thoracic surgeries

7/30/2019 Thoracic Surgeries

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THORACIC SURGERIES

DEFINITION

Thoracic surgery is the field ofmedicine involved in the surgicaltreatment ofdiseases affecting

organs inside the thorax (the chest). Generally treatment of conditions of the lungs, chest wall,

anddiaphragm.

Thoracic surgery is often grouped with cardiac surgery and called cardiothoracic surgery.

TYPES OF PROCEDURESTYPES DESCRIPTION INDICATIONS

Exploratory

thoracotomy

Internal view of lung

Usually posterolateral

parascapular but could be

anterior incision

Chest tubes after procedure

May be used to confirm carcinoma

or for chest trauma (to detect source

of bleeding)

Lobectomy Lobe removal Thoracotomy incision at site

of lobe removal


Used when pathology is limited toone area of lung: bronchogenic

carcinoma, giant emphysematous

blebs or bullae, benign tumors,

metastatic malignant tumors,

bronchiectasis and fungal infections

Pneumonectomy Removal of an entire lung

Posterolateral or anterolateral

thoracotomy incision

Sometimes there is a rib

resection

Normally no chest drains or

tubes because fluid

accumulation in empty space is

desirable

Performed chiefly for carcinoma,

but may be used for lung abscesses,

bronchiectasis, or extensive

tuberculosis

Note: Right lung is more vascular

than left; may cause more

physiologic problems if removed

Segmentectomy Only certain segment of lung Used when pathology is localized
http://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Thoraxhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Chest_wallhttp://en.wikipedia.org/wiki/Thoracic_diaphragmhttp://en.wikipedia.org/wiki/Cardiac_surgeryhttp://en.wikipedia.org/wiki/Cardiothoracic_surgeryhttp://en.wikipedia.org/wiki/Cardiothoracic_surgeryhttp://en.wikipedia.org/wiki/Cardiac_surgeryhttp://en.wikipedia.org/wiki/Thoracic_diaphragmhttp://en.wikipedia.org/wiki/Chest_wallhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Thoraxhttp://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Medicine


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(segmental resection) removed

Segments function as

individual units

(such as in bronchiectasis) and

when the patient has preexisting

cardiopulmonary compromise

Wedge resection Small localized section of lung

tissue removedusually pie-

shaped

Incision made without regard

to segments


Performed for random lung biopsy

and small peripheral nodules

Considered when less invasive tests

have failed to establish a diagnosis

May be used as a therapeutic

procedure

Thoracoscopy Direct visualization of pleura

with thorascope via an

intercostal incision

Medical under sedation or

local anesthesia; allows for

visualization and biopsy

Video assisted thorascopic

surgery (VATS) under generalanesthesia; multiple puncture

sites and video screen allow for

visualization and manipulation

of the pleura, mediastinum, and

lung parenchyma

VATS may be used for lung

biopsy, lobectomy, resection of

nodules, repair of fistulas

Decortication Removal or stripping of thick

fibrous membrane from

visceral pleura

Use of chest tube drainage

system postoperatively

Empyema unresponsive to

conservative management

Thoracotomy not

involving lungs

Incision into the thoracic

cavity for surgical procedures

on other structures

Used for hiatal hernia repair, open

heart surgery, esophageal surgery,

tracheal resection, aortic aneurysm

repair


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Lung volume

reduction surgery

(LVRS)

Involves reducing lung

volume by multiple wedge

excisions or VATS

Performed in advanced bullous

emphysema, 1-antitrypsin

emphysema

Procedures

Emergency thoracotomy

A patient who has sustained truncal trauma but remains unstable or moribund despite

adequate resuscitation by way of infusion, chest drainage and ventilation should be

considered a candidate for emergency thoracotomy (ET). A penetrating injury anywhere

between the nipples laterally, the sternal notch superiorly and the umbilicus inferiorly

should be considered to have penetrated the heart till proven otherwise. Ideally I ncision

Incisions are adapted to the circumstances and the track of a weapon, the predicted injuries.

Sometimes the presence of a protruding weapon will determine what approach is suitable.

ET should be performed with the patient supine. If abdominal injuries are suspected, a

separate laparotomy incision can be made in the supine patient without having to reposition

him. For the patient who has circulatory collapse after a penetrating injury to the precordium

amedian sternotomy because it gives access to all the major important structures.

Anterior thoracotomy

1.2. The accepted, standard, approach for emergency thoracotomy is via the left anterior

fourth intercostal space. The image on the right is of a right hemiclamshell for a gunshot

wound (visible in the axilla). He subsequently underwent a 'rooftop' incision to repair a

liver injury.


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This incision allows good access to the cardiac ventricles, main pulmonary artery, left

hilum and the left lung.

In certain cases, open surgery is needed to diagnose and treat lung problems. If a

mass is found in the lung, surgery can help determine its cause. If necessary, the

mass can also be removed.

Wedge Resection

A wedge resection can be performed if the tumor / mass is confined to one area of the lung.

This procedure removes only the affected tissue.

Lobectomy

The lungs are composed of sections called lobes. A lobectomy removes an entire lobe. By

removing the entire lobe, the lobectomy hopefully removes all traces of cancer cells.

Surrounding lymph nodes may be removed at the same time in a procedure called a

lymphadenectomy.


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Pneumonectomy

A pneumonectomy removes an entire lung. Removal may be needed if cancer appears to

have spread through one entire side of the lungs, but the exact location is hard to pinpoint.

People often worry that their breathing will be compromised after lung removal, but the

remaining lung is usually more than sufficient.

PREOPERATIVE MANAGEMENT

Goal is to maximize respiratory function to improve the outcome postoperatively and reduce

risk of complications.

Encourage the patient to stop smoking to restore bronchial ciliary action and toreduce the amount of sputum, and likelihood of postoperative atelectasis, by

decreasing secretions and increasing oxygen saturation.

Teach an effective coughing technique.o Sit upright with knees flexed and body bending slightly forward (or lie on

side with hips and knees flexed if unable to sit up).

o Splint the incision with hands or folded towel.o Take three short breaths, followed by a deep inspiration, inhaling slowly and

evenly through the nose.

o Contract abdominal muscles and cough twice forcefully with mouth open andtongue out.

o Alternate techniquehuffing and coughingis less painful. Take a deepdiaphragmatic breath and exhale forcefully against hand; exhale in a quick

distinct pant, .

Humidify the air to loosen secretions. Administer bronchodilators to reduce bronchospasm. Administer antimicrobials for infection. Encourage deep breathing with the use of incentive spirometer to prevent atelectasis

postoperatively.

Teach diaphragmatic breathing.


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Carry out chest physical therapy and postural drainage to reduce pooling of lungsecretions .

Evaluate cardiovascular status for risk and prevention of complication. Encourage activity to improve exercise tolerance. Administer medications and limit sodium and fluid to improve heart failure, if

indicated.

Correct anemia, dehydration, and hypoproteinemia with I.V. infusions, tubefeedings, and blood transfusions as indicated.

Give prophylactic anticoagulant, as prescribed, to reduce perioperative incidence ofdeep vein thrombosis and pulmonary embolism.

Provide teaching and counseling.o Orient the patient to events that will occur in the postoperative period

coughing and deep breathing, suctioning, chest tube and drainage system,

oxygen therapy, ventilator therapy, pain control, leg exercises and range-of-

motion (ROM) exercises for affected shoulder.

Make sure that patient fully understands surgery and is emotionally prepared for it; verify

that informed consent has been obtained

NURSING DIAGNOSES

Ineffective Breathing Pattern related to wound closures Risk for Deficient Fluid Volume related to chest drainage and blood loss Acute Pain related to wound closure and presence of drainage tubes in the chest Impaired Physical Mobility of affected shoulder and arm related to wound closure

and the presence of drainage tubes in the chest

NURSING INTERVENTIONS

MAINTAINING ADEQUATE BREATHING PATTERN

Monitor rate, rhythm, depth, and effort of respirations. Auscultate chest for adequacy of air movement to detect bronchospasm,

consolidation.

Monitor pulse oximetry and obtain ABG analysis and pulmonary functionmeasurements as ordered.


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Monitor LOC and inspiratory effort closely to begin weaning from ventilator as soonas possible.

Suction, as needed, using meticulous aseptic technique. Elevate the head of the bed 30 to 40 degrees when patient is oriented and BP is

stabilized to improve movement of diaphragm and alleviate dyspnea.

Encourage coughing and deep-breathing exercises and use of an incentive spirometerto prevent bronchospasm, retained secretions, atelectasis, and pneumonia.

Provide optimal pain relief to promote deep breathing, turning, and coughing.

POST OPERATIVE MANAGEMENT

POSTOPERATIVE ASSESSMENT

The nurse monitors the heart rate and rhythm by auscultation andelectrocardiography because episodes of major dysrhythmias are common after

thoracic and cardiac surgery.

In the immediate postoperative period, an arterial line may be maintained to allow frequent monitoring of arterial blood gases, serum electrolytes, hemoglobin and

hematocrit values, and arterial pressure. Central venous pressure may be monitored

to detect early signs of fluid volume disturbances. Central venous pressure

monitoring devices are being used less frequently and for shorter periods of time

than in the past.

Early extubation from mechanical ventilation can also lead to earlier removal ofarterial lines

Another important component of postoperative assessment is to note the results ofthe preoperative evaluation of the patients lung reserve by pulmonary function

testing. A preoperative FEV1 of more than 2 L or more than 70% of predicted value

indicates a good lung reserve. Patients who have a postoperative predicted FEV1 of

less than 40% of predicted value have a higher incidence of morbidity and mortality

.This results in decreased tidal volumes, placing the patient at risk for respiratory

failure.

NURSING DIAGNOSES


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Based on the assessment data, the patients major postoperative nursing diagnoses may

include:

Impaired gas exchange related to lung impairment and surgery

Ineffective airway clearance related to lung impairment, anesthesia, and pain

Acute pain related to incision, drainage tubes, and the surgical procedure

Impaired physical mobility of the upper extremities related to thoracic surgery

Risk for imbalanced fluid volume related to the surgical procedure

Imbalanced nutrition, less than body requirements related to dyspnea and anorexia

Deficient knowledge about self-care procedures at home

POTENTIAL COMPLICATIONS

Based on assessment data, potential complications may include:

Respiratory distress

Dysrhythmias

Atelectasis, pneumothorax, and bronchopleural fistula

Blood loss and hemorrhage

Pulmonary edema

PLANNING AND GOALS

The major goals for the patient may include improvement of gas exchange and breathing,

improvement of airway clearance, relief of pain and discomfort, increased arm and shoulder

mobility, maintenance of adequate fluid volume and nutritional status, understanding

of self-care procedures, and absence of complications.

NURSING INTERVENTIONS

IMPROVING GAS EXCHANGE AND BREATHING

Gas exchange is determined by evaluating oxygenation and ventilation. In the immediate postoperative period, this is achieved by measuring vital signs

(blood pressure, pulse, and respirations) at least every 15 minutes for the first 1 to 2

hours, then less frequently as the patients condition stabilizes.

Pulse oximetry is used for continuous monitoring of the adequacy of oxygenation.


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It is important to draw blood for arterial blood gas measurements early in thepostoperative period to establish a baseline to assess the adequacy of oxygenation

and ventilation and the possible retention of CO2.

The frequency with which postoperative arterial blood gases are measured dependson whether the patient is mechanically ventilated or exhibits signs of respiratory

distress; these measurements can help determine appropriate therapy.

It also is common practice for patients to have an arterial line in place to obtainblood for blood gas measurements and to monitor blood pressure closely.

Hemodynamic monitoring may be used to assess hemodynamic stability. Breathing techniques, such as diaphragmatic and pursed-lip breathing, that were

taught before surgery should be performed by the patient every 2 hours to expand the

alveoli and prevent atelectasis.

Another technique to improve ventilation is sustained maximal inspiration therapy orincentive spirometry. This technique promotes lung inflation, improves the cough

mechanism, and allows early assessment of acute pulmonary changes.

Positioning also improves breathing. When the patient is oriented and blood pressure is stabilized, the head of the bed is

elevated 30 to 40 degrees during the immediate postoperative period. This facilitates

ventilation, promotes chest drainage from the lower chest tube, and helps residual air

to rise in the upper portion of the pleural space, where it can be removed through the

upper chest tube.

The nurse should consult with the surgeon about patient positioning. There iscontroversy regarding the best side-lying position.

In general, the patient should be positioned from back The manual vent should notbe used to lower the water level in the water seal when the patient is on gravity

drainage (no suction) because intrathoracic pressure is equal to the pressure in the

water seal. ! side frequently and moved from horizontal to semi-upright position as

soon as tolerated. Most commonly, the patient is instructed to lie on the operative

side.

However, the patient with unilateral lung pathology may not be able to turn wellonto that side because of pain.


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In addition, positioning the patient with the good lung (the nonoperated lung)down allows a better match of ventilation and perfusion and therefore may actually

improve oxygenation.

The patients position is changed from horizontal to semi-upright as soon as

possible, because remaining in one position tends to promote the retention of

secretions in the dependent portion of the lungs.

After a pneumonectomy, the operated side should be dependent so that fluid in thepleural space remains below the level of the bronchial stump, and the other lung can

fully expand.

The procedure for turning the patient is as follows:

Instruct the patient to bend the knees and use the feet to push. Have the patient shift hips and shoulders to the opposite side of the bed while pushing

with the feet.

Bring the patients arm over the chest, pointing it in the direction toward which thepatient is being turned. Have the patient grasp the side rail with the hand.

Turn the patient in log-roll fashion to prevent twisting at the waist and pain frompossible pulling on the incision.

IMPROVING AIRWAY CLEARANCE

Retained secretions are a threat to the thoracotomy patient after surgery. Trauma tothe tracheobronchial tree during surgery, diminished lung ventilation, and

diminished cough reflex all result in the accumulation of excessive secretions.

If the secretions are retained, airway obstruction occurs. This, in turn, causes the airin the alveoli distal to the obstruction to become absorbed and the affected portion of

the lung to collapse.

Atelectasis, pneumonia, and respiratory failure may result. Several techniques are used to maintain a patent airway. First, secretions are

suctioned from the tracheobronchial tree before the endotracheal tube is

discontinued. Secretions continue to be removed by suctioning until the patient can

cough up secretions effectively.

Nasotracheal suctioning may be needed to stimulate a deep cough and aspiratesecretions that the patient cannot cough up.


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However, it should be used only after other methods to raise secretions have beenunsuccessful .

Coughing technique is another measure used in maintaining a patent airway. Thepatient is encouraged to cough effectively; ineffective coughing results in exhaustionand retention of secretions . To be effective, the cough must be low-pitched, deep,

and controlled. Because it is difficult to cough in a supine position, the patient is

helped to a sitting position on the edge of the bed, with the feet resting on a chair.

The patient should cough at least every hour during the first 24 hours and whennecessary thereafter. If audible crackles are present, it may be necessary to use chest

percussion with the cough routine until the lungs are clear.

Aerosol therapy is helpful in humidifying and mobilizing secretions so that they caneasily be cleared with coughing. To minimize incisional pain during coughing, the

nurse supports the incision or encourages the patient to do so.

After helping the patient to cough, the nurse should listen to both lungs, anteriorlyand posteriorly, to determine whether there are any changes in breath sounds.

Diminished breath sounds may indicate collapsed or hypoventilated alveoli.

Chest physiotherapy is the final technique for maintaining a patent airway. If apatient is identified as being at high risk for developing postoperative pulmonary

complications, then chest physiotherapy is started immediately (perhaps even before

surgery).

The techniques of postural drainage, vibration, and percussion help to loosen andmobilize the secretions so that they can be coughed up or suctioned.


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RELIEVING PAIN AND DISCOMFORT

Pain after a thoracotomy may be severe, depending on the type of incision and thepatients reaction to and ability to cope with pain. Deep inspiration is very painful

after thoracotomy. Pain can lead to postoperative complications if it reduces the

patients ability to breathe deeply and cough, and if it further limits chest excursions

so that ventilation becomes ineffective.

Immediately after the surgical procedure and before the incision is closed, thesurgeon may perform a nerve block with a longacting local anesthetic such as

bupivacaine (Marcaine, Sensorcaine).

Bupivacaine is titrated to relieve postoperative pain while allowing the patient tocooperate in deep breathing, coughing, and mobilization.

However, it is important to avoid depressing the respiratory system with excessiveanalgesia: the patient should not be so sedated as to be unable to cough. There is

controversy about the effectiveness of injections of local anesthetic for pain relief

after thoracotomy surgery. Research has shown that bupivacaine was no more

effective than saline injections in treating postoperative thoracotomy pain.

Lidocaine and prilocaine are local anesthetic agents used to treat pain at the site ofthe chest tube insertion. These medications are administered as topical transdermal

analgesics that penetrate the skin.

Lidocaine and prilocaine have also been found to be effective when used together.Because of the need to maximize patient comfort without depressing the respiratory


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drive, patient-controlled analgesia (PCA) is often used. Opioid analgesic agents such

as morphine are commonly used. PCA, administered through an intravenous pump

or an epidural catheter, allows the patient to control the frequency and total dosage.

Preset limits on the pump avoid overdosage. With proper instruction, these methods

are well tolerated and allow earlier mobilization and cooperation with the treatment

regimen.

PROMOTING MOBILITY AND SHOULDER EXERCISES

Because large shoulder girdle muscles are transected during a thoracotomy, the armand shoulder must be mobilized by full range of motion of the shoulder. As soon as

physiologically possible, usually within 8 to 12 hours, the patient is helped to get out

of bed. Although this may be painful initially, the earlier the patient moves, the

sooner the pain will subside. In addition to getting out of bed, the patient begins arm

and shoulder exercises to restore movement and prevent painful stiffening of the

affected arm and shoulder

MAINTAINING FLUID VOLUME AND NUTRITION

Intravenous Therapy

During the surgical procedure or immediately after, the patient may receive atransfusion of blood products, followed by a continuous intravenous infusion.


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Because a reduction in lung capacity often occurs following thoracic surgery, aperiod of physiologic adjustment is needed. Fluids should be administered at a low

hourly rate and titrated (as prescribed) to prevent overloading the vascular system

and precipitating pulmonary edema.

The nurse performs careful respiratory and cardiovascular assessments, as well asintakeand output, vital signs, and assessment of jugular vein distention.

The nurse should also monitor the infusion site for signs of infiltration, includingswelling, tenderness, and redness.

Diet

It is not unusual for patients undergoing thoracotomy to have poor nutritional statusbefore surgery because of dyspnea, sputum production, and poor appetite. Therefore,

it is especially important that adequate nutrition be provided.

A liquid diet is provided as soon as bowel sounds return; the patient is progressedtoa full diet as soon as possible. Small, frequent meals are better tolerated and are

crucial to the recovery and maintenance of lung function.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Complications after thoracic surgery are always a possibility and must be identifiedand managed early. In addition, the nurse monitors the patient at regular intervals for

signs of respiratory distress or developing respiratory failure, dysrhythmias,

bronchopleural fistula, hemorrhage and shock, atelectasis, and pulmonary infection.

Respiratory distress is treated by identifying and eliminating its cause whileproviding supplemental oxygen. If the patient progresses to respiratory failure,

intubation and mechanical ventilation are necessary, eventually requiring weaning.

Dysrhythmias are often related to the effects of hypoxia or the surgical procedure.They are treated with antiarrhythmic medication and supportive therapy

Pulmonary infections or effusion, often preceded by atelectasis, may occur a fewdays into the postoperative course.

Pneumothorax may occur following thoracic surgery if there is an air leak from thesurgical site to the pleural cavity or from the pleural cavity to the environment.

Failure of the chest drainage system will prevent return of negative pressure in the

pleural cavity and result in pneumothorax. In the postoperative patient

pneumothorax is often accompanied by hemothorax.


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The nurse maintains the chest drainage system and monitors the patient for signs andsymptoms of pneumothorax: increasing shortness of breath, tachycardia, increased

respiratory rate, and increasing respiratory distress.

Bronchopleural fistula is a serious but rare complication preventing the return ofnegative intrathoracic pressure and lung reexpansion.

Depending on its severity, it is treated with closed chest drainage, mechanicalventilation, and possibly talc pleurodesis .

Hemorrhage and shock are managed by treating the underlying cause, whether byreoperation or by administration of blood products or fluids. Pulmonary edema from

overinfusion of intravenous fluids is a significant danger.The early symptoms are

dyspnea, crackles, bubbling sounds in the chest, tachycardia, and pink, frothy

sputum. This constitutes an emergency and must be reported and treated

immediately.

Evaluation

1. Demonstrates improved gas exchange, as reflected in arterial blood gas measurements,

breathing exercises, and use of incentive spirometry

2. Shows improved airway clearance, as evidenced by deep, controlled coughing and clear

breath sounds or decreased presence of adventitious sounds

3. Has decreased pain and discomfort by splinting incision during coughing and increasing

activity level

4. Shows improved mobility of shoulder and arm; demonstrates arm and shoulder exercises

to relieve stiffening

5. Maintains adequate fluid intake and maintains nutrition for healing

6. Exhibits less anxiety by using appropriate coping skills, and demonstrates a basic

understanding of technology used in care

7. Adheres to therapeutic program and home care

8. Is free of complications, as evidenced by normal vital signs and temperature, improved

arterial blood gas measurements, clear lung sounds, and adequate respiratory function


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CHEST DRAINAGE

Chest drainage is the insertion of a tube into the pleural space to evacuate air or fluid, and/or

help regain negative pressure. Whenever the chest is opened, there is loss of negative

pressure in the pleural space, which can result in collapse ofP.273

the lung. The collection of air, fluid, or other substances in the thoracic cavity can

compromise cardiopulmonary function and cause collapse of the lung.

TABLE 10-3 Indications for Chest Tube Use

INDICATION ACCUMULATING SUBSTANCE

Pneumothorax AirHemothorax Blood

Pleural effusionFluid

Chylothorax Lymphatic fluid

Empyema Pus

It is necessary to keep the pleural space evacuated postoperatively and to maintain negative

pressure within this potential space. Therefore, during or immediately after thoracic surgery,

chest tubes/catheters are positioned strategically in the pleural space, sutured to the skin, and

connected to a drainage apparatus to remove the residual air and fluid from the pleural or

mediastinal space. This assists in the reexpansion of remaining lung tissue.


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FIGURE 10-7 Chest drainage systems. (A) Strategic placement of a chest catheter in the

pleural space. (B) Three types of mechanical drainage systems. (C) A Pleur-evac operating

system: (1) the collection chamber, (2) the water-seal chamber, and (3) the suction control

chamber. The Pleurevac is a single unit with all three bottles identified as chambers.

Chest drainage can also be used to treat spontaneous pneumothorax or

hemothorax/pneumothorax caused by trauma (see Table 10-3). Sites for chest tube

placement are:

For pneumothorax (air)second or third interspace along midclavicular or anterioraxillary line.

For hemothorax (fluid)sixth or seventh lateral interspace in the midaxillary line.

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One-Bottle Water-Seal System

The end of the collecting tube is covered by a layer of water, which permits drainageof air and fluid from the pleural space, but does not allow air to move back into the

chest. Functionally, drainage depends on gravity, on the mechanics of respiration

and, if desired, on suction by the addition of controlled vacuum.


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The tube from the patient extends approximately 1 inch (2.5 cm) below the level ofthe water in the container. There is a vent for the escape of any air that may be

leaking from the lung. The water level fluctuates as the patient breathes; it goes up

when the patient inhales and down when the patient exhales.

At the end of the drainage tube, bubbling may or may not be visible. Bubbling canmean either persistent leakage of air from the lung or other tissues or a leak in the

system.

Two-Bottle Water-Seal System

The two-bottle system consists of the same water-seal chamber, plus a fluid-collection bottle.

Drainage is similar to that of a single unit, except that when pleural fluid drains, theunderwater-seal system is not affected by the volume of the drainage.

Effective drainage depends on gravity or on the amount of suction added to thesystem. When vacuum (suction) is added to the system from a vacuum source, such

as wall suction, the connection is made at the vent stem of the underwater-seal

bottle.

The amount of suction applied to the system is regulated by the wall gauge.

Three-Bottle Water-Seal System

The three-bottle system is similar in all respects to the two-bottle system, except forthe addition of a third bottle to control the amount of suction applied. Recent

research has shown that suction may actually prolong an air leak by pulling air

through the opening that would otherwise heal on its own.

The amount of suction is determined by the depth to which the tip of the ventingglass tube is submerged in the water and level of water in the suction chamber or

setting of a dialdepending on the system in use.

In the three-bottle system (as in the other two systems), drainage depends on gravityor the amount of suction applied. The mechanical suction motor or wall suction

creates and maintains a negative pressure throughout the entire closed drainage

system.


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The manometer bottle regulates the amount of negative pressure transmitted back tothe patient from the suction/vacuum device. This is accomplished through the use of

a water or dry system that downregulates the suction/vacuum applied.

In the commercially available systems, the three bottles are contained in one unit andidentified as chambers (see Figure 10-7C). The principles remain the same for the

commercially available products as they do for the glass bottle system.

First chamber acts as the collection chamber and receives fluid and air from the chestcavity through the collecting tube attached to the chest tube.

Second chamber acts as the water-seal chamber with 2 cm of water acting as a one-way valve, allowing drainage out but preventing backflow of air or fluid into the

patient.

Third chamber applies controlled suction. The amount of suction is regulated by thevolume of water (usually 20 cm) in the chamber not the amount of suction or

bubbling with a water system. In a dry suction control system no water is used, no

bubbling occurs, and a restrictive device or regulator is used to dial the desired

negative pressure (up to 40 cm suction).

NURSING ALERT

When the motor or the wall vacuum is turned off, the drainage system should be open to the

atmosphere so that intrapleural air can escape from the system. This can be done by

detaching the tubing from the suction port to provide a vent.

Nursing and Patient Care Considerations

Assist with chest tube insertion (see Procedure Guidelines 10-23, pages 275 to 277). Assess patient's pain at insertion site and give medication appropriately. If patient is

in pain, chest excursion and lung inflation will be hampered.

Maintain chest tubes to provide drainage and enhance lung reinflation (seeProcedure Guidelines 10-24, pages 277 to 279).

Maintain integrity of insertion site, observing for drainage, redness, impairedhealing, and subcutaneous emphysema.

NURSING ALERT

Milking and stripping of chest tubes to maintain patency is no longer recommended. This

practice has been found to cause significant increases in intrapleural pressures and damage

to the pleural tissue. New chest tubes contain a nonthrombogenic coating, thus decreasing


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the potential for clotting. If it is necessary to help the drainage move through the tubing,

apply a gentle squeezeand-release motion to small segments of the chest tube between your

fingers.

NURSING ALERT

Clamping of chest tubes is no longer recommended due to the increased danger of tension

pneumothorax from rapid accumulation of air in the pleural space. Clamp only momentarily

to change the drainage system. Check for leaks to assess the patient's tolerance for removal

of the chest tube (perhaps up to 24 hours).

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PROCEDURE GUIDELINES 10-23

Assisting with Chest Tube Insertion

EQUIPMENT

Tube thoracostomy tray Syringes Needles/trocar Basins/skin germicide Sponges Scalpel, sterile drape, and gloves Two large clamps Suture material Local anesthetic Chest tube (appropriate size); connector

Cap, mask, gloves, gown, drapes Chest drainage system-connecting tubes and tubing, collection bottles or commercial

system, vacuum pump (if required)

Sterile water

PROCEDURE

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Nursing Action Rationale

Preparatory phase

1.Assess patient for pneumothorax, hemothorax,

presence of respiratory distress.

2.Obtain a chest X-ray. Other means o

localization of pleural fluid include ultrasound

or fluoroscopic localization.

2.To evaluate extent of lung collapse or

amount of bleeding in pleural space.

3.Obtain informed consent.

4.Verify right patient and right

location/procedure.

5.Premedicate if indicated.

6.Assemble drainage system.

7.Reassure the patient and explain the steps o

the procedure. Tell the patient to expect a

needle prick and a sensation of slight pressure

during infiltration anesthesia.

7.The patient can cope by remaining

immobile and doing relaxed breathing

during tube insertion.

8.Position the patient as for an intercostal nerve

block or according to physician preference.

8.The tube insertion site depends on the

substance to be drained, the patient's

mobility, and the presence of coexisting

conditions.

Performance phase

eedle or intracath technique

1.Using universal precautions, the skin is

prepared, anesthetized, and draped, using local

anesthetic with a short 25G needle and using

aspetic technique. A larger needle is used to

infiltrate the subcutaneous tissue, intercostal

muscles, and parietal pleura.

1.The area is anesthetized to make tube

insertion and manipulation relatively

painless. Use of universal precautions

and aseptic technique prevent

contamination of chest tube. Patient may

feel pressure while tube is inserted.

2.An exploratory needle is inserted. 2.To puncture the pleura and determine

the presence of air or blood in the

pleural cavity.

3.The IntraCath catheter is inserted through the

needle into the pleural space. The needle is


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removed, and the catheter is pushed several

centimeters into the pleural space.

4.The catheter is taped to the skin; may be

sutured to the chest wall and covered with a

dressing.

4.To prevent it from being dislodged out

of the chest during patient movement or

lung expansion. The chest tube clamp is

removed once the chest tube is attached

to the system.

5.The catheter is attached to a connector/tubing

and attached to a drainage system (underwater-

seal or commercial system) and all connections

taped.

5.All connections are taped to prevent

disconnection.

Trocar technique for chest tube insertion

Using universal precautions and aseptic

technique, a trocar catheter is used for the

insertion of a large-bore tube for removal of a

moderate to large amount of air leak or for the

evacuation of serous effusion.

1.A small incision is made over the prepared,

anesthetized site. Blunt dissection (with a

hemostat) through the muscle planes in the

interspace to the parietal pleura is performed.

1.To admit the diameter of the chest tube.

2.The trocar is directed into the pleural space, the

cannula is removed, and a chest tube is inserted

into the pleural space and connected to a

drainage system.

2.There is a trocar catheter available

equipped with an indwelling pointed rod

for ease of insertion.

Hemostat technique using a large-bore chest

tube

Using universal precautions and aseptic

technique, a large bore chest tube is used to drain

blood or thick effusions from the pleural space.

1.Using universal precautions, aseptic technique,

and after skin preparation and anesthetic

infiltration, an incision is made through the

1.The skin incision is usually made one

interspace below proposed site of

penetration of the intercostal muscles


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skin and subcutaneous tissue. and pleura.

2.A curved hemostat is inserted into the pleural

cavity and the tissue is spread with the clamp.

2.To make a tissue tract for the chest tube.

3.The tract is explored with an examining finger. 3.Digital examination helps confirm the

presence of the tract and penetration of

the pleural cavity.

4.The tube is held by the hemostat and directed

through the opening up over the ribs and into

the pleural cavity.

5.The clamp is withdrawn and the chest tube is

connected to a chest drainage system.

5.The chest tube has multiple openings at

the proximal end for drainage of air or

blood.

6.The tube is sutured in place and covered with a

sterile dressing.

6.Prevents dislodgment.

7.Catheter is attached to a connector/tube and to

the system. All connections are taped.

7.Clamps are removed from the chest tube

once connected to the drainage system.

Chest tubes open to air at the time of

insertion will result in a pneumothorax.

Chest tube (tube thoracostomy) inserted via

hemostat technique.

Follow-up phase

1.Observe the drainage system for blood and air.

Observe for fluctuation in the tube on

respiration. (See page 274.)

1.If a hemothorax is draining through a

thoracostomy tube into a bottle

containing sterile normal saline, the

blood is available for autotransfusion.

2.Secure a follow-up chest X-ray. 2.To confirm correct chest tube placement

and reexpansion of the lung.

3.Assess for bleeding, infection, leakage of air

and fluid around the tube.

3.With too rapid removal of fluid, a

vasovagal response may occur with

resulting hypotension. Continued use of

petroleum gauzes or ointment can irritate


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the skin.

4.Maintain integrity of the chest drainage system. 4.Chest tube malposition is the most

common complication.

P.277

PROCEDURE GUIDELINES 10-24

Managing the Patient with Water-Seal Chest Drainage

EQUIPMENT

Closed chest drainage system Holder for drainage system (if needed) connector for emergency use Vacuum motor Sterile connector for emergency use (ie, sterile water)

PROCEDURE

P.278

Nursing Action Rationale

Performance phase

1. Attach the chest tube from the pleural

space (the patient) to the

collecting/drainage tubing and water-seal

drainage system. Add sterile water to

water-seal chambers as needed. Adjust

suction until bubbling is seen or set gauge

as directed. Keep drainage system below

level of chest.

1. Water-seal drainage provides for the escape

of air and fluid into a drainage bottle. The

water acts as a seal and keeps the air from

being drawn back into the pleural space.

Vigorous bubbling is not indicated.

2. Check the tube connections periodically.

Tape if necessary.

2. Tube connections are checked to ensure

tight fit, patency of the tubes, and to prevent

backflow of drainage or air.a. The tube should be as straight as

possible and coiled below level of chest

without dependent loops.


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b. Do not let the patient lie on

collecting/tubing drainage.

3. Mark the original fluid level with tape on

the outside of the drainage system. Mark

hourly and daily increments (date and

time) at the drainage level.

3. This marking will show the amount of fluid

loss and how fast fluid is collecting in the

drainage bottle. It serves as a basis for

blood replacement, if the fluid is blood.

Grossly bloody drainage will appear in the

bottle in the immediate postoperative period

and, if excessive, may necessitate

reoperation. Drainage usually declines

progressively after the first 24 hours.

4. Assess patient's clinical status at least

once per shift. Observe and report

immediately signs of rapid, shallow

breathing, cyanosis, pressure in the chest,

subcutaneous emphysema, or symptoms

of hemorrhage.

4. Removal of 1,000 to 1,200 mL of pleural

fluid at one time can result in hypotension

and rebound pleural effusion. Report to

physician immediately. More frequent

monitoring is required at the initiation o

therapy and when warranted by patient's

condition. Many clinical conditions may

cause these signs and symptoms, including

tension pneumothorax, mediastinal shift,

hemorrhage, severe incisional pain,

pulmonary embolus, and cardiac

tamponade. Surgical intervention may be

necessary.

5. Make sure the tubing does not loop or

interfere with the movements of the

patient.

5. Fluid collecting in the dependent segment

of the tubing will decrease the negative

pressure applied to the catheter. Kinking,

looping, or pressure on the drainage tubing

can produce back pressure, thus possibly

forcing drainage back into the pleural space

or impeding drainage from the pleural

space.

6. Encourage the patient to assume a 6. The patient's position should be changed


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position of comfort. Encourage good

body alignment. When the patient is in a

lateral position, place a rolled towel under

the tubing to protect it from the weight of

the patient's body. Encourage the patient

to change position frequently.

frequently to promote drainage and body

kept in good alignment to prevent postural

deformity and contractures. Proper

positioning helps breathing and promotes

better air exchange. Pain medication may

be indicated to enhance comfort and deep

breathing.

7. Put the arm and shoulder of the affected

side through ROM exercises several

times daily. Some pain medication may

be necessary.

7. Exercise helps to avoid ankylosis of the

shoulder and assists in lessening

postoperative pain and discomfort.

8. Make sure there is fluctuation (tidaling)

of the fluid level in the drainage system.

8. Fluctuation of the water level in the tube

shows that there is effective communication

between the pleural space and the drainage

system; provides a valuable indication o

the patency of the drainage system, and is a

gauge of intrapleural pressure.

9. Fluctuations of fluid in the tubing will

stop when:

a. the lung has reexpanded.

b. the tubing is obstructed by blood clots

or fibrin.

c. a dependent loop develops.

10.Watch for leaks of air in the drainage

system as indicated by constant bubbling

in the water-seal bottle.

10.Leaking and trapping of air in the pleural

space can result in tension pneumothorax.

a. Report excessive bubbling in the water-

seal change immediately.

11.Encourage the patient to breathe deeply

and cough at frequent intervals. If there

are signs of incisional pain, adequate pain

medication is indicated.

11.Deep breathing and coughing help to raise

the intrapleural pressure, which allows

emptying of any accumulation in the pleural

space and removes secretions from the

tracheobronchial tree so the lung expands.


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12.If the patient has to be transported to

another area, place the drainage system

below the chest level (as close to the floor

as possible).

12.The drainage apparatus must be kept at a

level lower than the patient's chest to

prevent backflow of fluid into the pleural

space.

13.If the tube becomes disconnected, cut of

the contaminated tips of the chest tube

and tubing, insert a sterile connector in

the chest tube and tubing, and reattach to

the drainage system. Otherwise, do not

clamp the chest tube during transport.

14.When assisting with removal of the tube: 14.The chest tube is removed as directed when

the lung is reexpanded (usually 24 hours to

several days). Signs of reinflation include

little or no drainage, absence of air leak, no

noted respiratory distress, no fluctuations in

fluid in water-seal chamber, no residual air

or fluid in chest X-ray. During the tube

removal, avoid a large sudden inspiratory

effort, which may produce a pneumothorax.

a. Administer pain medication 30 minutes

before removal of chest tube.

b. Instruct the patient to perform a gentle

Valsalva maneuver or to breathe

quietly.

c. The chest tube is clamped and

removed.

d. Simultaneously, a small bandage is

applied and made airtight with

petroleum gauze covered by a 4 4

gauze and thoroughly covered and

sealed with tape.

Follow-up phase

1. Monitor the patient's pulmonary status for

signs and symptoms of decompensation.

Observe insertion site for signs o

infection and changes in drainage.

1. Patient could have reformation o

pneumothorax after removal as well as

infection at injection site.

Evidence Base


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Coughlin, A., and Parchinsky, C. (2006). Go with the flow of chest tube therapy. Nursing

36(3):36-41. Halm, M. (2007). To strip or not to strip? Physiological effects of chest tube

manipulation. American Journal of Critical Care 16(6):609-612.

P.279

TABLE 10-4 Chest Drainage Units (CDU)

TYPES DESCRIPTION INDICATIONS FOR USE

Standard

CDU

Drainage of pleural cavity for air or

any type of fluid with or without the

use

Up to 2,000 ml capacity

Following surgery that impacts on the

continuity of suction of the thoracic

cavity (eg, thoracic, cardiac, esophageal

surgery)

Replaced when full Pneumothorax

Hemothorax

Pleural effusion

Pleurodesis

Smaller

Portable CDU

Drainage without use of suction For ambulatory patients

Dry seal system that prevents air

leaks

Home care

No lung reexpansion occurs Chronic conditions

500 ml maximum drainage

Emptied when used in home

Indwelling

PleuralCatheter

Small size chest tube or pigtail

catheter (smaller than standard 14F)

Pneumothorax

Chronic drainage of fluid

Can be irrigated if occluded by health

care provider

Not for trauma or blood

Can be used for pleurodesis

Less traumatic

Heimlich

Valve

One-way flutter valve Evacuates air from the pleural space

Removes air as patient exhalesUsed for emergency transport, home


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Valve opens when pleural space

pressure is greater than atmospheric

pressure and closes when the reverse

occurs

care, and long-term care units

COMPLICATIONS

Hypoxiaassess for restlessness, tachycardia, tachypnea, and elevated BP. Postoperative bleedingmonitor for restlessness, anxiety, pallor, tachycardia, and

hypotension.

Pneumonia; atelectasismonitor for fever, chest pain, dyspnea, changes in lungsounds on auscultation.

Bronchopleural fistula from disruption of a bronchial suture or staple; bronchialstump leak.

o Observe for sudden onset of respiratory distress or cough productive ofserosanguineous fluid.

o Position with the operative side down.o Prepare for immediate chest tube insertion and/or surgical intervention.

Cardiac dysrhythmias (usually occurring third to fourth postoperative day); MI orheart failure.

This information is intended toprovide a better understanding and

appreciation by our patients and their

families of the events surrounding operations

on the chest and lung. We hope you find it

interesting and informative while helping you

understand the importance you play in

maintaining your good health.

A thoracotomy is a surgical procedureallowing the surgeon to access your lungs


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prior to removal of all or part of your lung (pulmonary resection). An incision will

be made on the side of your chest, running behind your shoulder blade, depending on

the location of your lesion. Once your lung is exposed, the amount of lung tissue

removed is contingent on the type, size and location of the lesion. The breathing tests

you complete prior to surgery help ensure you will be able to tolerate a pulmonary

resection.


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A.Wedge Resection/Segmentectomy

With this procedure, only a small part of the

lung is removed. It is used most often if the

lesion proves to be non-cancerous or if the

lesion is small and peripherally located.

B. Lobectomy

Often times an entire

lobe of a lung must be

removed. Theleft lung is divided into an

upper and

lower lobe. The right lung

has an upper,

middle, and lower lobe.


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C. Pneumonectomy

If there is concern that cancer may

have spread throughout the left or

right lung, or the lesion is located

centrally, the whole lung may

need to be removed.

thoracic surgeries

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