Lung Surgery: UCSF/Mount Zion The respiratory system and how it works The lungs are very important. There are three sections of lung (lobes) on the right side of the chest and two sections (lobes) on the left side. Their most important job is to remove carbon dioxide from the blood and to replace it with oxygen. The lungs act like a pump and this exchange takes place with every breath you take. The air you breathe comes in through your nose or mouth, and passes though your trachea (windpipe) into the lungs through two tubes called mainstream bronchi. One of the tubes goes to the right lung and the other one to the left lung. In the lungs, each of the mainstem bronchi divide into smaller tubes, called bronchi, and then into even smaller tubes called bronchioles. The bronchioles end in tiny air sacs called alveoli where the exchange of oxygen and carbon dioxide, the gases you breathe, takes place. Lung disease and surgery The lungs, like any part of the body, can develop problems. Over the years your lungs have been exposed to cigarette smoke, dust, toxic chemicals, and bacteria. This exposure can cause lung problems. Cancer and emphysema are the two most common lung diseases which may require an operation. You will have had several tests to decide what type of operation is best for you. Types of lung operations include: a. mediastinoscopy: viewing the space between the lungs through a scope b. thoracoscopy: viewing the space around the lung through a scope c. thoracotomy: an operation which requires an incision through the chest wall d. wedge resection: removal of a pie-shaped wedge from a lung segment e. lobectomy: removal of a lung lobe f. pneumonectomy: removal of an entire lung
g. decortication: removal of a portion of the lung s lining h. lung volume reduction: removal of a portion or portions of lung which cannot work properly. Getting ready for your operation It is very important for you to be in the best possible physical condition before your operation, because it will help you recover more easily and more quickly. If you are still smoking, you must stop before your operation. If you need help with stopping smoking, please tell your doctor. It is also helpful if you strengthen your muscles before surgery. The following guidelines will help. Arm exercises: a. You can stand or sit to do this exercise. b. Place your arms level with your shoulders, so that your arms are straight and parallel to the floor. c. When you breathe in: raise your arms above your head, clasp your hands together, and hold for 2 seconds. d. When you breathe out: lower your arms slowly, exhale through pursed (puckered) lips, and stop when your arms are parallel to the floor. e. Repeat this exercise 10 times. f. Do this exercise 10 times a day. Leg exercises: a. You should sit in a chair to do this exercise. b. Lift one leg off the chair, tightening the muscles on top of your thigh, and then straighten your leg out; hold your leg out straight for 3 seconds. c. Bend your knee and lower your leg slowly; relax, and then repeat 10 times. d. Do this exercise 10 times a day. Sniff and blow exercises: a. This exercise helps your diaphragm (a breathing muscle). b. You should sit in a chair to do this exercise. c. Sniff twice, hold your breath for 2-3 seconds. d. Tighten your stomach muscles, and then blow out slowly. e. Repeat this exercise 10 times. f. Do this exercise 10 times a day. 2
Other exercises: a. Walk 1 mile, twice daily, in less than 20 minutes. b. Climb 2 flights of stairs, quickly, 4 times a day. Before your operation you will have several more tests. These may include: blood tests, urine test, an electrocardiogram (EKG), a chest x-ray, and a lung function test (PFT). You doctor may also order several other tests, including bone scans, MRI (magnetic resonance image), or V/Q scan (a type of scan of the lungs). These may help your doctor decide about the best possible treatment for your condition. Preregistration for surgery: You will need to pre-register in the Admitting Office on the first floor for your operation. You will then proceed to the Surgery and Procedure Center (SAPC) on the third floor. It is very important that you keep this appointment. You will speak with a nurse who can tell you more about your care before and after your operation. You may also meet with an anesthesiologist (the doctor who gives you the anesthetic and who watches your heart and breathing during the operation). The anesthesiologist will also ask you questions about your past and present medical and surgical history. It is very important that you have a list of any medicines you are taking when you come to this appointment. If you are taking aspirin or ibuprofen, you must stop taking it 7 days before your operation. The more you know what to expect about your operation and your hospital stay, the less anxious you will be. It is normal to be anxious before surgery. Please let us know if we can help you in making you feel more comfortable. You will be asked to take a shower or bath the night before or on the morning of your operation. Do not use any powder or body lotion after your shower. The evening before your operation you may eat a regular meal and may drink fluids up until midnight. Do not eat or drink anything after midnight. Please remove any lipstick or nail polish on the day of your operation. Please leave all valuables and jewelry at home or with a family member. Your doctor will tell you if you will go home after your operation, or if you will stay in the hospital. Your hospital stay The day of surgery It is very important not to eat or drink anything on the day of your operation. If you have been told to take your medicines, please use a very small sip of water only to help swallow your medicines. You will check in at the Surgical Waiting Area, M104-J on the first floor of the UCSF Medical Center approximately two hours before your scheduled surgery time. You will be taken to a room where you will change into a hospital gown. You will meet with your anesthesiologist and an intravenous (IV) line will be started. You may receive a medication which makes you sleepy. You will be taken to the operating room shortly after you are given this medicine. When your operation is done, your doctor will meet with your family in the waiting room (near the intensive care unit). 3
After your operation Your doctor will tell you before your operation whether you will need to stay in the hospital after your operation. If you go home after your procedure or operation, you will go to the Recovery Room when your operation is over. There you will be monitored until you are fully awake. You will receive instructions about your care at home when you go back to your room at SAPC. If you will be staying in the hospital after your operation, you may spend at least one night in the Intensive Care Unit (ICU). Your family can visit the ICU (any time except 7-8 a.m., 3-4 p.m. and 11-12 p.m.). Short visits are better so that you have time to rest. The nurse caring for you will decide the length of your visits, depending on your needs or other activities in the ICU. When your doctor feels you are ready, you will be transferred from the ICU to a room on the surgical floor, usually 7 East. You will stay there for several more days, depending on the type of operation you had. Your activities and care will focus on getting you ready to go home. After your operation, you will be connected to several pieces of equipment, which will help the doctors and nurses watch your condition closely. Most of the tubes are removed one or two days after surgery. The following are brief descriptions of the tubes and equipment used during your hospital stay: Respirator and Breathing Tube After you have received your anesthetic in the operating room, the anesthesiologist will insert a tube through your mouth or nose into your trachea (windpipe). The tube is connected to a machine that breathes for you during your operation and while you are waking up. The tube is placed between your vocal cords and you will be unable to speak, eat, or drink as long as it is in place. Writing materials will be available for you to communicate. As soon as you are able to breathe on your own the tube will be removed. You will then be able to speak, although your throat may feel sore for a day or two.if the breathing tube has to stay in your trachea for more than several hours, you will receive medicine to help you relax until the tube can be removed. Chest Tube The chest tube is placed after your anesthetic and during your operation. This tube drains air and blood which have collected around your lung during the operation. It is connected to a special collection container at the side of your bed. The nurse will measure the amount of fluid that drains into the container. Your doctor will remove the tube when the lung has reexpanded and the air and fluid have stopped draining. The tube usually can be removed in 4 to 5 days. Your doctor will decide when the tube can be removed. Heart Monitor Five sticky electrode pads will be put on your chest and attached to a heart monitor. This machine monitors your heart rate and rhythm and has an alarm that sounds on occasion. It is so sensitive that it may make a sound even if the nurse touches you or if you move around in bed. Do not worry if you hear the alarm often. Intravenous (IV)/Arterial Line You may have several IV lines. These are important for giving you fluids and medicines. The arterial line gives important information about your blood pressure, pulse, and amount of oxygen in your blood. Foley Catheter This tube drains urine from your bladder. It is inserted after your anesthetic and before your operation. The nurse measures the amount of urine while you are in the ICU. It is usually removed several days after surgery. Epidural Catheter This tube is inserted by the anesthesiologist before your operation to help treat your pain after your operation. While it is in place, you should have very little or no pain. Please tell your nurse if you are having pain. We will ask you to rate your pain on a scale of 0 to 10 in order to measure how well your pain medicine is working. A score of 0 means that you have no pain at all. A score of 10 means you have the worst pain you have ever had. 4
0-10 Numeric Pain Intensity Score 0 1 2 3 4 5 6 7 8 9 10 No pain Moderate pain Worst possible pain Patient Controlled Analgesia (PCA) This is a pain control method where the pain medicine is in an intravenous (iv) solution and you can push a special button to give yourself the pain medicine whenever you feel you need it. The doctor will prescribe certain limits so that you cannot receive too much. If your pain is not adequately relieved, please tell your nurse so that your doctor can adjust the amount you receive. Sequential Compression Stockings These plastic sleeves are wrapped around your legs and squeeze your legs while you are in bed. This helps your circulation and helps prevent blood clots. When you are able to walk in the hall several times a day, you will not need to use them anymore. Vital Signs The nurse will check your vital signs (blood pressure, pulse, breathing rate, and temperature) and your oxygen saturation (the percentage of oxygen in your blood) to make sure you are breathing well and recovering from your operation. You will be weighed every day, usually before 6 a.m. The nurse will measure how much fluid you take in (your intravenous fluid and what you drink) and how much fluid you put out (urine). So, it will be important for you to save your urine in the container given to you. Things you can do to help your recovery Breathing and oxygenation You will receive oxygen as needed. It is given to you through a small tube placed just inside your nose, or you may wear a mask. Notify the nurse immediately if you feel short of breath or winded. It is very important for you to help get rid of the secretions (mucus) in your lungs after your operation. You can help by using your incentive spirometer (a breathing exerciser) and coughing and deep breathing 10 times every one to two hours while you are awake. Small, throaty coughs will not clear the mucus. To cough well, place a pillow over your incision. Take a deep breath in through your nose. As you get ready to cough, hug the pillow, then cough twice. Repeat these steps until your chest feels clear. Your nurse will show you how to use your incentive spirometer. Being physically active will exercise your lungs and help with your breathing and oxygenation. After your operation you may feel tired, but your lungs will improve more rapidly the more you sit up in a chair and take frequent walks in the hall. Pain medication In order to be able to deep breathe and cough, it is important that you take the pain medicine that your doctor orders. It makes coughing, deep breathing, and walking more comfortable. Please tell your nurse if your pain medicine is not keeping you comfortable, especially when you are doing your deep breaths and coughing. 5
Physical activity It is very important that you resume normal physical activity as soon as possible after your operation. This helps to clear your lungs and helps the circulation in your legs. You will begin by sitting up in a chair next to your bed. Once you are out of the ICU, you will begin walking. Your nurse will show you how to support your incision to help decrease the discomfort with coughing and other physical activities (such as getting in and out of bed). Your nurse may help you walk for the first few days. You will need to walk in the hall at least 3 times a day. You should use both arms as you normally would. Nutrition It is normal to lose your appetite for several days after an operation. However, good nutrition is important to help your body recover. Even if you are not hungry, try to eat at least half of each meal or small portions six times a day. Bowel elimination It is common after surgery to become constipated due to the pain medicines and less activity. You will receive medicine to help prevent constipation. Eating high fiber foods such as prunes, bran muffins or bran cereal, and fresh fruit can also help. Please tell your nurse or doctor if you have not had a bowel movement by the second or third day after your operation. The following section Your Recovery at Home covers information about activity, diet, medicines, wound care, and when to call your doctor. The nurses and doctors are available to answer any questions you or your family may have about your recovery. Your recovery at home Most patients go home from the hospital about five to seven days after their operation. This section will give you some general guidelines to follow once you are home. Your nurse and/or doctor will review this information with you. They can answer any questions you might have. If you have questions, let your nurse know and he/she will get more information for you. Activity Here are some general guidelines: Get up and get dressed each morning. Regular activity is an important part of your recovery. Use both arms as you normally would. Walking also helps your recovery. Begin with short walks, gradually increasing your distance every day. Space your activities throughout the day. Avoid rushing, and stop to rest if you feel tired. To help your incision heal, do not lift object weighing more than ten pounds (for example, children, heavy bags of groceries) for 4 to 6 weeks after surgery. You make take a shower at home. The Steristrips (paper stitches) will fall off by themselves in a few weeks. You may drive a car in days (discuss with your doctor). You may return to work in days/weeks (discuss with your doctor). 6
Here are some specific guidelines: Breathing exercises Why? Deep breathing exercise should be continued at home so that your lungs will stay clear. You should continue with the deep breathing exercises until your cough does not produce mucus (sputum). The deep breathing exercises usually are most effective when you are sitting in a chair with your back well supported. How? Place both hands over the lower front part of your rib cage. Take a deep breath in through your nose and blow out slowly through your mouth with pursed (puckered) lips. With each deep breath, try to expand your rib cage as much as possible. Take four deep breaths in a row and then rest. After 10 minutes of deep breathing, take one deep breath in, support your incision with a pillow and cough. This exercise should be done at least twice a day if you continue to cough up mucus. Shoulder range of motion exercises Why? Your shoulder on the side of your operation may become stiff. Therefore, range of motion exercises should be done 2 to 3 times a day until your shoulder is not stiff anymore. These exercises are best done in front of a mirror so that you can watch your posture. How? 1. With both hands clasped together, lift your arms straight up over your head and then lower to the starting position. Repeat 5 times. 2. With both hands clasped together, lift your arms up over your head and touch the back of your neck. Then lower your hands to the starting position and repeat the exercise 5 times. 3. Place one hand behind your back and with the tip of your thumb, try to touch your shoulder blade. Lower your hand to the starting position, and repeat 5 times. Posture Keeping your back straight (keeping a good posture) is important after your operation, so that your lungs can expand properly. Therefore, keep your shoulders level and your back straight when you sit, stand, and walk. Diet It is important to eat a well-balanced diet to promote healing of your incision. Your appetite should return to near normal after a few weeks, especially as your activity increases. If your appetite is poor, try to eat high calorie and high protein foods. Small meals, 4 to 6 times a day, may be easier to eat. If you are not eating enough, a vitamin supplement can be used. Constipation is a common problem after surgery, usually caused by the pain medicines. Drinking plenty of fluids and eating fresh fruit or bran will help prevent this problem. A stool softener may be ordered for you by your doctor. Please tell your doctor if this becomes a problem. 7
Medications It is not unusual to have increased pain the first few days you are home due to increased activity. Your doctor may order pain medicine for your to use at home. Your pain will slowly decrease as healing occurs, but you may be stiff or achy for up to three months after surgery, especially on cold or wet days. You may have pain in your incision for several weeks after your operation, and you will be given pain medicine to take at home. Do NOT take pain medicine before driving or with alcohol. By 6 to 8 weeks after your operation, most of the pain in your incisions will be gone. You will also notice that the bump along the incision will have gone down. It is normal for the area around your incision to feel numb for many months, and this will improve with time. This numbness may be worse on cold or damp days. Wound Care Tightness, itching, numbness or tingling around the incision area are often normal. These feelings may last for several weeks. When To Call Your Doctor Call your surgeon if you have any of the following signs or symptoms: 1. a large increase in mucus coughed up from your lungs 2. a change in the color of the mucus (for example, yellow, green, bright red) 3. difficulty breathing or new shortness of breath 4. a fever of 101.5 for more than 24 hours 5. your incision becomes red or more painful or swollen 6. increased, constant, or smelly drainage from the incision Call your family doctor soon after you go home to let him/her know that you have left the hospital. Your family doctor will receive a letter from your surgeon at UCSF/Mount Zion about your hospital stay. Follow-up Care You need to schedule a follow-up appointment with Dr. in days/ weeks. Please call the office at (415) 885-3882 to schedule this appointment. SDSUR0120 Rev. 3/08