Chest Physiotherapy

Definition

Chest physiotherapy is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.

Purpose

The purpose of chest physiotherapy, also called chest physiotherapy, is to help patients breathe more freely and to get more oxygen into the body. Chest physiotherapy includes postural drainage, chest percussion, and chest vibration, turning, deep breathing exercises, and coughing. It is usually done in conjunction with other treatments to rid the airways of secretions. These other treatments include suctioning, nebulizer treatments, and the administration of expectorant drugs.

Chest physiotherapy can be used with newborns, infants, children, and adults. People who benefit from chest physiotherapy exhibit a wide range of problems that make it difficult to clear secretions from their lungs. Some people who may receive chest physiotherapy include people with cystic fibrosis or neuromuscular diseases like Guillain-Barré syndrome, progressive muscle weakness (myasthenia gravis), or tetanus. People with lung diseases such as bronchitis, pneumonia, or chronic obstructive pulmonary disease (COPD) also benefit from chest physiotherapy. People who are likely to aspirate their mucous secretions because of diseases such as cerebral palsy or muscular dystrophy also receive chest physiotherapy, as do some people who are bedridden, confined to a wheelchair, or who cannot breathe deeply because of postoperative pain.

Precautions

Chest physiotherapy should not be performed on people with

• bleeding from the lungs
• neck or head injuries
• fractured ribs
• collapsed lungs
• damaged chest walls
• tuberculosis
• acute asthma
• recent heart attack
• pulmonary embolism
• lung abscess
• active haemorrhage
• some spine injuries
• recent surgery, open wounds, or burns

Description

Chest physiotherapy can be performed in a variety of settings including critical care units, hospitals, nursing homes, outpatient clinics, and at the patient's home. Depending on the circumstances, chest physiotherapy may be performed by anyone from a respiratory care therapist to a trained member of the patient's family. Different patient conditions warrant different levels of training.

Chest physiotherapy consists of a variety of procedures that are applied depending on the patient's health and condition. Hospitalised patients are revaluated frequently to establish which procedures are most effective and best tolerated. Patients receiving long term chest physiotherapy are revaluated about every three months.

Turning

Turning from side to side permits lung expansion. Patients may turn themselves or be turned by a caregiver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours around the clock.

Coughing

Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs. Coughing is repeated several times a day.

Deep breathing

Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods.

Postural drainage

Postural drainage uses the force of gravity to assist in effectively draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. The patient is placed in a head or chest down position and is kept in this position for up to 15 minutes. Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Percussion and vibration may be performed in conjunction with postural drainage.

Percussion

Percussion is rhythmically striking the chest wall with cupped hands. It is also called cupping, clapping, or tapotement. The purpose of percussion is to break up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.

Vibration

As with percussion, the purpose of vibration is to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.

Preparation

The only preparation needed for chest physiotherapy is an evaluation of the patient's condition and determination of which chest physiotherapy techniques would be most beneficial.

Aftercare

Patients practice oral hygiene procedures to lessen the bad taste or odour of the secretions they spit out.

Risks

Risks and complications associated with chest physiotherapy depend on the health of the patient. Although chest physiotherapy usually poses few problems, in some patients it may cause

• oxygen deficiency if the head is kept lowered for drainage
• increased intracranial pressure
• temporary low blood pressure bleeding in the lungs
• pain or injury to the ribs, muscles, or spine
• vomiting inhaling secretions into the lungs
• heart irregularities
• Normal results

The patient is considered to be responding positively to chest physiotherapy if some, but not necessarily all, of these changes occur:

• increased volume of sputum secretions
• changes in breath sounds
• improved vital signs
• improved chest x ray
• increased oxygen in the blood as measured by arterial blood gas values
• patient reports of eased breathing

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Nebulizer Therapy

A nebulizer changes liquid medicine into fine droplets (in aerosol or mist form) that are inhaled through a mouthpiece or mask. Nebulizers can be used to deliver bronchodilator (airway-opening) medicines such as albuterol (Ventolin®, Proventil® or Airet®) or ipratropium bromide (Atrovent®).
A nebulizer may be used instead of a metered dose inhaler (MDI). It is powered by a compressed air machine and plugs into an electrical outlet. Portable nebulizers, powered by an internal battery or cigarette lighter, are available for individuals requiring treatments away from home.
Nebulizer care guidelines Your home care company will show you how to use the nebulizer. You will need the following supplies to give the nebulizer treatment:

• Air compressor
• Nebulizer cup
• Mask or mouthpiece
• Clean eye droppers or other measuring devices to dispense the medication

Treatment procedure
1. Place the air compressor on a sturdy surface that will support its weight. Plug the cord from the compressor into a properly grounded (three prong) electrical outlet.
2. Wash your hands with soap and warm water, and dry completely with a clean towel.
3. Carefully measure the medicine exactly as you have been instructed. Use a separate, clean  measuring
device (eyedropper or syringe) for each medicine. 
4. Remove the top part of the nebulizer cup, as shown to the left.
5. Place your medicine in the bottom of the nebulizer cup, as shown to the right.
6. Attach the top portion of the nebulizer cup and connect the mouthpiece or face mask to the cup.

7. Connect the tubing to both the aerosol compressor and nebulizer cup.
8. Turn on the compressor with the on/off switch. Once you turn on the compressor, you should see a light mist coming from the back of the tube opposite the mouthpiece as shown to the left.
9. Sit up straight on a comfortable chair.
10. If you are using a mask, position it comfortably and securely on your face as shown to the right.
11. If you are using a mouth piece, place it between your teeth and seal your lips around it as shown to the left..
12. Take slow, deep breaths through your mouth. If possible, hold each breath for two to three seconds before breathing out. This allows the medication to settle into the airways.
13. Continue the treatment until the medication is gone (about seven to 10 minutes).
14. If you become dizzy or feel "jittery," stop the treatment and rest for about five minutes. Then continue the treatment, but try to breathe more slowly. If these symptoms continue with future treatments, inform your health care provider.
15. Turn the compressor off.
16. Take several deep breaths and cough. Continue coughing and try to clear any secretions you might have in your lungs. Cough the secretions into a tissue and dispose of it properly.
17. Wash your hands with warm water and soap, and dry them with a clean towel.
Care of nebulizer Cleaning and disinfecting your equipment is simple, yet very important. Cleaning should be done in a dust- and smoke-free area away from open windows. Here is how to clean your equipment:
1. After each treatment, rinse the nebulizer cup with warm water, shake off excess water and let it air dry.
2. At the end of each day, the nebulizer cup, mask, or mouthpiece should be washed in warm, soapy water using a mild detergent, rinsed thoroughly, and allowed to air dry.
Note: There is no need to clean the tubing that connects the nebulizer to the air compressor.
Do not put these parts in the dishwasher.
3. Every third day, after washing your equipment, disinfect the equipment using a vinegar/water solution or the disinfectant solution your supplier suggests.
To use the vinegar solution, mix 1/2 cup white vinegar with 1-1/2 cups of water. Soak the equipment for 30 minutes and rinse well under a steady stream of water. Shake off the excess water and allow to air dry on a paper towel. Always allow the equipment to completely dry before storing in a plastic, zipper storage bag.
Compressor care

1. Cover the compressor with a clean cloth when not in use. Keep it clean by wiping it with a clean, damp cloth as needed.
2. Do not put the air compressor on the floor either for treatments or for storage.
3. Check the air compressor's filter as directed. Replace or clean according to the directions from your equipment supplier.
4. Always have an extra nebulizer cup and mask or mouthpiece in case you need it.
5. Store your medicines in a cool, dry place. Check them often. If they have changed color or formed crystals, throw them away and replace them with new ones.
6. All equipment for your nebulizer therapy can be obtained through your equipment supplier.

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Postural drainage

Definition
Postural drainage (bronchial drainage) is a means of mobilizing secretions in one or more lung segments to the central airways by placing the patient in various positions so that gravity assists in the drainage process. When secretions are moved to the larger airways, they are then cleared by coughing or Endotracheal suctioning. Postural drainage therapy also includes the use of manual techniques, such as percussion and vibration, as well as voluntary coughing.
1. Positions are based on the anatomy of the lungs and the tracheobronchial tree.
2. The patient may be positioned on a.

Bronchial Drainage

• Postural drainage table that can be elevated at one end.
• Tilt table.
• Reinforced padded table with a lift.
• Hospital bed.
• A small child can be positioned on the therapist’s lap.

Goals of Postural Drainage
1. Prevent accumulation of secretions in patients at risk for pulmonary complications. This may include:

• Patients with pulmonary diseases that are associated with increased production or viscosity of mucus, such as chronic bronchitis and cystic fibrosis.
• Patients who are on prolonged bed rest.
• Post surgical patients who have received general anesthesia and who may have painful incisions that restrict deep breathing and coughing postoperatively.
• Any patient who is on a ventilator if they are stable enough to tolerate the treatment.

2. Remove secretions already accumulated in the lungs of:

• Patients with acute or chronic lung disease, such as pneumonia, Atelectasis, acute lung infections, and COPD.
• Patients who are generally very weak or are elderly.
• Patients with artificial airways.

  To drain the middle and lower portions of your lungs, you should be positioned with your chest above your head. Possible techniques to achieve this position are:

  • If a hospital bed is available, put in Trendelenburg position (head lower than feet)
  • Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip
  • Stack 18-20 inches of pillow under hips.

  • Place on a tilt table, with head lower than feet.

  • Lower head and chest over the side of the bed.

     To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.

     When you are in the proper postural drainage position, change your position per the following sequence:

  • Turn side to side
  • Lay on stomach
  • Lay on back

  Remain in each position approximately five to ten minutes. Use suction or assisted cough before changing position to insure removal of any secretions drained while in that position. Postural draining is usually taught by your physical therapist.

  Inspiratory Muscle Trainer is a device to assist in building inspiratory muscle strength. The device should be used daily as part of your daily routine to keep lungs healthy.

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Lobectomy

Definition

A lobectomy is the removal of a lobe, or section, of the lung.

Purpose

Lobectomies are performed to prevent the spread of cancer to other parts of the lung or other parts of the body, as well as to treat patients with such noncancerous diseases as chronic obstructive pulmonary disease (COPD). COPD includes emphysema and chronic bronchitis, which cause airway obstruction.

Demographics

Lung cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. It is expected to claim nearly 157,200 lives in 2003. Lung cancer kills more people than cancers of the breast, prostate, colon, and pancreas combined. Cigarette smoking accounts for nearly 90% of cases of lung cancer in the United States.

Lung cancer is the second most common cancer among both men and women and is the leading cause of death from cancer in both sexes. In addition to the use of tobacco as a major cause of lung cancer among smokers, second-hand smoke contributes to the development of lung cancer among nonsmokers. Exposure to asbestos and other hazardous substances is also known to cause lung cancer. Air pollution is also a probable cause, but makes a relatively small contribution to incidence and mortality rates. Indoor exposure to radon may also make a small contribution to the total incidence of lung cancer in certain geographic areas of the United States.

In each of the major racial/ethnic groups in the United States, the rates of lung cancer among men are about two to three times greater than the rates among women. Among men, age-adjusted lung cancer incidence rates (per 100,000) range from a low of about 14 among Native Americans to a high of 117 among African Americans, an eight-fold difference. For women, the rates range from approximately 15 per 100,000 among Japanese Americans to nearly 51 among Native Alaskans, only a three-fold difference.

Chronic obstructive pulmonary disease

The following are risk factors for COPD:

• current smoking or a long-term history of heavy smoking
• employment that requires working around dust and irritating fumes
• long-term exposure to second-hand smoke at home or in the workplace
• a productive cough (with phlegm or sputum) most of the time
• shortness of breath during vigorous activity
• shortness of breath that grows worse even at lower levels of activity
• a family history of early COPD (before age 45)

Description

Lobectomies of the lung are also called pulmonary lobectomies. The lungs are a pair of cone-shaped breathing organs within the chest. The function of the lungs is to draw oxygen into the body and release carbon dioxide, which is a waste product of the body's cells. The right lung has three lobes: a superior lobe, a middle lobe, and an inferior lobe. The left lung has only two, a superior and an inferior lobe. Some lobes exchange more oxygen than others. The lungs are covered by a thin membrane called the pleura. The bronchi are two tubes which lead from the trachea (windpipe) to the right and left lungs. Inside the lungs are tiny air sacs called alveoli and small tubes called bronchioles. Lung cancer sometimes involves the bronchi.

To perform a lobectomy, the surgeon makes an incision ( thoracotomy ) between the ribs to expose the lung while the patient is under general anesthesia. The chest cavity is examined and the diseased lung tissue is removed. A drainage tube (chest tube) is then inserted to drain air, fluid, and blood out of the chest cavity. The ribs and chest incision are then closed.

Lung surgery may be recommended for the following reasons:

• presence of tumors
• small areas of long-term infection (such as highly localized pulmonary tuberculosis or mycobacterial infection)
• lung cancer
• abscesses
• permanently enlarged (dilated) airways (bronchiectasis)
• permanently dilated section of lung (lobar emphysema)
• injuries associated with lung collapse (atelectasis, pneumothorax, or hemothorax)
• a permanently collapsed lung (atelectasis)

Diagnosis/Preparation

Diagnosis

In some cases, the diagnosis of a lung disorder is made when the patient consults a physician about chest pains or other symptoms. The symptoms of lung cancer vary somewhat according to the location of the tumor; they may include persistent coughing, coughing up blood, wheezing, fever, and weight loss. Patients with a lung abscess often have symptoms resembling those of pneumonia, including a high fever, loss of appetite, general weakness, and putrid sputum. The doctor will first take a careful history and listen to the patient's breathing with a stethoscope . Imaging studies include x ray studies of the chest and CT scans . If lung cancer is suspected, the doctor will obtain a tissue sample for a biopsy. If a lung abscess is suspected, the doctor will send a sample of the sputum to a laboratory for culture and analysis.

For patients with lungs that have been damaged by emphysema or chronic bronchitis, pulmonary function tests are conducted prior to surgery to determine whether the patient will have enough healthy lung tissue remaining after surgery. A test may be used before surgery to help determine how much of the lung can safely be removed. This test is called a quantitative ventilation/perfusion scan, or a quantitative V/Q scan.

Preparation

Patients should not take aspirin or ibuprofen for seven to 10 days before surgery. Patients should also consult their physician about discontinuing any blood-thinning medications such as Coumadin (warfarin). The night before surgery, patients should not eat or drink anything after midnight.

Aftercare

If no complications arise, the patient is transferred from the surgical intensive care unit (ICU) to a regular hospital room within one to two days. Patients may need to be hospitalized for seven to 10 days after a lobectomy. A tube in the chest to drain fluid will probably be required, as well as a mechanical ventilator to help the patient breathe. The chest tube normally remains in place until the lung has fully re-expanded. Oxygen may also be required, either on a temporary or permanent basis. A respiratory therapist will visit the patient to teach him or her deep breathing exercises. It is important for the patient to perform these exercises in order to re-expand the lung and lower the risk of pneumonia or other infections. The patient will be given medications to control postoperative pain. The typical recovery period for a lobectomy is one to three months following surgery.

Risks

The specific risks of a lobectomy vary depending on the specific reason for the procedure and the general state of the patient's health; they should be discussed with the surgeon. In general, the risks for any surgery requiring a general anesthetic include reactions to medications and breathing problems. As previously mentioned, patients having part of a lung removed may have difficulty breathing and may require the use of oxygen. Excessive bleeding, wound infections, and pneumonia are possible complications of a lobectomy. The chest will hurt for some time after surgery, as the surgeon must cut through the patient's ribs to expose the lung. Patients with COPD may experience shortness of breath after surgery.

Normal results

The outcome of lobectomies depends on the general condition of the patient's lung. This variability is related to the fact that lung tissue does not regenerate after it is removed. Therefore, removal of a large portion of the lung may require a person to need oxygen or ventilator support for the rest of his or her life. On the other hand, removal of only a small portion of the lung may result in very little change to the patient's quality of life.

Morbidity and mortality rates

A small percentage of patients undergoing lung lobectomy die during or soon after the surgery. This percentage varies from about 3–6% depending on the amount of lung tissue removed. Of cancer patients with completely removable stage-1 non-small cell cancer of the lung (a disease in which malignant cancer cells form in the tissues of the lung), 50% survive five years after the procedure.

Alternatives

Lung cancer

The treatment options for lung cancer are surgery, radiation therapy, and chemotherapy, either alone or in combination, depending on the stage of the cancer.

After the cancer is found and staged, the cancer care team discusses the treatment options with the patient. In choosing a treatment plan, the most significant factors to consider are the type of lung cancer (small cell or non-small cell) and the stage of the cancer. It is very important that the doctor order all the tests needed to determine the stage of the cancer. Other factors to consider include the patient's overall physical health; the likely side effects of the treatment; and the probability of curing the disease, extending the patient's life, or relieving his or her symptoms.

Chronic obstructive pulmonary disease

Although surgery is rarely used to treat COPD, it may be considered for people who have severe symptoms that have not improved with medication therapy. A significant number of patients with advanced COPD face a miserable existence and are at high risk of death, despite advances in medical technology. This group includes patients who remain symptomatic despite the following:

• smoking cessation
• use of inhaled bronchodilators
• treatment with antibiotics for acute bacterial infections, and inhaled or oral corticosteroids
• use of supplemental oxygen with rest or exertion
• pulmonary rehabilitation

After the severity of the patient's airflow obstruction has been evaluated, and the foregoing interventions implemented, a pulmonary disease specialist should examine him or her, with consideration given to surgical treatment.

Surgical options for treating COPD include laser therapy or the following procedures:

• Bullectomy. This procedure removes the part of the lung that has been damaged by the formation of large air-filled sacs called bullae.
• Lung volume reduction surgery. In this procedure, the surgeon removes a portion of one or both lungs, making room for the remaining lung tissue to work more efficiently. Its use is considered experimental, although it has been used in selected patients with severe emphysema.
• Lung transplant. In this procedure a healthy lung from a donor who has recently died is given to a person with COPD.

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Lung Cancer and Nursing careplan

When abnormal cell growth starts in the lungs, it is called lung cancer. The most common causes of the disease are associated with tobacco use. There are two general types of lung cancer: non-small cell lung cancer and small cell lung cancer. Symptoms of both may include a persistent cough, shortness of breath, and coughing up blood. Treatment options for the condition include surgery, chemotherapy, and radiation therapy.

Lung cancer is a disease in which uncontrolled growth of abnormal cells begins in the lungs. It is, by far, the leading cause of cancer death in the United States. The five-year survival rate for the disease is only 15 percent.

Other types of cancers may spread to the lungs from other organs. However, this is not considered lung cancer because it did not start in the lungs. When cancer cells spread from one organ to another, they are called metastases.

The diagnosis of lung cancer brings with it many questions and a need for clear, understandable answers.

Cancer research has led to progress against the disease -- and our knowledge is increasing. Researchers continue to look for better ways to prevent, detect, diagnose, and treat lung cancer.

Causes of Lung Cancer

Researchers have discovered several causes of lung cancer, but the most common are related to the use of tobacco.

Causes include:

• Cigarettes
• Cigars and pipes
• Environmental tobacco smoke ("secondhand smoke")
• Radon
• Asbestos
• Pollution
• Lung diseases.

Types of Lung Cancer

Cancers that begin in the lungs are divided into two major types -- non-small cell lung cancer and small cell lung cancer -- depending on how the cells look under a microscope. Each type grows and spreads in different ways and is treated differently.

Non-Small Cell Lung Cancer

Non-small cell lung cancer is more common than small cell lung cancer, and it generally grows and spreads more slowly. There are three main types of non-small cell lung cancer; they are named for the type of cells in which the cancer develops:

• Squamous cell carcinoma (also called epidermoid carcinoma)
• Adenocarcinoma
• Large cell carcinoma.

Small Cell Lung Cancer

Small cell lung cancer, sometimes called oat cell cancer, is less common. This type of lung cancer grows more quickly and is more likely to spread to other organs in the body.

Symptoms of Lung Cancer

People with lung cancer may experience symptoms caused by the cancer or by side effects from cancer treatments. Common symptoms can include:

• Shortness of breath
• A persistent cough that gets worse over time
• Wheezing
• Coughing up blood
• Pain
• Fever
• Weight loss.

Side effects vary, depending on the type of lung cancer treatment.

Diagnosing and Treating Lung Cancer

    Information about how large a cancer is or how far it has spread is often used to determine the cancer's stage. Healthcare providers use information about the stages to plan lung cancer treatment and to monitor progress.

There are several ways to treat lung cancer. The treatment depends on the type and how far it has spread. Common treatment options include:

• Surgery (see Lung Cancer Surgery)
• Chemotherapy (see Lung Cancer Chemotherapy)
• Radiation (see Lung Cancer Radiation).

People often receive more than one kind of treatment for lung cancer.

These treatments may be provided by different doctors on your medical team, including:

• Pulmonologists (doctors who are experts in diseases of the lungs)
• Surgeons (doctors who perform operations)
• Medical oncologists (doctors who are experts in lung cancer and treat cancers with medicines)
• Radiation oncologists (doctors who treat lung cancers with radiation).

Nursing Priorities

1. Maintain/improve respiratory function.

2. Control/alleviate pain.

3. Support efforts to cope with diagnosis/situation.

4. Provide information about disease process/prognosis and therapeutic regimen

NURSING DIAGNOSIS: impaired Gas Exchange May be related to Removal of lung tissue Altered oxygen supply (hypoventilation) Decreased oxygen-carrying capacity of blood (blood loss) Possibly evidenced by Dyspnea Restlessness/changes in mentation Hypoxemia and hypercapnia Cyanosis DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Respiratory Status: Gas Exchange (NOC) Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal range. Be free of symptoms of respiratory distress.

ACTIONS/INTERVENTIONS Respiratory Management (NIC) Independent Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, changes in skin/mucous membrane color; e.g., pallor, cyanosis.

RATIONALE     Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. However, increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve; e.g., elderly client or extensive COPD.

Auscultate lungs for air movement and abnormal breath sounds.     Investigate restlessness and changes in mentation/level of consciousness.     Assess client response to activity. Encourage rest periods/limit activities to client tolerance.       Note development of fever.     Airway Management (NIC) Maintain patent airway by positioning, suctioning, use of airway adjuncts.   Reposition frequently, placing client in sitting and supine to side positions.   Avoid positioning client with a pneumonectomy on the operative side; instead, favor the “good lung down” position.     Encourage/assist with deep-breathing exercises and pursed-lip breathing as appropriate.   Tube Care: Chest (NIC) Maintain patency of chest drainage system following lobectomy, segmental/wedge resection procedures. Note changes in amount/type of chest tube drainage.

Consolidation and lack of air movement on operative side are normal in the pneumonectomy client; however, the lobectomy client should demonstrate normal airflow in remaining lobes.   May indicate increased hypoxia or complications such as mediastinal shift in pneumonectomy client when accompanied by tachypnea, tachycardia, and tracheal deviation. Increased oxygen consumption/demand and stress of surgery can result in increased dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise. Fever within the first 24 hr after surgery is frequently due to atelectasis. Temperature elevation within the 5th to 10th postoperative day usually indicates an infection; e.g., wound or systemic.   Airway obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance.)   Maximizes lung expansion and drainage of secretions.   Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion. Promotes maximal ventilation and oxygenation and reduces/prevents atelectasis.     Drains fluid from pleural cavity to promote reexpansion of remaining lung segments.   Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding/hemothorax; sudden cessation suggests blockage of tube, requiring further evaluation and intervention.

Observe presence/degree of bubbling in water-seal chamber.       Airway Management (NIC) Collaborative Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated.   Assist with/encourage use of incentive spirometer. Monitor/graph ABGs, pulse oximetry readings. Note hemoglobin (Hb) levels.

Air leaks immediately postoperative are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in client versus the drainage system.     Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiologic shift of circulation to remaining functional alveolar units. Prevents/reduces atelectasis and promotes reexpansion of small airways. Decreasing Pao2 or increasing Paco2 may indicate need for ventilatory support. Significant blood loss can result in decreased oxygen-carrying capacity, reducing Pao2.

NURSING DIAGNOSIS: ineffective Airway Clearance May be related to Increased amount/viscosity of secretions Restricted chest movement/pain Fatigue/weakness Possibly evidenced by Changes in rate/depth of respiration Abnormal breath sounds Ineffective cough Dyspnea DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Respiratory Status: Airway Patency (NOC) Demonstrate patent airway, with fluid secretions easily expectorated, clear breath sounds, and noiseless respirations.

ACTIONS/INTERVENTIONS Airway Management (NIC) Independent Auscultate chest for character of breath sounds and presence of secretions. Assist client with/instruct in effective deep breathing and coughing with upright position (sitting) and splinting of incision.       Observe amount and character of sputum/aspirated secretions. Investigate changes as indicated.           Suction if cough is weak or breath sounds not cleared by cough effort. Avoid deep endotracheal/nasotracheal suctioning in pneumonectomy client if possible.       Encourage oral fluid intake (at least 2500 mL/day) within cardiac tolerance. Assess for pain/discomfort and medicate on a routine basis and before breathing exercises. Collaborative Provide/assist with incentive spirometer; postural drainage/percussion as indicated.       Use humidified oxygen/ultrasonic nebulizer. Provide additional fluids via IV as indicated.   Administer bronchodilators, expectorants, and/or analgesics as indicated.

RATIONALE Noisy respirations, rhonchi, and wheezes are indicative of retained secretions and/or airway obstruction. Upright position favors maximal lung expansion, and splinting improves force of cough effort to mobilize and remove secretions. Splinting may be done by nurse (placing hands anteriorly and posteriorly over chest wall) and by client (with pillows) as strength improves. Increased amounts of colorless (or blood-streaked)/watery secretions are normal initially and should decrease as recovery progresses. Presence of thick/tenacious, bloody, or purulent sputum suggests development of secondary problems (e.g., dehydration, pulmonary edema, local hemorrhage, or infection) that require correction/treatment. “Routine” suctioning increases risk of hypoxemia and mucosal damage. Deep tracheal suctioning is generally contraindicated following pneumonectomy to reduce the risk of rupture of the bronchial stump suture line. If suctioning is unavoidable, it should be done gently and only to induce effective coughing.     Adequate hydration aids in keeping secretions loose/enhances expectoration. Encourages client to move, cough more effectively, and breathe more deeply to prevent respiratory insufficiency. Improves lung expansion/ventilation and facilitates removal of secretions. Note: Postural drainage may be contraindicated in some clients, and in any event must be performed cautiously to prevent respiratory embarrassment and incisional discomfort. Providing maximal hydration helps loosen/liquefy secretions to promote expectoration. Impaired oral intake necessitates IV supplementation to maintain hydration. Relieves bronchospasm to improve airflow. Expectorants increase mucus production and liquefy and reduce viscosity of secretions, facilitating removal. Alleviation of chest discomfort promotes cooperation with breathing exercises and enhances effectiveness of respiratory therapies.

NURSING DIAGNOSIS: acute Pain May be related to Surgical incision, tissue trauma, and disruption of intercostal nerves Presence of chest tube(s) Cancer invasion of pleura, chest wall Possibly evidenced by Verbal reports of discomfort Guarding of affected area Distraction behaviors; e.g., restlessness Narrowed focus (withdrawal) Changes in BP, heart/respiratory rate DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Pain Level (NOC) Report pain relieved/controlled. Appear relaxed and sleep/rest appropriately. Participate in desired/needed activities.

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Ask client about pain. Determine pain location and characteristics; e.g., continuous, aching, stabbing, burning. Have client rate intensity on a 0–10 scale.     Assess client’s verbal and nonverbal pain cues. Note possible pathophysiologic and psychologic causes of pain.       Evaluate effectiveness of pain control. Encourage sufficient medication to manage pain; change medication or time span as appropriate.     Encourage verbalization of feelings about the pain.

RATIONALE     Helpful in evaluating cancer-related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of rating scale aids client in assessing level of pain and provides tool for evaluating effectiveness of analgesics, enhancing client control of pain. Discrepancy between verbal/nonverbal cues may provide clues to degree of pain, need for/effectiveness of interventions. Fear, distress, anxiety, and grief over confirmed diagnosis of cancer can impair ability to cope. In addition, a posterolateral incision is more uncomfortable for client than an anterolateral incision. The presence of chest tubes can greatly increase discomfort. Pain perception and pain relief are subjective, thus pain management is best left to client’s discretion. If client is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis. Fears/concerns can increase muscle tension and lower threshold of pain perception. (Refer to ND: Fear/Anxiety [specify level], following.)

Provide comfort measures; e.g., frequent changes of position, back rubs, support with pillows. Encourage use of relaxation techniques; e.g., visualization, guided imagery, and appropriate diversional activities.   Schedule rest periods, provide quiet environment. Assist with self-care activities, breathing/arm exercises, and ambulation.     Collaborative Assist with client-controlled analgesia (PCA) or analgesia through epidural catheter. Administer intermittent analgesics routinely as indicated, especially 45–60 min before respiratory treatments, deep-breathing/coughing exercises.

Promotes relaxation and redirects attention. Relieves discomfort and augments therapeutic effects of analgesia.     Decreases fatigue and conserves energy, enhancing coping abilities.   Prevents undue fatigue and incisional strain. Encouragement and physical assistance/support may be needed for some time before client is able or confident enough to perform these activities because of pain or fear of pain.   Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort/coping.

NURSING DIAGNOSIS: Fear/Anxiety [specify level] May be related to Situational crises Threat to/change in health status Perceived threat of death Possibly evidenced by Withdrawal Apprehension Anger Increased pain, sympathetic stimulation Expressions of denial, shock, guilt, insomnia DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Fear Self-Control/Anxiety Self-Control (NOC) Acknowledge and discuss fears/concerns. Demonstrate appropriate range of feelings and appear relaxed/resting appropriately. Verbalize accurate knowledge of situation. Report beginning use of individually appropriate coping strategies.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Evaluate client/SO level of understanding of diagnosis.       Acknowledge reality of client’s fears/concerns and encourage expression of feelings.     Provide opportunity for questions and answer them honestly. Be sure that client and care providers have the same understanding of terms used. Accept, but do not reinforce, client’s denial of the situation.     Note comments/behaviors indicative of beginning acceptance and/or use of effective strategies to deal with situation.   Involve client/SO in care planning. Provide time to prepare for events/treatments.   Provide for client’s physical comfort.

RATIONALE Client and SO are hearing and assimilating new information that includes changes in self-image and lifestyle. Understanding perceptions of those involved sets the tone for individualizing care and provides information necessary for choosing appropriate interventions. Support may enable client to begin exploring/dealing with the reality of cancer and its treatment. Client may need time to identify feelings and even more time to begin to express them. Establishes trust and reduces misperceptions/misinterpretation of information.     When extreme denial or anxiety is interfering with progress of recovery, the issues facing client need to be explained and resolutions explored. Fear/anxiety will diminish as client begins to accept/deal positively with reality. Indicator of client’s readiness to accept responsibility for participation in recovery and to “resume life.”   May help restore some feeling of control/independence to client who feels powerless in dealing with diagnosis and treatment. It is difficult to deal with emotional issues when experiencing extreme/persistent physical discomfort.

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs May be related to Lack of exposure, unfamiliarity with information/resources Information misinterpretation Lack of recall Possibly evidenced by Statements of concern; request for information Inadequate follow-through of instruction Inappropriate or exaggerated behaviors; e.g., hysterical, hostile, agitated, apathetic DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Knowledge: Disease Process (NOC) Verbalize understanding of ramifications of diagnosis, prognosis, possible complications. Participate in learning process. Knowledge: Treatment Regimen (NOC) Verbalize understanding of therapeutic regimen. Correctly perform necessary procedures and explain reasons for the actions. Initiate necessary lifestyle changes.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Discuss diagnosis, current/planned therapies, and expected outcomes.     Reinforce surgeon’s explanation of particular surgical procedure, providing diagram as appropriate. Incorporate this information into discussion about short-/long-term recovery expectations. Discuss necessity of planning for follow-up care before discharge.     Identify signs/symptoms requiring medical evaluations; e.g., changes in appearance of incision, development of respiratory difficulty, fever, increased chest pain, changes in appearance of sputum.

RATIONALE Provides individually specific information, creating knowledge base for subsequent learning regarding home management. Radiation or chemotherapy may follow surgical intervention, and information is essential to enable the client/SO to make informed decisions. Length of rehabilitation and prognosis depend on type of surgical procedure, preoperative physical condition, and duration/degree of complications.   Follow-up assessment of respiratory status and general health is imperative to assure optimal recovery. Also provides opportunity to readdress concerns/questions at a less stressful time. Early detection and timely intervention may prevent/minimize complications.

Help client determine activity tolerance and set goals.         Evaluate availability/adequacy of support system(s) and necessity for assistance in self-care/home management.   Recommend alternating rest periods with activity and light tasks with heavy tasks. Stress avoidance of heavy lifting, isometric/strenuous upper body exercise. Reinforce physician’s time limitations about lifting.       Recommend stopping any activity that causes undue fatigue or increased shortness of breath. Encourage inspection of incisions. Review expectations for healing with client.       Instruct client/SO to watch for/report places in incision that do not heal or reopening of healed incision, any drainage (bloody or purulent), localized area of swelling with redness or increased pain that is hot to touch. Suggest wearing soft cotton shirts and loose-fitting clothing, cover/pad portion of incision as indicated, leave incision open to air as much as possible. Shower in warm water, washing incision gently. Avoid tub baths until approved by physician.   Support incision with Steri-Strips as needed when sutures/staples are removed. Instruct/provide rationale for arm/shoulder exercises. Have client/SO demonstrate exercises. Encourage following graded increase in number/intensity of routine repetitions.

Weakness and fatigue should decrease as lung(s) heals and respiratory function improves during recovery period, especially if cancer was completely removed. If cancer is advanced, it is emotionally helpful for client to be able to set realistic activity goals to achieve optimal independence.   General weakness and activity limitations may reduce individual’s ability to meet own needs.   Generalized weakness and fatigue are usual in the early recovery period but should diminish as respiratory function improves and healing progresses. Rest and sleep enhance coping abilities, reduce nervousness (common in this phase), and promote healing. Note: Strenuous use of arms can place undue stress on incision because chest muscles may be weaker than normal for 3–6 months following surgery. Exhaustion aggravates respiratory insufficiency.   Healing begins immediately, but complete healing takes time. As healing progresses, incision lines may appear dry with crusty scabs. Underlying tissue may look bruised and feel tense, warm, and lumpy (resolving hematoma).   Signs/symptoms indicating failure to heal, development of complications requiring further medical evaluation/intervention.   Reduces suture line irritation and pressure from clothing. Leaving incisions open to air promotes healing process and may reduce risk of infection. Keeps incision clean, promotes circulation/healing. Note: “Climbing” out of tub requires use of arms and pectoral muscles, which can put undue stress on incision. Aids in maintaining approximation of wound edges to promote healing. Simple arm circles and lifting arms over the head or out to the affected side are initiated on the first or second postoperative day to restore normal range of motion (ROM) of shoulder and to prevent ankylosis of the affected shoulder.

Stress importance of avoiding exposure to smoke, air pollution, and contact with individuals with URIs. Review nutritional/fluid needs. Suggest increasing protein and use of high-calorie snacks as appropriate.   Identify individually appropriate community resources; e.g., American Cancer Society, visiting nurse, social services, home care.

Protects lung(s) from irritation and reduces risk of infection.   Meeting cellular energy requirements and maintaining good circulating volume for tissue perfusion facilitate tissue regeneration/healing process.   Agencies such as these offer a broad range of services that can be tailored to provide support and meet individual needs.

POTENTIAL CONSIDERATIONS following hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

• ineffective Airway Clearance—increased amount/viscosity of secretions, restricted chest movement/pain, fatigue/weakness.
• acute Pain—surgical incision, tissue trauma, disruption of intercostal nerves, presence of distress/anxiety.
• Self-Care Deficit—decreased strength/endurance, presence of pain, intolerance to activity, depression, presence of therapeutic devices; e.g., IV lines.

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Pneumonectomy

Definition

Pneumonectomy is the medical term for the surgical removal of a lung.

 

Purpose

A pneumonectomy is most often used to treat lung cancer when less radical surgery cannot achieve satisfactory results. It may also be the most appropriate treatment for a tumor located near the center of the lung that affects the pulmonary artery or veins, which transport blood between the heart and lungs. In addition, pneumonectomy may be the treatment of choice when the patient has a traumatic chest injury that has damaged the main air passage (bronchus) or the lung's major blood vessels so severely that they cannot be repaired.

Demographics

Pneumonectomies are usually performed on patients with lung cancer, as well as patients with such noncancerous diseases as chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. These diseases cause airway obstruction.

Approximately 361,000 Americans die of lung disease every year. Lung disease is responsible for one in seven deaths in the United States, according to the American Lung Association. More than 25 million Americans are now living with chronic lung disease.

Lung cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. It is expected to claim nearly 157,200 lives in 2003. Lung cancer kills more people than cancers of the breast, prostate, colon, and pancreas combined. Cigarette smoking accounts for nearly 90% of cases of lung cancer in the United States.

Lung cancer is the second most common cancer among both men and women and is the leading cause of death from cancer in both sexes. In addition to the use of tobacco as a major cause of lung cancer among smokers, second-hand smoke contributes to the development of lung cancer among nonsmokers. Exposure to asbestos and other hazardous substances is also known to cause lung cancer. Air pollution is also a probable cause, but makes a relatively small contribution to incidence and mortality rates. Indoor exposure to radon may also make a small contribution to the total incidence of lung cancer in certain geographic areas of the United States.

In each of the major racial/ethnic groups in the United States, the rates of lung cancer among men are about two to three times greater than the rates among women. Among men, age-adjusted lung cancer incidence rates (per 100,000) range from a low of about 14 among Native Americans to a high of 117 among African Americans, an eight-fold difference. For women, the rates range from approximately 15 per 100,000 among Japanese Americans to nearly 51 among Native Alaskans, only a three-fold difference.

Chronic obstructive pulmonary disease

The following are risk factors for COPD:

• current smoking or a long-term history of heavy smoking
• employment that requires working around dust and irritating fumes
• long-term exposure to second-hand smoke at home or in the workplace
• a productive cough (with phlegm or sputum) most of the time
• shortness of breath during vigorous activity
• shortness of breath that grows worse even at lower levels of activity
• a family history of early COPD (before age 45)

Diagnosis/Preparation

Diagnosis

In some cases, the diagnosis of a lung disorder is made when the patient consults a physician about chest pains or other symptoms. The symptoms of lung cancer vary somewhat according to the location of the tumor; they may include persistent coughing, coughing up blood, wheezing, fever, and weight loss. In cases involving direct trauma to the lung, the decision to perform a pneumonectomy may be made in the emergency room. Before scheduling a pneumonectomy, however, the surgeon reviews the patient's medical and surgical history and orders a number of tests to determine how successful the surgery is likely to be.

In the case of lung cancer, blood tests, a bone scan, and computed tomography scans of the head and abdomen indicate whether the cancer has spread beyond the lungs. Positron emission tomography (PET) scanning is also used to help stage the disease. Cardiac screening indicates how well the patient's heart will tolerate the procedure, and extensive pulmonary testing (e.g., breathing tests and quantitative ventilation/perfusion scans) predicts whether the remaining lung will be able to make up for the patient's diminished ability to breathe.

Preparation

A patient who smokes must stop as soon as a lung disease is diagnosed. Patients should not take aspirin or ibuprofen for seven to 10 days before surgery. Patients should also consult their physician about discontinuing any blood-thinning medications such as coumadin or warfarin. The night before surgery, patients should not eat or drink anything after midnight.

Description

In a conventional pneumonectomy, the surgeon removes only the diseased lung itself. The patient is given general anesthesia. An intravenous line inserted into one arm supplies fluids and medication throughout the operation, which usually lasts one to three hours.

The surgeon begins the operation by cutting a large opening on the same side of the chest as the diseased lung. This posterolateral thoracotomy incision extends from a point below the shoulder blade around the side of the patient's body along the curvature of the ribs at the front of the chest. Sometimes the surgeon removes part of the fifth rib in order to have a clearer view of the lung and greater ease in removing the diseased organ.

A surgeon performing a traditional pneumonectomy then:

• deflates (collapses) the diseased lung
• ties off the lung's major blood vessels to prevent bleeding into the chest cavity
• clamps the main bronchus to prevent fluid from entering the air passage
• cuts through the bronchus
• removes the lung
• staples or sutures the end of the bronchus that has been cut
• makes sure that air is not escaping from the bronchus
• inserts a temporary drainage tube between the layers of the pleura (pleural space) to draw air, fluid, and blood out of the surgical cavity
• closes the chest incision

Nursing Management

As part of preparing for a pneumonectomy, your healthcare provider should give you specific instructions, telling you where and when to arrive at the medical facility, how to prepare yourself, and what to expect the day of and the days following your procedure.

Make sure to bring a list of the medicines you take right now, including:

• Prescriptions from your doctor
• Over-the-counter medications
• Supplements, like vitamins or herbal remedies.

Make a note of what time and how much of each medicine you take. Also tell your healthcare provider if you have any allergies. This is important for every visit with your doctor and any time you need to go to the hospital.

You might need to stop taking some kinds of medicine before the pneumonectomy. If you smoke, you need to stop smoking before the surgery. You will also be asked to not eat or drink anything for at least eight hours before your operation.

A pneumonectomy is done in the hospital. Following the surgery, most people need to stay in the hospital for about five to seven days. Some people need to stay longer. You may want to have someone drive you to the hospital and help you get settled in. Also, most people need someone to drive them home when leaving the hospital.

Chest tubes drain fluid from the incision and a respirator helps the patient breathe for at least 24 hours after the operation. The patient may be fed and medicated intravenously. If no complications arise, the patient is transferred from the surgical intensive care unit to a regular hospital room within one to two days.

After care

A patient who has had a conventional pneumonectomy will usually leave the hospital within 10 days. Aftercare during hospitalization is focused on:

• relieving pain
• monitoring the patient's blood oxygen levels
• encouraging the patient to walk in order to prevent formation of blood clots
• encouraging the patient to cough productively in order to clear accumulated lung secretions

If the patient cannot cough productively, the doctor uses a flexible tube (bronchoscope) to remove the lung secretions and fluids.

Recovery is usually a slow process, with the remaining lung gradually taking on the work of the lung that has been removed. The patient may gradually resume normal non-strenuous activities. A pneumonectomy patient who does not experience postoperative problems may be well enough within eight weeks to return to a job that is not physically demanding; however, 60% of all pneumonectomy patients continue to struggle with shortness of breath six months after having surgery.

Risks

The risks for any surgical procedure requiring anesthesia include reactions to the medications and breathing problems. The risks for any surgical procedure include bleeding and infection.

Between 40% and 60% of pneumonectomy patients experience such short-term postoperative difficulties as:

• prolonged need for a mechanical respirator
• abnormal heart rhythm (cardiac arrhythmia); heart attack (myocardial infarction); or other heart problem
• pneumonia
• infection at the site of the incision
• a blood clot in the remaining lung (pulmonary embolism)
• an abnormal connection between the stump of the cut bronchus and the pleural space due to a leak in the stump (bronchopleural fistula)
• accumulation of pus in the pleural space (empyema)
• kidney or other organ failure

Over time, the remaining organs in the patient's chest may move into the space left by the surgery. This condition is called postpneumonectomy syndrome; the surgeon can correct it by inserting a fluid-filled prosthesis into the space formerly occupied by the diseased lung.

Normal results

The doctor will probably advise the patient to refrain from strenuous activities for a few weeks after the operation. The patient's rib cage will remain sore for some time.

A patient whose lungs have been weakened by noncancerous diseases like emphysema or chronic bronchitis may experience long-term shortness of breath as a result of this surgery. On the other hand, a patient who develops a fever, chest pain, persistent cough, or shortness of breath, or whose incision bleeds or becomes inflamed, should notify his or her doctor immediately.

Morbidity and mortality rates

In the United States, the immediate survival rate from surgery for patients who have had the left lung removed is between 96% and 98%. Due to the greater risk of complications involving the stump of the cut bronchus in the right lung, between 88% and 90% of patients survive removal of this organ. Following lung volume reduction surgery, most investigators now report mortality rates of 5–9%.

Alternatives

Lung cancer

The treatment options for lung cancer are surgery, radiation therapy, and chemotherapy, either alone or in combination, depending on the stage of the cancer.

After the cancer is found and staged, the cancer care team discusses the treatment options with the patient. In choosing a treatment plan, the most significant factors to consider are the type of lung cancer (small cell or non-small cell) and the stage of the cancer. It is very important that the doctor order all the tests needed to determine the stage of the cancer. Other factors to consider include the patient's overall physical health; the likely side effects of the treatment; and the probability of curing the disease, extending the patient's life, or relieving his or her symptoms.

Chronic obstructive pulmonary disease

Although surgery is rarely used to treat COPD, it may be considered for people who have severe symptoms that have not improved with medication therapy. A significant number of patients with advanced COPD face a miserable existence and are at high risk of death, despite advances in medical technology. This group includes patients who remain symptomatic despite the following:

• smoking cessation
• use of inhaled bronchodilators
• treatment with antibiotics for acute bacterial infections, and inhaled or oral corticosteroids
• use of supplemental oxygen with rest or exertion
• pulmonary rehabilitation

After the severity of the patient's airflow obstruction has been evaluated, and the foregoing interventions implemented, a pulmonary disease specialist should examine him or her, with consideration given to surgical treatment.

Surgical options for treating COPD include laser therapy or the following procedures:

• Bullectomy. This procedure removes the part of the lung that has been damaged by the formation of large air-filled sacs called bullae.
• Lung volume reduction surgery. In this procedure, the surgeon removes a portion of one or both lungs, making room for the remaining lung tissue to work more efficiently. Its use is considered experimental, although it has been used in selected patients with severe emphysema.
• Lung transplant. In this procedure a healthy lung from a donor who has recently died is given to a person with COPD.

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Chest Injuries

Mechanisms of injury

• blunt injuries
• crush injuries
• penetrating injuries
• inhalation burns
• aspiration of foreign bodies

2 major forces within chest which lead to injury: compression and distraction. Compression results in destruction of vascular components, haemorrhage, oedema and impairment of function. Distraction injuries usually result in shearing forces which destroy integrity of intrathoracic viscera

 

Blunt trauma

- mode of injury important
- where there has been massive deformity of a car or a history of a fall of 5 metres or more major intrathoracic injuries should always be suspected. The physical nature of chest wall allows for considerable elastic recoil, especially in young patients and therefore degree of injury within chest may need to be judged initially by deformity to car rather than appearance of patient
- blunt injuries occur in 3 major directions: AP, lateral and transdiaphragmatic
- AP deformity results in relative backward motion of heart. This may result in disruption of aorta at level of ligamentum arteriosum just below left subclavian. As heart swings back and up it may cause so-called wishbone # of a proximal bronchus
- injuries to heart occur in up to 1/2 of patients after deceleration injuries
- deceleration with impact to back causes relatively few intrathoracic injuries
- lateral compression of chest during deceleration causes fractures typically of lower ribs with risk of injury to liver, spleen and kidneys
- when lateral compression results in flail segments damage to thoracic cavity is usually relatively small and most frequently limited to contusion and laceration of lung parenchyma
- lap belt of seat belts leads to rise in intrabdominal pressure in massive deceleration and this, combined with shearing and twisting of upper trunk may result in diaphragmatic rupture

Penetrating injuries

• result in parenchymal damage related to track of missile or stabbing implement and velocity
• more solid structures (eg heart and major vessels) suffer greater injury where high-velocity missiles are penetrating weapon
• most lethal complication is haemorrhage
• often associated with abdominal trauma

Crush injury

• occurs where elastic limits of chest and its contents have been exceeded
• patients usually have AP deformity
• majority have flail chests with multiple fractures, pneumothorax or haemothorax
• most have pulmonary contusion
• injuries of heart, aorta, diaphragm, liver , kidney and spleen are common
• another group of patients with crush injuries are those with "traumatic asphyxia" syndrome, where constrictive forces are applied over a wide area for as little as 2-5 mins. Profound venous hypertension associated with relative stasis is mechanism of injury. There is widespread capillary dilatation and rupture, subconjunctival haemorrhage and retinal haemorrhage. Simultaneous injuries (eg intracranial haemorrhage) must be suspected
• severe crush injuries have a high mortality

Chest trauma haemodynamics

• hypovolaemia most important mechanism
• cardiac tamponade
• myocardial contusion
• valve injury
• intracardiac shunt

Chest trauma hypoxia

Due to:

• reduced blood volume
• ventilatory failure
• contusion
• displacement of mediastinum
• pneumothorax

Clinical features:

Initial history and examination are often abbreviated

Examination

• air hunger; use of accessory muscles; tracheal deviation; cyanosis or distended neck veins; (evidence of tension pneumothorax, or tamponade);
• tracheal deviation (evidence of tension pneumothorax)
• major defects in the chest (sucking chest wounds);
• unilaterally diminished breath sounds or hyperresonance to percussion (evidence of closed pneumothorax or tension pneumothorax);
• decreased heart sounds (pericardial tamponade);
• location of foreign bodies;
• location of entry and exit wounds.

Investigations

CXR

- CXR most useful screening investigation
- Look for subcutaneous air, foreign bodies, bony fractures, widening of mediastinum, pneumothorax, pneumomediastinum, pleural fluid, pulmonary parenchymal abnormalities(infiltrates, atelectasis etc)
- Check ETT, and other hardware.
- Inspiratory/expiratory films for checking for pneumothorax.
- supine AP film Þ some conditions have different radiological features. Look in particular for the following:
- pneumothorax: (NB up to 30% of pneumothoraces missed on supine CXR) air collects in anterior-inferior pleural space producing:

• "deep" costophrenic sulcus (image)
• "double-diaphragm" contour +/- depression of hemidiaphragm
• hyperlucency in lower thorax and upper abdomen
• sharp demarcation of cardiac apex
• visceral pleura at base of lung may be outlined

- pneumomediastinum:

• parietal pleura visible along left mediastinal border. NB pleura descends below mid-hemidiaphragm
• sharply defined edge to descending aorta which can often be followed into upper abdomen
• "continuous diaphragm" sign under cardiac shadow
• subcutaneous, retroperitoneal or intraperitoneal emphysema

- pneumopericardium

• air around heart that does not rise above level of pericardial reflection at root of great vessels
• air shifts with position of patient (unlike pneumomediastinum)

- pleural effusion:

• uniform increase in density over hemithorax
• pleural cap

- pulmonary contusion:

• homogenous infiltrates that tend to be peripheral and non-segmental
• may be associated with adjacent rib fractures
• air bronchograms are rare due to blood in small airways

- ruptured hemidiaphragm:- more commonly left sided

• non-specific signs include: apparent elevation of hemidiaphragm, obliteration or distortion of contour of hemidiaphragm, contralateral displacement of mediastinum, pleural effusion
• presence of gas containing viscera in thorax, particularly with a focal constriction across gas-containing bowel is pathognomonic
• haemopneumothorax may be misdiagnosed when dilated stomach gives horizontal air-fluid interface on erect CXR
• in absence of right rib #s a small right haemothorax with a "high R diaphragm" suggestive of ruptured diaphragm
• findings may be absent in 25-50% initially

- chest wall injuries:

• may give clues to associated injuries
• fractures of first 3 ribs in particular indicates significant trauma
• thoracic outlet fractures associated with brachial plexus or vascular injuries
• subclavian vascular injury should be suspected in patients with fractures of first 3 ribs, clavicle and scapula, particularly when associated with significant fracture displacement, extrapleural haematoma, brachial plexus neuropathy or radiological evidence of mediastinal haemorrhage (image)
• fractures of sternum are rare and require both lateral and oblique views of thorax for diagnosis. The presence of a fractured sternum and an abnormal mediastinal contour should prompt a search for injury to great vessels

- haemopericardium:

• NB rapid accumulation of blood in pericardial space often causes cardiac tamponade wthout altering appearance of cardiac silhouette

CT Scan

• Valuable tool
• Aids in diagnosis and precise location of numerous lesions.
• Contrast is useful particularly when looking for mediastinal haemorrhage and periaortic haematomas.

Echocardiography

Cardiac wall motion abnormalities and valve function and presence of pericardial fluid or blood.

ECG

Most common abnormality in thoracic trauma are S-T and T wave changes and findings indicative of bundle branch block

Angiography

Remains the gold standard for defining thoracic vascular injuries

Bronchoscopy

Indications include evaluation of airway injury, haemoptysis, segmental or lobar collapse, and removal of aspirated foreign bodies.

Management

Immediate management

- assure patent airway, oxygenation and ventilation
- exclude or treat:

• pneumothorax
• haemothorax
• cardiac tamponade

- assess for extrathoracic injuries
- decompress stomach
- provide pain relief
- reconsider endotracheal intubation, ventilation. In particular take into account gross obesity, significant pre-existing lung disease, severe pulmonary contusion or aspiration, need for surgery for thoracic or extrathoracic injuries

General management

Treatment of specific injuries

Monitoring

Should include follow-up CXRs. Common for patients with pulmonary contusion to deteriorate in first 24-48 hrs following injury. Not necessarily due to progression of contusion but is more often due to development of pneumothorax, haemothorax, atelectasis or pulmonary oedema. For this reason serial CXRs are necessary in first 24 hrs
Following are danger signs requiring full reassessment:

• resp rate > 20/min
• heart rate > 100/min
• systolic BP < 100 mmHg
• reduced breath sounds on affected side
• Pao2 < 9 kPa on room air
• Paco2 > 8 kPa
• increased size of pneumothorax, haemothorax or increased width of mediastinum on CXR

Deterioration in any of these signs must be followed by a search for evidence of blood loss, tension pneumothorax, head injury, sepsis or fat embolism. Chest drains should be checked for patency

Chest drains

Indications for insertion of chest drains in stable patients:

• pneumothorax > 10% in non-ventilated patient (ie >1 intercostal space)
• haemothorax > 500 ml (ie above neck of 7th rib)
• surgical emphysema
• confluent opacity of lung field in a supine CXR suggesting haemothorax

There are arguments both for and against the insertion of prophylactic chest drains in patients with rib fractures who are to be ventilated for a GA. However without air or fluid draining the drain is likely to become blocked at an early stage. In a series of patients with blunt chest trauma one pneumothorax occurred per 79 days of ventilation when prophylactic drains were used as opposed to one per 62 days when they were not. Complication rate associated with insertion 6-9%

Theoretically, all that is required to drain pneumothorax is a small-bore tube but this is more likely to become blocked. When blood or pus is to be drained in an adult a 32 FG tube is recommended

Antibiotics

• use of prophylactic antibiotics controversial. Some recommend them for patients treated conservatively in whom a chest drain is inserted
• cefuroxime and metronidazole for patients with perforated viscus (in addition to exploration and drainage)

 

General measures:

• pain relief (eg pleural block)
• physio
• humidification
• bronchodilators (especially smokers or those exposed to smoke, irritant chemicals or those with tracheobronchial burns)
• consider cricothyroidotomy or "minitracheostomy" for those in whom general measures insufficient

Bronchoscopy

Indications for flexible bronchoscopy:

• massive air leak
• failure of lung to re-expand
• lobar collapse
• diagnosis and assessment of tracheal burns
• bronchial toilet

Rigid bronchoscopy has less of a role in the trauma patient but may be used in cases of persistent lobar collapse to aspirate a blood clot or plug of sputum

Mechanical ventilation

- most centres use PCV or PSV to reduce incidence of barotrauma
- PCV and PSV also provide some compensation for air leaks

Analgesia

Of extreme importance in determining whether deep breathing and coughing possible. Options:

• IV opioids in frequent small doses or by continuous infusion
• Entonox inhalation during physiotherapy
• intercostal nerve block:

• multiple individual nerve blocks (rptd as necessary)
• single large volume (eg 20 ml 0.5% bupivicaine) into 1 intercostal space. Spreads to block nerves above and below
• intrapleural bupivicaine via intercostal catheters using intermittent injections or continuous infusions

• epidural LA/opioids
• NSAIDs: fully resuscitated patients with normal renal function

Post-operative intensive care

• following tracheobronchial, lung or diaphragmatic repair high inflation pressures should be avoided
• tracheal suction must be minimal where there is a tracheobronchial suture line
• avoid fluid overload
• prevent gastric distension

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