Care of patients undergoing thoracic surgery or procedures of the lungs and respiratory system is discussed in this chapter. These procedures range from minimally invasive procedures to open thoracotomies. The procedures are performed on patients with underlying conditions such as emphysema or malignant disease that must be surgically treated. Care of these patients in the PACU involves respiratory function, observation for complications, management of pain, and promotion of oxygenation and ventilation.
Thoracic surgery involves procedures in the structures within the chest cavity including the lungs, heart, great vessels, and esophagus. In this chapter, discussion focuses on procedures of the lungs and respiratory system. Postanesthesia care after cardiac surgery is discussed in Chapter 35, care after surgery of the great vessels is discussed in Chapter 36, and care after surgery of the esophagus is discussed in Chapter 40.
Pulmonary surgery may be recommended for the diagnosis and treatment of
•Abnormal chest radiograph results
•Tumors (solitary pulmonary nodules)
•Small areas of long-term infection (highly localized tuberculosis or mycobacterium)
•Permanently enlarged (dilated) section of lung (lobar emphysema)
•Permanently collapsed lung tissue (atelectasis)
•Injuries with collapsed lung tissue (atelectasis, pneumothorax, hemothorax)
•Correction of congenital or acquired chest wall deformities
AtelectasisCollapse of the alveoli caused primarily by obstruction of lower airways. Most commonly, this obstruction is caused by accumulation of respiratory secretions, but it may also be caused by diminished lung volumes, tumors, prolonged bronchospasm, and foreign bodies.
Bronchial Thermoplasty (BT)A newer treatment method for patients with severe or persistent asthma. Performed as an outpatient procedure, BT uses a bronchoscopically introduced catheter to deliver strictly controlled thermal energy to the airways.
BronchoscopyDirect visualization of the tracheobronchial tree with use of a lighted scope. It is used for diagnostic and therapeutic interventions for visualization of structures of the tracheobronchial tree; removal of secretions, washings, mucous plugs, or foreign bodies; and performance of a tissue biopsy or application of medication. Bronchoscopy can be combined with yttrium aluminum garnet (YAG) laser therapy for ablation of tracheal and bronchial obstructions. It can be performed in the operating room, special procedures unit, or at the patient’s bedside, depending on the degree of urgency and the patient’s status.
Chest TubeA drainage tube into the intrapleural space to remove air, fluid, or blood with the goal of restoring normal negative pressure and to allow re-expansion of the lung. The tube is placed on the operative side after open chest procedures.
Chest Wall ReconstructionRepair of chest wall defects caused by trauma, tumor, or chest wall deformities with the use of muscle or omentum (underlying abdominal tissue). It provides for protection of underlying structures and organs and provides support for respiration.
Decortication of the LungRemoval of fibrous deposits or restrictive membranes on the visceral or parietal pleura that interfere with ventilatory action. The goal is restoration of normal lung function.
Endobrachial UltrasoundA procedure that may be performed during a bronchoscopy to provide further information to diagnose or determine the stage of a lung cancer. This allows visualization of the lungs and surrounding chest area, which have traditionally required more invasive surgical procedures to evaluate.
Endobronchial Valve (EBV)A minimally invasive treatment to reduce lung volume that has been shown to improve clinical outcomes in patients with advanced emphysema and severe hyperinflation.
HemothoraxAccumulation of blood, serosanguineous fluid, or both within the pleural cavity compromising lung expansion.
LobectomyRemoval of one or more lobes of the lung. Lobectomy is the preferred procedure when a cancerous lesion involves a single lobe of the lung. It is used primarily in the treatment of bronchial cancer and is also used in the treatment of bronchiectasis, emphysematous blebs, large benign tumors, fungal infections, and congenital anomalies.
MediastinoscopyDirect visualization of lymph nodes or tumors at the tracheobronchial junction, subcarinal, or upper lobe bronchi via a lighted scope. This procedure is done by passing the mediastinoscope through a small incision at the suprasternal area and then down along the anterior course of the trachea. It is a diagnostic procedure for patients with identified changes on chest radiograph results.
Needle BiopsyInsertion of a needle with subsequent aspiration of lung tissue or fluid for diagnostic purposes. It is generally performed with local anesthesia via a percutaneous approach.
PneumonectomyRemoval of an entire lung, most commonly for lung cancer when lobectomy cannot be performed for total removal of bronchial cancer. It is occasionally indicated for removal of a lung destroyed by chronic infections.
PneumothoraxAccumulation of air or gas within the pleural cavity that compromises lung expansion. Pneumothorax can occur as a direct result of a thoracotomy incision or after chest wall trauma such as a stab wound.
Segmentectomy (Segmental Resection)Excision of individual bronchovascular segments of the lobe of the lung with ligation of segmental branches of the pulmonary artery and vein and division of the segmental bronchus. Segmentectomy conserves healthy tissue while allowing for removal of localized lesion.
Sleeve ResectionSurgical removal of part of the bronchi, with healthy tissue left for reanastomosis, thus preserving some tissue and lung function. Sleeve resection is used primarily for metastatic disease in either the right or left upper bronchus.
SternotomyIncision through the sternum.
ThoracentesisInsertion of a needle through the chest wall into the pleural space to remove either air or fluid to relieve lung compression or for diagnostic purposes. Removed fluid is evaluated for chemical, bacteriologic, and cellular composition. This procedure is generally performed at the bedside with local anesthesia.
ThoracoplastyRemoval of ribs or portions of the ribs to reduce the size of the thoracic space and to collapse a diseased lung.
ThoracoscopyThe insertion of an endoscope, a narrow-diameter tube with a viewing mirror or camera attachment, through a small incision in the chest wall for examination of the lungs or other structures in the chest cavity without the use of a large incision. The procedure may be diagnostic or therapeutic.
ThoracostomyAn incision of the chest wall for the purpose of drainage. Closed thoracostomy is used to place chest tubes or catheters for drainage of air or fluid to restore normal negative pressure within pleural space. It also can be used to create a surgical access port for video-assisted lobectomy and other endoscopic procedures. Open thoracostomy (partial rib resection) allows healing and reinflation of an infected lung.
ThoracotomyIncision into the chest cavity that can be used as a diagnostic tool to diagnose or stage cancer. It allows the surgeon access to the thoracic organs including the heart, esophagus, great vessels, or the lungs. Surgery can result from benign or malignant conditions.
TransplantationRemoval of a diseased recipient lung with an immediate replacement of a cadaveric donor lung.
Volume Reduction SurgeryIncision and removal of the parts of the lung that are the most destroyed, most commonly from emphysema, to allow for full function of remaining lung structures. (See Endobronchial Valve for an alternative to surgery.)
Wedge ResectionExcision of a small wedge-shaped section from the peripheral portion of the lobe of a lung. It is commonly used to remove cancerous growths in the outer section of the lung, sparing lung tissue and function.
Invasive surgery that involves the chest cavity is generally performed with general anesthesia, although diagnostic procedures such as bronchoscopy, needle biopsy, and thoracentesis are commonly performed with local (topical) anesthesia, often with small, titrated amounts of intravenous (IV) sedation.1 Epidural catheters can also be placed before surgery for use during surgery and for extended postoperative pain control after pneumonectomy or lobectomy. Because these procedures involve the airway in addition to anesthesia, patients are given nothing by mouth before any procedure.
Topical anesthesia involves the instillation or spray of a local anesthetic, commonly 4% lidocaine hydrochloride (Xylocaine), onto the laryngeal and pharyngeal surfaces. Although uncommon, toxic reactions or bronchospasm can occur; therefore, emergency equipment should be readily available. Postanesthesia care of the patient after topical anesthesia requires airway assessment, ready availability of emergency resuscitation equipment, and the administration of humidified oxygen after the procedure. The patient must be given nothing by mouth until the pharyngeal and laryngeal reflexes have returned (2 to 4 hours). Patients should be advised to rest their voices after the procedure; in fact, the surgeon may prescribe a time interval for voice rest. When the gag reflex has returned, throat lozenges and warm drinks may help to relieve the sore throat that inevitably follows bronchoscopy.
Epidural anesthesia involves placement of a catheter into the epidural space of the thoracic vertebrae with subsequent instillation of an infusion combination of an opioid and local anesthetic to achieve sensory blockade of pain without compromising motor function needed for coughing, deep breathing, and ambulating. Thoracic epidural anesthesia can be used in combination with either sedation or general anesthesia.1 The catheter can be left in place for up to 3 days after surgery for pain control and may be regulated solely by medical personnel or controlled by the patient. Epidural anesthesia is commonly used as an adjunct to general anesthesia.
Paravertebral or intercostal blockade is a regional technique used for the thoracic surgery patient. The advantage of these blocks is neural blockade; the disadvantage is that they last only until the local anesthetic is metabolized.1 Paravertebral block (PVB) can be used on one side only or both sides with a single-injection technique or via a catheter.2 PVBs provide analgesia equal or superior to that with thoracic epidural analgesia (TEA) but with fewer side effects.3–5 See Table 34.1 for a comparison between PVB and TEA. The most commonly used anesthetics for these blocks are lidocaine, bupivacaine, and ropivacaine. Intrapleural local anesthetic instillation can be used for postoperative analgesia but has the potential for systemic absorption and toxicity.1 See Chapters 24 and 25 for information on local anesthetics and regional anesthesia.
LA, Local anesthetic; PVB, paravertebral blockade; TEA, thoracic epidural analgesia.
* Cardiac arrest has been described secondary to blockade of cardiac accelerator fibers resulting in profound bradycardia or asystole after TEA. Delayed cardiac arrest after thoracic PVB has been presumed to be associated with LA toxicity and/or inadvertent intravascular administration during infusion.
From D’Ercole F, Arora H, Kumar PA. Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth. 2018;32:915–927.
General anesthesia involves the administration of some combination of inhalation anesthetics, IV anesthetics, benzodiazepines, opioids, muscle relaxants, and reversal agents and aims to render the patient amnestic and pain free. Somatic, autonomic, and endocrine reflexes are eliminated, and skeletal muscle relaxation is achieved. Because of the effects of general anesthesia on respiratory function and effort, in conjunction with a preexisting compromise in the respiratory system that necessitates surgery, nursing care must emphasize respiratory assessment, monitoring, and application of prompt intervention if evidence of compromise is noted after surgery.
The patient and family should receive detailed information preoperatively. When possible, taking time to improve the patient’s pulmonary, physical, and nutritional status is desirable.6 Smoking cessation is an important preoperative aspect of surgery. Pulmonary complications are reduced in thoracic surgery patients who stop smoking for at least 4 weeks before surgery.3 Preoperative medications should be continued with the exception of anticoagulant medications.6 The perianesthesia nurse should review the diagnostic and laboratory tests preoperatively. Preoperative evaluation of the patient who will undergo thoracic surgery may include laboratory tests and pulmonary function tests listed in Table 34.2.
Laboratory Studies for Assessment of Patients Undergoing Thoracic Procedures
Significance of Abnormal Findings
Perfusion Studies—Arterial Blood Gases
Changes indicate metabolic or respiratory acidosis.
35–45 mm Hg
Elevations indicate possible COPD, asthma, pneumonia, anesthetic effects, or use of opioids (respiratory acidosis). Decreased levels indicate hyperventilation/respiratory alkalosis.
Elevations indicate possible respiratory acidosis as compensation for primary metabolic alkalosis. Decreased levels indicate possible respiratory alkalosis as compensation for primary metabolic acidosis.
80–100 mm Hg
Elevations may indicate possible excessive oxygen administration. Decreased levels indicate possible COPD, asthma, chronic bronchitis, cancer of bronchi and lungs, respiratory distress syndrome, or any other cause of hypoxia.
Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.
Complete Blood Count
Male: 4.7–6.1 million/mm3
Elevated levels may be due to excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, such as COPD. Decreased levels may indicate anemia, hemorrhage, or hemolysis.
Female: 4.2–5.4 million/mm3
Male: 14–18 g/dL
Same as for RBCs.
Female: 12–16 g/dL
Same as for RBCs.
Elevations indicate possible acute bacterial infections or inflammatory conditions (smoking). Decreased levels may indicate overwhelming infection or immunosuppression.
FVC (forced vital capacity): Records maximum amount of air that can be exhaled as quickly as possible after maximum inspiration.
Provides an indication of respiratory muscle strength and ventilatory reserve. Often reduced in obstructive disease (because of air trapping) and in restrictive disease.
FEV1 (forced expiratory volume in 1 second): Records maximum amount of air that can be exhaled in first second of respiration.
Effort dependent and declines with age. Reduced in certain obstructive and restrictive disorders.
FEV1/FVC: Ratio of expiratory volume in 1 second to FVC
Provides a more sensitive indicator of obstruction to airflow. Ratio is normal or increased in restrictive disease.
FEF25%–75%: Records forced expiratory flow over 25%–75% volume (middle half) of FVC.
This measure provides a more sensitive index of obstruction in smaller airways.
FRC (functional residual capacity): Amount of air remaining in lungs after normal expiration.
Increased FRC indicates hyperinflation or air trapping, which can result from obstructive disease.
TLC (total lung capacity): Amount of air remaining in lungs at end of maximum inhalation
Increased TLC indicates air trapping associated with obstructive pulmonary disease. Decreased TLC indicates restrictive disease.
RV (residual volume): Amount of air remaining in lungs at the end of a full, forced exhalation
RV is increased in obstructive pulmonary disease, such as emphysema.
DLco (diffusion capacity of carbon monoxide): Reflects surface area of alveolocapillary membrane
DLco is reduced when alveolocapillary membrane is diminished, such as in emphysema, pulmonary hypertension, and pulmonary fibrosis.
COPD, Chronic obstructive pulmonary disease; HCO3, bicarbonate ion; Paco2, partial pressure of arterial carbon dioxide; PaO2, partial pressure of arterial oxygen; RBC, red blood cell; WBC, white blood cell.
From Pagana KD, Pagana TJ. Mosby’s diagnostic and laboratory test references. 15th ed. St. Louis, MO: Elsevier; 2020; Rees HC. Assessment of the respiratory system. In: Ignatavicius DD, Workman ML, eds. Medical-surgical nursing: patient-centered collaborative care. 10th ed. Philadelphia, PA: Elsevier; 2021.
Surgical procedures can be diagnostic or therapeutic in nature. Diagnostic procedures can include bronchoscopy, mediastinoscopy, laryngoscopy, and thoracoscopy. Bronchoscopies are performed to visualize the airway or remove abnormal tissue, mucous plugs, or foreign bodies. They also aid in evaluating lung lesions and staging of lung cancer. Complications can include airway obstruction, hypoxemia, pneumothorax, hemorrhage, or cardiovascular problems such as dysrhythmias or hypotension.
Mediastinoscopy is performed for direct visualization of lymph nodes or tumors at the tracheobronchial junction, subcarinal, or upper lobe bronchi via a lighted scope. The potential for hemorrhage is present because of the close proximity of the innominate vessels and aortic arch to the mediastinoscope. Other complications can include venous air embolism, vagally mediated reflex bradycardia from compression of the trachea or great vessels, airway or esophageal injury including subcutaneous emphysema, chest pain, or pneumothorax. Recurrent laryngeal nerve injury can occur and manifest symptoms such as hoarseness or vocal cord paralysis.7 A laryngoscopy is performed to visualize or biopsy the oropharynx, laryngopharynx, larynx, or proximal trachea. Complications include trauma to the lips, mucous membranes, teeth, or eyes; rupture of the esophagus; hypoxemia; or laryngospasm. Endobronchial ultrasound (EBUS) is a minimally invasive technique that allows the proceduralist to see beyond the lumen of the airway. There are two EBUS systems currently available—the radial probe EBUS allows for evaluation of central airways and accurate definition of airway invasion and facilitates the diagnosis of peripheral lung lesions; and the linear EBUS guides transbronchial needle aspiration of hilar and mediastinal lymph nodes.8,9 The linear EBUS-guided system has also added therapeutics to its role, such as the local delivery of a therapeutic agent for lung cancer treatment.8 The most commonly reported complications include patient-related issues, such as bleeding, infection, and pneumothorax; and instrument-related ones such as bronchoscope damage and needle fracture.8
Thoracoscopy is the insertion of an endoscope, a narrow-diameter tube with a camera attachment, through a small incision in the chest wall for examination of the lungs or other structures in the chest cavity without the use of a large incision. It is performed for basic diagnostic (undiagnosed pleural fluid or pleural thickening) and therapeutic procedures (pleurodesis). Complications can include bleeding, infection of the pleural space, and injury to intrathoracic organs, atelectasis, and respiratory failure.10,11 This procedure is different from video-assisted thoracoscopic surgery (VATS), an invasive procedure that uses a high-level access platform and multiple ports for separate viewing and working instruments to access pleural space.10 VATS can be diagnostic or therapeutic and is used often for biopsy of mediastinal masses, to perform wedge resections, to obtain hemostasis, or to evacuate blood clots. A variety of procedures can be performed via thoracoscopy, from lung volume reduction to a biopsy and excision of mediastinal lesions. Robotic-assisted thoracic procedures can enhance the speed and safety of VATS. Smaller incisions are used for robotic surgery, which may contribute to less postoperative pain and morbidity10,11 (Fig. 34.1). In one systematic review and meta-analysis, VATS was superior to muscle-sparing thoracotomy in the reduction of intraoperative trauma, postoperative complications, and enhanced recovery after surgery for patients with operable lung cancer.12
A significant advantage of thoracoscopy is that it is minimally invasive and results in less incisional pain. It can also decrease recovery time and length of hospital stay. In some facilities, patients come to the PACU with a small chest tube that is removed if chest radiograph results are clear; the patient is then allowed to go home in a few hours. VATS may be converted to an open surgery if there is an inability to achieve one-lung ventilation, extensive pleural adhesions, uncontrolled or significant intraoperative bleeding, an inability to identify target lesion for biopsy, or technical difficulties with or, rarely, primary failure of video equipment and/or endoscopic instruments.11
A thoracentesis requires insertion of a needle through the chest wall into the pleural space to remove either air or fluid to relieve lung compression or for diagnostic purposes. The fluid is then evaluated for chemical, bacteriologic, and cellular composition. This procedure can be performed at the bedside and generally local anesthesia is used. The most common complication is pneumothorax, although the incidence has decreased with experience and the use of ultrasound to visualize the pleural effusion.13,14 Other rarer complications are bleeding and reexpansion pulmonary edema; however, recent studies have determined that patients can safely undergo thoracentesis without stopping anticoagulant medication.13,14
EBV reduction is a minimally invasive treatment to reduce lung volume that has been shown to improve clinical outcomes in patients with advanced emphysema and severe hyperinflation.15 EBVs are intended to achieve bronchoscopic lung volume reduction (BLVR) by causing lobar atelectasis. Elimination of the most damaged emphysematous lobe with EBV allows air to exit during expiration but stops it from entering during inspiration. The result is atelectasis of the targeted lobe and a reduction of hyperinflation.16 Suitable patients who typically respond to this treatment are those limited by severe hyperinflation who have an appropriate emphysema target lobe and absence of collateral ventilation.15 Complications of EBV can include pneumothorax and in rare cases postobstruction pneumonia, severe hemoptysis, airway kinking, hypoxia due to shunting, and persistent cough.15 Misplaced valves can result in a lack of initial benefit. In one retrospective study, 107 out of 423 treated patients had complications.16 The most common complication was pneumothorax (17.3%); other complications were chronic obstructive pulmonary disease exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%).16 However, in all cases the complications resolved with suitable treatment.16
Two valves were approved by the U.S. Food and Drug Administration in 2018 for BLVR: the Zephyr® EBV (Pulmonx; Fig. 34.2A and B) and the Spiration® Valve System (Olympus) (SVS; Fig. 34.3).17 Both valves are implantable devices used to occlude all airways into the hyperinflated lobe of a lung that is most diseased with emphysema with minimally invasive therapy. In a clinical trial with 190 patients randomized 2:1 to treatment with Zephyr valve versus usual care, the patients in the treatment group had significant improvements in validated standardized instrument treatment scores for breathlessness, activity, and psychosocial scores for at least 12 months.18 A systematic review and meta-analysis was conducted to explore the efficacy of SVS.19 Four randomized controlled trials with a total of 629 participants were included. The results of the study showed clinically significant improvements in lung function and health-related quality of life following SVS placement in patients with severe heterogeneous emphysema, and hyperinflation. The study’s authors also pointed out the importance of patient selection.19 In another systematic review, the authors conducted a network comparative meta-analysis to study the effect of EBVs in patients with heterogeneous emphysema without collateral ventilation and the effects of valves and coils in patients with mixed homogeneous and heterogeneous emphysema.20 In the 10 randomized controlled trials included in the study, they found that in patients with heterogeneous emphysema without collateral ventilation, both Zephyr and Spiration valves are equally effective.20