THORACIC SURGERIES

DEFINITION
Thoracic surgery is the field of medicine involved in the surgicaltreatment of diseases affecting organs inside the thorax (the chest). Generally treatment of conditions of the lungs, chest wall, anddiaphragm. Thoracic surgery is often grouped with cardiac surgery and called cardiothoracic surgery.

TYPES OF PROCEDURES
TYPES Exploratory thoracotomy DESCRIPTION Internal view of Usually INDICATIONS lung May be used to confirm carcinoma posterolateral or for chest trauma (to detect source but could be of bleeding)

parascapular anterior

incision

Chest tubes after procedure Lobectomy Lobe removal Used when pathology is limited to Thoracotomy incision at site one area of lung: bronchogenic of lobe removal carcinoma, giant emphysematous blebs or bullae, benign tumors, metastatic malignant tumors, Chest tubes after procedure

bronchiectasis and fungal infections Pneumonectomy Removal of an entire lung Performed chiefly for carcinoma, Posterolateral or anterolateral but may be used for lung abscesses, thoracotomy incision bronchiectasis, or extensive Sometimes there is a rib tuberculosis resection Note: Right lung is more vascular left; may cause more Normally no chest drains or than tubes because

fluid physiologic problems if removed

accumulation in empty space is desirable Segmentectomy Only certain segment of lung Used when pathology is localized

(segmental resection)

removed Segments function

(such as in bronchiectasis) and as when the patient has preexisting cardiopulmonary compromise

individual units Wedge resection

Small localized section of lung Performed for random lung biopsy tissue removedusually pie- and shaped small peripheral nodules

Considered when less invasive tests

Incision made without regard have failed to establish a diagnosis to segments May be used as a therapeutic procedure Chest tubes after procedure Thoracoscopy

Direct visualization of pleura VATS may be used for lung with thorascope via an biopsy, lobectomy, resection of nodules, repair of fistulas

intercostal incision Medical under sedation or local anesthesia; allows for visualization and biopsy Video assisted thorascopic surgery (VATS) under general anesthesia; multiple puncture sites and video screen allow for visualization and manipulation of the pleura, mediastinum, and lung parenchyma Decortication

Removal or stripping of thick Empyema fibrous membrane

unresponsive

to

from conservative management

visceral pleura Use of chest tube drainage system postoperatively Thoracotomy involving lungs not Incision into the thoracic Used for hiatal hernia repair, open cavity for surgical procedures heart surgery, esophageal surgery, on other structures tracheal resection, aortic aneurysm repair

Lung reduction (LVRS)

volume

Involves

reducing

lung Performed in advanced bullous 1-antitrypsin

surgery volume by multiple wedge emphysema, excisions or VATS emphysema

Procedures Emergency thoracotomy A patient who has sustained truncal trauma but remains unstable or moribund despite adequate resuscitation by way of infusion, chest drainage and ventilation should be considered a candidate for emergency thoracotomy (ET). A penetrating injury anywhere between the nipples laterally, the sternal notch superiorly and the umbilicus inferiorly should be considered to have penetrated the heart till proven otherwise. Ideally Incision Incisions are adapted to the circumstances and the track of a weapon, the predicted injuries. Sometimes the presence of a protruding weapon will determine what approach is suitable. ET should be performed with the patient supine. If abdominal injuries are suspected, a separate laparotomy incision can be made in the supine patient without having to reposition him. For the patient who has circulatory collapse after a penetrating injury to the precordium amedian sternotomy because it gives access to all the major important structures. Anterior thoracotomy

1. 2. The accepted, standard, approach for emergency thoracotomy is via the left anterior fourth intercostal space. The image on the right is of a right hemiclamshell for a gunshot wound (visible in the axilla). He subsequently underwent a 'rooftop' incision to repair a liver injury.

This incision allows good access to the cardiac ventricles, main pulmonary artery, left hilum and the left lung.

In certain cases, open surgery is needed to diagnose and treat lung problems. If a mass is found in the lung, surgery can help determine its cause. If necessary, the mass can also be removed.

Wedge Resection A wedge resection can be performed if the tumor / mass is confined to one area of the lung. This procedure removes only the affected tissue. Lobectomy The lungs are composed of sections called lobes. A lobectomy removes an entire lobe. By removing the entire lobe, the lobectomy hopefully removes all traces of cancer cells. Surrounding lymph nodes may be removed at the same time in a procedure called a lymphadenectomy.

Pneumonectomy A pneumonectomy removes an entire lung. Removal may be needed if cancer appears to have spread through one entire side of the lungs, but the exact location is hard to pinpoint. People often worry that their breathing will be compromised after lung removal, but the remaining lung is usually more than sufficient.

PREOPERATIVE MANAGEMENT
Goal is to maximize respiratory function to improve the outcome postoperatively and reduce risk of complications.

Encourage the patient to stop smoking to restore bronchial ciliary action and to reduce the amount of sputum, and likelihood of postoperative atelectasis, by decreasing secretions and increasing oxygen saturation.

Teach an effective coughing technique.

o

Sit upright with knees flexed and body bending slightly forward (or lie on side with hips and knees flexed if unable to sit up).

o o

Splint the incision with hands or folded towel. Take three short breaths, followed by a deep inspiration, inhaling slowly and evenly through the nose.

Contract abdominal muscles and cough twice forcefully with mouth open and tongue out. Alternate techniquehuffing and coughingis less painful. Take a deep diaphragmatic breath and exhale forcefully against hand; exhale in a quick distinct pant, .

Humidify the air to loosen secretions. Administer bronchodilators to reduce bronchospasm. Administer antimicrobials for infection. Encourage deep breathing with the use of incentive spirometer to prevent atelectasis postoperatively.

Teach diaphragmatic breathing.

Carry out chest physical therapy and postural drainage to reduce pooling of lung secretions .

Evaluate cardiovascular status for risk and prevention of complication. Encourage activity to improve exercise tolerance. Administer medications and limit sodium and fluid to improve heart failure, if indicated.

Correct anemia, dehydration, and hypoproteinemia with I.V. infusions, tube feedings, and blood transfusions as indicated.

Give prophylactic anticoagulant, as prescribed, to reduce perioperative incidence of deep vein thrombosis and pulmonary embolism.

Provide teaching and counseling.

o

Orient the patient to events that will occur in the postoperative period coughing and deep breathing, suctioning, chest tube and drainage system, oxygen therapy, ventilator therapy, pain control, leg exercises and range-ofmotion (ROM) exercises for affected shoulder.

Make sure that patient fully understands surgery and is emotionally prepared for it; verify that informed consent has been obtained

NURSING DIAGNOSES

Ineffective Breathing Pattern related to wound closures Risk for Deficient Fluid Volume related to chest drainage and blood loss Acute Pain related to wound closure and presence of drainage tubes in the chest Impaired Physical Mobility of affected shoulder and arm related to wound closure and the presence of drainage tubes in the chest

NURSING INTERVENTIONS MAINTAINING ADEQUATE BREATHING PATTERN

Monitor rate, rhythm, depth, and effort of respirations. Auscultate chest for adequacy of air movement to detect bronchospasm, consolidation.

Monitor pulse oximetry and obtain ABG analysis and pulmonary function measurements as ordered.

Monitor LOC and inspiratory effort closely to begin weaning from ventilator as soon as possible.

Suction, as needed, using meticulous aseptic technique. Elevate the head of the bed 30 to 40 degrees when patient is oriented and BP is stabilized to improve movement of diaphragm and alleviate dyspnea.

Encourage coughing and deep-breathing exercises and use of an incentive spirometer to prevent bronchospasm, retained secretions, atelectasis, and pneumonia.

Provide optimal pain relief to promote deep breathing, turning, and coughing.

POST OPERATIVE MANAGEMENT

POSTOPERATIVE ASSESSMENT The nurse monitors the heart rate and rhythm by auscultation and

electrocardiography because episodes of major dysrhythmias are common after thoracic and cardiac surgery. In the immediate postoperative period, an arterial line may be maintained to allow frequent monitoring of arterial blood gases, serum electrolytes, hemoglobin and hematocrit values, and arterial pressure. Central venous pressure may be monitored to detect early signs of fluid volume disturbances. Central venous pressure monitoring devices are being used less frequently and for shorter periods of time than in the past. Early extubation from mechanical ventilation can also lead to earlier removal of arterial lines Another important component of postoperative assessment is to note the results of the preoperative evaluation of the patients lung reserve by pulmonary function testing. A preoperative FEV1 of more than 2 L or more than 70% of predicted value indicates a good lung reserve. Patients who have a postoperative predicted FEV1 of less than 40% of predicted value have a higher incidence of morbidity and mortality .This results in decreased tidal volumes, placing the patient at risk for respiratory failure.

NURSING DIAGNOSES

Based on the assessment data, the patients major postoperative nursing diagnoses may include: Impaired gas exchange related to lung impairment and surgery Ineffective airway clearance related to lung impairment, anesthesia, and pain Acute pain related to incision, drainage tubes, and the surgical procedure Impaired physical mobility of the upper extremities related to thoracic surgery Risk for imbalanced fluid volume related to the surgical procedure Imbalanced nutrition, less than body requirements related to dyspnea and anorexia Deficient knowledge about self-care procedures at home

POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include: Respiratory distress Dysrhythmias Atelectasis, pneumothorax, and bronchopleural fistula Blood loss and hemorrhage Pulmonary edema

PLANNING AND GOALS The major goals for the patient may include improvement of gas exchange and breathing, improvement of airway clearance, relief of pain and discomfort, increased arm and shoulder mobility, maintenance of adequate fluid volume and nutritional status, understanding of self-care procedures, and absence of complications.

NURSING INTERVENTIONS IMPROVING GAS EXCHANGE AND BREATHING Gas exchange is determined by evaluating oxygenation and ventilation. In the immediate postoperative period, this is achieved by measuring vital signs (blood pressure, pulse, and respirations) at least every 15 minutes for the first 1 to 2 hours, then less frequently as the patients condition stabilizes. Pulse oximetry is used for continuous monitoring of the adequacy of oxygenation.

It is important to draw blood for arterial blood gas measurements early in the postoperative period to establish a baseline to assess the adequacy of oxygenation and ventilation and the possible retention of CO2.

The frequency with which postoperative arterial blood gases are measured depends on whether the patient is mechanically ventilated or exhibits signs of respiratory distress; these measurements can help determine appropriate therapy.

It also is common practice for patients to have an arterial line in place to obtain blood for blood gas measurements and to monitor blood pressure closely. Hemodynamic monitoring may be used to assess hemodynamic stability. Breathing techniques, such as diaphragmatic and pursed-lip breathing, that were taught before surgery should be performed by the patient every 2 hours to expand the alveoli and prevent atelectasis.

Another technique to improve ventilation is sustained maximal inspiration therapy or incentive spirometry. This technique promotes lung inflation, improves the cough mechanism, and allows early assessment of acute pulmonary changes.

Positioning also improves breathing. When the patient is oriented and blood pressure is stabilized, the head of the bed is elevated 30 to 40 degrees during the immediate postoperative period. This facilitates ventilation, promotes chest drainage from the lower chest tube, and helps residual air to rise in the upper portion of the pleural space, where it can be removed through the upper chest tube.

The nurse should consult with the surgeon about patient positioning. There is controversy regarding the best side-lying position. In general, the patient should be positioned from back The manual vent should not be used to lower the water level in the water seal when the patient is on gravity drainage (no suction) because intrathoracic pressure is equal to the pressure in the water seal. ! side frequently and moved from horizontal to semi-upright position as soon as tolerated. Most commonly, the patient is instructed to lie on the operative side.

However, the patient with unilateral lung pathology may not be able to turn well onto that side because of pain.

In addition, positioning the patient with the good lung (the nonoperated lung) down allows a better match of ventilation and perfusion and therefore may actually improve oxygenation.

The patients position is changed from horizontal to semi-upright as soon as possible, because remaining in one position tends to promote the retention of secretions in the dependent portion of the lungs.

After a pneumonectomy, the operated side should be dependent so that fluid in the pleural space remains below the level of the bronchial stump, and the other lung can fully expand.

The procedure for turning the patient is as follows: Instruct the patient to bend the knees and use the feet to push. Have the patient shift hips and shoulders to the opposite side of the bed while pushing with the feet. Bring the patients arm over the chest, pointing it in the direction toward which the patient is being turned. Have the patient grasp the side rail with the hand. Turn the patient in log-roll fashion to prevent twisting at the waist and pain from possible pulling on the incision.

IMPROVING AIRWAY CLEARANCE Retained secretions are a threat to the thoracotomy patient after surgery. Trauma to the tracheobronchial tree during surgery, diminished lung ventilation, and

diminished cough reflex all result in the accumulation of excessive secretions. If the secretions are retained, airway obstruction occurs. This, in turn, causes the air in the alveoli distal to the obstruction to become absorbed and the affected portion of the lung to collapse. Atelectasis, pneumonia, and respiratory failure may result. Several techniques are used to maintain a patent airway. First, secretions are suctioned from the tracheobronchial tree before the endotracheal tube is discontinued. Secretions continue to be removed by suctioning until the patient can cough up secretions effectively. Nasotracheal suctioning may be needed to stimulate a deep cough and aspirate secretions that the patient cannot cough up.

However, it should be used only after other methods to raise secretions have been unsuccessful . Coughing technique is another measure used in maintaining a patent airway. The patient is encouraged to cough effectively; ineffective coughing results in exhaustion and retention of secretions . To be effective, the cough must be low-pitched, deep, and controlled. Because it is difficult to cough in a supine position, the patient is helped to a sitting position on the edge of the bed, with the feet resting on a chair.

The patient should cough at least every hour during the first 24 hours and when necessary thereafter. If audible crackles are present, it may be necessary to use chest percussion with the cough routine until the lungs are clear.

Aerosol therapy is helpful in humidifying and mobilizing secretions so that they can easily be cleared with coughing. To minimize incisional pain during coughing, the nurse supports the incision or encourages the patient to do so.

After helping the patient to cough, the nurse should listen to both lungs, anteriorly and posteriorly, to determine whether there are any changes in breath sounds. Diminished breath sounds may indicate collapsed or hypoventilated alveoli.

Chest physiotherapy is the final technique for maintaining a patent airway. If a patient is identified as being at high risk for developing postoperative pulmonary complications, then chest physiotherapy is started immediately (perhaps even before surgery).

The techniques of postural drainage, vibration, and percussion help to loosen and mobilize the secretions so that they can be coughed up or suctioned.

RELIEVING PAIN AND DISCOMFORT Pain after a thoracotomy may be severe, depending on the type of incision and the patients reaction to and ability to cope with pain. Deep inspiration is very painful after thoracotomy. Pain can lead to postoperative complications if it reduces the patients ability to breathe deeply and cough, and if it further limits chest excursions so that ventilation becomes ineffective. Immediately after the surgical procedure and before the incision is closed, the surgeon may perform a nerve block with a longacting local anesthetic such as bupivacaine (Marcaine, Sensorcaine). Bupivacaine is titrated to relieve postoperative pain while allowing the patient to cooperate in deep breathing, coughing, and mobilization. However, it is important to avoid depressing the respiratory system with excessive analgesia: the patient should not be so sedated as to be unable to cough. There is controversy about the effectiveness of injections of local anesthetic for pain relief after thoracotomy surgery. Research has shown that bupivacaine was no more effective than saline injections in treating postoperative thoracotomy pain. Lidocaine and prilocaine are local anesthetic agents used to treat pain at the site of the chest tube insertion. These medications are administered as topical transdermal analgesics that penetrate the skin. Lidocaine and prilocaine have also been found to be effective when used together. Because of the need to maximize patient comfort without depressing the respiratory

drive, patient-controlled analgesia (PCA) is often used. Opioid analgesic agents such as morphine are commonly used. PCA, administered through an intravenous pump or an epidural catheter, allows the patient to control the frequency and total dosage. Preset limits on the pump avoid overdosage. With proper instruction, these methods are well tolerated and allow earlier mobilization and cooperation with the treatment regimen.

PROMOTING MOBILITY AND SHOULDER EXERCISES Because large shoulder girdle muscles are transected during a thoracotomy, the arm and shoulder must be mobilized by full range of motion of the shoulder. As soon as physiologically possible, usually within 8 to 12 hours, the patient is helped to get out of bed. Although this may be painful initially, the earlier the patient moves, the sooner the pain will subside. In addition to getting out of bed, the patient begins arm and shoulder exercises to restore movement and prevent painful stiffening of the affected arm and shoulder

MAINTAINING FLUID VOLUME AND NUTRITION Intravenous Therapy During the surgical procedure or immediately after, the patient may receive a transfusion of blood products, followed by a continuous intravenous infusion.

Because a reduction in lung capacity often occurs following thoracic surgery, a period of physiologic adjustment is needed. Fluids should be administered at a low hourly rate and titrated (as prescribed) to prevent overloading the vascular system and precipitating pulmonary edema.

The nurse performs careful respiratory and cardiovascular assessments, as well as intakeand output, vital signs, and assessment of jugular vein distention. The nurse should also monitor the infusion site for signs of infiltration, including swelling, tenderness, and redness. Diet

It is not unusual for patients undergoing thoracotomy to have poor nutritional status before surgery because of dyspnea, sputum production, and poor appetite. Therefore, it is especially important that adequate nutrition be provided.

A liquid diet is provided as soon as bowel sounds return; the patient is progressed toa full diet as soon as possible. Small, frequent meals are better tolerated and are crucial to the recovery and maintenance of lung function.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS Complications after thoracic surgery are always a possibility and must be identified and managed early. In addition, the nurse monitors the patient at regular intervals for signs of respiratory distress or developing respiratory failure, dysrhythmias, bronchopleural fistula, hemorrhage and shock, atelectasis, and pulmonary infection. Respiratory distress is treated by identifying and eliminating its cause while providing supplemental oxygen. If the patient progresses to respiratory failure, intubation and mechanical ventilation are necessary, eventually requiring weaning. Dysrhythmias are often related to the effects of hypoxia or the surgical procedure. They are treated with antiarrhythmic medication and supportive therapy Pulmonary infections or effusion, often preceded by atelectasis, may occur a few days into the postoperative course. Pneumothorax may occur following thoracic surgery if there is an air leak from the surgical site to the pleural cavity or from the pleural cavity to the environment. Failure of the chest drainage system will prevent return of negative pressure in the pleural cavity and result in pneumothorax. In the postoperative patient pneumothorax is often accompanied by hemothorax.

The nurse maintains the chest drainage system and monitors the patient for signs and symptoms of pneumothorax: increasing shortness of breath, tachycardia, increased respiratory rate, and increasing respiratory distress.

Bronchopleural fistula is a serious but rare complication preventing the return of negative intrathoracic pressure and lung reexpansion. Depending on its severity, it is treated with closed chest drainage, mechanical ventilation, and possibly talc pleurodesis . Hemorrhage and shock are managed by treating the underlying cause, whether by reoperation or by administration of blood products or fluids. Pulmonary edema from overinfusion of intravenous fluids is a significant danger.The early symptoms are dyspnea, crackles, bubbling sounds in the chest, tachycardia, and pink, frothy sputum. This constitutes an emergency and must be reported and treated immediately.

Evaluation 1. Demonstrates improved gas exchange, as reflected in arterial blood gas measurements, breathing exercises, and use of incentive spirometry 2. Shows improved airway clearance, as evidenced by deep, controlled coughing and clear breath sounds or decreased presence of adventitious sounds 3. Has decreased pain and discomfort by splinting incision during coughing and increasing activity level 4. Shows improved mobility of shoulder and arm; demonstrates arm and shoulder exercises to relieve stiffening 5. Maintains adequate fluid intake and maintains nutrition for healing 6. Exhibits less anxiety by using appropriate coping skills, and demonstrates a basic understanding of technology used in care 7. Adheres to therapeutic program and home care 8. Is free of complications, as evidenced by normal vital signs and temperature, improved arterial blood gas measurements, clear lung sounds, and adequate respiratory function

CHEST DRAINAGE Chest drainage is the insertion of a tube into the pleural space to evacuate air or fluid, and/or help regain negative pressure. Whenever the chest is opened, there is loss of negative pressure in the pleural space, which can result in collapse of P.273

the lung. The collection of air, fluid, or other substances in the thoracic cavity can compromise cardiopulmonary function and cause collapse of the lung. TABLE 10-3 Indications for Chest Tube Use INDICATION ACCUMULATING SUBSTANCE Pneumothorax Air Hemothorax Blood

Pleural effusionFluid Chylothorax Empyema Lymphatic fluid Pus

It is necessary to keep the pleural space evacuated postoperatively and to maintain negative pressure within this potential space. Therefore, during or immediately after thoracic surgery, chest tubes/catheters are positioned strategically in the pleural space, sutured to the skin, and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. This assists in the reexpansion of remaining lung tissue.

FIGURE 10-7 Chest drainage systems. (A) Strategic placement of a chest catheter in the pleural space. (B) Three types of mechanical drainage systems. (C) A Pleur-evac operating system: (1) the collection chamber, (2) the water-seal chamber, and (3) the suction control chamber. The Pleurevac is a single unit with all three bottles identified as chambers. Chest drainage can also be used to treat spontaneous pneumothorax or

hemothorax/pneumothorax caused by trauma (see Table 10-3). Sites for chest tube placement are:

For pneumothorax (air)second or third interspace along midclavicular or anterior axillary line. For hemothorax (fluid)sixth or seventh lateral interspace in the midaxillary line.

P.274

One-Bottle Water-Seal System

The end of the collecting tube is covered by a layer of water, which permits drainage of air and fluid from the pleural space, but does not allow air to move back into the chest. Functionally, drainage depends on gravity, on the mechanics of respiration and, if desired, on suction by the addition of controlled vacuum.

The tube from the patient extends approximately 1 inch (2.5 cm) below the level of the water in the container. There is a vent for the escape of any air that may be leaking from the lung. The water level fluctuates as the patient breathes; it goes up when the patient inhales and down when the patient exhales.

At the end of the drainage tube, bubbling may or may not be visible. Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system.

Two-Bottle Water-Seal System

The two-bottle system consists of the same water-seal chamber, plus a fluidcollection bottle.

Drainage is similar to that of a single unit, except that when pleural fluid drains, the underwater-seal system is not affected by the volume of the drainage.

Effective drainage depends on gravity or on the amount of suction added to the system. When vacuum (suction) is added to the system from a vacuum source, such as wall suction, the connection is made at the vent stem of the underwater-seal bottle.

The amount of suction applied to the system is regulated by the wall gauge.

Three-Bottle Water-Seal System

The three-bottle system is similar in all respects to the two-bottle system, except for the addition of a third bottle to control the amount of suction applied. Recent research has shown that suction may actually prolong an air leak by pulling air through the opening that would otherwise heal on its own.

The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged in the water and level of water in the suction chamber or setting of a dialdepending on the system in use.

In the three-bottle system (as in the other two systems), drainage depends on gravity or the amount of suction applied. The mechanical suction motor or wall suction creates and maintains a negative pressure throughout the entire closed drainage system.

The manometer bottle regulates the amount of negative pressure transmitted back to the patient from the suction/vacuum device. This is accomplished through the use of a water or dry system that downregulates the suction/vacuum applied.

In the commercially available systems, the three bottles are contained in one unit and identified as chambers (see Figure 10-7C). The principles remain the same for the commercially available products as they do for the glass bottle system.

First chamber acts as the collection chamber and receives fluid and air from the chest cavity through the collecting tube attached to the chest tube.

Second chamber acts as the water-seal chamber with 2 cm of water acting as a oneway valve, allowing drainage out but preventing backflow of air or fluid into the patient.

Third chamber applies controlled suction. The amount of suction is regulated by the volume of water (usually 20 cm) in the chamber not the amount of suction or bubbling with a water system. In a dry suction control system no water is used, no bubbling occurs, and a restrictive device or regulator is used to dial the desired negative pressure (up to 40 cm suction).

NURSING ALERT When the motor or the wall vacuum is turned off, the drainage system should be open to the atmosphere so that intrapleural air can escape from the system. This can be done by detaching the tubing from the suction port to provide a vent. Nursing and Patient Care Considerations

Assist with chest tube insertion (see Procedure Guidelines 10-23, pages 275 to 277). Assess patient's pain at insertion site and give medication appropriately. If patient is in pain, chest excursion and lung inflation will be hampered.

Maintain chest tubes to provide drainage and enhance lung reinflation (see Procedure Guidelines 10-24, pages 277 to 279).

Maintain integrity of insertion site, observing for drainage, redness, impaired healing, and subcutaneous emphysema.

NURSING ALERT Milking and stripping of chest tubes to maintain patency is no longer recommended. This practice has been found to cause significant increases in intrapleural pressures and damage to the pleural tissue. New chest tubes contain a nonthrombogenic coating, thus decreasing

the potential for clotting. If it is necessary to help the drainage move through the tubing, apply a gentle squeezeand-release motion to small segments of the chest tube between your fingers. NURSING ALERT Clamping of chest tubes is no longer recommended due to the increased danger of tension pneumothorax from rapid accumulation of air in the pleural space. Clamp only momentarily to change the drainage system. Check for leaks to assess the patient's tolerance for removal of the chest tube (perhaps up to 24 hours). P.275

PROCEDURE GUIDELINES 10-23 Assisting with Chest Tube Insertion EQUIPMENT

Tube thoracostomy tray Syringes Needles/trocar Basins/skin germicide Sponges Scalpel, sterile drape, and gloves Two large clamps Suture material Local anesthetic Chest tube (appropriate size); connector Cap, mask, gloves, gown, drapes Chest drainage system-connecting tubes and tubing, collection bottles or commercial system, vacuum pump (if required)

Sterile water

PROCEDURE P.276

Nursing Action Preparatory phase 1.Assess patient for pneumothorax, hemothorax, presence of respiratory distress.

Rationale

2.Obtain a chest X-ray. Other means of2.To evaluate extent of lung collapse or localization of pleural fluid include ultrasound amount of bleeding in pleural space. or fluoroscopic localization. 3.Obtain informed consent. 4.Verify right patient and right

location/procedure. 5.Premedicate if indicated. 6.Assemble drainage system. 7.Reassure the patient and explain the steps of7.The patient can cope by remaining the procedure. Tell the patient to expect a immobile and doing relaxed breathing needle prick and a sensation of slight pressure during tube insertion. during infiltration anesthesia. 8.Position the patient as for an intercostal nerve8.The tube insertion site depends on the block or according to physician preference. substance to be drained, the patient's mobility, and the presence of coexisting conditions. Performance phase Needle or intracath technique 1.Using universal precautions, the skin is1.The area is anesthetized to make tube prepared, anesthetized, and draped, using local insertion and manipulation relatively anesthetic with a short 25G needle and using painless. Use of universal precautions aspetic technique. A larger needle is used to and aseptic technique prevent

infiltrate the subcutaneous tissue, intercostal contamination of chest tube. Patient may muscles, and parietal pleura. 2.An exploratory needle is inserted. feel pressure while tube is inserted. 2.To puncture the pleura and determine the presence of air or blood in the pleural cavity. 3.The IntraCath catheter is inserted through the needle into the pleural space. The needle is

removed, and the catheter is pushed several centimeters into the pleural space. 4.The catheter is taped to the skin; may be4.To prevent it from being dislodged out sutured to the chest wall and covered with a of the chest during patient movement or dressing. lung expansion. The chest tube clamp is removed once the chest tube is attached to the system. 5.The catheter is attached to a connector/tubing5.All connections are taped to prevent and attached to a drainage system (underwater- disconnection. seal or commercial system) and all connections taped. Trocar technique for chest tube insertion Using universal precautions and aseptic

technique, a trocar catheter is used for the insertion of a large-bore tube for removal of a moderate to large amount of air leak or for the evacuation of serous effusion. 1.A small incision is made over the prepared,1.To admit the diameter of the chest tube. anesthetized site. Blunt dissection (with a hemostat) through the muscle planes in the interspace to the parietal pleura is performed. 2.The trocar is directed into the pleural space, the2.There is a trocar catheter available cannula is removed, and a chest tube is inserted equipped with an indwelling pointed rod into the pleural space and connected to a for ease of insertion. drainage system. Hemostat technique using a large-bore chest tube Using universal precautions and aseptic

technique, a large bore chest tube is used to drain blood or thick effusions from the pleural space. 1.Using universal precautions, aseptic technique,1.The skin incision is usually made one and after skin preparation and anesthetic interspace below proposed site of

infiltration, an incision is made through the penetration of the intercostal muscles

skin and subcutaneous tissue.

and pleura.

2.A curved hemostat is inserted into the pleural2.To make a tissue tract for the chest tube. cavity and the tissue is spread with the clamp. 3.The tract is explored with an examining finger. 3.Digital examination helps confirm the presence of the tract and penetration of the pleural cavity. 4.The tube is held by the hemostat and directed through the opening up over the ribs and into the pleural cavity. 5.The clamp is withdrawn and the chest tube is5.The chest tube has multiple openings at connected to a chest drainage system. the proximal end for drainage of air or blood. 6.The tube is sutured in place and covered with a6.Prevents dislodgment. sterile dressing. 7.Catheter is attached to a connector/tube and to7.Clamps are removed from the chest tube the system. All connections are taped. once connected to the drainage system. Chest tubes open to air at the time of insertion will result in a pneumothorax.

Chest tube (tube thoracostomy) inserted via hemostat technique. Follow-up phase 1.Observe the drainage system for blood and air.1.If a hemothorax is draining through a Observe for fluctuation in the tube on thoracostomy respiration. (See page 274.) tube into a bottle

containing sterile normal saline, the blood is available for autotransfusion.

2.Secure a follow-up chest X-ray.

2.To confirm correct chest tube placement and reexpansion of the lung.

3.Assess for bleeding, infection, leakage of air3.With too rapid removal of fluid, a and fluid around the tube. vasovagal response may occur with resulting hypotension. Continued use of petroleum gauzes or ointment can irritate

the skin. 4.Maintain integrity of the chest drainage system. 4.Chest tube malposition is the most common complication. P.277

PROCEDURE GUIDELINES 10-24 Managing the Patient with Water-Seal Chest Drainage EQUIPMENT

Closed chest drainage system Holder for drainage system (if needed) connector for emergency use Vacuum motor Sterile connector for emergency use (ie, sterile water)

PROCEDURE P.278

Nursing Action Performance phase

Rationale

1. Attach the chest tube from the pleural1. Water-seal drainage provides for the escape space (the patient) to the of air and fluid into a drainage bottle. The water acts as a seal and keeps the air from being drawn back into the pleural space. Vigorous bubbling is not indicated.

collecting/drainage tubing and water-seal drainage system. Add sterile water to water-seal chambers as needed. Adjust suction until bubbling is seen or set gauge as directed. Keep drainage system below level of chest.

2. Check the tube connections periodically.2. Tube connections are checked to ensure Tape if necessary. a. The tube should be as straight as possible and coiled below level of chest without dependent loops. tight fit, patency of the tubes, and to prevent backflow of drainage or air.

b. Do

not

let

the

patient

lie

on

collecting/tubing drainage. 3. Mark the original fluid level with tape on3. This marking will show the amount of fluid the outside of the drainage system. Mark hourly and daily increments (date and time) at the drainage level. loss and how fast fluid is collecting in the drainage bottle. It serves as a basis for blood replacement, if the fluid is blood. Grossly bloody drainage will appear in the bottle in the immediate postoperative period and, if excessive, Drainage may necessitate declines

reoperation.

usually

progressively after the first 24 hours. 4. Assess patient's clinical status at least4. Removal of 1,000 to 1,200 mL of pleural once per shift. Observe and report immediately signs of rapid, shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema, or symptoms of hemorrhage. fluid at one time can result in hypotension and rebound pleural effusion. Report to physician immediately. More frequent

monitoring is required at the initiation of therapy and when warranted by patient's condition. Many clinical conditions may cause these signs and symptoms, including tension pneumothorax, mediastinal shift, hemorrhage, pulmonary severe embolus, incisional and pain, cardiac

tamponade. Surgical intervention may be necessary. 5. Make sure the tubing does not loop or5. Fluid collecting in the dependent segment interfere with the movements of the patient. of the tubing will decrease the negative pressure applied to the catheter. Kinking, looping, or pressure on the drainage tubing can produce back pressure, thus possibly forcing drainage back into the pleural space or impeding drainage from the pleural space. 6. Encourage the patient to assume a6. The patient's position should be changed

position of comfort. Encourage good body alignment. When the patient is in a lateral position, place a rolled towel under the tubing to protect it from the weight of the patient's body. Encourage the patient to change position frequently.

frequently to promote drainage and body kept in good alignment to prevent postural deformity and contractures. Proper

positioning helps breathing and promotes better air exchange. Pain medication may be indicated to enhance comfort and deep breathing.

7. Put the arm and shoulder of the affected7. Exercise helps to avoid ankylosis of the side through ROM exercises several times daily. Some pain medication may be necessary. 8. Make sure there is fluctuation (tidaling)8. Fluctuation of the water level in the tube of the fluid level in the drainage system. shows that there is effective communication between the pleural space and the drainage system; provides a valuable indication of the patency of the drainage system, and is a gauge of intrapleural pressure. 9. Fluctuations of fluid in the tubing will stop when: a. the lung has reexpanded. b. the tubing is obstructed by blood clots or fibrin. c. a dependent loop develops. 10.Watch for leaks of air in the drainage10.Leaking and trapping of air in the pleural system as indicated by constant bubbling in the water-seal bottle. a. Report excessive bubbling in the waterseal change immediately. 11.Encourage the patient to breathe deeply11.Deep breathing and coughing help to raise and cough at frequent intervals. If there are signs of incisional pain, adequate pain medication is indicated. the intrapleural pressure, which allows emptying of any accumulation in the pleural space and removes secretions from the tracheobronchial tree so the lung expands. space can result in tension pneumothorax. shoulder and assists in lessening

postoperative pain and discomfort.

12.If the patient has to be transported to12.The drainage apparatus must be kept at a another area, place the drainage system below the chest level (as close to the floor as possible). 13.If the tube becomes disconnected, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the chest tube and tubing, and reattach to the drainage system. Otherwise, do not clamp the chest tube during transport. 14.When assisting with removal of the tube: 14.The chest tube is removed as directed when a. Administer pain medication 30 minutes before removal of chest tube. b. Instruct the patient to perform a gentle Valsalva quietly. c. The chest tube is clamped and maneuver or to breathe the lung is reexpanded (usually 24 hours to several days). Signs of reinflation include little or no drainage, absence of air leak, no noted respiratory distress, no fluctuations in fluid in water-seal chamber, no residual air or fluid in chest X-ray. During the tube removal, avoid a large sudden inspiratory effort, which may produce a pneumothorax. level lower than the patient's chest to prevent backflow of fluid into the pleural space.

removed. d. Simultaneously, a small bandage is applied and made airtight with petroleum gauze covered by a 4 4 gauze and thoroughly covered and sealed with tape. Follow-up phase

1. Monitor the patient's pulmonary status for1. Patient signs and symptoms of decompensation. Observe insertion site for signs of infection and changes in drainage. Evidence Base

could

have

reformation

of

pneumothorax after removal as well as infection at injection site.

Coughlin, A., and Parchinsky, C. (2006). Go with the flow of chest tube therapy. Nursing 36(3):36-41. Halm, M. (2007). To strip or not to strip? Physiological effects of chest tube manipulation. American Journal of Critical Care 16(6):609-612. P.279

TABLE 10-4 Chest Drainage Units (CDU) TYPES Standard CDU DESCRIPTION INDICATIONS FOR USE

Drainage of pleural cavity for air orFollowing surgery that impacts on the any type of fluid with or without thecontinuity of suction of the thoracic use Up to 2,000 ml capacity Replaced when full cavity (eg, thoracic, cardiac, esophageal surgery) Pneumothorax Hemothorax Pleural effusion Pleurodesis

Smaller Portable CDU

Drainage without use of suction

For ambulatory patients

Dry seal system that prevents airHome care leaks No lung reexpansion occurs 500 ml maximum drainage Emptied when used in home Indwelling Pleural Catheter Can be irrigated if occluded by healthNot care provider Less traumatic Heimlich Valve Removes air as patient exhalesUsed for emergency transport, home One-way flutter valve Evacuates air from the pleural space for trauma or blood Small size chest tube or pigtailPneumothorax catheter (smaller than standard 14F) Chronic drainage of fluid Chronic conditions

Can be used for pleurodesis

Valve opens when pleural spacecare, and long-term care units pressure is greater than atmospheric pressure and closes when the reverse occurs

COMPLICATIONS

Hypoxiaassess for restlessness, tachycardia, tachypnea, and elevated BP. Postoperative bleedingmonitor for restlessness, anxiety, pallor, tachycardia, and hypotension. Pneumonia; atelectasismonitor for fever, chest pain, dyspnea, changes in lung sounds on auscultation.

Bronchopleural fistula from disruption of a bronchial suture or staple; bronchial stump leak.
o

Observe for sudden onset of respiratory distress or cough productive of serosanguineous fluid.

o o

Position with the operative side down. Prepare for immediate chest tube insertion and/or surgical intervention.

Cardiac dysrhythmias (usually occurring third to fourth postoperative day); MI or heart failure.

This information is a better

intended to and

provide

understanding

appreciation by our patients and their families of the events surrounding operations on the chest and lung. We hope you find it interesting and informative while helping you understand the importance you play in maintaining your good health.

A thoracotomy is a surgical procedure

allowing the surgeon to access your lungs

prior to removal of all or part of your lung (pulmonary resection). An incision will be made on the side of your chest, running behind your shoulder blade, depending on the location of your lesion. Once your lung is exposed, the amount of lung tissue removed is contingent on the type, size and location of the lesion. The breathing tests you complete prior to surgery help ensure you will be able to tolerate a pulmonary resection.

A. Wedge

Resection/Segmentectomy

With this procedure, only a small part of the lung is removed. It is used most often if the lesion proves to be non-cancerous or if the lesion is small and peripherally located.

B. Often times

Lobectomy an entire

lobe of a lung must be removed. The

left lung is divided into an upper and

lower lobe. The right lung has an upper,

middle, and lower lobe.

C.

Pneumonectomy

If there is concern that cancer may have spread throughout the left or right lung, or the lesion is located centrally, the whole lung may need to be removed.