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PHTY3250 > L11: Thoracic Surgery > Flashcards

L11: Thoracic Surgery Flashcards

1
Q

What are the 8 types of thoracic surgery?

A
  1. Lung biopsy
  2. Wedge resection
  3. Lobectomy
  4. Pneumonectomy- Removal of whole lung
  5. Talc pleurodesis- Stick lung open after collapse (usually for recurrent collapse)
  6. Lung Volume Reduction Surgery (LVRS)- For emphysema (take out of hyperinflation of lungs)
  7. Lung Transplantation
  8. Pulmonary Thromboendarectomy- Removal of blood clot in lung
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2
Q

What are the 4 surgical incisions? What are the surgeries?

A
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3
Q

What is the

A

Inserting a long, thin tube (videoscope) with a camera attached and small surgical instruments into your chest through small cuts made between your ribs

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4
Q

What is lung biopsy? What are the indications?

A

Is where a small piece of tissue is removed for a diagnostic test

Indications

  1. To provide a specific diagnosis or to assess disease activity
  2. For example:
    • To investigate suspected neoplastic (cancerous) or infectious processes (eg. fungal)
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5
Q

What are the indications of lung biopsy?

A

To provide a specific diagnosis or to assess disease activity

For example:

  • To investigate suspected neoplastic (cancerous) or infectious processes
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6
Q

What are 2 procedure types of lung biopsy?

A
  1. Fine needle biopsy
  2. Surgical lung biopsy
    1. Either by an open thoracotomy or videoassisted thoracotomy lung surgery (VAT)
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7
Q

What is a transbronchial lung biopsy?

A

Using a fibre optic bronchoscopy

Eg used to confirm possible rejection post lung transplant

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8
Q

What does a wedge resection VS lobectomy VS pneumonectomy look like?

A
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9
Q

What are 4 characteristics of wedge resections (or segmentectomy)?

A
  1. Is where a small wedge-shaped piece of lung is removed
  2. Typically to remove a contained lung cancer with a small margin of healthy tissue around the cancer
  3. Should have little effect on the person’s lung function
  4. Higher risk of lung cancer recurring

The smaller amount removed –> high risk of relapse (not getting all of the cancerous tissue)

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10
Q

What are 2 characteristics of lobectomy?

A
  1. Is where the entire lobe of the lung is removed
  2. Should still have little effect on the person’s lung function
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11
Q

What are 3 characteristics of pneumonectomy?

A
  1. Is the surgical removal of one lung
  2. Most frequently for management of bronchogenic carcinoma
  3. Rarely performed for pulmonary metastases & other benign lung diseases such as:
    1. Inflammatory lung disease eg bronchiectasis
    2. Traumatic lung disease
    3. Congenital lung disease
    4. Bronchial obstruction with a destroyed lung

Very uncommon and can have significant effect

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12
Q

What are 3 characteristics of day 1 post op pneumonectomy?

A

Immediately postsurgery

  1. Air fills the space previously occupied by the lung
  2. A chest tube may not be inserted following surgery
  3. Trachea is in the midline
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13
Q

What are 2 characteristics of day 5 post op pneumonectomy?

A

Over time fluid accumulates into the air space (previously occupied by the lung)

  1. Fluid fills at approx. 2 rib spaces per day
  2. At 2 wks – 80-90% of the
  3. space is filled with fluid
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14
Q

What are 4 anatomical changes of pneumonectomy?

A
  1. Decreased size of postpneumonectomy space (PPS)
  2. Elevated hemidiaphragm
  3. Hyperinflation of remaining lung
  4. Mediastinal shift to PPS
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15
Q

What is the consequence of mediastinal shift & elevation of the hemidiaphragm in pneumonectomy?

A

Location of vital organs (including the heart & great vessels, liver & spleen) changes as a consequence of the mediastinal shift & elevation of the hemidiaphragm

  • Eg (R) Pneumonectomy
  • Heart moves into vacant pleural space
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16
Q

What is the mortality for pneumonectomy?

A

30 day mortality quoted between 2.4 - 11.6% (for elective surgery)

  1. Right sided pneumonectomy has a higher mortality
  2. Affected by a person’s co-morbidities
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17
Q

What are the 3 possible complications of pneumonectomy?

A
  1. Pulmonary oedema
  2. Post-pneumonectomy syndrome (compression of trachea/main bronchus)
  3. Pleural space problems (eg empyema)
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18
Q

What are the 2 affects of pulmonary function of pneumonectomy?

A
  1. Forced expiratory volume in one second (FEV1) & forced vital capacity (FVC) decreased
    • Usually by less than 50%
  2. Gas diffusion capacity (DLCO) is decreased
    • Usually by less than 50%
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19
Q

What is the consequence of pneumonectomy?

A

Diminished levels of physical function, dyspnoea & quality of life

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20
Q

What are 2 ways to perform is a Talc Pleurodesis?

A
  1. Medical procedure through the chest drain
  2. Surgical procedure via a mini-thoracotomy
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21
Q

What are 2 characteristics of Tal Pleurodesis?

A
  1. Used to “stick” open a lung following a persistent or recurrent pneumothorax or pleural effusion (eg malignancy)
  2. Recovery/ management as per other minor thoracic surgery
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22
Q

What are 4 medical management of thoracic surgery?

A
  1. Pre-operative management
  2. Post-operative management
  3. Chest drains
  4. Common complications
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23
Q

What are the 3 pre-operative of medical management of thoracic surgery?

A
  1. Assess suitability for surgery
  2. Hospital admission
    1. Obtain full medical/surgical/social history
    2. Medically fit for surgery
  3. Informed consent
    1. Written consent
    2. Explain risks
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24
Q

What are the 5 post-operative of medical management of thoracic surgery?

A
  1. Medications
    • Pain relief , antibiotics, etc
  2. Manage/monitor recovery
    • Chest x-rays, ECG’s, blood tests
    • Wound healing
  3. Chest drains
  4. Manage complications
  5. Discharge planning
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25
Q

What is a chest tibe in medical management of thoracic surgery?

A

Is used after lung surgery to drain air, fluid and blood out of your chest cavity

  • Helps promote reexpansion of lung
26
Q

What are 4 proper function of inter-costal catheter (ICC) for chest tubes as medical management of thoracic surgery?

A
  1. Swinging - eg rises with inspiration
  2. Bubbling – if continuous/ rapid 􀃆 large air leak
  3. Draining – observed in collection part/bottle
  4. ? Suction – to promote drainage
27
Q

What are 4 safety of chest tube as medical management of thoracic surgery?

A
28
Q

What are 7 characteristics of chest tubes as medical management for thoracic surgery?

A
  1. Is used after lung surgery to drain air, fluid and blood out of your chest cavity
    • Helps promote reexpansion of lung
  2. Proper function of Inter Costal Catheter (ICC)
    1. Swinging - eg rises with inspiration
    2. Bubbling – if continuous/ rapid 􀃆 large air leak
    3. Draining – observed in collection part/bottle
    4. ? Suction – to promote drainage
  3. Safety
    1. Keep bottle below insertion level into patients chest wall
    2. If ICC dislodged from chest wall apply pressure
  4. Suction – may be on wall suction to help drainage/ lung “stick open”
    1. Check with medical team if not sure about disconnecting
    2. Can use portable suction to mobilise patient
  5. Correct placement/ insertion – often checked by Xray
  6. Removal – once drainage of fluid/blood has slowed +/- air leak has stopped
  7. Handling
29
Q

What doe wall suction look like?

A
30
Q

What is the chest tube in a pneumothorax for medical management?

A
31
Q

What is the chest tube in a pleural effusion for medical management?

A
32
Q

Chest drains or Intercostal catheter (ICC)

  • Radio-opaque on X-ray
  • How many chest drains do you see?
A

4

33
Q
A
  1. Anaesthesia → Decreased ventilatory drive, monotonous breathing, decreased gas exchange
  2. Restrictive reduction in lung volumes (drowsiness, pain, altered chest wall dynamics)
  3. Decreased Functional Residual Capacity
  4. Atelectasis
  5. Slowing of mucociliary clearance
  6. Secretion retention/ painful cough
  7. Abnormalities in gaseous exchange
  8. Impaired surfactant production and sigh mechanism
  9. Diaphragmatic dysfunction
  10. Removal of lung tissue
  11. Lung deflation
  12. Chest drains in situ/ chest wall incision (once chest drains are out –> more freedom to move)
  13. Integrity of lung tissue remaining
  14. Enforced immobility/ supine positioning
  15. Preoperative status – older, exisiting cardiopulmonary disease, smoking history
  16. Leads to: Susceptible to development of pulmonary infection, pneumonia, hypoxaemia & respiratory failure
34
Q

What are 8 common complications for medical management of thoracic surgery?

A
  1. Post-operative bleeding – if severe re-open
  2. Respiratory failure
  3. Bronchopleural fistula- Spaces where infections can occur
  4. Empyema- Infection in lining of lung
  5. Pulmonary embolus
  6. Pneumonia
  7. Myocardial infarction
  8. Cardiac arrhythmia (especially atrial fibrillation
    1. Usually have ECGs attached
35
Q

What are 5 physiotherapy amended post opertaive pulmonary complications?

A
  1. Atelectasis
  2. Sputum retention
  3. Respiratory infections
  4. Respiratory failure
  5. Exacerbation of underlying chronic lung disease
36
Q

What are 4 non-physiotherapy amended post opertaive pulmonary complications?

A
  1. Pleural effusion
  2. Pulmonary embolus
  3. Pneumothorax
  4. Pulmonary oedema
37
Q

What are 5 physiotherapy management of thoracic surgery?

A
  1. Pre-operative
  2. Interpret available information
  3. Subjective assessment
  4. Objective assessment
  5. Treatment & discharge planning
38
Q

What are 6 post-operative physiotherapy management of thoracic surgery?

A
  1. Obtain medical history including smoking history, previous surgical & medical history
  2. Assess patient’s chest
    • Basal expansion, auscultation & cough
  3. Assess patient mobility & any limitations in limb movement (esp. walking)
  4. Frailty considerations
  5. Educate patient on physio’s role post-op
  6. Teach breathing exercise techniques
39
Q

What are 7 available information in post-operative physiotherapy management of thoracic surgery?

A

Interpret available information

  1. Medical chart - Operation notes, post-op orders, initial recovery, interpret medical history & likely effects on surgery/recovery
  2. Bed chart – Vital signs, medications
  3. Other - Chest X-rays, ECG, Arterial blood gases
  4. If concerned liaise with senior physiotherapist, medical/surgical team, nursing staff
  5. Ward rounds, work unit guidelines, etc
40
Q

What are 5 subjective assessment in post-operative physiotherapy management of thoracic surgery?

A
  1. Pain – is it well controlled (ie able to take a deep breath & cough), where is it?
  2. SOB – at rest & on exertion, how is their breathing?
  3. Cough – are they producing any secretions? Can they clear them?
  4. Ascertain activity level – are they doing their breathing exercises? have they just mobilised?
  5. This will enable you to direct your objective assessment/ treatment
41
Q

What are 8 objective assessment in post-operative physiotherapy management of thoracic surgery?

A
  1. Interpret vital signs including:
    1. Level of consciousness
    2. Oxygen requirements & delivery method
    3. Heart rate & rhythm
  2. Be aware of & understand attachments
    1. Chest drains, ECG leads, presence of a urinary catheter, intravenous line (peripheral or central access), pacemaker & pacing wires
  3. Surgical incision
  4. Assess breathing pattern
    1. Are they able to take a deep breath?
    2. Is their breathing pattern guarded or restricted?
    3. Assess their breathing pattern/ basal expansion?
  5. Auscultation
    1. Anteriorly & if possible posteriorly
  6. Huffing/coughing ability
    1. Is it effective or affected by pain?
    2. Are the secretions sticky &/or discoloured?
  7. Bed mobility & positioning
    1. Are they slumped in the bed?
    2. Can they sit up or do they need assistance?
    3. Transfers & mobility
  8. Can they transfer independently or do they need assistance?
    1. Are they dizzy, light headed or nauseous?
    2. How far can they walk?
    3. What about all the attachments & equipment?
42
Q

What are 4 treatment in post-operative physiotherapy management of thoracic surgery?

A
  1. Breathing exercises
    1. Basal expansion exercises
    2. Staged basal expansion exercises
    3. Incentive spirometry
  2. Limb exercises – demand ventilation, circulation exercises, regaining range of movement & muscle strength
  3. Airway clearance – effective huff/cough, may need more specific techniques
  4. Mobility as appropriate
    1. Change of position - effect on breathing pattern
    2. Sitting out of bed (SOOB)
    3. Mobilise – number of people needed to mobilise person plus carry the equipment
      1. What equipment can be disconnected?
      2. What equipment needs to be taken?
      3. What mobility aid is required?
      4. Where is the walk heading? Move equipment out of the way or position a chair where you are planning to go.
43
Q

What equipment needs to be taken?

A
44
Q

What are 5 re-assessment in post-operative physiotherapy management of thoracic surgery?

A
  1. Response to intervention such as improved oxygen saturation &/or gas exchange
  2. Better breathing pattern?
  3. Are they improving?
  4. Can they be progressed next treatment?
  5. No adverse response to treatment?
    • If so who do you notify or discuss this with?
45
Q

What are 6 discharge planning in post-operative physiotherapy management of thoracic surgery?

A
  1. Independently mobile
  2. Safe on stairs
  3. Home exercise program
    • Graduated walking program & limb exercises
  4. Discuss return to activity
    • Usually institutional guidelines
  5. Referral to community services
    • Do they need on going physiotherapy care?
  6. Require referral to pulmonary rehabilitation?
46
Q

What are the 3 characteristics of Lung Volume Reduction Surgery (LVRS)?

A
  1. Conventional LVRS: Involves resection of the most severely affected areas of emphysematous, non- bullous lung (aim for 20-30%)
  2. Can improve lung elastic recoil and diaphragmatic function
    • Aim to deflate the hyperinflated lungs
  3. Incision: Mini-thoractomy
47
Q

What are the 2 complications of LVRS?

A
  1. Mortality at 90 days was 1.8% & Survival at 3 and 5 years 91.1% and 76% respectively
  2. Prolonged air leak
  3. Mean duration post surgery until all ICC’s removed is 10.9 ± 8.0 days
48
Q

What are the 4 medical management of LVRS?

A
  1. Assessing suitability for LVRS
    1. Confirm severity of diagnosis & presentation
    2. Screen for co-morbidities
  2. Surgery – Thoracic surgeon
  3. Manage recovery & complications
  4. Long term follow-up on an outpatient basis
49
Q

What are the 5 physiotherapy management of LVRS?

A
  1. Pulmonary (exercise) rehabilitation is considered essential pre & post LVRS
  2. Breathing retraining
  3. Mobility
  4. Thoracic mobility
  5. Muscle strengthening
50
Q

What are 2 experimental medical management of LVRS?

A
  1. Endobronchial approaches to create artificial airways with stents (Gas trapping)
  2. Trialing steam
    • Current trial for people unsuitable for conventional LVRS
    • Benefits/ outcomes are being investigated
51
Q

What are 3

A
  1. This techniques uses a one way valve delivered through a bronchoscope
  2. Pulmonary EBV – unilateral approach
  3. Olympus EBV – bilateral approach
52
Q

What are the 4 steps of Bronchial Thermal Vapour (Steam) Ablation?

A
53
Q

What are the 3 conditions suitable for a lung transplantation?

A
  1. Chronic, end-stage lung disease
  2. Who are failing optimal maximal medical therapy, interventional and surgical treatment
    • Or for whom no effective medical therapy exists
  3. Poor quality of life, potentially with intractable symptoms and repeated hospital admissions
54
Q

What are 2 musts for potential candidates for lung transplantation?

A
  1. Be well informed and demonstrate adequate health behaviour
  2. Have a willingness to adhere to guidelines from health care professionals
55
Q

What are 9 post-operative challenges of lung transplantation?

A
  1. Denervated
  2. Impaired mucociliary escalator
  3. Poor cough reflex
  4. Impaired lymphatic drainage
  5. Location - exposure to inhaled material
  6. Higher immunosuppression
  7. Chronic Lung Allograft
  8. Dysfunction (e.g. common phenotype is Obliterative
  9. Bronchiolitis
56
Q

What is the early physiotherapy management of lung transplantation?

A
57
Q

What are 3 characteristics of Pulmonary Thromboendarectomy?

A
  1. Operation that removes organized clotted blood (thrombus) from the pulmonary arteries
  2. Treatment for chronic thromboembolic pulmonary hypertension induced by recurrent/chronic pulmonary emboli
  3. Requires a full cardiopulmonary bypass, deep hypothermia and full cardiac arrest to perform surgery
58
Q

What is the Sample Patient Pathway post Thoracic Surgery: Day 1 post?

A
  • Assess patient, note:
    • Extubated, Stable on 2L/min O 2 (if unstable possibly in ICU)
    • 1 x chest drain, Telemetry
    • PCA for pain relief
    • Breath sounds over remaining lung areas
    • Productive cough
  • Treatment (2 X treatment)
    • Deep breathing exercises /Incentive spirometry
    • Huff/cough
    • Lower limb exercises
    • Mobilise x 2 assist approximately 15-30m 1 st walk
    • Sit out of bed
59
Q

What is the Sample Patient Pathway post Thoracic Surgery: Day 2-3 post?

A
  • Assess patient, note:
    • 1 x drain in-situ (may be removed during day)
    • PCA (removed when drains removed)
    • Stable on Room air or 2L/min O2, less productive cough
  • Treatment (1xtreatment ± 1xreview):
    • Deep breathing exercises /Incentive spirometry
    • Huff/cough
    • Lower limb exercises
    • Mobilise x 2 assist approximately 30-150m
    • Sit out of bed
60
Q

What is the Sample Patient Pathway post Thoracic Surgery: Prior to D/C post?

A
  • Assess patient, note:
    • Chest clear breath sounds, Dry cough
    • ICC removed, off telemetry
    • Mobilising around ward independently
    • Possibly home later today or tomorrow
  • Treatment (1xsession):
    • Home exercise program
    • Stair test
    • Referral for pulmonary rehabilitation
    • Discharge from physiotherapy

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