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The patient is usually admitted to the ICU with four chest tubes on waterseal. In the first 24 h, chest X-rays are performed every 4 h and as needed. After this time, the patient receives a daily chest X-ray to evaluate lung reexpansion. Chest tubes are discontinued sequentially based on the chest films. Chest tube output and the presence of air leaks and crepitus should be evaluated every hour in the immediate postoperative period and at least every 8 h thereafter. Excessive output (>100 cm3/h) or presence of a new air leak or crepitus should be reported to the medical staff immediately. The patient's respiratory status should be monitored if a new air leak is noted, with particular attention paid to the oxygen saturation and chest X-ray. Suction (-10 cm H20) is only applied if the following criteria are met: > 30% pneumothorax; inability to maintain an oxygen saturation > 90% after adequate pain control, chest physical therapy and bronchodilation therapy; or significant subcutaneous emphysema (1). Chest tube dressings are changed every 48-72 h.

Each time a change occurs involving the chest tube system (i.e., discontinuance of a chest tube, change to/from suction/water seal) the staff needs to make more frequent assessments of the patient's respiratory status. Reports of increased dyspnea with increased oxygen requirements necessitate immediate nursing intervention and notification of the medical staff. These patients are very sensitive to changes in pleural pressure and can exhibit respiratory distress in various ways. A significant increase in the amount of oxygen needed to maintain an oxygen saturation >90% should trigger a complete physical exam focused on the respiratory system. Changes in the air leak status or the occurrence of crepitus should be followed closely with notification of the medical staff.

Breath sounds should be auscultated every hour immediately postoperatively, then every 4 h once the patient is deemed stable. Assessment of the patient's ability to cough and ability to clear secretions should be made. The amount, color, and frequency of the sputum need to be assessed on a continual basis. Significant changes need to be communicated expeditiously to the medical staff. Short-acting bronchodilators are administered every 4 h. Immediately postoperatively, the patient uses an acorn nebulizer. This treatment should be followed by chest physical therapy.

Intensive chest physical therapy is necessary to assist the patient in maintaining adequate oxygenation postoperatively. The nursing staff and pulmonary physical therapists need to collaborate to provide the patient with percussion and vibration, coughing and deep breathing exercises, and early ambulation. Instruction on incentive spirometry should be reiterated and a return demonstration provided to assure proper use. It is imperative that the patient be encouraged to use the incentive spirometer frequently (10 repetitions every hour) followed by coughing and deep breathing. Splinting with a pillow or similar device will provide support to the surgical incision. Patients need constant reinforcement in the use of diaphragmatic and pursed lip breathing as instructed preoperatively in the pulmonary rehabilitation program.

Early mobilization is critical to the care of the postoperative LVRS patient. On the first postoperative day, the team ensures that the hemo-dynamically stable patient is transferred out of bed to the chair. The patient is progressed to stepping and ambulating at the bedside on the first postoperative afternoon. The postoperative LVRS patient is routinely walked, even though attached to chest tubes, epidural and foley catheters, oxygen, and a pulse oximeter. Oxygen is titrated to keep the saturation above 90%. It needs to be reinforced that these patients routinely desaturate with activity and oxygen delivery should be adjusted accordingly. The patient is progressed to walking on the treadmill, leg exercises, and unweighted arm exercises while in the hospital.

Despite the use of bovine pericardium and pleural tents, persistent air leaks continue to complicate the postoperative course of many LVRS patients. Because the chest tube collection system is cumbersome (especially as the patient's activity level increases), we routinely utilize the Heimlich flutter valve in the management of persistent air leaks. The Heimlich valve is a one-way valve that allows air to exit from the pleural space without allowing air re-entry during inhalation (14). The valve attaches directly to the chest tube. Because blood or pleural fluid may obstruct the ends of the valve, it is not recommended for use in patients with substantial pleural drainage. Assessments should include checks for patency. The walls of the patent Heimlich valve should open with exhalation, allowing air to escape, and close with inhalation, preventing the inflow of air (15). The phasic fluttering of the valve usually stops when the airleak/pneu-mothorax resolve, but until the chest X-ray confirms this and rules out valve dysfunction, the staff needs to properly assess the patient for respiratory distress. If the patient's clinical status or chest X-ray suggest a worsening air leak of pneumothorax, the staff should assess the valve for possible obstruction and replace it as needed. If drainage and obstruction continue to be a problem, the chest tube may have to be reconnected to a standard collection system.

Although prolonged ventilator use is not routine, the staff needs to be aware that the LVRS patient is at significant risk for ventilator dependence. The staff must be cognizant of the potential need for chronic weaning, tracheostomy, or placement in a chronic care facility. These potential outcomes need to be addressed when the patient is considering the potential risks and benefits of surgery. It is imperative that the LVRS staff address the issues of Health Care Proxy and Advance Directives, because these patients are at significantly higher risk for ventilator dependence and chronic illness requiring advanced care.

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