNP, and arterial blood gas.
• Noninvasive hemodynamic monitoring.
• Chest XR and CT scan
– Evaluating the etiology of hypoxemia.
• EKG and echo
– To evaluate cardiac function if concerned for cardio-
genic shock.
Treatment
Common Curveballs
• Patients are borderline and require aggressive conservative management.
• The presence of relative contraindications (severe coagulopathy, advanced age, obesity, mechanical ventilation
>7days, limited vascular access).
• Evidence of “chatter” in the circuit (volume resuscitation
indicated).
• Evidence of recirculation in V-V ECMO (cannula tips too
close together or ow is too high).
Clean Kills
• Failure to recognize distal limb ischemia secondary to
arterial cannulation.
• Failure to recognize an air embolism in the circuit.
• Failure to recognize dual circulation and its associated
effects.
• Moving to V-V ECMO prior to optimizing conventional
management.
• Cannulating a patient with an absolute contraindication.
Summary
Respiratory and circulatory failure are severe problems
that can present in a multitude of ways in the surgical
patient. Quick diagnosis and management of the presenting problems are critical in order to optimally treat these
patients. When aggressive conventional management is
insufcient, early consideration and initiation of ECMO
has been shown to be benecial in certain patient populations. Prior to initiating ECMO, it is important to assess
for potential disease reversibility or targeted intervention, conrm the patient meets criteria for therapy, evaluate for possible contraindications, and ensure ECMO
aligns with the patient’s overall goals of care.
• Supplemental oxygen (noninvasive vs invasive based on
patient needs).
• Lung protective ventilation.
• Hemodynamic support with vasopressors and inotropes.
• Volume resuscitation vs diuresis as indicated.
• Treatment of underlying pathology.
• Early consideration of ECMO in refractory cases.
Bibliography
McLaren G, Brodie D, Lorusso R, Peek G, Thiagarajan R, Vercaemst
L, editors. Extracorporeal life support: the ELSO red book. 6th ed.
Extracorporeal Life Support Organization; 2022.
Part XIII
Thoracic
Empyema
MargoCarlin andAsanthiRatnasekera
109
Way Question May BeAsked?
“A 60-year-old female presents with fevers and a history of
pneumonia 2 weeks ago. A CXR is performed signicant for
a pleural effusion.” Your primary focus to help diagnose
empyema should include recent history of respiratory symptoms, infections, or trauma. Risk factors for empyema
include recent pneumonia, parapneumonic effusion, pleural
effusion with signs of sepsis, bronchogenic carcinoma,
esophageal rupture, retained foreign body, blunt or penetrating chest trauma, and mediastinitis. Pleural effusion in the
aforementioned scenario is an empyema until determined
otherwise, and your workup should focus on getting the uid
out timely.
How toAnswer?
History
• History of pneumonia or sick contacts
• Recent hospitalizations
• Recent unexplained weight loss
• Procedural history to include GI studies and
bronchoscopy
• History of standard or completion pneumonectomy
• History of blunt or penetrating chest trauma
• Substance abuse (i.e., intravenous drug use, alcohol
abuse)
Be sure to rule out other possibilities:
• Congestive heart failure
• Malignant effusion
• Retained hemothorax
• Sympathetic effusion from abdominal source
M. Carlin (*) · A. Ratnasekera
Trauma, Emergency General Surgery, and Surgical Critical Care,
Newark, DE, USA
e-mail: margo.carlin@christianacare.org;
asanthi.ratnasekera@christianacare.org
Diagnostic Tests
• Lab abnormalities consistent with infected pleural
space:
– Hypoalbuminemia (<30g/dL)
– Hyponatremia (<130mmol/L)
– Elevated CRP (>100mg/L)
• Chest XR
– Require 175mL to blunt costodiaphragmatic angle
– Miss 10% of pleural effusions
– Chronic empyema: rib space narrowing, contraction of
the thorax, mediastinal shift to affected side
• Chest ultrasound
– Suspicious for empyema:
Complex, septated collections
Echogenic pleural effusions
Anechoic effusions exudative in 27%
Parietal thickening
• CT chest
– Follows suspicious CXR and chest US
– Imaging ndings:
Parietal thickening
Pleural enhancement
“Split pleura sign” (thickening + enhancement of
the pleural)
High attenuation of extra pleural adipose tissue
• Diagnostic thoracentesis
– Indications: pleural effusion >1cm on CXR or >2cm
on CT
– Test sample within 1 h for pH, glucose, LDH, gram
stain, and culture
– Pleural uid consistent with empyema:
pH <7.20
Glucose <40
LDH >1000 IU/L
Positive Gram stain
Positive culture
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_109
369
370
M. Carlin and A. Ratnasekera
Treatment
Early diagnosis and treatment is critical as management progresses from minimally invasive to maximally invasive if
diagnosis is delayed.
Antibiotics
• Effusions <2–2.5cm may respond to antibiotics alone
• Community-acquired empyema
– IV second- or third-generation cephalosporin + metro-
nidazole or
– IV aminopenicillin + B-lactamase inhibitor (ampicil-
lin/sulbactam)
• Hospital-acquired empyema
– Include coverage for MRSA and pseudomonas (i.e.,
vancomycin, cefepime, metronidazole or vancomycin,
piperacillin, and tazobactam)
• Duration of therapy: 2–6 weeks
Chest Tube Drainage Versus CT-Guided Catheter
Placement
• Indications:
– Frank pus on thoracentesis
– Pleural uid with pH <7.2, glucose <40, LDH >1000
IU/L
– Early-stage empyema with minimal septations
• Drain should be ushed frequently to prevent occlusion.
• Follow-up CT should be performed to assess for persis-
tent collections; if noted, place additional drains or proceed with surgical management.
Surgical Management
Goals of surgery are to obtain source control, evacuate
infected uid, and re-expand the lung. If a patient is not progressing with management with antibiotics and tube thoracostomy, alternative options should be entertained. VATS or
open thoracotomy is indicated for failure of conservative
management, radiographic evidence of multiple collections,
or inability to completely evacuate a complex collection due
to multiple septations or late-stage empyema.
Video-Assisted Thoracoscopy Surgery (VATS)
• First-line approach in patients able to tolerate single-lung
ventilation.
• Preoperative CT chest is helpful for operative planning to
guide safe port placement.
• Benets of VATS include less postoperative pain, reduced
length of stay, lower blood loss, and reduced overall
complications.
• Intraoperative complications including damage to nearby
structures, uncontrolled hemorrhage, and inability to ven-
tilate prompt immediate conversion to open
thoracotomy.
Open Thoracotomy and Decortication
• Consider early decortication with multiple loculations or
rind >1cm.
• Consider as rst-line approach for patients with history of
previous thoracic interventions.
Chronic Empyema
In chronic empyema, there is formation of granulation tissue
around the lung from sustained inammation that results in a
dense rind surrounding the lung parenchyma. This condition
requires surgery for decortication and drainage of abscesses
and will not respond to chest tube drainage alone.
Decortication
• Peeling brinous layer off the lung to permit debridement
of infected tissue.
• Indications for lung resection: frankly necrotic tissue,
frank abscess, symptoms of hemoptysis.
• Avoid extensive resection as the infected eld predisposes
to bronchopleural stulas (BPF).
Tissue Flaps
• Help ll cavities with incomplete lung expansion after
decortication
• Primary options for pedicled aps:
– Serratus anterior
– Latissimus dorsi
– Pectoralis major
• Options for aps when chest wall is not available
(complex):
– Lower abdominal muscles
– Omentum (may seed abdominal cavity upon entry)
Open Thoracic Window
• Can be considered for patients unable to tolerate decortication and muscle aps or have a BPF.
• Procedure involves marsupialization of the infected thorax, resection of ribs, and frequent dressing changes.
Post-resectional Empyema
Infection of the thorax after standard or completion pneumonectomy is a potentially fatal condition and is most likely to
occur concomitantly with a BPF.It is essential to identify the
presence of a stula early in the presentation with exible
bronchoscopy. Immediately place a chest tube for a patient
presenting with BPF and respiratory distress, as tension
109 Empyema
371
pneumothorax from BPF can be rapidly fatal. After drainage,
place the patient in the lateral decubitus position to promote
draining of the affected cavity and to prevent spreading
infection to the contralateral thorax. Following resuscitation
and stabilization, the most commonly used procedure for
management includes open pleural drainage, wet to dry
dressings, and closure by secondary intention. If BPF is present at time of operative intervention, attempts should be
made to close it primarily with reinforcement by viable muscle ap.
Common Curveballs
Some bacterial pleural space infections will result in elevated
pH (i.e., those caused by Proteus).
Most common drain complications are occlusion and dislodgement. Prevent occlusion with frequent drain ushing
(i.e., 20mL q6h). Dislodgement and malposition are better
diagnosed on CXR than CT.
Fibrinolytics are not used routinely in management of
empyema (although results of MIST2 trial showed improved
drainage and reduced rates of progression to operative intervention, a large meta-analysis showed no statistically signicant benet).
Retained hemothorax in trauma patients can progress to
empyema.
Clean Kills
• Failure to place a pleural drain after thoracentesis for
empyema
• Failure to escalate therapy for undrained pleural
collections
• Failure to perform follow-up CT scan to ensure adequate
drainage after tube thoracostomy
• Not converting to open thoracotomy when VATS becomes
unsafe
• Not obtaining timely source control with unresolving
sepsis
• Not placing a chest tube for a post-resectional empyema
presenting with BPF
Summary
Failure to respond to antibiotic therapy within a couple
of days in the setting of parapneumonic effusion or
infected pleural uid suggests progression to empyema.
Aggressive management to obtain source control is crucial. Delayed evacuation of infected pleural uid signicantly increases mortality. Early empyema is amenable
to VATS and should be considered early. Infectious disease consultation should be considered for prolonged
course of antibiotics and complicated infections.
Bibliography
Asensio J, Trunkey D.Current therapy of trauma and surgical critical
care. 2nd ed. Elsevier; 2016.
Shen KR, Bribriesco A, Crabtree T, Denlinger C, Eby J, Eiken P,
Jones DR, Keshavjee S, Maldonado F, Paul S, Kozower B. The
American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg.
2017;153(6):e129–46.
Wait MA, Beckles DL, Paul M, Hotze M, Dimaio MJ.Thoracoscopic
management of empyema thoracis. J Minim Access Surg.
2007;3(4):141–8. https://doi.org/10.4103/0972- 9941.38908.
Lung Nodule/Lung Cancer
SirivanSeng
110
Way Question May BeAsked
“A 57-year-old male presents to the clinic with an incidental
1cm solid pulmonary nodule at the right lower lobe that was
found on a computed tomography (CT) scan of the abdomen
after a motor vehicle collision. How would you proceed?”
How toAnswer?
History
• Symptoms
– Cough
– Shortness of breath
– Weight loss
– Recurrent pneumonia
– Dysphonia
– Hemoptysis
– Neurological symptoms
– Chest/bone pain
– *Look for symptoms consistent with paraneoplastic
syndromes
• Past medical history
– Chronic obstructive pulmonary disease (COPD)
– Pulmonary brosis
– Previous cancer (i.e., consider metastasis)
• Social history
– Current or previous tobacco use
– Second-hand smoke exposure
– Occupational exposures (e.g., radon, asbestos, arsenic,
chromium, nickel, coal tar, iatrogenic radiation)
– Recent travel history
• Family history
– Cancer
S. Seng (*)
Department of Surgery, Northwestern Memorial Hospital,
Chicago, IL, USA
Physical Examination
• Thorough lymph node basin examination (i.e., cervical,
supraclavicular)
• Thoracic auscultation
• Abdominal exam
Diagnostic Tests
• Laboratory
– Complete blood count (CBC)
– Complete metabolic panel (CMP)
• Imaging
– First: Acquire and compare previous imaging
– Chest radiograph
– CT of the chest (extend down to liver and adrenals)
Evaluate mass size and location (e.g., solid, subsolid,
ground-glass, perissural, calcied, spiculated)
Evaluate lymph nodes
Evaluate for metastases
– Fludeoxyglucose-18 positron emission tomography
(FDG-PET)/CT
– *Obtain respective imaging if suspicious for
metastasis
• Screening guidelines
– Current or former smokers (i.e., quit within 15 years
with at least a 30-pack year smoking history) should
obtain an annual low- dose CT chest (LDCT) starting
from age 55 until age 74 (Table110.1)
Lung Cancer Diagnosis
• Nonsurgical biopsy
– Flexible bronchoscopy
– Transbronchial biopsy
– Transthoracic CT-guided needle biopsy
– Electromagnetic navigation bronchoscopy
• Surgical biopsy
– Cervical mediastinoscopy (provides access to Levels
2, 4, and 7)
– Left anterior mediastinotomy, also known as
“Chamberlain procedure” (provides access to Levels 5
and 6)
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_110
373
374
Table 110.1 2017 Fleischner Society Guidelines for management of incidentally detected solid pulmonary nodules in adults (35+ years old)
<6mm 6–8mm >8mm
Single
Low risk No routine follow-up 6–12-month LDCT
*Consider 18–24- month LDCT
High risk 12-month LDCT (optional) 6–12-month LDCT, then 18–24-month LDCT 3-month LDCT or FDG-PET/CT or
Multiple
Low risk No routine follow-up 3–6-month LDCT
*Consider 18–24- month LDCT
High risk 12-month LDCT (optional) 3–6-month LDCT, then 18–24month LDCT 3–6-month LDCT, then 18–24-
LDCT low-dose CT chest
3-month LDCT or FDG-PET/CT or
tissue sampling
tissue sampling
3–6-month LDCT, then 18–24month LDCT
month LDCT
S. Seng
– Video-assisted thoracoscopy (provides access to
Levels 5, 6, 8, and 9)
– Thoracotomy
• Techniques to assist with biopsy
– Fiduciary markers: metal coils, hook wires
– Methylene blue dye
– Radiotracer
Lung Cancer TNM Classication
• Tumor (T)
– Tis: Carcinoma in situ
– T1: ≤3cm, surrounded by lung or visceral pleura
– T2: 3 to ≤5 cm, or involving main bronchus, visceral
pleura, or associated with atelectasis or pneumonitis
– T3: >5 to ≤7 cm, or invading parietal pleura, chest
wall, phrenic nerve, parietal pericardium, or separate
nodule in the same lobe as primary
– T4: >7 cm, or invading diaphragm, mediastinum,
heart, great vessels, trachea, recurrent laryngeal nerve,
esophagus, vertebral body, carina, separate nodule in
lobe different from primary
• Node (N)
– N1: Ipsilateral peribronchial and/or hilar lymph nodes
and intrapulmonary nodes
– N2: Ipsilateral mediastinal and/or subcarinal lymph
nodes
– N3: Contralateral mediastinal and/or hilar, scalene, or
supraclavicular
• Metastasis (M)
– M1: Distant metastasis
Preoperative Planning
• ABG (Arterial blood gas)
• Pulmonary function tests (PFTs)
• Ventilation-perfusion (V/Q) scan
– Pneumonectomy
• Surgical techniques
– Thoracotomy
– Video-assisted thoracic surgery (VATS)
– Robotic-assisted pulmonary resection
• Considerations
– T3 and T4 tumors requiring en bloc resection with
negative margins
• Contraindications to surgery
– N3 lesions
– Malignant pleural effusion
Common Curveballs
• No lesion will be benign
• Lesion can be a metastasis
• Tumor may be unresectable
– Pancoast tumor with Horner’s syndrome
– Positive cytology from pleural effusion
– Tracheoesophageal stula
– Nerve encasement
• Can present as hemoptysis
• Can present as pleural effusion
• Can present as lung abscess
• Paraneoplastic syndrome
– Adrenocorticotropic hormone (ACTH)
– Parathyroid hormone-related protein (PTHrP)
– Antidiuretic hormone (ADH)
• Postoperative complications
– Bronchopleural stula
– Atrial brillation
– Hemoptysis
– Hemorrhage
– Air embolus
– Mediastinal shift on post-operative imaging
Treatment
• Resection
– Wedge resection
– Lobectomy
Clean Kills
• Not checking for prior imaging
• Not performing a bronchoscopy