VOL: 101, ISSUE: 06, PAGE NO: 61
Benjamin Smith, Dip HE, BA, is senior staff nurse, surgical unit, Papworth Hospital NHS Trust, Cambridge
Development of treatment
In the 1950s Brantigan proposed that excision of the most hyper-inflated and diseased lung tissue could improve lung elastic recoil, reduce airflow limitation and improve chest-wall mechanics.
It was suggested that this could restore normal chest movement during respiration and utilise the remaining lung tissue to reduce symptoms of breathlessness. Unfortunately, in practice, it was found that the procedure resulted in high mortality, morbidity and limited clinical success (Yusen et al, 2002).
However, medical advances including lung transplantation have meant that LVRS could now be a viable procedure (Cooper and Patterson, 1996).
Health care professionals now have a much better understanding of emphysema and there are improved imaging techniques, pulmonary function testing, critical care and surgical procedures.
Proposals were made in 1997 for a multi-centre randomised controlled trial in the UK to compare LVRS and pulmonary rehabilitation with pulmonary rehabilitation alone (Lomas et al, 1997).
The trial began in 1999 and aims to evaluate the effectiveness of LVRS in improving both symptoms and lung function of patients with advanced emphysema.
The procedure can be used to ease the functional decline associated with emphysema or bridge the gap for patients waiting for lung transplantation. Papworth Hospital is one of seven UK centres taking part in this ongoing trial. Patients are assessed against strict inclusion and exclusion criteria before being selected for LVRS (Box 1).
John Jones is a 52-year-old married man with severe emphysema whose symptoms have increased over the past three years. He had to give up his job as a carpenter because of increasing shortness of breath. He had a history of exposure to asbestos and used to smoke up to 50 cigarettes a day.
Mr Jones underwent a six-week course of pulmonary rehabilitation which included a twice-weekly outpatient exercise programme and an education programme. He was then reassessed and was randomly selected for the LVRS rather than the alternative pulmonary rehabilitation maintenance programme.
At a preoperative assessment clinic, baseline preoperative tests were conducted. Mr and Mrs Jones also had uninterrupted time to discuss the surgery, their fears and expectations, and discharge plans.
Mr Jones had LVRS to both lungs via a median sternotomy (Box 2). During the procedure the lungs can be separately inflated or deflated using a double lumen endotracheal tube. The most severely diseased lung is operated on first.
The lung is deflated and approximately 30-40 per cent of lung volume is removed predominantly from the upper lobe. The upper lobes are affected most by standard smoking-related emphysema (Larson et al, 1998).
Patients are usually nursed in a critical care unit for 24 hours following surgery. When they are clinically stable, they are transferred to the postoperative ward, where they continue to require close monitoring of their respiratory function, pain and underwater sealed intrapleural drain.
When Mr Jones returned to the ward he was breathing without the support of a ventilator and was prescribed 28 per cent humidified oxygen via a face mask. This maintained his oxygen saturations at about 96 per cent and he had a respiration rate of 17 breaths a minute.
He was able to eat and drink. However, a central venous line provided access for intravenous fluid support, prophylactic intravenous antibiotics and anti-emetics. Mr Jones required a urinary catheter because he was receiving epidural analgesia that may affect normal bladder function and possibly lead to urinary retention. The urinary catheter also enabled the fluid balance to be carefully monitored.
The three important aspects of Mr Jones’ care discussed in this article are pain control, physiotherapy and management of underwater sealed intrapleural drains. See Dougherty and Lister (2004) for a more detailed discussion of the routine care of underwater sealed intrapleural drains.
Painful inspiration and expiration after lung surgery can affect patients’ ability to expand their lungs. Therefore good pain control is an essential part of their postoperative care.
Mr Jones had an epidural cannula for the administration of analgesia. This usually remains in place until the underwater sealed intrapleural drains have been removed (Scullion, 1999). Patients report that the drains cause considerable discomfort and also restrict movement (Owen and Gould, 1997).
Mr Jones’ pain was assessed using a five-point visual analogue scale (zero represented no pain and five was intolerable pain). He initially said he was comfortable but it became clear that coughing and movement caused some discomfort.
We explained that Mr Jones must also include these symptoms in his assessment of pain. Following this he was able to guide the nurses and achieve effective pain control.
On the forth day after surgery, the epidural catheter began to migrate out of its original position. It was therefore removed and regular oral analgesia was prescribed with good effect.
Physiotherapy - Optimal pain control enabled Mr Jones to increase his mobility and breathing exercises. The short and long-term aims of the physiotherapy after surgery are described in Boxes 3-4.
Responsibility for pulmonary hygiene was a shared responsibility between nurse and physiotherapist. Whenever possible nurses encouraged Mr Jones to continue his breathing exercises and administered prescribed nebulised bronchodilators.
On the forth day after surgery, Mr Jones developed clinical signs of a chest infection including tightness across the chest and a productive cough. He was also pyrexial and had a raised white-cell count. His sputum was thick and green so a specimen was sent for culture, and antibiotics were prescribed.
The taste of this sputum spoilt Mr Jones’ appetite for two or three days so the dietician was informed and his food intake was monitored.
His poor appetite combined with the drying effect of oxygen therapy on the oral mucosa meant that he required frequent mouth care.
Fortunately he recovered from the chest infection and his dietary intake began to improve.
Underwater sealed intrapleural drains - These allow the passage of fluid and air from the pleural space and this facilitates reinflation of the lung following surgery.
If the drain tubes become kinked or disconnected then the respiratory status of the patient can be compromised. If this occurs, immediate action is required (Dougherty and Lister, 2004; Newsome and Ott, 1997).
Mr Jones had an apical underwater sealed intrapleural drain positioned at the top of the pleural space to drain air (pneumothorax), and a basal drain positioned at the base of the pleural space to remove blood (haemothorax) and serous fluid on the right and left sides.
Each drainage system was attached to 7kPa of suction. This increases the negative pressure in the pleural space and enhances lung expansion. The content, volume of drainage and activity of the drains, such as air bubbling through the water, was recorded.
Excessive drainage of blood could indicate a haemothorax. Associated clinical signs include shortness of breath developing into chest pain, increasing respiratory distress, decreased breath sounds and decreased chest-wall movement on the affected side.
A slight air leak after surgery (indicated by bubbling of water in the drain) is expected and usually resolves within three days. However, a large air leak - indicated by continuous bubbling - may suggest there is a tear at the suture line on the lungs that may need immediate repair.
Other causes of air leaks include poor tube connections and a poor seal around the entry site of the drain - for example, as a result of the tube slipping - and require prompt attention. For more information consult Dougherty and Lister (2004).
Mr Jones experienced a moderate air leak that took 19 days to resolve. Morse (1998) says prolonged air leaks are one of the most common problems following LVRS.
Specific complications associated with underwater sealed intrapleural drains - The longer the drains remain in place the greater the risk of infection. Mr Jones’ drain sites were therefore monitored for signs of inflammation or more seriously purulent discharge.
As the patient becomes more mobile the drain can move from its original location, which results in subcutaneous emphysema. This presents as air under the skin that crackles when touched. In extreme cases it can compromise the patient’s airway. Mr Jones did have a small amount of subcutaneous emphysema but this resolved without complications.
Criteria for chest drain removal
The criteria for chest drain removal following LVRS is based on a combination of factors including:
- No air leakage and drainage from the underwater sealed intrapleural drains;
- The patient’s breath sounds are satisfactory;
- X-ray shows the lungs are fully inflated (Allibone, 2003).
Seventeen days after surgery Mr Jones was able to have his drains removed on the left side. The air leak on the right side resolved two days later and the drains were subsequently removed. In both cases the chest X-ray after the removal of drains demonstrated that the lungs had remained fully inflated.
Following removal of the drains Mr Jones made good progress and with renewed enthusiasm he was soon ready for discharge. A district nurse was required to check his wounds and remove the drain sutures. Temporary oxygen therapy was organised at Mr Jones’ home.
The thoracic link nurse was informed of discharge so she could check Mr Jones’ progress at home. Arrangements were made for Mr Jones to continue the pulmonary rehabilitation programme with the physiotherapists as an outpatient.
Psychological care - Mr Jones was frustrated that his drains restricted his mobility particularly when they were attached to the wall suction. He also wanted to experience the benefits of his surgery.
Mr and Mrs Jones had not anticipated such a long recovery period and it was clear that their ability to cope was being stretched. They needed a lot of reassurance and support.
Despite the comprehensive preoperative education it is suggested that this group of patients commonly experience low periods resulting from the high expectations they have of surgery (Miracle, 2004).
Rogers and Rogers (1997) believe that the patient’s attitude is the key to a quick recovery following LVRS. The trial is continuing to evaluate the effectiveness of LVRS.
Cordova and Criner (2001) suggest that if patients with end-stage emphysema are carefully selected, LVRS can offer symptomatic relief for shortness of breath, improved lung function and exercise capacity, and quality of life.
Mr Jones feels that he now has a greater exercise tolerance and requires oxygen therapy less frequently. He believes that he has made an improvement following his surgery.