What are some special considerations post lobectomy?

1.

Auerbach, Andrew D. (2024). In Goldman-Cecil Medicine (pp. 2659). DOI: 10.1016/B978-0-323-93038-3.00399-3

Pulmonary function tests, arterial blood gases, and chest radiography are generally not indicated to assess perioperative pulmonary risk, unless the patient has new or unstable respiratory symptoms. Pulmonary function tests are routinely recommended, however, in surgical planning for lung reduction or resection surgeries to identify residual lung reserve and the feasibility of the surgery itself. When the respiratory risk is high, changes in surgical technique (e.g., laparoscopic vs. open) or anesthetic approach (e.g., regional versus general anesthesia) should be considered. Preoperative respiratory muscle training is promisingbut not widely available. Patients should be encouraged to discontinue smoking at least 8 weeks before surgery, and nicotine replacement therapy should be prescribed if they continue to experience cravings at the time of surgery. Courses of corticosteroids or antibiotics for patients with otherwise stable chronic bronchitis are not indicated and may worsen clinical outcomes. Patients at higher risk (>2%) for major pulmonary complications may be candidates for further attention, particularly postoperatively. Patients with sleep apnea may be candidates for modified pain regimens or continuous pulse oximetry after surgery. Inhaled β-agonists or anticholinergics agents may be useful in reducing bronchospasm and improving patients’ ability to ventilate and clear secretions. Lung expansion maneuvers, such as incentive spirometry, are useful if performed several times per hour, so they are less effective in patients who are somnolent, in pain, or have difficulty managing the device because of drains or intravenous catheters. Methods for lung expansion and airway clearance using positive airway pressure should be considered when available. Medical consultants can also aid in management of respiratory risk by encouraging the use of nonopioid pain regimens (seeTable 26-4), orders for positioning and activity, and consideration of more aggressive monitoring (e.g., step-down unit or continuous pulse oximetry) in selected patients.

2.

O’Donnell, Anne E. (2024). In Goldman-Cecil Medicine (pp. 560). DOI: 10.1016/B978-0-323-93038-3.00078-2

Incentive spirometry is commonly prescribed to prevent or treat atelectasis in patients with limited mobility because of recent surgery, neuromuscular weakness, or any prolonged immobilization, but no randomized controlled trials have proved its effectiveness. Preoperative inspiratory muscle training and recruitment maneuvers may reduce atelectasis in patients undergoing upper abdominal or cardiac surgery,and prophylactic use of noninvasive ventilation may reduce pulmonary dysfunction after lung resection surgery. Other modalities such as positive expiratory pressure devices, high-frequency chest wall oscillation airway clearance, and pharmacologic agents are of no proven benefit.Patchy atelectasis is treated by addressing the underlying disease process in the lung parenchyma. Compression atelectasis is treated by alleviating the pleural space process.Obstructive or resorptive atelectasis often requires bronchoscopy for diagnosis and treatment. In patients with obstruction owing to retained secretions, multiple bronchoscopies are sometimes required, but the mucus often rapidly reaccumulates and will resolve only when the patient’s overall status improves.Rounded atelectasis does not require treatment. CT is helpful in distinguishing rounded atelectasis from parenchymal tumor.

3.

Khuri, Fadlo R. (2024). In Goldman-Cecil Medicine (pp. 1329). DOI: 10.1016/B978-0-323-93038-3.00177-5

Patients should be provided with counseling and behavioral therapy and other treatment modalities to assist their efforts to discontinue smoking (Chapter 363).CT scans are commonly used to follow patients who undergo surgical resection or chemoradiotherapy, but the relative merits of CT scan versus chest radiography, the frequency of evaluation, and the role of PET scans are unclear. For patients with advanced-stage disease, CT scans are used to assess response to therapy after every two or three cycles of treatment. In view of the proven role for salvage therapy, patients who are in follow-up after combination chemotherapy should be closely observed for development of new symptoms or clinical deterioration in addition to periodic radiographic studies.Supportive CareRespiratory therapy should be offered and strongly recommended to patients with dyspnea after surgery or chemoradiotherapy. Because a high proportion of these patients also have smoking-related pulmonary diseases, referral to a pulmonologist should be considered in symptomatic patients. Overall, a team approach that includes supportive care personnel, oncologic psychiatrists, nutritionists, oncologists, and appropriate additional specialists should be used to ensure the return of lung cancer survivors to normalcy to the fullest extent possible.Because the cure rate for lung cancers is only 16%, even in the most advanced health care systems, early discussion and institution of palliative and supportive care (Chapter 3) are therefore critical to maximize quality of life. The early integration of supportive care not only helps maintain and improve quality of life but also may produce a meaningful impact on overall survival. Among family members of elderly patients who died with advanced-stage lung cancer, perceptions of better end-of-life care were associated with earlier enrollment in hospice care, avoidance of ICU admissions, death outside the hospital, and advanced care planning consistent with patients’ preferences.