Lung cancer is a malignant disease that is currently a serious threat to human health. The current prevalence of lung cancer and the harm it has caused to human beings have fulfilled the prediction made by the World Health Organization in the 1980s: “Lung cancer and AIDS are the two major diseases that seriously threaten human health in the 21st century. To date, lung cancer is still the number one killer of malignant neoplasm diseases that cause human death. Despite decades of struggle with lung cancer, the five-year survival rate of lung cancer is still less than 15%, which is similar to that of other solid tumors. Surgical resection is still the best treatment for lung cancer. However, only 25% of patients clinically diagnosed with lung cancer can be surgically resected, which means that only 1/4 of lung cancer patients can be potentially cured through surgical treatment. In other words, only 1/4 of lung cancer patients can be cured by surgery, while 3/4 of patients can only prolong their lives and improve their quality of life through chemotherapy, radiotherapy, and other comprehensive treatments. This often brings some frustration to medical workers and disappointment to patients in medical technology in clinical practice to a greater or lesser extent. Therefore, striving for early detection and early surgical treatment is the only best way to improve the survival rate of lung cancer at present.
When it comes to surgery, we cannot talk about surgery without mentioning thoracic surgeons. When a good and experienced thoracic surgeon sees a lung cancer patient in the clinic, besides giving a comprehensive analysis of the patient, his rich clinical experience will form a sense that can help him make a series of judgments such as whether the patient can tolerate surgery, what kind of surgery is needed, the patient’s surgical risk and prevention, and how to guide the patient to cooperate with the treatment. All these seemingly complicated and esoteric reasoning revolves around one purpose: to successfully perform surgical treatment on lung cancer patients. The aim is to completely eradicate the malignant tumor like digging leeks.
In addition to those objective clinical bases of examination, there is also an emphasis on the surgeon’s sense of the patient, a sense that comes from clinical experience. It is often said that a good surgeon is not whether he can do surgery or not, and what kind of surgery he can do, but he understands what kind of patients should be operated, and what kind of surgery method should be used to the best advantage of the patients. Once the surgery is determined, perioperative preparation and management should be made according to the different physical conditions of the patient and different surgical methods.
Preoperative preparation and management of lung cancer, like other types of surgery, requires preoperative assessment of the patient’s physical condition before surgery. It includes the assessment of general condition and the functional status of important organs such as heart, lung, liver and kidney to evaluate whether the body, especially the important organs, can tolerate the trauma caused by anesthesia and surgery. For patients preparing for surgery for lung cancer, the assessment and maintenance of lung function is critical because of the inevitable damage to lung function caused by the opening of the chest cavity and the removal of some lung tissue. The surgical principles of lung resection are two maximal: one is to maximize the removal of the lesion, and the other is to maximize the protection of lung function.
As you may know, the human lung is divided into five lobes on the left and right sides, with the right lung divided into three lobes at the top, middle and bottom and the left lung divided into two lobes at the top and bottom. The lungs specifically have a strong reserve function, and a person’s life can be sustained with 40% lung function. Therefore, with normal lung function, life can be sustained with two lobes of the lung, which means even if three lobes of the whole right lung are removed. In other words, 60% of a person’s lung function may be disused or depleted due to chronic disease during his or her lifetime. Smoking and chronic bronchitis are common causes of chronic depletion of lung function.
Therefore, to protect your lungs, avoid smoking and prevent chronic lung diseases such as chronic bronchitis are necessary methods. In addition, swimming, jogging is an effective means to maintain good lung function. The closed air of swimming has more use of the development of lung function. Clinically, many patients over 80 years old who have been treated by surgery and patients who have had most of their lung tissue removed are good swimmers and adhere to swimming exercises. Therefore, clinically, if a patient answers that he swims regularly, his lung function is in the doctor’s mind.
The following are a few common and easy to perform tests to assess lung function.
1, blowing candles test. Light a candle at a distance of one meter and ask the patient to hold his breath and blow out the candle, which means that the lung compensatory function is okay, and vice versa.
2, can not intermittently climb five floors, if you can indicate that the lung function is okay, and vice versa is poor.
3, can walk 2/3 of a mile every day, such as to the free market to buy groceries, to school to pick up elementary school students, etc., if you can do it, it means that the lung function is okay, and vice versa is poor.
4.Breath holding test. Let the patient take a deep breath and test it with a stopwatch. If the patient can hold it for 30 seconds, it means that the lung function is okay. Greater than 45 seconds, indicating good lung function compensation.
When the patient is hospitalized and enters the preoperative preparation process, avoiding smoking and sputum excretion is a necessary preparation procedure, and the patient can measure the amount of sputum excretion one day and night before surgery. If it is more than 100 ml, the patient should also perform breathing exercises under the guidance of the medical staff and do deep chest and abdominal breathing. Thoracic breathing is mainly done by the active movement of intercostal muscles. Abdominal breathing is mainly done by the active movement of diaphragm. Another is coughing exercise, especially sitting and lying coughing. You may not believe it, but many people do not cough actively. The coughing movement is accomplished by the joint movement of the pharynx, intercostal muscles, abdominal muscles and diaphragm, not just the coughing sound emitted by the larynx.
Post-operative care.
1. Postural care: Before the patient is awake after surgery, give him a decubitus position with the head tilted to the side to avoid asphyxia or complications of aspiration pneumonia due to vomitus and secretion inhalation. After the patient is fully awake and the vital signs are stable, give the head of the bed elevated 30°-45° lying position. This position can make the diaphragm fall and increase the lung capacity. It facilitates sputum discharge and reduces the occurrence of pulmonary infection and atelectasis. Reduce wound tension, reduce pain, and facilitate breathing.
2. Observation of vital signs: perform cardiac monitoring, observe the patient’s respiration, blood pressure, pulse, oxygen saturation and temperature changes in a timely manner, and keep records, notify the doctor of any abnormality and assist the doctor to handle the situation accordingly. Give oxygen inhalation: give 3 liters/min oxygen inhalation after lobe and segmental lung resection patients, and give 4-6 liters/min oxygen inhalation after total lung resection patients.
3, the care of infusion: for patients with total pneumonectomy, when one lung is removed, all the blood flows to the remaining lung for gas exchange, which makes the heart and lungs overloaded. After surgery, fluid should be strictly controlled to avoid inducing heart failure and pulmonary edema due to excessive and rapid infusion. The total intake of patients after total lung resection should not exceed 2000ml in 24 hours, and special attention should be paid to the elderly or patients with heart disease originally, and the infusion volume should not exceed 100ml/h.
4.Care of closed chest drainage.
(1) maintain the drainage system closed, the joint is firmly fixed water seal bottle filled with sterile saline 500 ml, long drainage tube submerged 2-3 cm, the water seal bottle should be located below the chest.
The water seal bottle joint is wrapped with sterile gauze to prevent upstream infection. The drainage tube should be clamped with hemostatic forceps to prevent air from entering. Pay attention to ensure that the drainage tube is firmly and tightly connected to the drainage bottle, and do not leak air.
(2) Keep the drainage unobstructed. Keep the drainage tube of appropriate length to prevent pressure, folding, twisting and dislodgement during body-protective activities. After the patient is awake from general anesthesia, take a 30-45 degree lying position, and use the affected side when turning to facilitate the drainage of fluid in the chest cavity. Encourage the patient to cough to facilitate the drainage of fluid in the thoracic cavity and facilitate lung reopening. Squeeze the drainage tube downward every 30-60 minutes to prevent the lumen from being blocked by blood clots and pus and to keep it open.
(3) Observe the amount, color and nature of the drainage fluid and record the drainage flow every hour for the first 5 hours, and every 8 hours thereafter or as needed. The normal drainage flow is about 100-300 ml in the first 2h, about 500 ml in the first 24h, and the drainage fluid is bloody in the first 8h, and later the color is light red and not easy to clot. If the drainage flow is high, bright red or dark red in color, and more viscous and easy to clot, active bleeding in the chest cavity is suspected, and the physician should be notified promptly to take measures [2].
(4) Indications for extubation and precautions, extubation can be performed if the drainage is less than 50 ml within 8 hours and there is no gas drainage, clear breath sounds on auscultation, small or no fluctuation of fluid in the water seal bottle, combined with the patient’s condition, good x-ray and lung retension. Ask the patient to inhale deeply and then hold it, and withdraw the tube lumen. Pay attention to observe whether the patient has chest tightness, breath-holding, dyspnea, pneumothorax and subcutaneous emphysema within 24 hours after extubation. Observe whether there is local blood and exudate. If there is any change, promptly notify the doctor for treatment.
(5) Postoperative pain care Explain the cause, duration and treatment care measures of pain to the patient and family members to relieve the patient’s concerns and stabilize their emotions. Assist the patient to adopt a comfortable lying position and adjust it regularly, and assist the patient in breathing training and effective coughing. Avoid adverse external stimuli and provide a quiet and comfortable sleeping environment for the patient. Properly fix the closed chest drainage to prevent pulling pain. Observe the patient’s pain, correctly assess the pain, and use sedative or analgesic drugs as prescribed by the doctor if necessary. Instruct the patient and family members to use methods such as listening to music and massage to distract and reduce the patient’s sensitivity to pain.
(6) Instruction on postoperative activities inform patients of the importance of early activities, and work out appropriate activity plans with patients’ families according to their conditions to promote the recovery of endurance. On the first day after surgery, patients can be instructed to carry out bed activities such as arm lifting, turning or shoulder and arm lifting and rotation on the operated side, which can help increase the mobility of the chest wall on the affected side, promote pleural lymphatic reflux and accelerate the absorption of pleural effusion. On the second day after surgery, a thick rope can be tied at the end of the bed, and patients can practice sitting up by themselves with the help of the pull of the rope to increase their lung capacity. For elderly and frail patients, lower limb massage should be given as early as possible after surgery to promote blood circulation in the lower limbs and prevent pulmonary embolism. After the removal of the closed chest drainage tube, the patient can freely get out of bed and gradually increase the amount of activity.
(7) Instruction of respiratory function training
(1) On the postoperative day, abdominal breathing exercises can be taken first: that is, the abdomen rises when inhaling and slowly retracts when exhaling to reduce the stimulation of the thoracic surgical incision.
②1-2 days after surgery, you can add thoracic breathing exercises after abdominal breathing: thoracic augmentation during inhalation and reversion and relaxation during exhalation. Through the rhythmic expansion and relaxation of the thorax, blood circulation is improved to prevent tissue adhesion and wound skin tightening and promote wound healing.
③Local breathing exercises: Performed after the above exercises without discomfort. Press both hands firmly on the lobectomized part of the lung and make the pressed part bulge when inhaling, while the pressurized hand gradually decreases the pressure, holding it for 2-3 seconds at the end of inspiration and then exhaling. This exercise can make the remaining lung expand and fill the cavity to avoid residual cavity left after surgery and secondary infection, and also relieve local trauma pain.
(8) Dietary guidance: eat a semi-liquid diet on the first day after surgery, and gradually transition to a normal diet after 2-3 days. Pay attention to eating less and more meals, and eat a diet rich in high calories, high protein and high vitamins, such as eggs, milk, vegetables and fruits. Eat slowly to prevent coughing and lung infection caused by accidental inhalation of food.
5.Discharge guidance
(1) life guidance: regular life, work and rest, pay attention to dietary hygiene, avoid overeating, quit drinking, quit smoking, and keep a comfortable mood.
(2) Review: Postoperative patients need to be reviewed regularly, usually once every 3-6 months, and to determine whether radiotherapy or chemotherapy is needed.