Thoracic surgeries Flashcards
The upper respiratory tract…
nasal cavity connects to the pharynx
breathing through nasal passages provides protection for the lower airway (nose is lined with small hairs and mucous, when sick mucous is less effective in filtering)
olfactory nerves, lymphatic tissue (adenoids and tonsils), epiglottis, trachea, R and L bronchi
What is the carina?
Middle part of the two bronchi that is highly sensitive and suctioning there can cause uncontrollable coughing
The lower respiratory tract…
starts after air passes the carina
mainstem bronchi, pulmonary vessels and nerves enter the lungs through hilum
bronchi –> bronchioles –> alveoli
bronchioles are circled by smooth muscles that constrict and dilate in response to stimuli (increased/decrease airway)
What should be noted about the bronchi?
The R mainstem bronchus is shorter, wider and straighter than L = aspiration is more likely in R
Atomical Dead Space
tract from the nose to bronchioles serves only as a conducting pathway (no gas exchange, but still filled with air with each breath)
Tidal Volume
volume of air exchange with each breath
Alveoli
small sacs that are functional unit of lungs that are interconnected by pores of kohn that allow air to transfer form alveoli to alveoli (this causes spread of bacteria in lungs)
alveolar-capillary membrane is very thin and is the sire if gas exchange
Surfactant
a lipoprotein that lowers the surface tension in the alveoli, reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse - atelectasis (allows lungs to not collapse - natural tendency)
Pulmonary circulation
gas exchange: pulmonary artery receives deoxygenated blood from the R ventricle of heart and branches to reach alveoli (O2-Co2 exchange occurs)
pulmonary veins return oxygenated blood to L atrium of heart
Bronchial circulation
bronchial arteries (arise from thoracic aorta)
provides O2 to bronchi and other pulmonary tissues
deoxygenated blood returns from bronchial circulation into L atrium
Chest wall
shaped, supported and protected by 12 ribs on each side
Parietal pleura
lines chest cavity (has pain nerve fibers)
Visceral pleura
lines lungs
Parietal and Visceral pleura…
joined to form closed, double walled sac
intrapleural space
fluid in-between layers, facilitating expansion of pleura and lung during inspiration (drained by lymphatic circulation)
pleural effusions
accumulation of fluid
Empyema
presence of purulent pleural fluid with bacterial infection
Diaphragm
major muscle of respiration
Inspiration: diaphragm contracts, pushing abd contents downward and other muscles contract increasing lung capacity
includes phrenic nerves
Empyema leads to
pneumothorax
hemothorax
decreased ventilation, diffusion of gas and decreased perfusion of tissues
Pneumothorax
air in pleural space = leads to collapsed lung
hemothorax
blood in pleural space = leads to collapsed lung
Physiology of ventilation
involves inspiration (active) and expiration (passive)
intrathoracic pressure changes
air moves in and out of lungs because of intrathoracic pressure changes
involves contraction of diaphragm, airway opening, other muscles increase chest
Gas movement
moves from high (atmospheric) - low (intrathoracic) pressure
Inspiration
intrathoracic pressure is lowering (with increasing space as chest expands) causing gas to come in
Expiration
chest cavity decreases, causing increased intrathoracic pressure, causing gas to move out
What happens to expiration with asthma or emphysema?
expiration is active and labored causing abdominal and intercostal muscles to assist in expelling air
Compliance
measure of elasticity of lungs and thorax (when decreased infiltration of lungs is more difficult)
the ability of the lungs to properly oxygenate arterial blood is determined by the partial pressure of o2 in arterial blood (PaO2) and oxygen saturation of arterial blood (SaO2)
PaO2
amount of O2 in the plasma
SaO2
amount of O2 bound to hgb
Oxygen-hgb dissociation curve
affinity of hgb for O2
Oxygen delivery to tissues depends on the amount of O2 transported to the tissues and the wase in which hgb gives up O2 once it reaches tissues
Upper portion of OHDC
fairly large changes in PaO2 cause small changes in hgb sat (hgb remains saturated even with drop in PaO2)
Lower portion of OHDC
as hgb is desaturated, larger amounts of O2 are released for tissue use (maintains pressure between blood and tissues)
–> end organ perfusion!!!!!!
Shift to the L (OHDC)
Higher HbO2 affinity
Decreased CO2
Increased pH
Decreased temp
Shift to the R (OHDC)
reduced HbO2 affinity
increased Co2
decreased pH
increased temp
Organ perfusion
metabolically we are looking at end organ perfusion to evaluate if tissue O2 needs are being met
Organ perfusion assessment
brain - LOC
heart - myocardia; ischemia (angina, SOB, ECG changes)
lungs - decreased PaO2 and SaO2 (poor gas exchange)
gut - decreased gut function (decreased motility, abd pain, N/V)
liver - changes in labs
kidneys - BUN and creatinine, decreased amount of urine
BP and HR
reflects the diameter and elasticity of the blood vessels
Mean Arterial Pressure (MAP)
average arterial pressure at a certain time (CO and vascular resistance)
tells us perfusion (needs to be >65)
Anaphylaxis treatment
call for help
epinephrine 0.5mg (1mg/ml) IM in the Vastus lateralis muscle
repeat q5min x2 (max 3 doses) for ongoing symptoms
secure airway
remove allergen
Airway obstruction
can be complete or partial
prompt assessment and treatment is critical, especially if acute
Airway symptoms
stridor, wheezing, restlessness, tachycardia, cyanosis
airway tx
Heimlich maneuver (if chocking)
cricothyroidotomy (if tumor)
endotracheal intubation (anaphylaxis and upper airway burns)
tracheostomy
Tracheotomy
surgical incision into the trachea for the purpose of establishing an airway
Tracheostomy
the stoma resulting
Indications for a tracheostomy
- to bypass an upper airway obstruction
- facilitate removal of secretions
- Permit long-term mechanical ventilation
- Permit oral intake and speech in pt who requires long term mechanical ventilation
Nursing care of tracheostomies
all trachs contain a faceplate or flange (rests on neck b/w clavicle and outer cannula
also contain obturator which is used when inserting the tube and in the event of accidental decannulation
Tracheostomies beside equipment
spare tracheostomy set
obturator
tracheal dilator
Cleaning tracheostomies
have a inner cannular which is removed for cleaning
cleaning removes mucous plugging
What helps with mucous plugging with tracheostomies?
Humidification (eliminates mucous build up)
Tracheostomy nursing care
suctioning airway prn to remove secretions
cleaning the inner cannula
cleaning around stoma
changing tracheostomy ties
2 kinds of trachs
CUFFED
UNCUFFED
Cuffed trachs
used if pt is at risk for aspiration or needs mechanical ventilation
cuff pressure should not exceed 20mmhg or 25 cm of H2O (puts too much pressure on tracheal mucosa - compress tracheal capillaries, limit blood flow, cause tracheal necrosis)
Uncuffed trachs
when pts can protect their airways from aspiration and do not require mechanical ventilation
Suctioning tracheostomies
suctioning should be assessed q2h and prn (when pt is visibly distressed)
Indicators for suctioning tracheostomies
coarse crackles or wheezes over large airways
moist cough
restless/agitation if accompanied by decreases in SpO2 and PaO2
pts should NOT be suctioned routinely or if they are able to clear their own secretions with coughing (risk of infection by bringing suction close to lungs)
Vocalization with tracheostomy
in an independently breathing pt
- deflate cuffs allow exhaled air to flow over vocal cords
- volume can be increased by plugging the tuve with a finger or plug
small cuffless tuvbes can be inserted so exhaled air can pass freely around tuve
refer to speech language pathologist to assist
Fenestrated tubes
tracheostomy device that has an opening on the surface of the outer cannula that permits air from the lungs to flow over the vocal cords
Decannulation of trachs
possible where temporary trachs have been required (anaphylaxis)
possible when pts can exchange air and expectorate secretions
stoma is closed and secured with steristrips and an exclusive drsg
drsg should only be changed if soiled/wet
pt should splint the stoma when coughing, swallowing, speaking for first 24/48 hours
the opening will close in several days
surgical intervention to close stoma is rarely required
Lung cancer
small cell and nonsmall cell
risk factors for lung cancer
smoking and inhaled environmental carcinogens
clinical manifestations of lung cancer
clinically silent for most individuals for most of its course
usually nonspecific and appear late in the disease process
depend on type of primary lung cancer, its location and metastatic spread
often are extensive metastases before before symptoms are apparent
first symptom to often occur is a persistent cough
later symptoms = anorexia, fatigue, weight loss, N/V
Lung cancer diagnostic studies
CXR
CT scan (most effective, non-invasive)
bronchoscopy with biopsy
Lung cancer surgical therapies
surgical resection is the tx of choice for nonsmall cell lung cancer stages I and II b/c the disease is potentially curable
Thoracotomy
Lobectomy
Pneumonectomy
Thoracotomy
surgical procedure to gain access into pleural space of chest
Lobectomy
removal of lobe of lung
Pneumonectomy
removal of entire lung
Chest Trauma and thoracic injuries
Blunt trauma - appear minor on surface, but could cause life threatening injuries
- contracoup trauma - blunt trauma that is caused by the impact of parts of the body against other objects (inside)
Penetrating trauma
Pneumothorax
the presence of air in the pleural space causing complete or partial lung collapse
can be open or closed
pneumothorax associated with trauma (blunt) can be accompanied by a hemothorax (hemo-pneumothorax)
Closed pneumothorax
most common form is spontaneous and most commonly occur in underweight males and often reoccur
spontaneous = accumulation of air with no apparent event caused
Open pneumothorax
air enters the pleural space through an opening in the chest wall.
what is the treatment of open pneumothorax?
covering with a vented (3 sided dressing. Air can go out but not in) drsg
Tension pneumothorax
MEDICAL EMERGENCY
occurs with rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant pressure on heart and great vessel
can be caused by open or closed pneumothorax
can result from chest tubes being clamped or blocked in a pt with a pneumothorax
unclamping with relieve it
What is the treatment for tension pneumothorax?
needle thoracostomy
Hemothorax
accumulation of blood in the intrapleural space
frequently associated with pneumothorax
Hemothorax causes
chest trauma
lung malignancy
complications of anticoagulant therapy
pulmonary embolus
testing of pleural adhesions
Hemothorax manifestations
tachycardia and dyspnea
chest pain
cough
no breath sounds over affected area (air isnt moving)
decreased sat
shallow, rapid RR
Fractured ribs
most common type of chest injury resulting from trauma
if fracture is displaced or splintered, damage to pleura or lungs may result
Fractured ribs manifestations
pain on inspiration at site of injury
shallow breath - leads to poor ventilation and atelectasis
Fractured rib care
NURSE –> pain control!!!
analgesia
splinting when deep breathing and coughing
incentive spirometry
Flail chest
uncommon but severe form of rib fractures and can indicate blunt trauma
often requires advanced airway management and surgical repair
Chest tube insertion
PNEUMOTHORAX
catheter is placed anteriorly though the 2nd intercostal space to remove air
HEMOTHORAX
catheter is placed laterally or posteriorly in the 8th or 9th intercostal space, mid-axillary line to drain fluid and blood
tubes are sutured in place
puncture wound is covered with airtight drsg
tubes are clamped during insertion and are only unclamped once connected to drainage system
ONLY clamp chest tubes when…
- ordered by physician
- temporarily when changing chest tube drainage system
- in the 4-b hours prior to chest tube removal to ensure that the pt is adequately ventilating and perfusing
Management of chest tubes
monitor the chest drainage system
listen for breath sounds over lung fields
measure amount of fluid drainage
monitor for changes in resp status secondary to chest tube intervention
Chest surgery
Lobectomy
Pneumonectomy
Wedge resection
Video assisted thoracoscopic surgery (VATs)
Thoracotomy
Lobectomy (chest tube)
most common. postop chest tubes usually in place
Pneumonectomy (chest tube)
no post op chest tubes. Position pt on operative side to facilitate expansion of remaining lung
Wedge resection
removal of small localized lesion that occupies only part of a segment
post op tubes in place
Video assisted thoracoscopic surgery (VATs)
can be used for lung biopsies, lobectomies, resection of nodules and repair of fistulas
Thoracotomy (chest tube)
median sternotomy - splinting the sternum (open heart)
Lateral thoracotomy - incision anteriorly or posteriorly through bone muscle, cartilage
Post op care for chest tubes
care of chest tubes connected to water sealed drainage usually required
O2 often required for 24h postop
ROM exercises on affected side very important
pts often have severe pain post-op therefore aggressive pain management is important
postop DB+C and incentive spirometry very important
Pleural effusion
a collection of fluid in pleural space
not a disease but sign of serious disease
the 2 types of pleural effusion
Transudate (hydrothorax)
Exudative
Transudate pleural effusion
occurs primarily in non-inflammatory conditions by increased hydrostative pressure (HF) or decreased oncotic pressure (hypoalbuminemia).
Fluid has low/no protein content and is pale, yellow or clear
Exudative pleural effusion
an accumulation of fluids and cells in an area of inflammation caused primarily by malignancies, PE, pulmonary infections and GI disease
Fluid has high protein contents and is dark yellow or amber
How do you know it is transudate or exudative pleural effusion?
Colour
from a sample taken via thoracentesis
Manifestations of pleural effusion
progressive dyspnea
decreased movement of chest wall on affected side
pleuritic chest pain from underlying disease (sometimes)
dullness to percussion
reduced or absent breath sounds on/over affected area
CXR will indicate abnormality if effusion is >250mL
additional with empyema: fever, night sweats, cough, weight loss
thoracentesis: exudate is thick, purulent
Thoracentesis
needed if the cause of pleural effusion is not known
needed if degree of pleural effusion is causing impaired breathing
preformed under local anesthesia (interventional radiology)
all fluid is removed at once or catheter is left in place for more gradual
usually 1000-1200 mL is removed at a time
b/c high volumes are removed, can cause hypotension, hypoxemia and pulmonary edema
recurrent in the case of malignancies and chronic disease (done as palliative or comfort measures)
