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Care of the
Post-Pneumonectomy
Patient
Raja M Flores, MD
Professor and Chief of Thoracic Surgery
Mount Sinai School of Medicine
New York, New York
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Background
• Lung cancer – 220,000 cases / year
• CT screening - the NEW standard of
care care
• More tumors diagnosed early
• More lung surgery
• Major complications -10% of patients
• of which cardiopulmonary complications
constitute over 50%.
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Anatomy
• Right Lung
• Left Lung
• Pericardium
• Phrenic Nerve• Phrenic Nerve
• Recurrent Laryngeal Nerve (left)
• Diaphragm
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Types of Pneumonectomies
• Standard Pneumonectomy
• Radical Pneumonectomy
• Intrapericardial Pneumonectomy• Intrapericardial Pneumonectomy
• Extrapleural Pneumonectomy
• Sleeve Pneumonectomy
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Normal post pneumonectomy
recovery
• POD1 – ICU
• POD 2 and 3 TICU or Step down
• (cardiac monitor and O2 Sat)• (cardiac monitor and O2 Sat)
• Pod 4 – Regular Floor
• Pod 5 - Home
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Complications
Non-operative Complications
VersusVersus
Operative Complications
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Non –operative Complications
• Atelectasis and pneumonia
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Routine care
Must clear secretions
1. Pain control1. Pain control
2. Chest Physiotherapy
3. Bronchoscopy
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Pain Control
• Systemic Opioids
• Non-steroidal anti-inflammatory agents,
intercostal blocks, Intrapleuralintercostal blocks, Intrapleural
analgesia
• Epidural Analgesia
• Meta-analysis suggests that thoracic
epidural with local anesthetic plus opioid is
the most effective
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Chest Physiotherapy
• Incentive spirometry
• Coughing
• Chest percussion• Chest percussion
• Vibration
• Postural drainage
•WALKING
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When they still cannot clear
secretions
BronchoscpyBronchoscpy
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Acute Lung Injury
• ALI, ARDS, Pulmonary edema
• Fluid Restriction - “ Dry lungs work
better than wet lungs” (DIURECTIC)better than wet lungs” (DIURECTIC)
• Aspiration (Left Recurrent laryngeal
nerve Injury)
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Cardiac Arrhythmia
• Atrial Fibrillation
• Normal BP - Meds
• Dropping BP - Shock• Dropping BP - Shock
• Ventricular Fibrillation / Tachycardia
• Cardiac Herniation
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Operative Complications
• Bleeding
• Bronchopleural Fistula
• Empyema• Empyema
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Post-Pneumonectomy Empyema
• 42 y/o M hx of Right Squamous cell
cancer of the lung
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CXR POD#1
Right Pneumonectomy
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Normal CXR
2 Week Post pneumonectomy
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CXR
3 Week Postpneumonectomy
Coughing up thin secretions
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Immediate
LIFE SAVING
Maneuvers
• Right side down
• Chest tube set up ( above the incision)• Chest tube set up ( above the incision)
• Bronchoscopy – identify BPF and
pulmonary toilet
• ABC’S ??????????????????
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Bronchopleural Fistula (BPF) vs None
• Physical exam
• CXR
• CT• CT
• Bronchoscopy
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Empyema Fluid Characteristics
• pH < 7.0• Glucose < 40 mg/dL
• LDH > 1000 IU/dL• LDH > 1000 IU/dL
• Positive Gram stain
• Specific gravity > 1.018
• WBC > 500 cells mm3
• Protein > 2.5 g/dL
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Post-Pneumonectomy Empyema
• Uncommon but serious complication
• Mortality 16-71%
• May be higher with Bronchopleural• May be higher with Bronchopleural
Fistula
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Post-pneumonectomy empyema
• Typically 2-3 weeks post operation
• Anorexia
• Malaise• Malaise
• Chills, fever, sweating
• Rapid fluid accumulation within space
• Occasionally not evident for ~ 1 year
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Management of Empyema
• Initial management of empyema typically
chest tube thoracostomy + BPF
• 1-2 weeks to allow for mediastinal • 1-2 weeks to allow for mediastinal
stabilization prior to open drainage
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Clagett’s Method
• OR
• Edges débrided & mobilized
• Cavity irrigated & cleaned• Cavity irrigated & cleaned
• Cavity filled with saline (+250 mg
neomycin/100 cc NSS)
• Closed in layers as watertight as possible
Clagett, JTCVS 45:141-145, 1962
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Eloesser Procedure
• Superficial fascia sutured to periosteum
of resected rib (Eloesser)
• No tubes inserted• No tubes inserted
• Cavity irrigated daily with antibiotic
solution
• Daily irrigations for 6-8 weeks (shower)
• Dressing changes
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Single Stage Complete Muscle
Flap Closure
• 5 consecutive pts 1981-1983
• 2/5 with BPF
• Prior to closure 3 managed with chest • Prior to closure 3 managed with chest tubes, 2 with open window thoracostomy
• All managed with single-stage complete muscle flap closure
• Omental, Latissimus dorsi flaps in all + other muscles prn
Miller, Ann Thor Surg 38:227-231, 1984
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Omental Graft
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Suggested Treatment Algorithm
(See Saborio, 2001)
Miller, Ann Thor Surg 38:227-231, 1984
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Conclusions• Basic Anatomy
• Must Clear Secretions (pain control, chest
physiotherapy, bronchoscopy)
• Dry lungs work better than wet lungs• Dry lungs work better than wet lungs
• Atrial Fibrillation
• Infected Space with or without BPF (Hole in
Bronchus)
• Acute BPF (Life saving Maneuvers)
• Eloesser Flap
• Must be Proactive