34 Care of the thoracic surgical patient
Atelectasis: Collapse 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.
Bronchoscopy: Direct 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 aluminium 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 Tube: A drainage tube into the intrapleural space to remove air, fluid, or blood with the goal of restoring normal negative pressure and to allow reexpansion of the lung. The tube is placed on the operative side after open chest procedures.
Chest Wall Reconstruction: Repair 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 Lung: Removal 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 Ultrasound: A 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.
Lobectomy: Removal 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.
Mediastinoscopy: Direct visualization of lymph nodes or tumors at the tracheobronchial junction, subcarina, 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.
Pneumonectomy: Removal 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.
Pneumothorax: Accumulation of air or gas within the pleural cavity, thus compromising 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 Resection: Surgical 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.
Thoracentesis: 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. Removed fluid is evaluated for chemical, bacteriologic, and cellular composition. This procedure can be performed at the bedside, generally with local anesthesia.
Thoracoscopy: The 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 a large incision. The procedure may be diagnostic or therapeutic.
Thoracostomy: An 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.
Thoracotomy: Incision 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.
Wedge Resection: Excision 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 to spare lung tissue and function.
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.
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 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 all 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. Recovery 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 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.
General anesthesia involves the administration of some combination of inhalation anesthetics, intravenous 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.2 Smoking cessation is an important preoperative aspect of surgery; however, the effects of smoking linger after cessation with benefits noted after a year. Smokers who have recently quit have no difference in pulmonary complications than current smokers.3 Preoperative medications should be continued with the exception of anticoagulant medications.2 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 34-1.
|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
|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.
|Same as for RBCs.
|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 sec): 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 sec 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 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, ed 9, St. Louis, 2009, Mosby; Rees HC: Assessment of the respiratory system. In Ignatavicius DD, Workman ML, editors: Medical-surgical nursing: patient-centered collaborative care, ed 6, Philadelphia, 2010, Saunders.