thoracic surgery tute [compatibility mode]

8/2/2019 Thoracic Surgery Tute [Compatibility Mode]

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COMMONWEALTH OF AUSTRALIA

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Thoracic Surgery

Carla Gordon, [email protected]

Thoracic Surgery

Lung resection surgery.

Lung volume reduction surgery (LVRS).

Lung biopsy, video assisted thoracic surgery(VATS).

Pleural surgery.

Chest wall surgery.

Mediastinal surgery. Chest trauma surgery.

Cardiac surgery.

Organ transplantation.

Lung Resection Surgery

Indications

Sequestrated lobe.

Benign tumours.

Bronchiectasis Poorly controlled frequent exacerbations.

Lung Carcinoma

Video Assisted Thoracic

Surgery

Four 1 inch incisions are made.

A video scope which projects the image ontoa screen is inserted.

Enables biopsies, wedge resections andsimple pleural procedures to be performed.

Patient will still have an ICC and UWSD insitu post-operatively as the pleural cavityis entered.

Thoracic Surgery Incisions Thoracotomy

Most common. Posterolateral

From vertebral border of the

scapula following the line ofthe 6th rib.

Anterolateral Along a rib line from near midline anteriorly to the posterior

axillary line.

Sternotomy Clam shell Thoraco abdominal Mini thoracotomy


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Lobectomy Excision of one (or two) entire lung lobe(s).

Most common form of lung resection

If metastatic lung Ca, hilar lymph nodes mayalso be excised.

Segmental resection

Excision of one or more of the 10 bronchopulmonary segments.


Sleeve resection Removal of a section of bronchus (usually

with lobectomy).

Primary bronchial re-anastomosis to preserve

remaining lung tissue.

Wedge resection Excision of a small wedge shaped section of

lung tissue (usually for biopsy or a small non-

malignant tumour).

Lung Resection

Surgical Procedure

Posterolateral incision most commonly used: .

Muscles incised include latissimus dorsi, serratusanterior, trapezius, rhomboids, intercostals.

Removal of lung tissue and suture bronchi.

Test lung for air leaks.

Insertion of intercostal catheter

Usually two

Basal for predominately drainage of haemo serousfluid.

Apical for drainage of air.

Post-operative Management

ICCs on UWSD (usually with suction) until anyair leaks have resolved, up to 7 days.

Analgesia Narcotics: IM, IV (infusion or PCA).

Epidural.

Intercostal nerve blocks.

Oral narcotics e.g. morphalgin. Oral simple analgesics (e.g. panadeine forte).

PR (often NSAIDs).

Oxygen.

Fluids, medications.

Complications

Pulmonary

Atelectasis, sputumretention, respiratorydepression.

Persistent air leak.

Stump break down.

Bronchopleural fistula.

Empyema.

Diaphragmaticparalysis.

Wound dehiscence.

Surgical emphysema.

Cardiovascularinstability.

Blood loss.

Analgesia side effects

Nausea/vomiting.

Urinary retention.

Hypotension.

Physiotherapy

Pre operative Subjective information as for general surgery.

Physical examination As for general surgery, only particular attention to trunk and

UL ROM.

Treat existing lung issues (commonly occur).

Advise patients on bed mobility: inabili ty to push downwith effected UL, need to bottom shuffle up the bed.

Advise patients on post-operative exercise routine Early mobilisation and SOOB (within limitations of ICC, UWSD

and suction).

Deep breathing, supported cough/huff.

Foot and ankle exercises.

UL exercises.


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Physiotherapy

Post-operatively Thorough assessment and treat as per findings

and problem list. Positioning: Specific deep breathing exercises: Mobilisation:

Bed mobility. Early sitting out of bed and early ambulation (MOS,

walking, stairs). Upper limb / thoracic cage exercises

Elevation to point of discomfort.

Posture re-education.

Patient Case

A 35 year old, Day 3 post left lower lobectomy via left postero-lateral

thoracotomy incision for cavitating abscess. Current history: History of non resolving pneumonia, asymptomatic until 6

months ago. Investigations revealed abscess. Smoker - 15 per day for 15 years No other respiratory history. Past History: IV drug user, Hep C positive. Medication: Methadone Post-operative A ssessment:

Two ICCs connected to UWSDs in situ. Attached to 20cmH2O of suction. PCA - morphine infusion (no background infusion) 1mg/activation, 5 minute

lockout, maximum 5mg/hr. Patient has used PCA 15 times in last 30 minutes. Subjective Assessment: Complaining of intense pain, reluctant to move. Physical Examination

Patient looks unwell, gray, sweaty, restless Vital observations BP 110/60 Temp 38.5C RR 30 breaths/min HR ST120 ABG's pH 7.34 PaO2 55 PaCO2 48 SaO2 82% HCO3 26 BE +1 on 35% O2 Now on 60% O2 via mask and fisher & paykel humidifier, with SpO2 of 97% CXR signs of patchy collapse & consolidation both lung fields (L) > (R). Breathing pattern marked use of accessory muscles, upper chest movement,

decreased basal expansion (L) > (R) Auscultation: decreased breath sounds (R) and (L) base, more marked on (L).

scattered crackles throughout (L) lung Cough: weak, moist

Measures Used in Assessment

Premorbid exercise tolerance SOB

On exertion

Orthopnea, PND.

Respiratory medications Social History Sputum production (Premorbid and current)

Reassessment SpO2 Cough

Auscultation Breathing pattern (?)CXR

Problem List

1. Pain

2. Sputum retention

3. Decreased ventilation

4. Increased WOB

Respiratory failure

Acidotic, hypoxic and hypercapnic

Special Considerations

Febrile INFECTION!

Also increased HR and RR (note: may also relate to pain andanxiety).

IV drug user Analgesia issues

Hep C positive Universal precautions

Possible psychosocial issues

Restless and unwell Cooperative ?

Pneumonectomy

Removal of an entire lung.

Presents as a restrictive disorder post-operatively.

Surgery & post-operative orders

As for lobectomy, except

Only one ICC, which is clamped.

The patient must NOT cough when the ICC is notclamped.

Huffing preferred to coughing to protect

the stump.


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Pneumonectomy

Haemo serous fluid collects within the hemi-thorax while remaining air is absorbed.

ICC clamp is removed for 1-2 min every hour tocontrol rate of fluid accumulation as per surgeonsorders. Prevents mediastinal and tracheal diversion.

Fluid begins to fibrose over the month post-operatively.

By 2-3months the CXR shows an opaquehemithorax, crowded ribs, elevatedhemidiaphragm and mediastinal shift to thepneumonectomy side.

Pneumonectomy Physiotherapy management

As for lung resection surgery.

However note that the ICC should NOT bedraining.

Contraindications/precautions: Positioning

Side lying on non-thoracotomy side Bronchial stump may be bathed in fluid and potentiate

stump break down.

Suctioning Trauma to the bronchial stump.

Lung Volume Reduction Surgery(LVRS)

Surgery Median sternotomy or clam shell. Suturing or stapling of bullae. Approximately 1/3 of the lung removed. Two ICC on each operative side.

Indications COPD, particularly with hyperinflation and lung bullae.

Apical bullae.

Proposed mechanism of improvement Removes areas of V/Q mismatch. Recruits regions of healthy lung tissue. Restores respiratory muscle dynamics.

Lung Volume Reduction Surgery

(LVRS) Specific Selection Criteria

Age < 70 years.

Non-smoker > 3 months.

Compliant with exercise program e.g. pulmonaryrehabilitation.

Lung function FEV1 15-40% predicted.

RV > 150%.

DLCO > 30% predicted.

PaCO2 < 55 mmHg.

PAP < 50 mmHg.

Exercise tolerance 6mwt distance > 150m.

Lung Volume Reduction Surgery

(LVRS) Post operative medical management


Often persistent air leak

ICCs may stay in situ for up to 10 days.

Complications


Physiotherapy

Thorough assessment pre operatively.

Functional status, exercise tolerance, lung status, compliancewith exercise routine.

Patient will often be included in a pre-operativepulmonary rehabilitation.


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Lung Volume Reduction Surgery(LVRS)

Physiotherapy Post operatively

As for lung resection.

Addition of breathing control for dyspnea.

Pulmonary rehabilitation.

Contraindications Manual hyperinflation.

Precautions Oxygen therapy: hypoxic drive.

High levels of intermittent positive pressureventilation, invasive and non-invasive.

Pleurodesis

Indications

Recurrent pneumothorax.

Recurrent pleural effusion.

Empyema.

Pleural cancer e.g. mesothelioma.

Closed pleurodesis

Chest drain or VATS.

Chemical irritation of pleura.

Two ICCs on UWSD suction postprocedure.

Pleurodesis

Open (Scrub) Pleurodesis orPleurectomy

Anterior thoracotomy.

Scrub Pleurodesis

Abrasive irritation of the pleura.

Pleurectomy

Partial stripping of parietal pleura.

Two ICCs on UWSD suction post procedure.

Mesothelioma

Arises from the mesothelium lining of theserous membrane of the pleura.

Also can occur on pericardium and peritoneum.

Highly malignant and aggressive.

Usually attributable to asbestos exposure.

20-30 year development time. Locally infiltrative (uncommon to find

malignancies).

Mesothelioma

Presents as pleural effusion pleuralthickening.

S + S = SOB and a dry painful cough.

Treatment

Pleurectomy and debulking decortication(removal of pleura).

Radiotherapy and/or chemotherapy.

Pleural Surgery

Post-operative medical and physiotherapymanagement, complications, andcontraindications/precautions are as for alung resection surgery.


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Mediastinal Surgery

MediastinoscopyVideo assisted surgery examining the

mediastinum.

Two small incisions are made superior to thesternoclavicular joints.

Lymph node excision/biopsy.

Examination of the trachea and great vessels.

No ICC needed post-operatively as the pleural

cavity is not entered.

thoracic surgery tute [compatibility mode]

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