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what is cardiothoracic surgery (CT)?
- - surgery in the thorax- above diaphragm
- - heart, lungs, pleura, mediastinum
- - things particular to this sugery- chest drains, CPB, cardioplegia, collapsed lungs during surgery
- - CT surgery can be open or closed
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What is a median sternotomy incision?
- down the middle of the sternum
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what is a thoracoscopy incision?
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What are indications for thoracic surgery?
- Lung
- - Cancer
- - chronic infection
- - excision of other tissue eg abscess
- Pleura
- - chronic infection- empyema (puss in pleural space)
- chest wall
- medaistinum
- oesophagus
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what is empyema?
- pus in pleural space
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Where do most complications occur with surgery?
- post op complications will occur more in thoracic surgery
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What is a thoracoscopic surgery used for?
- - VATS
- - pleural surgery eg Bx or pleuradesis (layers stick together such as a pneumothorax)
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when is a thoracotomy surgery used?
- - mm sparing (through IC mm)
- - ribs retracted
- - may # ribs or resect a section for better access
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thoracic surgery
- will need to see these pt
- - no CPB (central pulmonary bypass)
- - return to step downward unless risk factors
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what are the types of pleural surgeries?
- may not see pt unless in pain
- remember the shoulder
- - pleurodesis- sticking together of the two pleura (viceral to parietal). There is a thoracoscopic or open, fusion of pleura, material introduced to set up inflam reaction such as talc
- - decortication- stripping of the pleura. Done when chronic pleural infection, thickened pleura stripped off lung, allows lungs to reexpand
- - repair of defects eg pneumothorax (stapling of blebs)
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what pt of thoracic surgery have high complications?
- very high risk of complications for:
- - smoking
- - thoracic incision
- - pain
- - lung collapse
- Preop is essential
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What is a lobectomy?
- removal of one or more lobes of a lung
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when is a lobectomy used?
- - pt has cancer
- - chronic infection
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bronchietasis
- chronic infection
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What is the surgical procedure of lobectomy?
- - thorocotomy
- - r/o lobes
- - drains
- - remaining lung expands and fills space
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what is a drain draining at the apical point of a lung?
- air
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what is a drain draining at the basal point of the lung>
- fluid
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What is a TEA?
thoracic epidural
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WHat is the post opcare of a lobectomy?
- - 2 drains
- - pain controlled by TEA or PCA
- - physio asap
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What are the physiotherapy key points of a lobectomy?
- - LIE AFFECTED LUNG UPPERMOST- using gravity to open the lung
- - better ventilation
- - helps re-expand
- -better for pain control
- - can assist with drainage of pulmonary secretions
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What must you NOT do with a lobectomy patient?
- unless told to do by a surgeon
- - suction
- - use CPAP or PEP
- - remember the shoulder
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What is a pneumonectomy?
- removal of a whole lung
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When should a pneumonectomy be conducted?
- when a pt has cancer
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What is the surgical procedure for a pneumonectomy?
- - these patients can go off very quickly due to poor lung clearance due to pain
- - thoracotomy
- - r/o lung- chop off bronchus
- - bronchial stump oversewn
- - +/- ICC, may be clamped
- - cavity fills up with fluid (blood)- should be lower than the level of the stump, eventually fibrosis occurs
- - postpneuomonectomy space
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What is the post op care of a pneumonectomy?
- - pain control through thoracic epidural or PCA
- - physio commences asap
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What are the key physiotherapy points?
- - very high for postop complications
- - smoking, lung disease
- - pain
- - thoracic mechanism
- - do not lie affected side up (MISSING LUNG DOWN, WE DONT WANT FLUID OVER STUMP or it will drain into other lung) as draining blood into good lung, wetting bronchial
- - DO NOT suction or use CPAP or PEP
- - remember the shoulder
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What is a LVRS?
- - lung volume reduction surgery
- - to reduce volume
- -bulectomy
- - restore better respiratory mechanics through less volume
- - wedge resection, sleeve resection, segmental resection
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What are other names for chest drains?
- - chest tubes
- - chest drains
- - intercostal catheter (ICC)
- - underwater seal drain (UWSD)
- - pleurocath
- - they are put in the pleural space
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Why would a chest drain be used?
- - open thorax- thoracotomy/ sternotomy
- - loss of negative intrapleural pressure
- - remove build up of air or fluid without allowing air to return to pleural space
- - prevents extraair into pleural space
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Chest drain set up
- - chest drains need to have a one way valve to allow fluid and air to escape but not to be sucked back into the pleural space- underwater seal!
- - fluid drains via gravity- drains MUST ALWAYS BE HELD BELOW THE THORAX
- - suction may be aplied to hasten drainage
- - water cannot be sucked into the pts pleural space due to length of tube (-ve pressure neded) and gravity dependent position of the drain
- SEE NOTES
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What thing do we usually observe with chest drains?
- - drain site
- - amount drainage - how much fluid in 1st contain
- - bubbling - air 2nd container- not good for healthy person
- - swing- good, means drain is workng, transmission of pleural pressure changes to the fluid in the tube
- Fluid moves towards pt on inspiration and away on experation
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Removing chest drains
- - once drainage has reduced
- - once bubbling has stopped
- - if CXR shows no Ptx or effusion
- - technique for remval - cut, hold breath, pull out
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Chest drains physiotherapy key points
- - mobilisation- you can but suction usually attached to wall. You can disconnect, unless told otherwise
- - transferring
- - positioning
- - treatment eg percussion- around
- - pain
- Safety
- - movement
- - disconnection at patient
- - disconnection at drain
- - clamping- only after pneuomectony
- Dont kick, keep upright, dont pull, keep below pt chest
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