Download Lung Volume Reduction Surgery - Clinical Practice Guidelines

Lung Volume Reduction Surgery
Background
•
•
•
The Ohio State University W exner Medical
Center (OSUW MC) has been re-certified by
The Joint Commission as one of the locations
in the United States able to provide lung
volume reduction surgery (LVRS).
This surgery reduces the size of the lungs
damaged by emphysema by removing some of
the most diseased parts of the lungs.
o Having LVRS will allow the remaining
lung to function more normally.
OSUW MC was one of 17 centers nationwide
that participated in the National Emphysema
Treatment Trial (NETT) study which examined
the risks, benefits and appropriate selection
criteria for the lung volume reduction surgery.
Selection Criteria
•
Effective for services performed on or after
January 1, 2004 Medicare will only consider LVRS
reasonable and necessary when all of the
following requirements are met.
o Click here for LVRS patient selection
criteria.
Labs and Imaging
Typical post-operative LVRS orders include the following
laboratory and imaging orders:
Order
Extubation within 4 hours of surgery
Early ambulation
Effective pain management
Infection prevention
Air Leak prevention
Length of stay goal 6-10 days
Consults
•
•
•
•
•
Pulmonology
Pulmonary rehabilitation
Infectious disease, as needed
Respiratory therapy
Physical therapy
Notify Physician
Notify the House Officer for the following:
• SBP > 180 mmHg or < 90 mmHg
• DBP > 90 mmHg or < 60 mmHg
• HR > 120 bpm or < 60 bpm
• RR > 24 or < 8
• Temperature > 101.5°F (38.6°C)
• Oxygen saturation < 88% at rest or with
increased oxygen requirement
• pO 2 < 60, or if pCO 2 is > 55
• Chest tube output > 100 ml/hr
• Urinary output < 30 mL/hour or
< 240 mL/8 hour
Timing
Arterial Blood Gas
Call results to physician on
call for Thoracic Surgery
In Recovery, STAT one
time, 6 hours after initial
blood gas in Recovery
CBC, EDIFF, Platelet,
Chem7
Every morning
Chest X-Ray
STAT Post-op, every
morning and prior to
discharge
Activity
•
•
Key Aspects of Care
•
•
•
•
•
•
1
Patient should be out of bed to chair 4 hours after
surgery unless patient remains intubated.
o If patient remains intubated, request
Physical Therapy consult.
Beginning POD 1, the patient should be out of bed
during the day and ambulate in hallway or on
treadmill with both nursing and pulmonary rehab
staff four times a day.
o The patient should be ambulating 3-10
minutes at each outing.
Medications and IV Fluids
•
•
•
Reconcile medications at each transition of care
(e.g., admission and discharge).
Continue home medications and inhalers.
Typical post-operative LVRS orders include the
following medications and IV fluids:
Pain management
Epidural and other as ordered
VTE prophylaxis
Pharmacological or mechanical if
drug therapy is contraindicated
Maintenance IV
solutions
As ordered – convert to IV lock
when tolerating oral diet
Post-op antibiotics
(2 doses)
Cefazolin if no PCN allergy
Clindamycin if PCN allergy
Antiemetic
As needed (no phenergan)
GI related
Stool softener and laxative as
needed
2
Care and Assessment
•
Typical post-operative LVRS orders include the following
nursing care and assessments:
•
Vital signs
As ordered and PRN
Pulse oximetry
Continuous, at least until
weaned down to 2 l/m or RA and
then every 4 hours
Cardiac monitoring
Continuous
Weigh patient
Every morning
Pain management
Goal < 5 (scale 1-10)
Intake and output
Every hour for 4 occurrences
Every 4 hours for 6 occurrences
Every 8 hours, ongoing
Assess degree of
dyspnea with activity
Continuous
Air leak grading
Every 8 hours, record air leak
grading as +1 to +7
Subcutaneous
emphysema
Upon arrival to the floor and with
each set of vital signs
Chest tube
Tube care per Chest Drainage
System protocol
Indwelling Foley
catheter tube care
Remove Foley catheter by postop day one or LIP to document
reason for continuing
Notify respiratory
therapy evaluator
Notify respiratory therapy
evaluator upon patient arrival to
floor (page 0813)
Incentive spirometry
encourage deep
breathing and
coughing
Every hour while awake
Oxygen
RT continuous
Wean to room air as tolerated
Apply nasal cannula PRN to
keep O2 sat > 88%
Patient Education
•
•
•
•
•
•
Arrange home health care if indicated and if Mini
Sahara in place
Arrange home oxygen if room air O2 sat < 88% (at
rest or with exertion)
Complete and call Continuity of Care if needed
Schedule follow-up appointment with surgeon in
2 weeks with chest x-ray prior to appointment
T/S: Post-Op LVRS
References
•
•
•
•
Provide and explain information to educate the
patient and family about the following items:
o Educate about equipment and unit rules
o Review activity progression and energy
conservation
o Explain medications
o Provide emotional support
o Educate about cough and deep breathing
o Review proper breathing techniques
o Review pain management and narcotic
use and side effects
o Explain wound care
o Review signs and symptoms of infection
o Explain when to contact physician
o Reinforce activity progressions and
limitations
o Explain oxygen use (arrange for home
oxygen if indicated)
o Instruction on Mini Sahara care if
indicated
Provide and explain Patient Education Materials:
o Your Home Care after Lung Volume
Reduction Surgery
o Caring for Your Chest Tube at Home
Order Set
•
Discharge Planning
Schedule follow-up appointment with OSUW MC
pulmonologist as needed
Pulmonary rehab will contact the patient to
resume outpatient therapy as soon as patient is
ready after discharge
Centers for Medicare & Medicaid Services. NCD
for Lung Volume Reduction Surgery (Reduction
Pneumoplasty). (240.1). Effective November 17,
2005. Accessed October 2011.
Winifred S. Hayes, Inc. 2010 Med tech review.
Lung Volume Reduction Surgery for Chronic
Obstructive Pulmonary Disease. Updated
December 9, 2003. Archived November 12, 2008.
Accessed October 2011.
Medicare National Coverage Determinations
Manual. Chapter 1, Part 4. Section 240.1 Lung
Volume Reduction Surgery (Reduction
Pneumoplasty).
National Emphysema Treatment Trail Research
Group. (2003). A randomized trial comparing lung
–volume reduction surgery with medical therapy
for severe emphysema. The New England Journal
of Medicine, 2059-2073.
3
Quality Measures
•
•
•
•
Improvement in dyspnea associated ADL
Post-operative complication rate
90-day mortality rates
Patient Satisfaction – overall satisfaction 9 or 10
Guideline Authors
•
•
•
•
•
Susan Moffatt-Bruce, MD, PhD
Phillip Diaz, MD
Mahasti Rittinger, RRT, BS
Scott Cackler, PA
Karen Prenger, RN MS, CNS, CPHQ
Guideline Approved
August 31, 2016. Fourth Edition.
Disclaimer: Clinical practice guidelines and algorithms at
The Ohio State University Wexner Medical Center
(OSUWMC) are standards that are intended to provide
general guidance to clinicians. Patient choice and clinician
judgment must remain central to the selection of
diagnostic tests and therapy. OSUWMC’s guidelines and
algorithms are reviewed periodically for consistency with
new evidence; however, new developments may not be
represented.
Copyright © 2016. The Ohio State University Wexner
Medical Center. All rights reserved. No part of this
document may be reproduced, displayed, modified, or
distributed in any form without the express written
permission of The Ohio State University Wexner Medical
Center.