The Clagett open-window thoracostomy is performed to give patients with empyema improved quality of life and other outcomes. Adult health nurses care for patients undergoing this procedure preoperatively, postoperatively, and at home, and must consider several important issues to prevent serious complications and facilitate family care.Postpneumonectomy empyema with or without bronchopleural fistula is a rare but extremely serious complication of surgery that can have devastating effects on patients and families.
With mortality ranging from 8% to 33%. (Orringer, 1988), aggressive management is usually indicated.
The Clagett open-window thoracostomy is a potential long-term strategy that provides symptom relief and can facilitate healing. Nursing care is essential for effective treatment of the physical and emotional aspects of postpneumonectomy empyema.
in this review, postpneumonectomy empyema and an overview of comprehensive nursing care from admission for Clagett open-window thoracostomy through home care are discussed. A case study illustrates several key aspects of managing patients experiencing this complex procedure.Empyema, an infection of the pleural space in which pus collects within the hemithorax (Alexander & Fetter, 1992), can occur for a variety of reasons including pneumonia, postpulmonary resection, bronchopleural fistulas, and trauma (Sealy, 1992).
Twenty-five percent of all empyemas occur following thoracic surgical procedures.
, most of those are following a pneumonectomy. The incidence of empyema following a pneumonectomy is 13%, whereas the incidence is estimated to be between 1% and 4% following other pulmonary resections (Alexander a Fetter, 1992). Approximately 40% of postpneumonectomy empyemas have a bronchopleural or esophageal fistula (Light, 1986). Most empyemas are evident within 4 weeks of surgery but may occur anywhere from 8 days to 7 years postoperatively.
Signs and SymptomsEmpyema can cause septic complications. There is local expansion of the infection with erosion and invasion into surrounding tissues. A generalized catabolic state can occur. Empyema with a bronchopleural fistula exposes the remaining lung to direct bacterial contamination.
A tension pneumothorax can occasionally develop if a one-way valve opening occurs (Alexander & Fetter, 1992).Lemmer, Botham, and Orringer (1985) found that most empyema patients presented with complaints of dyspnea, fever, chest pain, weight loss, and night sweats, but often the patient may complain of nonspecific symptoms such as anorexia, malaise, chills, and expectoration of serosanguinous or purulent fluid (Duhaylongsod & Wolfe, 1992). Even though the onset of symptoms is variable, most symptoms usually present 2 to 3 weeks after surgery. If patients also have a bronchopleural fistula, they may complain of a change in cough pattern, sudden unrelenting paroxysms of coughing, and a change in sputum production to a thin dark brown or rust-colored fluid (Alexander & Fetter, 1992).
DiagnosisA chest x-ray frequently shows a fluid collection or unexplained air within the hemithorax. Postpneumonectomy, the trachea bows toward the operative side on the typical chest film. If a bronchopleural fistula is present, the trachea will be in a midline position or bowed toward the unoperative side if a tension pneumothorax is present. An increasing volume of air and a decreasing fluid volume in the pleural space also may be noted.
Computerized tomographic (CT) scan, magnetic resonance imaging (MRI) scan, and ultrasound also may be used to diagnose an empyema. A thoracentesis is done to obtain a sample of fluid. A positive bacterial culture indicates probable empyema. However, if the patient has been on antibiotics, the culture may be negative.
The most common bacteria cultured is Staphylococcus aureus but a variety of organisms have been found (Alexander & Fetter, 1992).PathophysiologyFollowing a pneumonectomy, there is air in the pleural cavity The air is gradually absorbed and the space fills with serous and serosanguinous fluid. The hemithorax gradually decreases in size as the pleural cavity becomes layered with fibrous tissue. Pleural fluid is gradually absorbed, although residual pockets of serum continue to persist for most of the patient’s life.
These fluid pockets may become infected months or years later from transient bacteremia causing a late empyema. Early postpneumonectomy empyema most frequently occurs because of a contaminated pleural space and bronchopleural fistula (Duhaylongsod ; Wolfe, 1992).Bronchopleural fistulas predispose the patient to empyema when air contaminated by passage through the naso-oral cavities enters the pleural space. Bronchopleural fistulas occur following wound dehiscence at the bronchial stump and can occur because of infection, prior irradiation causing impaired healing and decreased tissue resistance to infection, and decreased stump perfusion with surgery.
The empyema that develops prevents successful closure of the bronchopleural fistula (Duhaylongsod ; Wolfe, 1992).TreatmentInitial treatment of a postpneumonectomy empyema is drainage by tube thoracostomy. Prompt drainage of the pleural cavity is essential to prevent rapid deterioration of the patient. Fluid is cultured and the appropriate antibiotics are given (Alexander ; Fetter, 1992).
Prior to open-window thoracostomy, the infected pleural space was treated with thoracostomy drainage followed by a thoracoplasty. Thoracoplasty involves extensive rib removal and removing the parietal pleura causing a collapse of the chest wall and obliteration of the thoracic cavity.Thoracoplasty is associated with considerable pain, high mortality, and often unsatisfactory results. There is significant cosmetic deformity and functional impairment.
Thoracoplasty is usually considered only in patients with adequate physiologic reserve and a good prognosis (Alexander ; Fetter, 1992; Eerola, Virkkula, ; Varstela, 1988; Sealy, 1992).In 1963, Clagett and Geraci described a two-stage method for treating the infected pneumonectomy space. The first stage involved creating an open-window thoracostomy by resecting parts of ribs to create an opening into the thorax to allow for drainage and antiseptic irrigation of the space. During the second stage, when the pleural space was clean and sterile, the space was filled with 0.
25% neomycin solution and closed surgically. The Clagett procedure was less mutilating, more successful, and had a lower morbidity and mortality than thoracoplasty (Shamji et al., 1983).This procedure has been copied, modified, and improved and exists in a number of variations today (Galvin, Gibbons, ; Maghout, 1988).
Several authorities (Bayes et al., 1987; Postmus, Kerstjens, de Boer, Homan van der Heide, ; Koeter, 1989; Shamji et al., 1983) report that open-window thoracoscopy controls the pleural infection, allows patients to recover from the toxic effects of sepsis, and prevents aspiration of bacteria into the remaining lung when patients have a bronchopleural fistula. Additionally, Shamji et al.
(1983) found that in one-third of their patients with bronchopleural fistula, the fistula closed without surgical intervention. They also reported that the open pneumonectomy space grew smaller with time; therefore, procedures not as complicated or as high risk as the thoracoplasty could be done to close the fistula.If a bronchopleural fistula is present, the Clagett’s procedure in its entirety is not as effective and re-infection frequently occurs. Therefore, many surgeons do not close the open-window thoracostomy (Bayes et al.
, 1987; Eerola et al., 1988; Postmus et al., 1989; Shamji et al., 1983).
For example, Weissberg (1982) made the open-window larger and packed the wound daily. Weissberg found that the infection subsided within 10 days to 4 months, fistulas closed within 1 to 4 months, and granulation tissue obliterated the empyema cavity within 1 to 8 months.Drainage of a postpneumonectomy empyema without a bronchopleural fistula can be done with a small open-window thoracostomy or a large, permanent open-window thoracostomy (see Figure 1). Openings can be closed at a later time when the pleural space is rendered sterile.
The large open-window thoracostomy may be permanently left open or covered with skin grafts.When a postpneumonectomy empyema is complicated with a large bronchopleural fistula, a large, permanent open-window thoracostomy is done. When the pleural cavity is clean, the bronchopleural fistula is closed using a muscle flap. Later, the open pleural cavity can be covered using skin grafts (Eerola et al.
, 1988).Nursing CareEmpyema, with or without a bronchopleural fistula, can be a long, complicated illness. Many of these patients are older and have a decrease in cardiopulmonary reserve. A pneumonectomy is usually done when metastasis has occurred to the lobar and hilar lymph nodes or when a lobectomy will not remove the entire tumor.
The patient may be malnourished and in a catabolic state due to the extent and duration of infection and history of lung cancer with associated radiation or chemotherapy treatment. The patient may present with septic complications (Duhaylongsod & Wolfe, 1992; Shamji et al., 1983). The overall goal of nursing care is to assist the patient to carry out prescribed therapies to preserve or improve pulmonary function and reduce disability.
Care is provided during the various phases of illness and treatment — pre-surgery, postoperatively, and postdischarge with home care.Preoperative CareWhen the patient is first admitted, a detailed patient history and assessment are done including a nutritional assessment. Findings may include systemic effects of lung cancer such as weakness, anorexia, weight loss, and anemia. It is important to recognize nutritional depletion, reverse the catabolic state, and supplement nutrition as needed.
Caloric needs are increased with infection, tissue damage, and plasma loss. The patient may need supplemental feedings, vitamins, and iron supplements (Finkelmeier, 1986).The nurse must assess for signs and symptoms of sepsis as well as monitor patient response o antibiotics. Prompt chest tube drainage is done to evacuate fluid on the operated side.
The chest tube may or may not be attached to water seal drainage. The nurse must care for and maintain patency of the chest tube. The patient should be instructed to lay on the operative side or back. Positioning is important to prevent contamination and asphyxiation of the solitary lung (Duhaylongsod & Wolfe, 1992).
Pulmonary function tests are done to measure the patient’s pulmonary reserve. Lung resection decreases ventilatory reserves; therefore, it can be a limiting factor in work capacity (Salazare-Schicchi, Haas, Axen, ; Reggiani, 1991). Decreased activity tolerance can be a major problem.Patients and their families have been faced with the emotional effects of cancer or major surgery and now have to cope with another critical and long-term illness, empyema.
Patients may be depressed, anxious, fearful, and discouraged. Patients and their family need emotional support and encouragement (O’Mara, 1986).The patient and family should be taught about procedures and tests that will done prior to surgery. They also should be instructed on what to expect during the postoperative period.
Preoperative teaching should include deep breathing and coughing exercises, pain control methods, turning and positioning, and extremity exercises (Black & Matassarin-Jacobs, 1993).Postoperative CarePostoperative nursing diagnoses include alteration in respiratory function (ineffective airway clearance, ineffective breathing patterns, impaired gas exchange); alteration in comfort; pain; potential alterations in nutrition: less than body requirements; impaired tissue integrity; activity intolerance; knowledge deficit; and anxiety.The following interventions from Hawthorne (1992) are applicable to patients with a Clagett’s window. The nurse should monitor the patient’s respiratory status and compare obtained values to baseline preoperative and admission values, assess for gradual increases in the patient’s effort to breathe and fatigue, assess for signs and symptoms of respiratory failure, auscultate breath sounds for presence of decreased or adventitious breath sounds, and monitor pulse oximetry.
Signs and symptoms of respiratory failure include shallow, rapid respirations; dyspnea and use of accessory muscles; decreased PaO2; initial decrease followed by a steady rise in PaCO2; tachycardia; pallor; diaphoresis; and anxiety, disorientation, or an obtunded mental status. The patient should be encouraged to use the incentive spirometer.The patient should be positioned with the head of the bed elevated at least 45 degrees. Elevating the head of the bed takes advantage of gravity by reducing abdominal pressure on the diaphragm thus reducing the risk of aspiration.
The patient should be turned only to the operative side to prevent leakage of fluid to the good lung. The patient should be turned and positioned every hour while awake and every 2 hours when resting. The patient can be out of bed and in a chair the first postoperative night.Pain management is important to ensure adequate respiration and movement.
An epidural block and/or patient-controlled analgesia (PCA) is recommended. Patient-controlled analgesia allows small frequent amounts of medication to be administered, thus reducing the risk of hypoventilation. Analgesic administration should be coordinated with respiratory care and movement. Passive relaxation, guided imagery, or music also may be used.
Fluid balance is important. Dehydration should be avoided to prevent tenacious secretions. Overload should be avoided to prevent putting an additional burden on the heart and pulmonary edema in the remaining lung. The nurse should observe for dysrhythmias and for signs and symptoms of mediastinal shift (Hawthorne, 1992).
Antibiotics are given as ordered. Dressing changes usually begin on the first postoperative day. The physician usually does the first dressing change. Dressings are changed 2 or 3 times daily as directed by the physician.
Home CareDue to the prolonged disease process, home care takes on an important role. The nurse must begin preparing early for discharge. The home health care nurse is responsible for doing dressing changes or ensuring that dressing changes are done appropriately by family members. The nurse must assess the patient for complications such as pneumonia, sepsis, respiratory failure, and cardiac insufficiency.
Knowledge deficit is initially addressed by the acute care hospital nurses and implementation is continued by the home health care nurse. The patient and family should be instructed on activity restrictions such as lifting and driving, signs and symptoms of complications, dressing changes, and medications.A specific plan of care should be developed to improve the patient’s activity level and to decrease fatigue. Short-term realistic activity goals should be written in consultation with the patient.
If needed, a physical therapist should be consulted to increase muscle strength and activity tolerance (Carpenito, 1987). Depression can decrease the patient’s desire to increase activity, diversional activities may need to be implemented or the patient should be encouraged to participate in activities he/she is able to do.Malnourishment due to pneumonectomy conditions such as cancer and infection may be present and affect the patient’s healing, activity level, and sense of well-being. A plan should be developed for improving the patient’s nutritional status.
Supplements, such as enteral products, vitamins, and minerals may need to be initiated. The patient should be instructed to rest prior to meals and to spend minimal energy in food preparation (freezing meals, requesting assistance from others) in order to avoid fatigue during meals. The nurse also should instruct the patient how to increase protein consumption to promote surgical wound closure. Foods that stimulate eating and appetite should be identified by the patient and family and included in meal planning (Carpenito, 1987).
Patients may experience anxiety and fear related to having a new long-term illness. To assist the patient and family, the nurse should provide reassurance and emotional support by allowing the patient and family to verbalize feelings and frustrations. Setting reachable short-term goals can help the patient realize that progress is being made toward improved health. Telephone numbers for emergency interventions and for questions should be provided (Carpenito, 1987).
The following case study demonstrates the course of illness and treatment of a patient having a Clagett open-window thoracostomy for treating a postpneumonectomy empyema due to a bronchopleural fistula.Case StudyMr. D is a 62-year-old male. He is a retired fireman who does carpentry in his spare time.
He is married and has one son. His wife is a practicing nurse. Mr. D quit smoking I year ago.
He lost 30 pounds in the past 6 months. Mr. D had a right pneumectomy for non-small cell carcinoma in the right upper and middle lobe. Lymph nodes were negative for metastasis.
Six weeks after the pneumonectomy was done, Mr. D started complaining of excruciating pain in his chest cavity and tenderness in the incision area. He was extremely short of breath with exertion and was unable to ambulate 10 feet. He was coughing a lot and was extremely pale.
His temperature was 100 to 101 degrees Fahrenheit in the afternoons.At this time, the patient was admitted with a diagnosis of postpneumonectomy empyema. A chest tube was inserted and he was placed on antibiotics. Two days later the pneumonectomy space was debrided and the cavity was irrigated and filled with neomycin.
When the empyema reoccurred, the procedure was repeated. During the second surgery, a bronchopleural fistula was found and repaired. Prior to discharge, the patient started coughing up bloody sputum. The original surgeon then referred the patient to another physician and facility for further treatment.
At the time of referral, the chest x-ray showed opacification of the right thorax and air at the apex. A bronchoscopy showed a small bronchopleural fistula. A xenogram showed increasing activity in the right apex region which was consistent with a bronchopleural fistula. A chest tube was inserted and Mr.
D was started on vancomycin and Timentin.Seven days later, Mr. D went to surgery to have a Clagett open-window thoracostomy. Postoperatively, Mr.
D received vancomycin, ticarcillin disodium, clavulanate potassium, and mini-dose heparin. Pain was controlled with morphine sulfate PCA. The patient was ordered bronchopulmonary hygiene with albuterol every 6 hours. Intravenous fluids were given at 75 cc per hour.
Oxygen was administered by mask and then nasal cannula to keep the oxygen saturation at 94%, or greater. Mr. D’s vital signs were temperature 37.5 degrees Centigrade, pulse 99, blood pressure 128/64, and respirations 16.
Mr. D’s white blood cell count decreased from 15,000 [mm.sup.3] to 11,000 [mm.
sup.3] 2 days after surgery.Mrs. D was instructed on dressing changes the day after the Clagett window procedure.
She changed the dressings in the hospital to increase her knowledge and comfort level with care at home. Home health care arrangements were made and all supplies were ordered (sterile gloves, instrument sets, Kerlix[R], Betadine[R], normal saline, and tape). As a nurse, Mrs. D was able to do a sterile dressing change very easily, but both she and her husband were anxious regarding their ability to handle the situation.
Mrs. D was very supportive of her husband. A home care nurse would do one dressing change per day so that Mrs. D could return to work.
Mr. D and his wife recognized their discharge needs and their limitations.Mr. D was discharged to home days after surgery.
The cultures done during surgery were positive for yeast and fungus; therefore, he was not sent home on antibiotics. Wound packing was done with Betadine-soaked Kerlix. At the time of discharge, four rolls of Kerlix were needed to pack the pneumonectomy space. Home care goals were to treat and prevent infection, improve the patient’s nutritional state and activity intolerance, and provide emotional support for the patient and family.
Complications that developed postdischarge included pneumonia and skin breakdown due to frequent dressing changes. The pneumonia was treated with antibiotics and dressings were changed to dry Kerlix. Artificial skin was applied to areas of skin breakdown for a few weeks. The patient also had difficulty when lying flat; a special bed was needed.
Mr. D required pain medication for only 2 weeks after discharge. At present, 3 months post-surgery, the pneumonectomy space has shrunk by 75% and is being packed with one Kerlix instead of four. The bronchopleural fistula is still open and is about 2 mm.
If the pneumonectomy space continues to be clean and free from infection, closure of the fistula is planned in 6 to 8 weeks. Mr. D now weighs 56.8 kg (up from 49 kg) and has a good appetite.
He now walks up stairs without shortness of breath. His lung capacity has improved. Mr. D sees the physician 1 to 2 times per month.
The home health care nurse sees the patient once a week.Mrs. D stated that mental and emotional support was important to prevent depression. Due to the home health nurse’s unfamiliarity with caring for a patient with a Clagett open-window thoracoscopy, physician support was important to her.
She needed to have someone available to ask questions regarding the significance of assessment findings. Mr. and Mrs. D are adjusting well and are excited about the progress that has been made thus far.
The difficulties with diagnosing and treating a patient with postpneumonectomy empyema are evident in this case study. The length of time from the patient’s original surgery to present is already 4 months. The patient and family still face months of medical care and further surgery. Mrs.
D has expressed the importance of supportive care from all involved. It is important to view accomplishments in increments such as weight gain, change in size of postpneumonectomy space, increase in ability to do activities of daily living, or ambulating without shortness of breath. Nursing care is essential for successful treatment. By better understanding the problems associated with postpneumonectomy empyema, nurses can provide comprehensive care for patients who have undergone a Clagett open-window thoracoscopy.
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