Pneumonectomy and its complications have not enjoyed very much attention in the CICM fellowship exam. Historic instances of their appearance in the exam papers are limited to Question 19 from the second paper of 2018 and Question 4 from the second paper of 2009, of which the latter presents us with a situation where a post-pneumonectomy patient has come back from the operating theatre with the chest drain attached to an underwater seal tube. More on that later.
For the purposes of answering the exam questions, a good review by Mesbah et al (2015) outlines the (relatively) recent evidence in analgesia, and Slinger (2009) contains an excellent discussion of fluid management.
Surely there must be people out there who do this well enough and often enough that they would have formed some sort of guidelines. Indeed, three seconds of Googling brings forth a paywalled UpToDate article, the 2013 ACCP clinical practice guidelines (which are available for free and which the UpToDate article is based on), and the 2001 BTS guidelines with which it is in general agreement.
In summary, the tests are:
For the purpose of answering Question 19 from the second paper of 2018, the exam candidate would only need to know a little about the analgesia and fluid management (which would be reasonably easy to work out from basic principles). However, one might look beyond the exam-centric focus of Φ to behold the training program as a process which produces competent intensivists, and those would probably be expected to have a more wholistic understanding of pneumonectomy management. One assumes that there's plenty of such wholistic intensivists at Liverpool Hospital, as their (publically available) post-pneumonectomy protocol is of a rather high quality. Borrowing heavily from this resource, the following management plan has been compiled:
Why is there a chest drain in the first place?
The main thing to remember is not to connect these drains to suction, or to leave them uclamped for any prolonged period of time. While the clamps are off, you need to be present in the room.
Now, this chapter may not be the most effective place to put this orphan topic, but it seems to have no other home. Question 26.4 from the second paper of 2011 asks the candidate to generate three reasons as to why a distressed patient might have a silent chest with the mediastinum shifted towards the silence.
Such a list of differentials will include the following
LITFL have an excellent summary of post-pneumonectomy care, which they admit they have appropriated from the policies and procedures manual of Royal Prince Alfred Hospital in Sydney.
Their summary of the RPAH summary has now become the skeletal frame for my own summary.
Weissberg, Dov. "Post-Pneumonectomy Chest Tubes." Texas Heart Institute Journal 29.2 (2002): 155. - this is a letter of communication, a bunch of Texans were debating chest drains in 2002. Read the letter above Weissberg's reply. Something about the hasty eating of a watermelon being the diagnostic hallmark of a Type A personality, on autopsy.
Cournand, André, and Frank B. Berry. "THE EFFECT OF PNEUMONECTOMY UPON CARDIOPULMONARY FUNCTION IN ADULT PATIENTS." Annals of surgery 116.4 (1942): 532-552.
Dyszkiewicz, Wojciech, Krystian Pawlak, and Łukasz Gąsiorowski. "Early post-pneumonectomy complications in the elderly." European journal of cardio-thoracic surgery 17.3 (2000): 246-250.
Mehiri, S., P. Herv, and B. Lescot. "Post-pneumonectomy pulmonary edema: analysis and risk factors." Eur J Cardio-thorac Surg 10 (1996): 929-933.
Iyer, Anand, and Sumit Yadav. "Postoperative Care and Complications After Thoracic Surgery." (2013).
Deslauriers, Jean, et al. "Long-term physiological consequences of pneumonectomy." Seminars in thoracic and cardiovascular surgery. Vol. 23. No. 3. WB Saunders, 2011.
Brunelli, Alessandro, et al. "Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer: American College of Chest Physicians evidence-based clinical practice guidelines." Chest 143.5 (2013): e166S-e190S.
British Thoracic Society Society of Cardiothoracic Surgeons of Great Britain Ireland Working Party. "Guidelines on the selection of patients with lung cancer for surgery." Thorax 56.2 (2001): 89-108.
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. "ATS statement: guidelines for the six-minute walk test." Am J Respir Crit Care Med 166 (2002): 111-117.
Powell, E. S., et al. "A prospective, multicentre, observational cohort study of analgesia and outcome after pneumonectomy." British journal of anaesthesia 106.3 (2011): 364-370.
Slinger, Peter. "Update on anesthetic management for pneumonectomy." Current Opinion in Anesthesiology 22.1 (2009): 31-37.
Mesbah, A., J. Yeung, and F. Gao. "Pain after thoracotomy." Bja Education 16.1 (2016): 1-7.
Bialka, Szymon, et al. "Comparison of different methods of postoperative analgesia after thoracotomy—a randomized controlled trial." Journal of thoracic disease 10.8 (2018): 4874.