Thorac Surg Clin 15 (2005) 195 – 201

Preoperative Patient Education in Thoracic Surgery

Richard I. Whyte, MDa,*, Patricia D. Grant, RNb
a
Department of Cardiothoracic Surgery, Stanford University Medical Center, CVRB 205, 300 Pasteur Drive,
Stanford, CA 94305, USA
b
Thoracic Surgery Service, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA

Optimal outcome after thoracic surgery, as with
any type of surgery, involves the coordinated activity
of many individuals, including the patient, surgeon,
anesthesiologist, nurses, resident physicians, respira-
tory therapists, and a host of other participants. The
phrase coordinated activity implies that each partici-
pant has knowledge of his or her role and expecta-
tions. For the patient, who is generally uneducated
in the course of the surgical process, this learning
process involves the preoperative and postoperative
period. Through the process of preoperative teaching,
the patient understands his or her role in the overall
process and how he (or she) can facilitate or delay
recovery. This article describes the role of preopera-
tive teaching in thoracic surgery. The focus is not on
the surgeon’s role, but rather the role of the greater
surgical team, which frequently involves nurses,
medical assistants, resident physicians, nurse practi-
tioners, and anesthesiologists.
Because most patients are new to the thoracic
surgical process, the amount of information may be
overwhelming—particularly when patients are con-
fronted with a new diagnosis of malignancy or when
they have no advance knowledge of the magnitude or
risks of the planned surgery. As such, important
concepts often are presented more than once or in
more than one way. Material that the surgeon covers
in the initial consultation often needs to be reinforced
at a subsequent preoperative visit or even again on
the day of surgery.
In the authors’ practice, a recommendation for
surgery often is given at the time of the initial
* Corresponding author.
E-mail address: riwhyte@stanford.edu (R.I. Whyte).
consultation. Sufficient time is allocated for the sur-
geon to describe the operation and its risks, benefits,
and alternatives. Questions are encouraged, but often
the patient cannot assimilate all of the information
and formulate appropriate questions. Questions often
arise in the following days, as the patient has had time
to digest the information, process it, and assimilate it
on intellectual and emotional levels. If a recommen-
dation for surgery is offered at the initial consultation,
the clinical nurse specialist spends additional time
with the patient interpreting and reinforcing what the
surgeon said, answering questions, and providing a
contact telephone number for subsequent questions.
Patients often have a separate visit a few days be-
fore surgery. At that time, the planned operation is
reviewed again with the patient, and additional ques-
tions are answered. Patients also are seen in a pre-
operative anesthesia clinic by a physician or an
anesthetic nurse practitioner. In this setting, informa-
tion flows two ways: The anesthesia service performs
a preoperative anesthesia assessment, and the patient
has an opportunity to learn more about the planned
anesthesia and postoperative pain issues. The final
opportunity for preoperative teaching is by the
perioperative nurses who, in doing their own pre-
operative patient assessment, answer any remaining
questions and deal with remaining concerns.
Content of preoperative teaching
The content of preoperative teaching should
include all significant issues related to a particular
patient’s operation. For the purposes of discussion,
the content can be separated into two groups: issues

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196 whyte
related to surgery (or thoracic surgery) in general and
issues related to a specific operation.
General preoperative education
At the initial consultation, the surgeon usually
provides an explanation of the proposed procedure.
Retention of this information is highly variable and
depends on the rapport between the surgeon and
patient; the surgeon’s willingness to provide infor-
mation; and the patient’s curiosity, emotional state of
mind, intelligence, and knowledge base. An intellec-
tually sophisticated patient with a background in the
medical sciences who presents to the office with an
Internet printout of all the latest lung cancer clinical
trials is likely to be handled differently than a poorly
educated patient who has done no background
investigations. Similarly the emotional state of the
patient must be taken into account because it is likely
that an emotionally upset patient hearing the diag-
nosis of ‘‘cancer’’ for the first time may have less
retention than someone who is being provided a sec-
ond opinion or someone who is seeing the surgeon
after a course of preoperative chemotherapy.
At the conclusion of the preoperative process, all
patients need to have some retained understanding of
the planned procedure, why it is being recommended,
what its risks are, whether there are alternatives, and
how their active participation in the surgical process
can make a difference in recovery. Although this
information is generally covered, at some level, by
the surgeon, the surgical nurse often has to review it
with the patient and focus on areas where retention
was inadequate.
Respiratory hygiene
Many of the common complications after tho-
racic surgery—atelectasis, pneumonia, and pulmo-
nary embolism—are pulmonary in nature. Although
pulmonary embolism cannot be prevented through
improvement in pulmonary hygiene, atelectasis and
pneumonia can be prevented through active patient
involvement. Coughing, deep breathing, using an
incentive spirometer, walking, sitting to eat, and
performing other seemingly minor activities all can
contribute to improved pulmonary hygiene and a
decreased incidence of postoperative pneumonia.
Although coughing per se is painful and controver-
sial in terms of its ability to prevent pneumonia,
avoidance of sputum retention is desired. Patients
can be taught to splint the operative side to mini-
& grant
mize pain with coughing. Deep breathing can open
collapsed alveoli and prevent overt atelectasis. Walk-
ing and use of an incentive spirometer aim for the
same goals—improved aeration of the lungs and
avoidance of alveolar and segmental collapse. Eat-
ing in bed should be avoided because the often
semirecumbent posture predisposes to aspiration
and regurgitation.
Although all of these respiratory hygiene mea-
sures can be addressed in the postoperative period, it
is best to address these concepts initially in the pre-
operative period. Setting expectations is important,
and in the postoperative period, when the patient’s
sensorium may be clouded by pain and narcotics,
learning is suboptimal. Teaching proper use of an
incentive spirometer is far more effective preopera-
tively than postoperatively when inhalation is com-
promised by pain. When patients are taught how to
use this device preoperatively, they have a relevant
basis from which to compare their postoperative
inspiratory effort and function. Convincing patients
that they can do much better is difficult if they have
never seen the device until the evening after surgery.
Pain
One of the most frightening things for patients
facing surgery is the expectation of pain. Other
frightening concepts include loss of personal control
and death. Because death is usually unlikely, and loss
of control is unavoidable, the expectation of pain
often becomes a major source of anxiety. In the pre-
operative period, the anxiety surrounding pain, rather
than the pain itself, is the problem. Effective pre-
operative teaching can allay these fears, reduce the
anxiety, and provide a framework for realistic expec-
tations regarding postoperative pain [1,2].
A discussion of narcotic analgesics, patient-
controlled analgesia, nonsteroidal analgesics, and epi-
dural anesthesia (continuous, intermittent, and patient
controlled) is appropriate. Side effects, including
nausea, gastrointestinal dysfunction, and the potential
for a lack of efficacy, should be discussed. The goal
of postoperative analgesia also should be discussed.
Patients should not expect to be oblivious to the fact
that they just had surgery, but the goal of post-
operative analgesia should be pain control that pro-
vides patients with an ability to function and interact
with their environment effectively.
Family members should be cautioned that patient-
controlled analgesia is for patients, not family mem-
bers, to control. Family members also should be
cautioned that narcotics may have undesirable side
 preoperative patient education
effects, such as somnolence, respiratory depression,
dysphoria, disorientation, and even delirium. Family
members should be advised that these side effects
generally resolve quickly after discontinuation of
narcotics, and that the physicians and nurses need
to be made aware if these side effects occur.
Patients should be advised that postoperative early
ambulation is desirable. The upright posture has
many advantages in terms of pulmonary function,
although multiple attachments such as chest tubes,
urinary catheters, epidural catheters, and infusion
pumps often make ambulation difficult. Effective
preoperative counseling sets the expectations, which
can be reinforced in the postoperative period.
Smoking cessation
In thoracic surgical practice, many of the rele-
vant diseases, particularly lung cancer and emphy-
sema, are smoking related. Although many patients
have quit smoking by the time they come to the
thoracic surgeon, others continue to smoke because
the addictive qualities of nicotine outweigh the
intellectual knowledge that smoking is harmful.
Faced with an upcoming operation, the patient may
use smoking as a method of coping with anxiety and
fear. Patients should be counseled vigorously, how-
ever, to stop smoking in preparation for surgery.
Cigarette smoking impairs the mucociliary clearance
mechanisms of the tracheobronchial tree and may
predispose to postoperative pulmonary complications.
The optimal time for smoking cessation is unclear,
and one article even suggested an increase in peri-
operative pulmonary complications when smoking
cessation occurred immediately before surgery [3,4].
Most surgeons encourage patients to stop smoking
in preparation for thoracic surgery. Whether surgery
should be denied to patients who continue to smoke
is controversial. Every effort should be made pre-
operatively to persuade the patient to stop smoking.
Diet and nutrition
Preoperative patient education should cover nu-
tritional issues routinely but is particularly important
in two classes of patients: (1) patients who have
recently experienced a significant weight loss and
(2) patients who are to undergo preoperative chemo-
therapy or radiation therapy. The first group includes
many patients with esophageal cancer in whom
dysphagia or odynophagia have limited their oral
intake and resulted in a long-standing caloric defi-
ciency. Although significant weight loss is common
197
in patients with metastatic disease, such patients
frequently are identified through preoperative staging
tests and often do not come to the attention of the
surgeon. The second group involves patients who
ideally should be seen by the surgeon before the
neoadjuvant therapy is started. In these patients,
nutritional deficiencies can be expected and conse-
quently preempted. Patient questions regarding nutri-
tional supplementation (including herbal or other
nontraditional forms of treatment) often arise at this
time and can be dealt with appropriately.
Wound care and drains
Although most thoracic surgery patients require
little or no postdischarge wound care, the preopera-
tive visit is a reasonable time to raise this issue. Pa-
tients often have negative expectations about wound
care and often are pleasantly surprised to learn that
care is usually minimal. Occasionally, patients are
discharged home with tubes or drains still in place.
Because percutaneous tubes and drains are an integral
part of modern surgical care and their use has become
ubiquitous, health care providers may become numb
to their invasiveness and the patient’s sense of a loss
of personal image. Patients should be taught about the
uses and benefits of percutaneous tubes and drains as
early as possible. In years past, patients routinely
were kept in the hospital until all drains and tubes
were out: mastectomy patients stayed in the hospital,
on intravenous antibiotics, until the Jackson-Pratt
drains were removed. Now, as a result of ‘‘best prac-
tice’’ analysis, evidence-based medicine, and changes
in reimbursement policies, practices have changed,
and patients are taught that it is acceptable to go
home with a small drain.
Postdischarge social issues
Although it may seem premature to enter into a
discussion of postdischarge psychosocial issues in the
preoperative phase, such a discussion is not inappro-
priate. Postdischarge issues, such as family involve-
ment in postoperative convalescence, job-related
concerns, and expectations regarding physical limi-
tations, including appetite, sleep irregularity, and sex-
ual function, can be broached in the preoperative
period and brought up again in more detail later.
Issues that potentially may delay discharge from the
hospital may become apparent in these discussions
(which are frequently left to the nursing staff), and it
is helpful to address these issues early so that they do
not become problems later. In dealing with the patient
198 whyte
and family, cultural sensitivity and family dynamics
may play crucial roles in effecting a smooth post-
operative recovery.
Contact numbers
Part of the preoperative teaching process is to
effect seamless communication between the patient
and the surgeon. Because many surgeons delegate
much of the preoperative teaching to resident phy-
sicians, nurses, and other nonphysician staff, it is
crucial to provide patients with a reliable method of
contacting the surgeon or his or her designee. Pa-
tient satisfaction has an increasing role in deter-
mining where patients go for their care, and one of
the simplest methods for improving patient satisfac-
tion is providing them with a reliable conduit to the
surgeon and his or her staff.
Procedure-specific teaching
In addition to the more general areas discussed
earlier, each patient needs teaching directed toward
the specific operation he or she is to undergo. Infor-
mation that needs to be covered at this stage includes
the size and location of the incision, the general
outline of the operation, the expected postoperative
physiologic state or deterioration from baseline, and
a general overview of the risks of complications or
death. Several common examples are detailed next.
Pulmonary resection (lobectomy/pneumonectomy)
In addition to providing information regarding in-
cision length and position, morbidity, mortality,
and other issues described previously, patients under-
going thoracotomy for pulmonary resection should
receive counseling on postthoracotomy pain and
the potential for decreases in pulmonary reserve.
Thoracotomy incisions are notoriously painful, and
although early postoperative pain can be managed
effectively by modern analgesic techniques, the late
issues of ongoing narcotic use and the incumbent
gastrointestinal side effects should be discussed
proactively. From the standpoint of loss of pulmo-
nary reserve, patients with marginal preoperative
lung function should be advised that they are likely
to have less exercise capacity and that nasal oxygen
therapy may be necessary on a short-term basis. In
the authors’ practice, patients who would be expected
to require supplemental oxygen on a long-term basis
rarely are offered surgery. Patients undergoing
pneumonectomy are at particular risk for symptom-
& grant
atic decreases in exercise capacity and should be
counseled accordingly.
Thoracoscopy
Patients scheduled for thoracoscopy, particularly
limited procedures such as lung biopsy, sympathec-
tomy, and pleural biopsy, often can be discharged the
day after surgery. Reports of outpatient thoracoscopy
have appeared in the literature, but the presence of a
chest tube often dictates an overnight stay [5]. Pa-
tients should be advised that the chest tube probably
will be removed on the morning after surgery, and
that issues such as pain, nausea, and general fatigue
will be managed on an outpatient basis.
Esophagectomy patients need to be forewarned
about early satiety and the possibility of dumping
syndrome. The presence of tubes and drains, which
are second nature to the surgeon, are not second na-
ture to the patient. The idea of having a chest tube can
be frightening to some patients. Drains, wound care,
and jejunostomy tubes, all of which are common
to thoracic surgery practice, are foreign to medically
naive patients. Clinicians must be cognizant of pa-
tients’ naiveté and address it through good preopera-
tive teaching.
Patients need to have some concept of the risks
of the planned procedure. Although some patients
do not want to face these considerations, the doc-
trine of informed consent is an integral part of the
medical system. The surgeon and members of his or
her team need to balance the patient’s desire for in-
formation (or lack thereof), the need to provide a basis
for informed consent, and the undesirable outcome of
fostering fear and anxiety. In general, at a minimum,
a description of common complications, a qualitative
assessment of morbidity and mortality, and an invi-
tation to go into greater detail should be offered.
Lung volume reduction surgery (and other operations
in patients with severe emphysema)
The major specific issue to address in patients
with severe emphysema is prolonged air leaks. Dis-
cussion of other complications, such as pain control,
risks of pneumonia, and the potential for postopera-
tive mechanical ventilation, should not be omitted,
but prolonged air leaks with the ongoing need for
chest tube drainage specifically should be mentioned.
Techniques such as the use of reinforcing strips for
surgical staplers and surgical glue can be discussed,
although these patients often stay in the hospital for
prolonged periods simply because of the need for
ongoing pleural drainage. Use of one-way valves and
the possibility of being discharged home with a chest
tube in place can be discussed in the preoperative
 preoperative patient education
phase of care—not as a likely outcome, but so that it
is not such a foreign concept if it needs to come up
again later.
Esophagectomy
Esophagectomy is one of the larger operations
that thoracic surgeons perform regularly. It is asso-
ciated with significant short-term and long term
morbidity and consequently warrants special atten-
tion in a discussion of preoperative teaching. From
the patient’s perspective, esophagectomy generally
is seen in the context of a diagnosis of cancer that
carries an unusually poor long-term outlook. The
operation generally involves two incisions and is as-
sociated with the possibilities of death, a stay in the
ICU, chest tubes, feeding tubes, and other daunting
obstacles. The ‘‘tradeoff’’ is that patients often start
with severe dysphagia (in contrast to lung cancer
patients who are generally asymptomatic) and end
having a much improved quality of swallowing.
For these patients, specific preoperative teaching
issues should include the surgical risks (bleeding,
infection, anastomotic leak, hoarseness [in the case of
a cervical anastomosis], and the risk of perioperative
and operative mortality—1 – 5% in various series). To
counterbalance these negatives, relief of dysphagia
and the possibility of cure can be raised. The post-
operative issues of early satiety, dumping, and regur-
gitation (the risks of which vary depending on the
planned operative approach) all should be discussed,
although it should be made clear that the degree of
these symptoms and their duration have a wide range.
Photodynamic therapy
Photodynamic therapy is a technique of ablating
obstructing tumors of the major bronchi or esopha-
gus (and now approved for the ablation of columnar-
lined esophageal mucosa) that has the undesirable
side effect of prolonged cutaneous photosensitivity.
The only governmentally approved and commer-
cially available photosensitizing agent in the United
States, Photofrin, is associated with a 6-week period
of photosensitivity, during which time patients
should avoid direct sunlight and wear protective
clothes when outside (eg, gloves, wide-brimmed hat,
long sleeves, long pants). Failure to be compliant
may result in a severe sunburn-like reaction, even to
the point of blistering. It is helpful to council pa-
tients repeatedly on these restrictions and to use a
combination of verbal direction, written material,
and a take-home video. Despite all of these modali-
ties, some patients are noncompliant, but because
the photosensitivity reaction develops quickly, they
rarely repeat their indiscretions.
199
Transplantation
On review of the literature on preoperative
teaching of patients for thoracic surgery, it is found
that the greatest amount of effort has gone into car-
diac surgery (not a topic of this article) and trans-
plantation [6 – 8]. One reason is that the preoperative
assessment of patients for transplantation is far
more complicated than it is for most other tho-
racic surgical patients. The other reason is that, for
most transplant patients, the transplant itself is just
the start of a transforming process that results in
lifelong involvement with the transplant center, the
ongoing use of multiple medications, and the need
for periodic physiologic and pathologic assessment
of the outcome (eg, pulmonary function tests, bron-
choscopy with biopsy). The preoperative evaluation
of transplant patients attempts to identify patients with
the greatest chance of benefiting from receiving a
scarce resource (donor organs) and involves a rigor-
ous medical screening and evaluation and a thorough
psychosocial evaluation. Drug or alcohol abuse,
destructive behavior, noncompliance, and lack of
social supports all argue against offering such pa-
tients donor organs. This preoperative assessment
frequently involves psychologists (or psychiatrists)
and social workers in addition to the more ‘‘nuclear’’
team of the surgeon, transplant pulmonologist, and
the rest of the transplant team. Given the complexity
and lifelong duration of the transplant process, it is
not surprising that the preoperative assessment and
teaching processes are more involved.
Research protocols
In addition to providing excellent patient care,
academic medical centers have the added responsi-
bilities of teaching and conducting research. For the
thoracic surgeon, clinical trials provide a mechanism
for improving the outcome of future patients with
lung cancer, esophageal cancer, and end-stage lung
disease. In many academic medical centers, clinical
trial nurses play a vital role in identifying patients for
clinical trials and in educating patients about these
trials. These discussions involve the nature of the
trial, inclusion and exclusion criteria, study design
(randomized/prospective versus open-label/historical
control), and risks and potential benefits associated
with the specific trial in question. Compared with
physician investigators, clinical trial nurses often
have more time to spend with the patients, may be
less perceived as having a vested interest in the out-
come of the trial, and may be more open to questions
than the physician investigator. The downside is that
the nurses may have a less detailed knowledge of
200 whyte
the trial (eg, pharmacology, pathophysiology, surgical
anatomy). Consequently, physician backup to these
clinical trial nurses must be available.
Preoperative teaching tools
Verbal instruction
Verbal instruction is the cornerstone tool to pre-
operative teaching, and whoever conveys information
verbally must be cognizant of the recipient’s intellec-
tual level, interest in acquiring the information, at-
tention span, and emotional ability to handle the
information. Multiple factors, such as language bar-
riers, learning disabilities, and cultural barriers, can
impair this knowledge transfer, and other strategies,
including repetition, provision of written material,
interpreters, and drawings, may be necessary. It is
often surprising to find that patients, after what was
thought to be a thorough preoperative discussion,
continue to have basic questions that they are reluc-
tant to discuss with the surgeon and that are asked to
the preoperative nurse or other staff only after the
surgeon has left.
Written material
Complementing verbal instruction and direction is
the dissemination of written material. Nonprofit orga-
nizations have a variety of patient education materials
available at relatively low cost. The American Cancer
Society has a telephone hotline for information that
can be sent to patients free of charge. The information
covers general cancer care and preparation for sur-
gery, including topics such as ‘‘what questions to ask
the doctor’’ and ‘‘what are the risks and side effects
of surgery.’’ The American Lung Association has a
large amount of free and low-cost written material
on smoking cessation and lung health, including pul-
monary function testing, bronchoscopy, lung cancer,
and lung transplantation. Lastly, information packets
for commonly performed operations can be bought
or made ‘‘in house’’; the latter has the advantage
of providing information specific to the institution
and surgeons.
Manufacturers of commercial products often pro-
vide free product-specific patient education packets
or booklets. One example is Axcan Pharmaceuticals,
which supplies patient education material on photo-
dynamic therapy for lung and esophageal cancer and
Barrett’s esophagus. Another example is Denver Bio-
& grant
medical, which provides written information and a
patient video on its PleurX pleural catheter. Other
companies, such as Bristol-Myers-Squibb Oncology
and Aventis Pharmaceuticals, supply product-specific
and disease-specific patient information and more
general cancer care information on topics such
as nutrition and exercise in the form of books
and pamphlets.
Web-based material
Much of the information described in this article,
in addition to a wealth of additional information, is
also available online. The American Cancer Society
and the American Lung Association have extensive
websites with large amounts of patient-oriented infor-
mation. In addition, for cancer patients, the National
Cancer Institute provides a detailed and user-friendly
website (www.cancer.gov) with a wealth of material
aimed at the patient level. The University of Pennsyl-
vania (www.oncolink.upenn.edu) also provides an
outstanding patient-centered website that is relatively
free of institutional and commercial bias. Addi-
tional patient-oriented information on clinical trials
is available through the Coalition of National Cancer
Cooperative Groups (www.cancertrialshelp.org).
Numerous pharmaceutical company websites also
offer disease-specific information on disease preven-
tion, diagnosis, causes, and treatment. With the ubiq-
uity of Web access, the authors caution patients that
information obtained on the Web can be highly bi-
ased, poorly referenced, and even self-serving and
promotional in nature, but that reputable sources can
provide valuable insights into their disease and the
treatment options that are available to them.
Audiovisual material
Another opportunity for teaching includes provi-
sion of audiovisual material. Axcan Pharmaceuti-
cals, the supplier of Photofrin, has created a video
detailing the risks of photosensitivity and how to
avoid such side effects. Diagrams and models also
may be used. Commercially available lung models
can help the surgeon or clinical nurse specialist ex-
plain the concepts of bronchopulmonary segments,
lobectomy, and wedge resection. Diagrams, which
can be hand-drawn or commercially obtained, can
be used to explain anatomic concepts. Lastly, use of
the patient’s own radiographs can be an excellent
teaching method, and patients generally pay a great
deal of attention to their own radiographs. It takes
 preoperative patient education
relatively little time to explain the basics of a CT
scan, and patients are often surprised that what
is a ‘‘lung nodule’’ to one physician is a ‘‘worri-
some mass’’ to another. Such teaching methods are
particularly helpful when patients are to be followed
radiographically for an indeterminate pulmonary
nodule. As the saying goes, ‘‘a picture is worth a
thousand words,’’ and 1 or 2 minutes spent with a real
radiograph can take the place of and be more
satisfying than a lengthy description of the films.
Summary
Preoperative patient teaching may take many
forms and is offered to patients across many venues
and formats. The goal of patient teaching is to im-
prove patients’ understanding of their disease process
and the operation that they are about to experience
with the goal of enlisting their active participation in
the healing process. The additional goal of obtaining
informed consent is not only codified in law, but also
has become an ingrained component to the current
physician-patient relationship. The preoperative
teaching process is best approached as a team effort,
and multiple modalities often must be used so that the
patient becomes a knowledgeable and willing mem-
ber of the team.
201
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