Routine Postoperative Care of the Thoracic Surgical Patient

Christopher C.C. Hudson
Jordan K.C. Hudson
Steven E. Hill
Atilio Barbeito

Clinical Vignette

The patient described in the vignette represents a common case scenario for patients undergoing pulmonary resection. While pulmonary resections are performed frequently in North America, this patient population represents a high morbidity group that merits special attention in the postoperative period. The increasing use of video-assisted thoracoscopic surgery (VATS) over the past 2 decades has led to decreased complications, but the overall goals and challenges of care in the thoracic surgery population remain.¹ In this chapter, we discuss the approach to routine postoperative care of the thoracic surgical patient. This will include risk stratification and initial assessment, pulmonary care and chest tube management, goals for fluid optimization, nutrition, glycemic control, and venous thromboembolism prophylaxis. Common respiratory, cardiovascular, and renal postoperative complications and their management have been discussed in Chapter 23. Analgesic strategies for thoracic surgical procedures will be covered in Chapter 24.

RISK STRATIFICATION

Optimal postoperative management of the thoracic surgical patient begins with a careful review of the patient’s comorbidities and a clear understanding of the intraoperative course. It is useful to risk stratify these patients into low, intermediate and high risk categories using their predicted postoperative FEV₁ (ppFEV₁), and especially the predicted postoperative DLCO (ppDLCO). Patients in the high-risk category benefit the most from aggressive chest physiotherapy, judicious fluid management and optimal postoperative analgesia. If limited resources are available in the postoperative care unit (eg, only 1 respiratory therapist is available for 6-8 patients), they should be concentrated on the high-risk patients. For a more extensive discussion of risk stratification please refer to Chapter 9.

ASSESSMENT UPON ADMISSION

Thoracic surgical patients generally require an intermediate or high acuity area for recovery until their respiratory status and analgesia are optimized. Patients who require mechanical ventilation postoperatively are generally admitted to the intensive care unit. It is important that the providers caring for these patients be familiar with the management of chest tubes, epidural catheters, and respiratory equipment.

Upon admission to the recovery area, the admitting team must carefully examine the patient, paying particular attention to level of consciousness, analgesia, and respiratory status. The chest tubes need to be inspected and any obstruction ruled out, and the quantity and quality of the drainage noted. A portable chest x-ray is routinely obtained in the immediate postoperative period to confirm lung re-expansion and correct chest tube placement, and to rule out contralateral disease. A baseline ABG is also generally obtained to assess oxygenation and to rule out hypercarbia, which is common in the postoperative period and is usually mild and transient, but may manifest itself as hypertension and somnolence or agitation if severe. Other laboratory tests are obtained as indicated by the extent of the resection.

Hypertension should be treated with short acting intravenous antihypertensive medications only after hypercarbia, pain and a distended bladder have all been ruled out as the primary cause.

POSTOPERATIVE VENTILATORY SUPPORT

Not all patients will meet extubation criteria following thoracic surgery, and many will require a temporary period of noninvasive ventilatory support following extubation. In patients requiring invasive postoperative ventilation, the standard of care is to apply lung protective strategies according to ARDSNet guidelines unless contraindicated.² However, high PEEP should be avoided to minimize the risk of developing a bronchopleural fistula.

Noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP) are options for the management of patients requiring additional ventilatory support after extubation, who are able to protect their airways and are not at increased risk of aspiration. These strategies have been implemented successfully in patients following lung resection and lung transplant.^3–5 Noninvasive ventilation improves postoperative oxygenation and FEV₁ in patients with decreased preoperative FEV₁ and on those who used NIPPV or CPAP pre-operatively.⁴ Caution should be used in esophagectomy patients, as they may be at increased risk of pulmonary aspiration.

PULMONARY PHYSIOTHERAPY AND EARLY AMBULATION

Physiotherapeutic interventions are typically instituted on the first postoperative day, and may begin immediately after surgery if the patient is able to participate. Although prophylactic chest physiotherapy has been widely accepted, its routine use is of uncertain benefit.⁶ Possible approaches include chest physiotherapy alone or in combination with incentive spirometry or noninvasive ventilation. Chest physiotherapy typically includes deep breathing exercises, airway clearance maneuvers, and early mobilization. Randomized controlled trials are currently underway to further evaluate the efficacy of various physiotherapy maneuvers in order to determine an evidence-based approach to postoperative care. In patients with acute respiratory failure after lung resection, chest physiotherapy combined with noninvasive ventilation reduces pulmonary complications, improves patient recovery, and reduces the need for intubation and invasive ventilation.⁷

When possible, early postoperative ambulation should be encouraged. Mobilization can begin as early as the first hour postoperatively, with staff accompaniment. A fast-track approach to rehabilitation consists of immediate postoperative extubation, early oral feeding, physiotherapy, and early removal of chest tubes, urinary catheters, and invasive lines. Appropriate patient selection is crucial, with low preoperative morbidity, adequate pain management, and avoidance of oversedation all being prerequisites. The fast-track approach has been shown to reduce postoperative complications and hospital length of stay after lobectomy.⁸

PNEUMONIA PREVENTION

Patients undergoing thoracic surgery are at increased risk of morbidity and mortality compared to the general surgical population.^9,10 Major respiratory complications, including pneumonia and respiratory failure are very common, occurring at an incidence of 13% in a recent review of the US data.¹¹ Pneumonia after lung resection has a mortality rate of 20% to 25%.¹² The most common causative organisms are community-acquired bacteria, notably Enterobacter, Streptococcus pneumoniae, Staphylococcus aureus, and Hemophilus influenzae. Risk factors include older age, cardiopulmonary comorbidities, smoking, worse pulmonary function, and more extensive surgical resections (pneumonectomy).¹³ While most risk factors are not modifiable, preoperative smoking cessation, minimizing surgical and anesthetic duration, aggressive pulmonary physiotherapy, and fast-track rehabilitation may help to reduce the incidence of postoperative pneumonia.

CHEST TUBE MANAGEMENT

Chest tube management is a routine part of the postoperative care of thoracic surgical patients. Following lung resection, chest tubes are placed to allow closed drainage of air and fluid from the pleural space, permitting re-expansion of the remaining lung to fill the intrathoracic cavity. The tubes are attached to a drainage system that permits one-way drainage only. These systems have evolved from the single bottle version developed in the late 1800s to compact versions of the three-bottle system described by Howe in 1952. Traditional chest drainage devices are generally composed of three chambers: the collecting chamber, the water-seal chamber, and the suction control chamber (Figure 22–1). Newer chest drain models are now equipped with a one-way valve that replaces the traditional water seal bottle. This valve requires no water, and hence maintains the patient seal even if the unit is tipped over. Newer systems also incorporate a dry suction system, where the suction pressure level is controlled by a self-compensating regulator instead of a column of water. This provides several advantages over the wet system: It can achieve higher suction pressures; fluid does not evaporate; requires virtually no maintenance; and it has a quieter operation, since there is no continuous bubbling in the suction chamber. Newer devices also share several common features: automatic and manual high negative pressure relief valves, a positive pressure relief valve, sampling ports, serrated, tapered catheter connectors, and an air leak meter¹⁴ (Figure 22–2).

Figure 22–1. The traditional three-bottle system. Suction is applied to the system until it reaches the pressure that will draw ambient air into the open tube of the suction control bottle. At this point, the suction pressure will equal the height of the column of water in this bottle, and the suction level will be maintained regardless of the amount of additional suction applied, since this will only draw more air into the bottle.

Figure 22–2. Components of a modern pleural drainage system. Note the one-way valve replacing the traditional water seal (second bottle in the three-bottle system) and the dry suction system replacing the traditional suction control bottle. (Reproduced with permission from Pleur-evac. Teleflex Medical).

The chest tubes and drainage system should be examined daily for patency, function, air leak, volume and character of drained fluid, and condition of the placement site. Chest tube drainage of less than 200 cc/d or 2 cc/kg/d is considered physiologic.^15,16 The character of chest tube fluid should gradually change from sanguineous to serous; purulent drainage is suggestive of empyema. Fluid oscillation in the water seal that is synchronous with patient respiration—known as “tidaling”—may be seen in the properly functioning chest tube and is a reflection of intrapleural pressure changes and a patent chest tube. These oscillations disappear once the lung is reinflated or if the chest tube is blocked or kinked. Blockages can be cleared by suction catheter aspiration, although this maneuver carries the risk of infection (empyema). “Stripping” refers to simultaneously occluding the tubing and pulling it away from the patient to produce a local suction effect. Pressures of up to –400 cm water have been reported to result from this maneuver and it is therefore generally discouraged.¹⁷

Care must be exercised to ensure the connecting tubing is not allowed to droop below the top of the drainage system, since any fluid that accumulates in the loop prevents the suction applied to the drainage system to reach the pleura.¹⁴ A chest tube should never be clamped, unless it is done temporarily to allow replacement of the collection system or with accidental disconnections.

Chest radiography should be performed early in the postoperative period to ensure proper chest tube placement and adequate lung re-expansion, but daily chest radiographs are otherwise not indicated in stable patients.¹⁸

Air Leaks

An air leak is defined as bubbling in the water-seal chamber after the air in the pleural space has been drained, and is termed “persistent” or “prolonged” if it persists beyond 4 to 7 days after chest tube insertion, or if it prolongs hospital stay.¹⁹ Persistent air leaks occur in approximately 10% cases, and represent the most common pulmonary complication after lung resection surgery.¹¹ Most commonly, the leak is caused by inspired gas moving from denuded lung parenchyma into the pleural space, and onto the chest tube and collecting system with each respiratory effort or cough episode.

Factors that have been shown to predict a persistent air leak after lung resections are FEV₁% of less than 79%, a history of steroid use, male gender, preoperative radiotherapy or chemotherapy exposure, and lobectomy operations.^20,21

In order to assess for an air leak, the patient should be asked to take 2 or 3 deep breaths and any bubbles consistently moving into the air leak reservoir should be noted. The patient should then be instructed to cough to rule out a forced expiratory air leak.

Air leaks have been classified according to their timing during the respiratory cycle (inspiratory [I], expiratory [E], forced expiratory [FE], or continuous [C]) and their extent (1, least severe, through 7, most severe, based on how many columns are filled with air bubbles upon observation of the air leak meter on the pleural drainage system)²² (Figure 22–3). Digital air leak meters that allow a more precise quantification of air leaks are also available, and they have been shown to reduce hospital length of stay if used continuously during the postoperative period.²³

Figure 22–3. Air leak meter. The seven columns allow a semi-quantitative evaluation of air leaks at the bedside. (Reproduced with permission from Pleur-evac. Teleflex Medical).

Related posts:

Practice Improvement and Patient Safety in Thoracic Anesthesia: A Human Factors Perspective Lung Separation Techniques Bronchopleural Fistula: Anesthetic Management Thoracic Trauma Management Pericardial Window Procedures Therapeutic Bronchoscopy, Airway Stents, and Other Closed Thorax Procedures

Stay updated, free articles. Join our Telegram channel

Join