Transcript Surgical Management of Lung Cancer

Thoracic Surgery
By
Mike Poullis
Overview
• What is it ?
• What do you need to know as a nurse on the
ward ?
What do you need to know as a
nurse on the ward ?
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Different pathologies
Different operations
Chest drains
Post operative care
Different pathologies
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Lung cancer
Pneumothorax
Pleural effusions
Lung biopsies
• Trauma
• Oddities
Different operations
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Bronchoscopy (oesophagoscopy)
Mediasteinoscopy
Mediasteinotomy / Chamberlains
Thoracoscopy VATS
Mini thoracotomy
Full thoracotomy
• Pneumonectomy / Lobectomy / Wedge
Anatomy
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Trachea
2 bronchi
2 Lungs
2 lobes on left
3 lobes on right
The Right Lung
The Left Lung
Bronchial system
Compartments of the chest
Lung cancer
• Small cell
• Non small cell
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Squamous
Adeno
Large cell
Undifferentiated
Lung cancer
• Except for small cell carcinoma of the lung
it is generally accepted that surgery is the
most effective therapy for lung carcinoma
Small Cell Lung Cancer
Assessment of Patient
• Fitness for surgery
• Operability of the tumour - Staging
Staging
• TNM
• T size and position of tumour
• N lymph node status
• M metastasis
Stages
• Stage Grouping—TNM Subsets
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Stage 0 (TisN0M0)
Stage IA (T1N0M0)
Stage IB (T2N0M0)
Stage IIA (T1N1M0)
Stage IIB (T2N1M0, T3N0M0)
Stage IIIA (T3N1M0), (T(1–3)N2M0)
Stage IIIB (T4, Any N, M0) (Any T, N3M0)
Stage IV (Any T, Any N, M1)
Survival
Stage
5 year Survival
1 A, B
60-85%
II A,B
40-60%
III A
10-40%
III B
<10%
IV
<5%
Fitness for Surgery
• Age
• Pulmonary function
• Cardiovascular function
• Medical conditions
• Nutritional Status
• Performance status
Assessment of Operability
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CT scan
Bone scan
PET scan
Mediastinoscopy
Anterior Mediastinotomy
VATS
Pleural effusions
• Fluid in chest
• Due to underlying cause
• Usually malignant, but what ?
• Drain for
– Symptoms
– Diagnosis
Pneumothorax
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What is a pneumothorax ?
How do you treat them ?
Who requires surgery ?
What does surgery entail ?
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Thoracotomy
Sternotomy
Mini thoracotomy
VATS
Lung biopsies
• Need tissue to diagnose “Interstitial lung
disease”
Bronchoscopy
oesophagoscopy
Mediastinoscopy
Mediastinoscopy
Mediastinotomy / Chamberlains
Mediastinotomy
Thoracoscopy
Video Assisted Thoracic Surgery
Thoracotomy
Posterolateral
Lateral
Anterolateral
Mini thoracotomy
Thoracotomy - Posterolateral
Thoracotomy - Anterolateral
Mini thoracotomy
• Small incision thoracotomy
Lung Resection
• Pneumonectomy
• Lobectomy
• Wedge
Lung Resection – Pneumonectomy
Intrapericardial
Extrapericardial
No reserve
Sputum
pO2
Fluid balance
Infiltrates
Temperature
AF
Lung Resection – Lobectomy
3 Lobes on RT
RUL
RML
RLL
(not RUL & RLL)
2 lobes on LT
LUL
LLL
Wedge resection
Chest drains
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What are they ?
Why use them ?
Suction and its role
What drain do you take out MARK IT
Function
• Conduit to remove fluid or air from the pleural
or pericardial spaces
• The fluid may be blood, pus or pleural effusion
• Allow the lungs and heart to work unrestricted
Spaces That Need Draining
Following Thoracic Surgery
• Only a single pleural cavity opened
• Air and blood may collect in the space
• Two drains
– Apical drain – Air
– Basal drain – Blood
• Traditionally apical drain is placed
anteriorly and basal drain at the back
Chest Drain
Suction
• What does it do?
– Makes the external pressure negative
• Air or blood drains more easily out of chest
Dangers
• If on to high tissues may get sucked into the
drain damaging them
• If connected but not on similar effect to
clamping the drains
• BEWARE PNEUMONECTOMY
Does and Don’ts of Chest Drains
• Do not clamp a functioning drain as this can
lead to a tamponade or a tension
pneumothorax
• If becomes disconnected, reconnect and ask
patient to cough
• Always keep drain below level of patient
– If raised above patient the contents may siphon
back into the chest
Drain Removal
and
Timing of Drain Removal
On Expiration
• Pleural pressures at their highest
– But still less than atmospheric pressure
• Difficult to hold breath at full expiration
• Natural reaction to pain is to take a deep
breath in
On Inspiration
• Easy to hold breath on maximal inspiration
• Pleural pressure most negative therefore air
more likely to move into pleural space
Valsalva Manoeuvre
• Forced expiration against a closed glottis
• Creates a positive intrapleural pressure
• Easy for patient to hold
Post operative care
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Blood pressure
Blood gases / saturation
Urine output
Bleeding
Sputum
Analgesia
Any Questions ?