The patient and family should receive detailed information preoperatively. When possible, taking time to improve the patient’s pulmonary, physical, and nutritional status is desirable.² Smoking cessation is an important preoperative aspect of surgery; however, the effects of smoking linger after cessation with benefits noted after a year. Smokers who have recently quit have no difference in pulmonary complications than current smokers.³ Preoperative medications should be continued with the exception of anticoagulant medications.² The perianesthesia nurse should review the diagnostic and laboratory tests preoperatively. Preoperative evaluation of the patient who will undergo thoracic surgery may include laboratory tests and pulmonary function tests listed in Table 34-1.

Table 34-1 Laboratory Studies for Assessment of Patients Undergoing Thoracic Procedures

LABORATORY STUDY	NORMAL RESULTS	SIGNIFICANCE OF ABNORMAL FINDINGS
Perfusion Studies—Arterial Blood Gases
pH	7.35-7.45	Changes indicate metabolic or respiratory acidosis.
PaCO₂	35-45 mm Hg	Elevations indicate possible COPD, asthma, pneumonia, anesthetic effects, or use of opioids (respiratory acidosis). Decreased levels indicate hyperventilation/respiratory alkalosis.
HCO₃⁻	21-28 mEq/L	Elevations indicate possible respiratory acidosis as compensation for primary metabolic alkalosis. Decreased levels indicate possible respiratory alkalosis as compensation for primary metabolic acidosis.
PaO₂	80-100 mm Hg	Elevations may indicate possible excessive oxygen administration. Decreased levels indicate possible COPD, asthma, chronic bronchitis, cancer of bronchi and lungs, respiratory distress syndrome, or any other cause of hypoxia.
O₂ saturation	95%-100%	Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.
Complete Blood Count
RBCs	Male: 4.7-6.1 million/mm³ Female: 4.2-5.4 million/mm³

Elevated levels may be due to excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, such as COPD. Decreased levels may indicate anemia, hemorrhage, or hemolysis. Hemoglobin

Male: 14.8 g/dL

Female: 12-16 g/dL

Same as for RBCs. Hematocrit

Male: 42%-52%

Female: 37%-47%

Same as for RBCs. WBCs 5000-10,000/mm³ Elevations indicate possible acute bacterial infections or inflammatory conditions (smoking). Decreased levels may indicate overwhelming infection or immunosuppression. TEST PURPOSE FVC (forced vital capacity): Records maximum amount of air that can be exhaled as quickly as possible after maximum inspiration. Provides an indication of respiratory muscle strength and ventilatory reserve. Often reduced in obstructive disease (because of air trapping) and in restrictive disease. FEV₁ (forced expiratory volume in 1 sec): Records maximum amount of air that can be exhaled in first second of respiration. Effort dependent and declines with age. Reduced in certain obstructive and restrictive disorders. FEV₁/FVC: Ratio of expiratory volume in 1 sec to FVC Provides a more sensitive indicator of obstruction to airflow. Ratio is normal or increased in restrictive disease. FEF_25%-75%: Records forced expiratory flow over 25%-75% volume (middle half) of FVC. This measure provides a more sensitive index of obstruction in smaller airways. FRC (functional residual capacity): Amount of air remaining in lungs after normal expiration. Increased FRC indicates hyperinflation or air trapping, which can result from obstructive disease. TLC (total lung capacity): Amount of air remaining in lungs at end of maximum inhalation Increased TLC indicates air trapping associated with obstructive pulmonary disease. Decreased TLC indicates restrictive disease. RV (residual volume): Amount of air remaining in lungs at end of a full, forced exhalation RV is increased in obstructive pulmonary disease, such as emphysema. DL_co (diffusion capacity of carbon monoxide): Reflects surface area of alveolocapillary membrane DL_co is reduced when alveolocapillary membrane is diminished, such as in emphysema, pulmonary hypertension, and pulmonary fibrosis.

COPD, Chronic obstructive pulmonary disease; HCO₃, bicarbonate ion; PaCO₂, partial pressure of arterial carbon dioxide; PaO₂, partial pressure of arterial oxygen; RBC, red blood cell; WBC, white blood cell.

From Pagana KD, Pagana TJ: Mosby’s diagnostic and laboratory test references, ed 9, St. Louis, 2009, Mosby; Rees HC: Assessment of the respiratory system. In Ignatavicius DD, Workman ML, editors: Medical-surgical nursing: patient-centered collaborative care, ed 6, Philadelphia, 2010, Saunders.

Surgical procedures

Surgical procedures can be diagnostic or therapeutic in nature. Diagnostic procedures can include bronchoscopy, mediastinoscopy, laryngoscopy, and thoracoscopy. Bronchoscopies are performed to visualize the airway or remove abnormal tissue, mucous plugs, or foreign bodies. They also aid in evaluating lung lesions and staging of lung cancer. Complications can include airway obstruction, hypoxemia, pneumothorax, hemorrhage, or cardiovascular problems such as dysrhythmias or hypotension (Fig. 34-1).

FIG. 34-1 Flexible fiber-optic bronchoscope.

(Courtesy Olympus America, Melville, NY.)

Mediastinoscopy is performed for direct visualization of lymph nodes or tumors at the tracheobronchial junction, subcarina, or upper lobe bronchi via a lighted scope. The potential for hemorrhage is present because of the close proximity of the innominate vessels and aortic arch to the mediastinoscope. Other complications can include venous air embolism; vagally mediated reflex bradycardia from compression of the trachea or great vessels; airway or esophageal injury, including subcutaneous emphysema; chest pain; or pneumothorax. Recurrent laryngeal nerve injury can occur and manifest symptoms such as hoarseness or vocal cord paralysis.⁴ A laryngoscopy is performed to visualize or biopsy the oropharynx, laryngopharynx, larynx, or proximal trachea. Complications include trauma to the lips, mucous membranes, teeth, or eyes; rupture of the esophagus; hypoxemia; or laryngospasm. Endobronchial ultrasound (EBUS) is a new minimally invasive technique that allows the proceduralist to see beyond the lumen of the airway. There are two EBUS systems currently available—the radial probe EBUS allows for evaluation of central airways, accurate definition of airway invasion, and facilitates the diagnosis of peripheral lung lesions; and the linear EBUS guides transbronchial needle aspiration of hilar and mediastinal lymph nodes.⁵

Thoracoscopy is the insertion of an endoscope, a narrow-diameter tube with a camera attachment, through a small incision in the chest wall for examination of the lungs or other structures in the chest cavity, without a large incision. It is performed for basic diagnostic (undiagnosed pleural fluid or pleural thickening) and therapeutic procedures (pleurodesis). Complications can include bleeding, infection of the pleural space, and injury to intrathoracic organs, atelectasis, and respiratory failure.⁶ This procedure is different from video-assisted thoracoscopic surgery (VATS), an invasive procedure that uses a high-level access platform and multiple ports for separate viewing and working instruments to access pleural space.⁶ VATS can be diagnostic or therapeutic and is used often for biopsy of mediastinal masses, to perform wedge resections, to obtain hemostasis, or to evacuate blood clots. A variety of procedures can be performed via thoracoscopy, from lung volume reduction to a biopsy and excision of mediastinal lesions. Robotic-assisted thoracic procedures can enhance the speed and safety of VATS. Smaller incisions are used for robotic surgery which may contribute to less postoperative pain and morbidity.⁷

A significant advantage of thoracoscopy is that it is minimally invasive and results in less incisional pain. It can also decrease recovery time and length of hospital stay. In some facilities, patients come to the PACU with a small chest tube that is pulled if chest radiograph results are clear; the patient then is allowed to go home in a few hours. VATS may be converted to an open surgery if there is an inability to achieve one-lung ventilation, extensive pleural adhesions, uncontrolled or significant intraoperative bleeding, an inability to identify target lesion for biopsy, or technical difficulties with or rarely, primary failure of video equipment and/or endoscopic instruments.⁸

Therapeutic thoracic surgeries may include pectus excavatum, chest wall reconstruction, wedge resection of a lung lesion, segmentectomy, lobectomy, or pneumonectomy. Excision of the right lung is less tolerated than removal of the left lung because of the larger vascular bed and breathing capacity. Other thoracic surgeries include lung volume reduction, for removal of emphysematous lung tissue, or lung transplant.

Perianesthesia nursing care after thoracic procedures

Admission assessment in the PACU is the same as for any other surgical patient (see Chapters 27 and 28). Common problems that lead to delayed discharge from the hospital for the patient who has undergone a thoracic procedure include inadequate pain control, prolonged air leak, severe nausea, fever, debility, and arrhythmias.² Postoperative care should target prevention or speedy treatment of these complications. Some specific issues for the patient after thoracic surgery are discussed.

Positioning

Positioning after thoracic procedures varies; therefore, medical orders must be checked. The patient may be kept in a side-lying position until awake, and then the head of the bed is elevated 30 to 45 degrees to facilitate ventilation. This position allows the diaphragm to drop into normal position, thus enhancing lung expansion and, if present, facilitating chest tube drainage. After lobectomy, segmentectomy, and wedge resection, the patient can be turned freely from side to side to allow full expansion of lung tissue on both the operative and nonoperative side. After pneumonectomy, the patient may be placed on the back or on the operative side.⁹ The patient is not positioned side lying on the nonoperative side because the mediastinum is no longer confined by lung tissue and may move freely, thereby compressing the remaining lung or creating traction or torsion of the vena cava. In addition, if the bronchial stump ruptures and bleeds profusely, the unaffected lung is compressed by secretions from the pneumonectomy site.

Position changes are important after thoracic surgery. If the patient undergoes an outpatient procedure, such as bronchoscopy, position changes are made independently. If the patient has a chest tube in place, the perianesthesia nurse needs to assist with position changes to ensure system patency and patient comfort. Position changes also include early return to ambulation, with the goal of promoting patient comfort, drainage of secretions, and prevention of venous stasis and atelectasis.

Respiratory assessment and care

On arrival, the patient is placed on oxygen via the delivery system required per the extent of the patient’s surgery, preexisting medical conditions, and need for continued assistance. Continued assistance may include a nasal cannula after bronchoscopy, face mask or face tent, or mechanical ventilation. Delivered oxygen should be given with humidification to help thin tracheobronchial secretions and thus permit the ciliary mechanism and coughing to clear the airway.

The perianesthesia nurse should assess respiratory function on arrival, beginning with inspection of the patient’s respiratory effort and ease of effort. Respiratory rate is noted; a rate of 10 to 20 breaths per minute is considered normal. A rate of greater than 20 is considered to be tachypnea and may be caused by pain, hypoxemia, hypoventilation, or secretions. The use of pulse oximetry helps in the quick assessment for hypoxemia. A respiratory rate of less than 10 is considered bradypnea, which may occur as a result of anesthetic and opioid administration. The patient should also be assessed for the quality of respirations. The patient may have a respiratory rate within normal limits but not deep enough to blow off the carbon dioxide of normal respirations. Some PACUs have the capability to monitor end-tidal CO₂ with a capnograph. The nurse should auscultate the patient’s lungs to assure that respirations are of good quality. Appropriate pain management can promote effective ventilation. The patient may also arrive in the PACU intubated with either a T piece, if respiratory effort is sufficiently present but loss of airway patency is a concern, or mechanical ventilation, if airway and ventilation are concerns.

Breath sounds should be assessed for depth, clarity, and the presence of adventitious sounds, including crackles, rhonchi, or a pleural friction rub. The use of accessory muscles should be noted. Accessory muscle actions include nasal flaring, suprasternal retractions, diaphragmatic breathing, and intercostal retractions.

The regularity of breathing is assessed as regular, irregular, or ventilated. Ventilator settings are confirmed. If arterial blood gases are drawn, adjustments are made, if necessary, after assessment of results. Ongoing pulse oximetry monitoring is necessary for any patient who has undergone a thoracic surgical procedure with capnography available if needed.

Intubation might have been used to protect the airway, to assist ventilation, or to provide a means for management of secretions through suctioning. Tracheal suctioning of the patient after thoracic surgery may be necessary to assist in removal of accumulated secretions.

Respiratory management

The modified stir-up regimen, including positioning, mobilization, sustained maximal inspiration (SMI), cascade coughing, and pain relief, is especially important for a patient recovering from a thoracic surgical procedure. Positioning and mobilization have already been discussed. The SMI and cascade coughing exercises are the easiest ways to maintain a patent airway after the patient is reactive to verbal commands. Preoperative teaching is extremely important; the patient who has been well educated and knows what is expected after surgery can cooperate by taking a deep breath, holding it for 3 seconds, exhaling (the SMI), taking a deep breath, and coughing throughout exhalation (the cascade cough). Effective preoperative teaching enhances the effectiveness of the modified stir-up regimen even if the patient is not fully reactive.

When the patient is fully conscious, rigorous SMIs and cascade coughing are continued every hour. This regimen is most effective with the patient sitting to allow full lung expansion. If the patient cannot sit, raise the head of the bed and have the patient bend the knees to relax the abdominal muscles. The patient is instructed to inspire deeply and hold the breath for 3 seconds to expand the lungs and relax the abdominal muscles so that the belly pouches out. Four to five SMIs are taken, and the patient is instructed to perform the cascade cough to clear the tracheobronchial tree of accumulated secretions. After the patient performs about three cascade coughs, a forceful cough is then usually produced spontaneously, thus clearing the airways of secretions. Endotracheal secretions are usually excessive after thoracic surgery because of manipulation and irritation of the tracheobronchial tree during the operation and intubation, decreased lung ventilation, and a decreased cough reflex. Pain or fear, or both, may interfere with the patient’s ability to perform the SMI and cascade cough.

Pain management

Although pain after bronchoscopy is usually limited to a sore throat, the patient undergoing thoracic surgery should be told before surgery to expect a fair amount of postoperative incisional pain. The patient should also be told that pain relief measures are available and may include epidural analgesia, patient-controlled analgesia, and nurse-administered opioids. The thoracotomy incision is an extremely painful incision because of irritation from respiratory effort and any upper body movement (Fig. 34-2).¹ Because acute pain after thoracic surgery has been linked to chronic thoracic pain months later, appropriate pain relief must occur. Severe pain during the first couple of days after surgery is predictive of chronic postthoracotomy pain with as many as 67% of patients who underwent a thoracotomy developed persistent postsurgical pain.¹⁰

FIG. 34-2 Multiple sources of afferent transmission of pain sensations after thoracotomy. 1, Intercostal nerves at the site of the incision (usually T4-6); 2, intercostal nerves at the site of chest drains (usually T7-8); 3, phrenic nerve afferents from the dome of the diaphragm; 4, vagal nerve innervation of the mediastinal pleura; 5, brachial plexus.

(From Miller RD, et al: Miller’s anesthesia, ed 7, Philadelphia, 2010, Churchill Livingstone.)

Evidence-Based Practice

Mathews and colleagues conducted an evidence-based study to determine whether patient-controlled analgesia with ketamine and morphine (PCA-MK) or PCA with morphine alone (PCA-MO) was best for postoperative analgesia in patients who have had thoracic surgery. All identified studies found that morphine requirements were reduced with use of PCA-MK. The authors conclude that adding low-dose ketamine to morphine PCA is safe and may provide better pain control than PCA-MO. Pain scores were lower with PCA-MK as well as improved oxygen saturations and PaCO₂ levels.

Implications for practice

The use of ketamine postoperatively in conjunction with an opioid provides safe and effective pain management for patients after thoracic surgery. The incidence of hallucination requiring intervention was 2.9%. Other randomized controlled trials found no hallucination or psychological side effects. The perianesthesia nurse should know the indications and side effects for the use of ketamine for acute postoperative pain in thoracic surgery patients.

Source: Mathews TJ, et al: Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain? Interact Cardiovasc Thorac Surg, 2011 [Epub ahead of print].

An effective modality for postsurgical thoracotomy pain is nerve conduction blockade with local anesthetics.¹ Pain management via epidural catheter has been shown to provide more effective pain relief after thoracotomy. Of best benefit is epidural analgesia with an opioid and local anesthetic that has begun at least 30 minutes before induction of anesthesia. Pain medications should be given in adequate doses and in a timely manner because pain interferes with needed activities after surgery, including deep breathing, coughing, and progressive mobilization. Because opioids can diminish respiratory function, care must be taken in their administration, especially after general anesthesia. However, a patient whose pain is not adequately controlled is unable to deep breath effectively to maintain oxygenation and prevent atelectasis (Box 34-1).

BOX 34-1 Postoperative Analgesia Modalities

Systemic analgesia

• Opioids

• Can control background pain, but pain control usually poor with interrupted sleep patterns when opioid levels fall below therapeutic range

• Amount needed to control pain during movement causes sedation and hypoventilation in most patients

• NSAIDs

• Can reduce opioid consumption after thoracotomy

• Has an antiinflammatory and analgesic effect, but can be associated with decreased platelet function, gastric erosions, increased bronchial reactivity, and decreased renal function

• Acetaminophen

• Is an antipyretic and analgesic that can be administered orally or rectally in doses up to 4 g/day

• Has a low toxicity compared with cyclooxygenase-inhibiting NSAIDs

• Ketamine

• Low-dose intramuscular ketamine (1 mg/kg) is equivalent to the same dose of meperidine and causes less respiratory depression

• Can also be administered as a low-dose intravenous infusion

• Psychomimetic effect with ketamine is a concern, but is rarely seen with analgesic, subanesthetic doses

• Dexmedetomidine

• A selective adrenergic α2-receptor agonist can significantly decrease the requirement for opioids when used in combination with epidural local anesthetics

• Associated with some hypotension, but seems to preserve renal function

Other techniques

• Application of a −60°C probe to the exposed intercostal nerves intraoperatively

• Produces an intercostal block that can persist for up to 6 months

• Moderately efficient to decrease postoperative pain, but is associated with an incidence of chronic neuralgia

• Transcutaneous electrical nerve stimulation

• May be useful in mild to moderate pain, but ineffective for severe pain

Epidural analgesia

• Spinal injection of opioids can have a duration of analgesia that approaches 24 hours after thoracotomy.

• Epidural techniques reduce the incidence of respiratory complications.

• The majority of thoracotomies received a thoracic epidural between T3 and T8, with infusions of bupivacaine plus either fentanyl or hydromorphone.

• Risks of respiratory depression and hemodynamic instability are due to the use of bolus injection techniques.

• Use of epidural infusions has an excellent record for patient safety when used on routine postoperative surgical wards.

• The majority of thoracotomies receive a thoracic epidural between T3 and T8, with infusions of bupivacaine plus either fentanyl or hydromorphone.

Paravertebral block

• Paravertebral local anesthetics provide a reliable multilevel intercostal blockade. Clinically, the analgesia is comparable to that from epidural local anesthetics.

• Advantages over epidural include comparable analgesia, fewer failed blocks, decreased risk of neuraxial hematoma, and less hypotension, nausea, or urinary retention.

NSAID, Nonsteroidal antiinflammatory drug.

From Slinger PD, Campos JH: Anesthesia for thoracic surgery. In Miller RD, et al: Miller’s anesthesia, ed 7, Philadelphia, 2010, Churchill Livingstone.

In addition to analgesics, pain relief measures can include use of a pillow to splint the incision while the patient coughs. Because coughing is the most effective way to clear secretions, pain medication should be offered and given regularly. See Chapter 31 more detailed information about pain management in the PACU.