wk6 Thoracic surgery Flashcards
Conditions presenting for lung resection
Lung Caner - small cells (20%), Non small Cells (mostly), Metastatic tumor, Pleural tumours
Carcinoma
Significant pulmonary disorder - bronchiectasis, emphysematous bullae
Oesophageal problems - cancer, hiatus herniation
Trauma
Causes of lung cancer
Smoking/ passive smoking Cannabis consumption (Marijuana) occupational hazards or materials e.g. toxic chem Atmospheric pollutants Genetic predisposition Metastatic disease
Prevalence of lung cancer in NZ
NZ Maori - 3 times higher than non-Maori
Mortality rate is also 2times higher than non-Maori (Euro)
5 year survival rate (poor compared to other developed)
5th leading cause of death world wide
Signs and symptoms of lung cancer
persistent cough sputum haemoptysis (blood clot expectoration) Dyspnoea chest pain Stridor - monophonic wheeze Wheeze Lymph node involvement Collapse/consolidation/effusion Hoarseness
Franky Haemoptysis
blood without sputum when cough
Stridor - monophonic wheeze
unchanging pitch sound due to obstruction in the airways
can involve in trachea or main bronchi
If trachea is affected, then can’t do surgery but can do surgery if bronchi is affected –> pneumonectomy
Hoarseness
weak vocal sound such as husky, breathy
Investigative Procedure
*currently no routine screening
*confirmation clinical diagnosis includes…
-sputum cytology & bronchial washings
-bronchoscopty & biopsy
-thoracoscopy
- PET scanning (positive emission) - uptake glucose –>show as bright
CT/MRI/CXR
Blood profiles
Evidence of metastatic spread –> BAD prognosis –> no point of having surgery
LUNG cancer staging - NMT
N: represents the lymph NODES involved by metastasis from the lung tumour
M: describes whether spread to other organs has occured - METASTASIS
T: represents the size of the TUMOR
Lung cancer staging - Stage 1 - 4
1- No metastasis / no node involvement / local tumor -75% survival rate post surgery
- Hilia lymph node involvement/ no distal metastasis/ 3cm or lager tumor - 10-20% survival
- mediastinal node on same side. Advanced node involvement - operable depending on site and spread
- Distal metastasis. Can’t do surgery
Treatment for lung cancer
surgery - lobectomy or pneumonectomy
Incision Types
- Key hole/scopic (VATS-video assisted thoraco surgery)
- minimal access
- open thoracotomy
Advantage of key hole/ VATS thoracotomy
Px can up and moving very quickly post op compared to ‘open thoracotomy’
Better function & less pain
What type of incision need for Lobectomy and Pneumonectomy
Small incision is enough for Lobectomy
Have to do big Open incision for Pneumonectomy
Muscles transected include…
Latissimus Dorsi Serratus Ant Trapezius Intercostals Pec Major and Minor
Data suggests PPC development occurs irrespective of preop physio education - Name the author and intervention they made
Reid et al, 2010. Face to Face VS written info only
No significant difference
Thus providing written information to patients is sufficient.
Feeney at al, 2011
“patients who developed a PPC engaged in less physical activity than those who did not- hence targeting physcial activity preoperatively may result in less PPCs”
Briefly describe Pneumonectomy
- type of Incision required
- Indications
- inclusion criteria
- number and type of drain used
- Type: Thoracotomy
- Indication: Carcinoma
- Inclusion criteria: FEV > 2L or 25% of VC
FEV1/FVC >50%
Vo2PEAK HIGH risk - No. Drain: 1 chest drain
Briefly describe Lobectomy
- type of Incision required
- Indications
- number and type of drain used
-type of Incision: Thoracotomy. Some surgeons now performing video assisted thoracoscopic lobectomy (VATS) -Indications: Usually Carcinoma, Bronchiectasis , Lung abscess
- Drain: Two - Apical chest (To remove air)
- Basal chest (To remove fluid)
Briefly describe Pleurectomy
- type of Incision required
- Indications
- Procedure
- number and type of drain used
type of incision: Thoracotomy and VATS
Indication: Treatment of recurrent or persistent pneumothoraxes
Procedure: Strip the parietal pleura off the chest wall. Pneumothorax is prevented as adhesion forms between Viceral pleura and chest wall as lung expands
Drain: one or two chest drains. removed when air leak stops.
Physiotherapy management following thoracic surgery
Post op care
- respiratory care (lung is quite small, deflated, after surgery so, Increase lung expansion to fill the space in the hemi-thorax, Also chest drain to increase lung function)
- Shoulder and Thoracic cage function
- Early mobilisation
Post operative pulmonary rehabilitation - lacking evidence
Post thoracotomy pain management - pain team tend to take over our role
Rationale for Early mobilisation
Decrease risk of PPC,
Decrease other sequela e.g. DVT, pulmonary emboli
Increase Vo2Max cardiovascular fitness
Increase respiratory Fitness
postoperative complications specific to thoracic surgery
Pneumonia, chest infection persistent air leaks Empyema - build up of pus in the pleural cavity due to bacterial infection recurrent laryngeal nerve damage Broncho pleural fistula Wound infection Post thoracotomy pain Surgical emphysema
Treatment of post thoracotomy pain
TENS is effective in px with mild pain. but not in severe pain. useful in moderate pain if used with other medications. (Freynet & Falcos, 2010)
Post operative management of Pneumonectomy
Patients MUST NOT lie on good side - this is to ensure the bronchial stump remains intact.
Chest drain clamped -released one minute every hour to control mediastinal shift.
No suction applied.
Chest drain removed after about 24 hours and mediatstinal space allowed to slowly fibrose.
Post operative management of Lobectomy
Postoperative care: O2, Chest drains on low grade suction. Basal chest drain removed
1-2 days post-op, apical chest drain removed when air leak ceases usually 4-5 days
post-op. May lie on either side, but should not lie on thoracotomy side unless necessary
for chest purposes
