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SPECIAL CARE AFTER THORACOTOMYBy E. F. CHIN, M.B., B.S., F.R.C.S.

Surgeon in charge, Thoracic Unit, Southampton Chest Hospital

It is only logical that some remarks on pre-operative care be submitted in a paper which isdealing with post-operative care of cases who haveundergone thoracotomy, as certain aspects followthrough directly and have an effect on the post-operative sequel. Some features are no moreimportant to thoracic work than to general surgicalwork, such as care and attention to the patient'sdental hygiene, general nutrition and the bloodpicture. There are specific features in relation tothoracic work and these are as follows:

(i) Pulmonary Infections. These must be con-trolled pre-operatively. There are those casescoming to thoracotomy who have chronic low-grade infection, seen usually in the older agegroups who suffer from so-called ' bronchitis.'These patients are prone to pulmonary infectionsand often have associated spasm. Another groupare those with severe pulmonary suppuration, and,indeed, it might be for this suppuration that theyare coming to surgery, such cases being bronchi-ectasis and chronic lung abscess.

It will depend upon the degree of infection whattreatment is undertaken. It is remarkable whatimprovement can be made by simple means suchas tipping and breathing exercises and activity.These patients should be encouraged to be as activeas possible and not to lie inertly in their beds allday, but to be up, fully dressed and about, to takeexercise outside the wards, and if such facilitiesas a gymnasium are available, to use that, par-ticularly in competitive games. If suppurationpersists, and the patient is still producing mucopuswhich is not diminished after adequate tipping andexercise, then a course of antibiotics is well worthwhile just prior to surgery; which drug is usedwill depend upon the organisms and their sensi-tivities. In certain pulmonary cases the pre-operative preparation might take some weeks, andthis is particularlv seen in children with bronchi-ectasis.

(2) Breathing Exercises. Breathing exercises, tobe effective, must be carried out diligently underthe instruction of a physiotherapist who reallyunderstands broncho-pulmonary anatomy and thepathology with which she is dealing. It is useless

to have an overworked physiotherapist visiting thepatient for five minutes once a day, as so oftenhappens. Also it is desirable that the patientsshould fully understand what the breathing exer-cises are for, and should do their exercises inclasses to engender a competitive spirit. Thebreathing exercises should be made very simpleand it is most desirable to reduce them to thesimplest common factor, so that in the post-operative phase the patient can cope and carrythem out as a conditioned reflex. The system ofexternal respiration should be completely ignoredand concentration made entirely on perfectingdiaphragmatic movement and control. Thereasons for this are:

(a) Man, being an orthograde animal, is adiaphragmatic breather. If fully trained in simplediaphragmatic movement, he then is not caughtup in the post-operative period between the systemof internal respiration and external respiration.Diaphragmatic movement is effective and is par-ticularly effective for lifting the bronchial secretions.

(b) Diaphragmatic breathing is painless afterthoracotomy and the patient who has a largethoracotomy scar with a tube in the pleural spaceis not at all keen to use the system of externalrespiration, but he can use diaphragmatic breathingpainlessly.

It must be stressed that the habit of diaphrag-matic breathing is so established in the patientthat he does it automatically before he comes tosurgery and with the slightest encouragement inthe immediate post-operative phase uses hisdiaphragm entirely.

(3) Activity. Pre-operative activity should bestressed. In some cases, of course, this is neitherpossible nor desirable. For example, cases incardiac failure need rest, not activity. But in themain patients should be up and about, fullydressed, and not slopping about in slippers anddressing-gowns. They should be encouraged totake walks and to get out of the atmosphere of theward. This improves their general health andimproves their muscle tone.

(4) X-ray. An X-ray should always be takenon admission and a further X-ray should be taken

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the day before operation. The importance of thepre-operative X-ray cannot be over-stressed. Ofcourse, there is no point in taking an X-ray if itis not viewed.

(5) Nose Swab. On admission all cases shouldhave a nose swab taken, and the only organism ofinterest is that of the staph. aureus, particularlyphage type 8o. The reason for this is to stop theward becoming endemic of this organism and totreat this patient so that he does not come to thetheatre with a heavy growth of staph. aureus inhis nose, which well may end up in a post-operative staph. aureus pneumonia. The best wayof treating such a case is by a spray consisting oftyrothricin (o-os per cent. in 40 ml.), neomycin(28o mg.) and aqua ad. (Ioo ml.). The nose shouldbe sprayed with this two-hourly. After two orthree days' treatment further swabs are taken andtreatment continued until negative cultures areobtained.

(6) Patients over the age of 50 should bedigitalized. A small percentage of cases in theolder age group, but still a significant percentage,tend to fibrillate after a thoracotomy. It is desirableto digitalize these patients pre-operatively, so thatif fibrillation does occur they are under controland it causes little disability. Digitalis can bestopped IO to 12 days post-operatively if sinusrhythm has been maintained.The role of the pre-operative phase is to improve

the general health of the patient and to increasehis activity; in other words, to train him for theoperation. Of course, this is not always possible,but it is desirable in those cases in which it can bemanaged. An effort should be made to improvethe respiratory function, to clear the bronchial treeof infection and to train the patient in such habitsas effective coughing, diaphragmatic breathing,and to explain to the patient why these manoeuvresare being undertaken and the fact that he is beingtrained in these habits purely for the post-opera-tive phase. In other words, the patient should bein the know.

Post-operative PeriodThis can be divided into three phases:

(a) In the Theatre(i) Blood Replacement. This should be complete

and it is a good idea to know what the blood losshas been. With very little trouble this can easilybe measured by the weight of the swabs and themeasurement of blood in aspiration bottles. Itcan be taken that i gm. = i c.c. of blood. Swabweighing in lots of io is the best method and,while the estimate of i gm. - i c.c. is not quiteaccurate, it is adequate to use as a basis for bloodreplacement.

(ii) It is unnecessary to perform a rib resection

at thoracotomy. The only time this is necessarv i8when doing a thoracoplasty. There is no otherthoracic operation which requires rib resection.The best approach is through the periosteal bed ofthe rib required. After this has been effected theback end of the rib should be divided and i in.resected; this prevents apposition of the ends andthus lessens pain. The reasons for avoiding a ribresection are that it is completely unnecessary andit makes for a much more painful post-operativecourse. There is little doubt that patients whohave had the intercostal nerve removed have amuch less painful post-operative course than thosein whom it remains, and hence it is desirable thatthe intercostal nerve be taken proximal to the ribdivision.

(iii) Before the endo-bronchial tube is removed,complete suction should be carried out via thetube, and if this is found not to be complete, thenthe patient should be bronchoscoped.

(iv) The patient, before leaving the theatre,should be breathing on his own and coughing atrequest. This should be the routine and not theexception.

(v) With few exceptions, all thoracotomiesshould have drainage on to an under-water seal.The tube should be of adequate size which willdrain fluid and air easily. The tube is insertedthrough a stab incision in the lower intercostalspace. This incision should be made long enough,so that the tube is not causing pressure on the skin,or else it will be painful. In those cases of pul-monary resection the tube, while inserted basally,is brought up to the apex. This siting of the tubemakes it much more efficient for the drainage of airand fluid. A tube in this position rarely becomesblocked. Any residual fluid at the base can easilybe obtained by tipping the end of the bed, layingthe patient flat and putting gentle suction throughthe under-water system. Oesophageal cases havea basal tube which is quite adequate.

(vi) Pneumonectomies are an exception anddrainage is unnecessary. If the patient is operatedon in the lateral position, when he is turned on tohis bed the intrapleural pressure must be stabilizedto atmospheric, and if a Maxwell box is not ava,able do this with a wide-bore needle insertdthrough an intercostal space, preferably the sEodanteriorly. This will stabilize the pleural pres6 resto atmospheric if it is left in while the patient taesseveral breaths.

(vii) The chest should not be closed until thelung is seen to be fully expanded.

(b) In the Ward-ImmediateThe patient should have a half-hourly blood

pressure recording and the drip is discontinuedwhen the pulse rate and the blood pressure readings

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are satisfactory. When these readings are satisfac-tory the patient can be slowly sat up. There areexceptions to this routine, but very few. In cardiaccases it might be desirable to leave the patient lyingsupine longer than in pulmonary or oesophagealcases. In all cardiac cases the pulse rate alone is notadequate, as this will not reveal whether there is apulse deficit present or not, and a chart should bekept of the apex beat as well as the pulse rate.

While most cases are nursed in a semi-recumbentor sitting position, there are exceptions to this. Inlobectomies and segmental resections it is a goodpractice to nurse the patient on his side with thegood side down. The advantages of this are thatthere is good bronchial drainage from the operatedside and the costo-phrenic angle is kept free offluid, so that there cannot be any obliteration ofthe costo-phrenic sulcus and thus subsequent im-pairment of fupction on the operated side.The relief of pain is important. The patient who

has pain cannot cough and cannot co-operate. Hispain should be relieved forthwith. There is nocontraindication to the use of morphine deriva-tives. Coughing is an active spontaneous actionand nothing will kill the patient's spontaneity morethan pain. It is essential for the nurse or thephysiotherapist to realize when the patient hasbronchial secretions which need to be coughed upand to try to get the patient to indulge in vigorouscoughing. The patient must be aided by havinghis chest firmly supported (Fig. i). However,when the patient is suffering intense pain the firstduty of the doctor or the nurse is to relieve the painand then to encourage the patient in his expec-toration.The under-water drainage should be checked

and it should be seen that it is swinging and thatit is not blocked. In the early post-operative coursethe commonest cause of block is by the patientlying on it. It is also important that the under-water drainage bottle be kept in a tin with sand inthe bottom, so that it cannot be kicked over. Abottle being kicked over and broken in the nightcan cause a patient's death by a total pneumothorax.

In this immediate phase the patient should bevisited by the physiotherapists, and in a unit whichis carrying out thoracotomies this should be asmuch a routine as the recording of the patient'sblood pressure. Sometimes a patient becomespanicky, but with a hand on the abdomen thepatient will steady down and control his respira-tion, and this is where the importance of goodpre-operative training pays its dividends. Ifsecretions are present, the patient should be en-couraged to cough and he should cough until hehas lifted his secretions. The only important aspectof this post-operative period is to make sure thepatient is not retaining bronchial secretions, and

both the nurses and the physiotherapists should beon the constant look-out for this and encourage thepatient to clear his bronchial tree of anyobstruction.

Full arm movements should be gone throughwithin two hours. There is little doubt that if afull range of movement is gone through within twohours, and is repeated several times in the next 24hours, there will be no trouble. But it is muchmore difficult to get a patient to go through fullarm movements if this initial action is delayed for24 hours.

(c) Intermediate PeriodDuring the whole of the post-operative period

the patient should clear himself of any bronchialsecretions and this is not a manoeuvre whichshould be indulged in just in the immediate periodand then forgotten about. It should be persistedwith until the patient leaves the hospital. It isdesirable to remove the under-water drainage asquickly as possible, as this renders the patientimmobile and it is often uncomfortable and oftenpainful. Most cases should have the tube removedon the following day, but this is not always possible,particularly after segmental resections, where theremay be an air leak which persists for some days.If after segmental resection or lobectomy air leakdoes persist, it is better to change the big basaltube after three days and insert a small apical tube,as most drainage will have ceased by now and thetube is merely there to remove air. The wholeobject of post-operative thoracic care is to closethe pleural space. Of course, this is quite im-possible after a pneumonectomy, as there is nothingto close the pleural space with, but with this oneexception the pleural space should be closed. Aclosed pleural space is a safe pleural space, and anopen space is a potential danger. The factors whichkeep a pleural space open are: (i) atelectasis, (ii)air in the pleura, and (iii) sero-sanguinous effusion.These will be discussed in detail. In a pneu-monectomy aspiration may be necessary if medi-astinal shift is occurring. This can readily be seenon the X-ray, but is often apparent clinically, as adeviation of the trachea to the contralateral side isapparent and the patient may be complaining ofincreasing dyspnoea.

(i) Atelectasis. Prevention is better than cure, andthe rate of atelectasis following a thoracotomy is adirect reflection on the standard of physiotherapyand nursing, but even with the highest standardsatelectasis will still occur intermittently. Atelectasismay not always be recognized clinically by thedoctor, the physiotherapist or the nurses, but itshould be picked up on the X-ray, and that is whyit is essential that all these cases have daily X-rays.Frequently it should be picked up by the house

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FIG. i.-The photograph illustrates a patient in bed being coughed after decortication. Effective coughingcannot be carried out unless the operated side is supported firmly, as is shown in the photograph. Thecoughing, to be effective, must be done in short bursts so that the patient is not tired easily.

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FIG. 2.-Shows a post-operative X-ray where everything is wrong. There is a hydro-pneumothorax and someatelectasis. This patient was handled by being bronchoscoped first of all and then the air and fluid were removedby aspiration. It is important that bronchoscopy be carried out prior to aspiration, as the lung cannot beexpanded if there is a central block, and if the pleura is aspirated with a central block the high negative pressureobtained tends to impact the mucus plug further.

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December I 957 CHIN: Special Care After Thoracotomy 617

staff or the physiotherapists or nurses. There isno place for laissez-faire and letting atelectasis lookafter itself. It must be treated energetically. Theimmediate handling should be conservative, inthat the patient is given an inhalation and is putinto the hands of the physiotherapists, when thepatient is coughed vigorously and tipped. If thisfails to relieve the bronchial obstruction, then thepatient must be bronchoscoped. There is no needto bring the patient to the theatre to do this. It isquite a simple matter to bronchoscope the patientsitting up in bed. Once the atelectasis is eradicatedthere is a tendency for it to recur owing to oedemaof the bronchial mucosa, and coughing should becontinued and the patient given bronchodilators.The whole manoeuvre may have to be repeatedsubsequently and once the vicious circle of re-curring atelectasis is set up it may be difficult tobreak, because it results in pulmonary infection,an increase in the pulmonary secretions and anincrease in the oedema of the bronchial mucosa.

(ii) Air in the Pleura. If the post-operativeX-ray shows a pneumothorax, then the under-water drainage should be connected to continuoussuction and a Roberts suction pump is a veryadequate form of continuous suction. Suctionmust be continued until there is no escape or air.Once this has ceased, then the pump cau be dis-continued and the tube removed only after it hasbeen left in for a further I2 hours and X-ray showsthat there is no re-accumulation of air.

(iii) Sero-sanguinous Effusion. The daily post-operative X-rays will show whether there is anyeffusion present or not and any effusion should beaspirated. The best means of aspiration is by aMartin's syringe, which has a three-way tap withbayonet fittings and will allow no air to enter thechest. The chest should be aspirated to dryness.

It will be seen from the above paragraphs thatit is essential that these patients should be X-rayed

daily post-operatively until the pleural space iscompletely clear, and then they should have checkX-rays every two or three days until they are readyfor discharge. All patients are got up as quickly aspossible, and even if it is found necessary to retaintheir intercostal tube, it is still desirable to getthem out of bed into a chair. In the immediatepost-operative phase a rocking chair is the bestsort of chair, as it allows the patient to exercise hislimbs and thus cuts down the incidence of pul-monary embolism. Patients are encouraged to getfully dressed once their tubes are out, and to walkaround. The fact that they are walking about anddressed does not mean that they cannot get post-operative complications and they still should bewatched very carefully and the daily X-ray shouldbe checked for atelectasis and effusion.To summarize, basicallv the essence of post-

operative care in thoracotomy cases is to obliteratethe pleural space, and this applies to segmentalresection, lobectomy, oesophagectomy, repair ofhiatal hernia, vagotomy, sympathectomy, cardiacoperation, and, indeed, any operation whichdemands a thoracotomy. While many operationspresent peculiar problems of their own (forexample, oesophagectomy demands the handling ofother features, such as the fluid balance of thepatient and a careful watch for paralytic ileus, andcardiac operations demand careful watch forarrhythmias and cardiac failure), a common factorin all these is to prevent pulmonary atelectasis, toprevent' the accumulation of air and fluid in thepleural space and to obliterate the pleural space,as an obliterated pleural space is a safe pleuralspace. Fig. 2 shows every undesirable feature.Combined with atelectasis there exists a hydro-pneumothorax. In such a case bronchoscopyshould be performed and after the bronchus blockhas been removed then the air and fluid completelyaspirated.

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