4.5 Thoracic Surgery & Airway Procedures

Minimally Invasive vs. Open Thoracic Surgery

Video-assisted thoracoscopic surgery (VATS) uses small incisions and a thoracoscope to perform lung resections, pleural biopsies, and other procedures with less postoperative pain, shorter chest tube duration, and faster recovery than an open thoracotomy. Standard postoperative care still includes a chest tube to evacuate air/fluid and monitor for re-expansion, incentive spirometry, early mobilization, and pain control that supports effective coughing and deep breathing.

Pneumonectomy vs. Lobectomy

Because a post-pneumonectomy patient has only one functioning lung, any degree of pulmonary edema, aspiration, or over-hydration is poorly tolerated. Progressive care nurses should track strict intake and output, auscultate for tracheal midline position, and report any sudden hypotension or oxygen desaturation immediately, since a rapid mediastinal shift can compress the remaining lung and great vessels.

Bronchoscopy

Bronchoscopy allows direct visualization of the airway for diagnostic purposes (biopsy, bronchoalveolar lavage for infection/culture, evaluating hemoptysis or a mass) or therapeutic purposes (removing mucus plugs or a foreign body, therapeutic aspiration). Key nursing points:

• The patient should be NPO for several hours before the procedure to reduce aspiration risk, particularly when moderate sedation is used.
• Topical anesthesia suppresses the gag reflex; the patient must remain NPO after the procedure until the gag reflex has clearly returned to prevent aspiration.
• Monitor closely afterward for bleeding (especially after biopsy), pneumothorax (particularly after transbronchial biopsy), laryngospasm/bronchospasm, and hypoxemia from sedation or the procedure itself.

Thoracentesis

Thoracentesis is needle aspiration of pleural fluid, performed for diagnostic evaluation (identifying transudate vs. exudate, infection, or malignant cells) or therapeutic relief of dyspnea from a large effusion. Key safety points:

• A post-procedure chest x-ray is standard to confirm no pneumothorax and to assess lung reexpansion.
• Fluid removal is typically limited to roughly 1–1.5 liters in a single session; removing larger volumes too quickly risks re-expansion pulmonary edema as the previously compressed lung rapidly re-inflates.
• Monitor for cough (a sign to slow or stop fluid removal), chest discomfort, hypotension, and signs of pneumothorax (sudden dyspnea, decreased breath sounds) during and after the procedure.

Chest Tube and Pleural Drain Management After Thoracic Surgery

Standard three-chamber drainage systems combine a collection chamber, a water seal chamber (which allows air to escape the pleural space but prevents it from re-entering, and shows tidaling with respirations), and a suction control chamber (regulates the applied negative pressure, typically to a set level regardless of wall suction strength—identified by gentle, continuous bubbling in that chamber only, which is normal and distinct from an air leak in the water seal chamber).

Criteria commonly used before a provider removes a chest tube: no active air leak, drainage has decreased to a low, stable level (commonly cited as less than roughly 100–200 mL over 24 hours, per institutional protocol), and chest x-ray confirms the lung is reexpanded. After removal, the insertion site is covered with an occlusive dressing, and the nurse monitors for signs of recurrent pneumothorax (sudden dyspnea, subcutaneous emphysema, decreased breath sounds) and obtains a follow-up chest x-ray per protocol.

Grading an Air Leak

When an air leak is identified in the water seal chamber, its size and timing help localize the problem and track whether it is improving:

• Leak only with forced expiration or coughing — typically minor, often resolves as the lung heals
• Leak throughout the entire respiratory cycle, including at rest — suggests a larger parenchymal or bronchopleural leak and warrants closer monitoring
• New or worsening leak in a previously stable patient — should be reported promptly, since it may indicate a dislodged tube, a new pneumothorax, or breakdown at the surgical site

Documenting when the bubbling occurs (inspiration, expiration, coughing, or continuously) gives the care team more useful information than simply noting "bubbling present."

Pain Management and Early Mobility

Thoracic incisions — whether VATS ports or an open thoracotomy — are notoriously painful because the chest wall moves with every breath. Under-treated pain leads directly to shallow breathing, poor cough effort, splinting, atelectasis, and retained secretions, so multimodal analgesia (regional techniques such as an epidural or paravertebral block plus scheduled non-opioid agents, with opioids for breakthrough pain) is standard rather than opioids alone. Adequate pain control is what makes incentive spirometry, coughing, and early ambulation achievable in the first 24–48 hours after surgery, and those activities are themselves what prevent the postoperative pneumonia and atelectasis that would otherwise prolong the ICU stay.