L11: Thoracic Surgery Flashcards
What are the 8 types of thoracic surgery?
- Lung biopsy
- Wedge resection
- Lobectomy
- Pneumonectomy- Removal of whole lung
- Talc pleurodesis- Stick lung open after collapse (usually for recurrent collapse)
- Lung Volume Reduction Surgery (LVRS)- For emphysema (take out of hyperinflation of lungs)
- Lung Transplantation
- Pulmonary Thromboendarectomy- Removal of blood clot in lung
What are the 4 surgical incisions? What are the surgeries?
What is the
Inserting a long, thin tube (videoscope) with a camera attached and small surgical instruments into your chest through small cuts made between your ribs
What is lung biopsy? What are the indications?
Is where a small piece of tissue is removed for a diagnostic test
Indications
- To provide a specific diagnosis or to assess disease activity
- For example:
- To investigate suspected neoplastic (cancerous) or infectious processes (eg. fungal)
What are the indications of lung biopsy?
To provide a specific diagnosis or to assess disease activity
For example:
- To investigate suspected neoplastic (cancerous) or infectious processes
What are 2 procedure types of lung biopsy?
- Fine needle biopsy
- Surgical lung biopsy
- Either by an open thoracotomy or videoassisted thoracotomy lung surgery (VAT)
What is a transbronchial lung biopsy?
Using a fibre optic bronchoscopy
Eg used to confirm possible rejection post lung transplant
What does a wedge resection VS lobectomy VS pneumonectomy look like?
What are 4 characteristics of wedge resections (or segmentectomy)?
- Is where a small wedge-shaped piece of lung is removed
- Typically to remove a contained lung cancer with a small margin of healthy tissue around the cancer
- Should have little effect on the person’s lung function
- Higher risk of lung cancer recurring
The smaller amount removed –> high risk of relapse (not getting all of the cancerous tissue)
What are 2 characteristics of lobectomy?
- Is where the entire lobe of the lung is removed
- Should still have little effect on the person’s lung function
What are 3 characteristics of pneumonectomy?
- Is the surgical removal of one lung
- Most frequently for management of bronchogenic carcinoma
- Rarely performed for pulmonary metastases & other benign lung diseases such as:
- Inflammatory lung disease eg bronchiectasis
- Traumatic lung disease
- Congenital lung disease
- Bronchial obstruction with a destroyed lung
Very uncommon and can have significant effect
What are 3 characteristics of day 1 post op pneumonectomy?
Immediately postsurgery
- Air fills the space previously occupied by the lung
- A chest tube may not be inserted following surgery
- Trachea is in the midline
What are 2 characteristics of day 5 post op pneumonectomy?
Over time fluid accumulates into the air space (previously occupied by the lung)
- Fluid fills at approx. 2 rib spaces per day
- At 2 wks – 80-90% of the
- space is filled with fluid
What are 4 anatomical changes of pneumonectomy?
- Decreased size of postpneumonectomy space (PPS)
- Elevated hemidiaphragm
- Hyperinflation of remaining lung
- Mediastinal shift to PPS
What is the consequence of mediastinal shift & elevation of the hemidiaphragm in pneumonectomy?
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
What is the mortality for pneumonectomy?
30 day mortality quoted between 2.4 - 11.6% (for elective surgery)
- Right sided pneumonectomy has a higher mortality
- Affected by a person’s co-morbidities
What are the 3 possible complications of pneumonectomy?
- Pulmonary oedema
- Post-pneumonectomy syndrome (compression of trachea/main bronchus)
- Pleural space problems (eg empyema)
What are the 2 affects of pulmonary function of pneumonectomy?
- Forced expiratory volume in one second (FEV1) & forced vital capacity (FVC) decreased
- Usually by less than 50%
- Gas diffusion capacity (DLCO) is decreased
- Usually by less than 50%
What is the consequence of pneumonectomy?
Diminished levels of physical function, dyspnoea & quality of life
What are 2 ways to perform is a Talc Pleurodesis?
- Medical procedure through the chest drain
- Surgical procedure via a mini-thoracotomy
What are 2 characteristics of Tal Pleurodesis?
- Used to “stick” open a lung following a persistent or recurrent pneumothorax or pleural effusion (eg malignancy)
- Recovery/ management as per other minor thoracic surgery
What are 4 medical management of thoracic surgery?
- Pre-operative management
- Post-operative management
- Chest drains
- Common complications
What are the 3 pre-operative of medical management of thoracic surgery?
- Assess suitability for surgery
- Hospital admission
- Obtain full medical/surgical/social history
- Medically fit for surgery
- Informed consent
- Written consent
- Explain risks
What are the 5 post-operative of medical management of thoracic surgery?
- Medications
- Pain relief , antibiotics, etc
- Manage/monitor recovery
- Chest x-rays, ECG’s, blood tests
- Wound healing
- Chest drains
- Manage complications
- Discharge planning
What is a chest tibe in medical management of thoracic surgery?
Is used after lung surgery to drain air, fluid and blood out of your chest cavity
- Helps promote reexpansion of lung
What are 4 proper function of inter-costal catheter (ICC) for chest tubes as medical management of thoracic surgery?
- Swinging - eg rises with inspiration
- Bubbling – if continuous/ rapid large air leak
- Draining – observed in collection part/bottle
- ? Suction – to promote drainage
What are 4 safety of chest tube as medical management of thoracic surgery?
What are 7 characteristics of chest tubes as medical management for thoracic surgery?
- Is used after lung surgery to drain air, fluid and blood out of your chest cavity
- Helps promote reexpansion of lung
- Proper function of Inter Costal Catheter (ICC)
- Swinging - eg rises with inspiration
- Bubbling – if continuous/ rapid large air leak
- Draining – observed in collection part/bottle
- ? Suction – to promote drainage
- Safety
- Keep bottle below insertion level into patients chest wall
- If ICC dislodged from chest wall apply pressure
- Suction – may be on wall suction to help drainage/ lung “stick open”
- Check with medical team if not sure about disconnecting
- Can use portable suction to mobilise patient
- Correct placement/ insertion – often checked by Xray
- Removal – once drainage of fluid/blood has slowed +/- air leak has stopped
- Handling
What doe wall suction look like?
What is the chest tube in a pneumothorax for medical management?
What is the chest tube in a pleural effusion for medical management?
Chest drains or Intercostal catheter (ICC)
- Radio-opaque on X-ray
- How many chest drains do you see?
4
- Anaesthesia → Decreased ventilatory drive, monotonous breathing, decreased gas exchange
- Restrictive reduction in lung volumes (drowsiness, pain, altered chest wall dynamics)
- Decreased Functional Residual Capacity
- Atelectasis
- Slowing of mucociliary clearance
- Secretion retention/ painful cough
- Abnormalities in gaseous exchange
- Impaired surfactant production and sigh mechanism
- Diaphragmatic dysfunction
- Removal of lung tissue
- Lung deflation
- Chest drains in situ/ chest wall incision (once chest drains are out –> more freedom to move)
- Integrity of lung tissue remaining
- Enforced immobility/ supine positioning
- Preoperative status – older, exisiting cardiopulmonary disease, smoking history
- Leads to: Susceptible to development of pulmonary infection, pneumonia, hypoxaemia & respiratory failure
What are 8 common complications for medical management of thoracic surgery?
- Post-operative bleeding – if severe re-open
- Respiratory failure
- Bronchopleural fistula- Spaces where infections can occur
- Empyema- Infection in lining of lung
- Pulmonary embolus
- Pneumonia
- Myocardial infarction
- Cardiac arrhythmia (especially atrial fibrillation
- Usually have ECGs attached
What are 5 physiotherapy amended post opertaive pulmonary complications?
- Atelectasis
- Sputum retention
- Respiratory infections
- Respiratory failure
- Exacerbation of underlying chronic lung disease
What are 4 non-physiotherapy amended post opertaive pulmonary complications?
- Pleural effusion
- Pulmonary embolus
- Pneumothorax
- Pulmonary oedema
What are 5 physiotherapy management of thoracic surgery?
- Pre-operative
- Interpret available information
- Subjective assessment
- Objective assessment
- Treatment & discharge planning
What are 6 post-operative physiotherapy management of thoracic surgery?
- Obtain medical history including smoking history, previous surgical & medical history
- Assess patient’s chest
- Basal expansion, auscultation & cough
- Assess patient mobility & any limitations in limb movement (esp. walking)
- Frailty considerations
- Educate patient on physio’s role post-op
- Teach breathing exercise techniques
What are 7 available information in post-operative physiotherapy management of thoracic surgery?
Interpret available information
- Medical chart - Operation notes, post-op orders, initial recovery, interpret medical history & likely effects on surgery/recovery
- Bed chart – Vital signs, medications
- Other - Chest X-rays, ECG, Arterial blood gases
- If concerned liaise with senior physiotherapist, medical/surgical team, nursing staff
- Ward rounds, work unit guidelines, etc
What are 5 subjective assessment in post-operative physiotherapy management of thoracic surgery?
- Pain – is it well controlled (ie able to take a deep breath & cough), where is it?
- SOB – at rest & on exertion, how is their breathing?
- Cough – are they producing any secretions? Can they clear them?
- Ascertain activity level – are they doing their breathing exercises? have they just mobilised?
- This will enable you to direct your objective assessment/ treatment
What are 8 objective assessment in post-operative physiotherapy management of thoracic surgery?
- Interpret vital signs including:
- Level of consciousness
- Oxygen requirements & delivery method
- Heart rate & rhythm
- Be aware of & understand attachments
- Chest drains, ECG leads, presence of a urinary catheter, intravenous line (peripheral or central access), pacemaker & pacing wires
- Surgical incision
- Assess breathing pattern
- Are they able to take a deep breath?
- Is their breathing pattern guarded or restricted?
- Assess their breathing pattern/ basal expansion?
- Auscultation
- Anteriorly & if possible posteriorly
- Huffing/coughing ability
- Is it effective or affected by pain?
- Are the secretions sticky &/or discoloured?
- Bed mobility & positioning
- Are they slumped in the bed?
- Can they sit up or do they need assistance?
- Transfers & mobility
- Can they transfer independently or do they need assistance?
- Are they dizzy, light headed or nauseous?
- How far can they walk?
- What about all the attachments & equipment?
What are 4 treatment in post-operative physiotherapy management of thoracic surgery?
- Breathing exercises
- Basal expansion exercises
- Staged basal expansion exercises
- Incentive spirometry
- Limb exercises – demand ventilation, circulation exercises, regaining range of movement & muscle strength
- Airway clearance – effective huff/cough, may need more specific techniques
- Mobility as appropriate
- Change of position - effect on breathing pattern
- Sitting out of bed (SOOB)
- Mobilise – number of people needed to mobilise person plus carry the equipment
- What equipment can be disconnected?
- What equipment needs to be taken?
- What mobility aid is required?
- Where is the walk heading? Move equipment out of the way or position a chair where you are planning to go.
What equipment needs to be taken?
What are 5 re-assessment in post-operative physiotherapy management of thoracic surgery?
- Response to intervention such as improved oxygen saturation &/or gas exchange
- Better breathing pattern?
- Are they improving?
- Can they be progressed next treatment?
- No adverse response to treatment?
- If so who do you notify or discuss this with?
What are 6 discharge planning in post-operative physiotherapy management of thoracic surgery?
- Independently mobile
- Safe on stairs
- Home exercise program
- Graduated walking program & limb exercises
- Discuss return to activity
- Usually institutional guidelines
- Referral to community services
- Do they need on going physiotherapy care?
- Require referral to pulmonary rehabilitation?
What are the 3 characteristics of Lung Volume Reduction Surgery (LVRS)?
- Conventional LVRS: Involves resection of the most severely affected areas of emphysematous, non- bullous lung (aim for 20-30%)
- Can improve lung elastic recoil and diaphragmatic function
- Aim to deflate the hyperinflated lungs
- Incision: Mini-thoractomy
What are the 2 complications of LVRS?
- Mortality at 90 days was 1.8% & Survival at 3 and 5 years 91.1% and 76% respectively
- Prolonged air leak
- Mean duration post surgery until all ICC’s removed is 10.9 ± 8.0 days
What are the 4 medical management of LVRS?
- Assessing suitability for LVRS
- Confirm severity of diagnosis & presentation
- Screen for co-morbidities
- Surgery – Thoracic surgeon
- Manage recovery & complications
- Long term follow-up on an outpatient basis
What are the 5 physiotherapy management of LVRS?
- Pulmonary (exercise) rehabilitation is considered essential pre & post LVRS
- Breathing retraining
- Mobility
- Thoracic mobility
- Muscle strengthening
What are 2 experimental medical management of LVRS?
- Endobronchial approaches to create artificial airways with stents (Gas trapping)
- Trialing steam
- Current trial for people unsuitable for conventional LVRS
- Benefits/ outcomes are being investigated
What are 3
- This techniques uses a one way valve delivered through a bronchoscope
- Pulmonary EBV – unilateral approach
- Olympus EBV – bilateral approach
What are the 4 steps of Bronchial Thermal Vapour (Steam) Ablation?
What are the 3 conditions suitable for a lung transplantation?
- Chronic, end-stage lung disease
- Who are failing optimal maximal medical therapy, interventional and surgical treatment
- Or for whom no effective medical therapy exists
- Poor quality of life, potentially with intractable symptoms and repeated hospital admissions
What are 2 musts for potential candidates for lung transplantation?
- Be well informed and demonstrate adequate health behaviour
- Have a willingness to adhere to guidelines from health care professionals
What are 9 post-operative challenges of lung transplantation?
- Denervated
- Impaired mucociliary escalator
- Poor cough reflex
- Impaired lymphatic drainage
- Location - exposure to inhaled material
- Higher immunosuppression
- Chronic Lung Allograft
- Dysfunction (e.g. common phenotype is Obliterative
- Bronchiolitis
What is the early physiotherapy management of lung transplantation?
What are 3 characteristics of Pulmonary Thromboendarectomy?
- Operation that removes organized clotted blood (thrombus) from the pulmonary arteries
- Treatment for chronic thromboembolic pulmonary hypertension induced by recurrent/chronic pulmonary emboli
- Requires a full cardiopulmonary bypass, deep hypothermia and full cardiac arrest to perform surgery
What is the Sample Patient Pathway post Thoracic Surgery: Day 1 post?
- 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
What is the Sample Patient Pathway post Thoracic Surgery: Day 2-3 post?
- 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
What is the Sample Patient Pathway post Thoracic Surgery: Prior to D/C post?
- 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
