lFEV 1(forced expiratory volume in one second) 20-30% of predicted (indexed to height and weight) <15%>35% rehab alone
lFVC(forced Vital capacity) 60% of predicted
lTLC (total lung capacity) 140% of predicted (increased residual volume of trapped gases)
lRV (residual volume) 250% of predicted( limit expiratory reserve, tidal volume and respiratory flow rates)
lincreased TGV (thoracic gas volumes)
lincreased RAW (resistence to airflow)
Cardiac function evaluation
lright ventricular hypertrophy
lECG to exclude coronary disease
lright and left catheterisation if suspect pulmonary hypertension(exclude patients with MPAP >35mmHg)
Post-operative care
Hypotension
·Hypovolaemia
Volume restriction due to strict limit of fluid given to prevent pulmonary oedema due to lung tissue manipulation. Peripheral vasodilatation due to sympathetic blockade (decreased: circulating epinephrine, vaso-motor tone, preload, stroke volume and cardiac output.)
Vassopressors and volume expanders only if necessary
·Post-operative bleeding
Serial hematocrit, haemoglobin and coagulation studies and hourly monitoring of drainage
·Hypothermia
Bair hugger warming, radiant heater warming
·Arrhythmias
Treat fluid/electrolyte imbalance (common in first 48-72 hrs)
UWSD management
NB. No suction is applied to chest tubes
l1hourly checks of UWSD
lobserve for bubbling, swinging and draining
ldetermine which chest drain is bubbling
limmediate chest x-R, then 4-6hrs post-op, then daily (to detect infiltrates or pneumothorax)
lheimlich valves for persistent air leaks as requested by MO (never attach a drainage bag to a Heimlich valve)
lmonitor insertion sites for redness, drainage or dislodgment.
lchanged weekly (UWSD) daily ( Heimlich valves)
lremoval of drains according to MO (as early as 24hrs, but may be a lot longer even post-discharge depending on air leak)
These patients are often claustrophobic and anxious and are best nursed in single rooms with lots of space and very calm staff
Rehabilitation
Discharge 7-10 days
lROM exercises ( aimed at increasing patient’s level of endurance and overall fitness)
ldiaphragmatic breathing and relaxation of shoulders exercises ( aimed at retraining and reconditioningthe diaphragm and accessory muscles and improving posture)
lambulation (SOOB 12hrs post-op, ambulate within room 24 hrs post-op day (treadmill evening of first post-op day in some centres), ambulate in ward day 2; aimed at ambulating independently length of the corridor (300 metres) 3 times daily prior to discharge)
Pain Management
Adequate but not excessive pain control is the goal
lepidural anaesthesia (maximum pain control with minimum respiratory depression usually bupivocaine and fentanyl)
lepidural analgesia (ropivocaine) at 4-10 ml/hr
lpanadol for break through pain (often shoulder tip)
lexcessive doses may cause respiratory depression, ineffective airway clearance, potential aspiration and immobility (strictly no CNS depressing drugs)
Sleep and diet
lsleep is essential but over sedation can be disastrous. Judicious use of sedation in consultation with MO
ladequate caloric intake
Patient outcomes
Duration of benefits uncertain. Early studies report 5 years. Recent studies report 3 years.
Improvement of
lpulmonary function(FEV1,FVC,reduced TLC)
ldyspnoea index
lquality of life, energy, physical mobility, ability to perform housework, enjoyment of social life, reduced anxiety levels
l6 minute walk distance from 150-300 meters
lmarked improvement in need for supplemental oxygen
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