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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
Chest tubes after procedure
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/Medicine7/30/2019 Thoracic Surgeries
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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
Chest tubes after procedure
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.