Elsevier

Thoracic Surgery Clinics

Volume 20, Issue 3, August 2010, Pages 345-357
Thoracic Surgery Clinics

Respiratory Mechanics and Fluid Dynamics After Lung Resection Surgery

https://doi.org/10.1016/j.thorsurg.2010.03.001Get rights and content

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Prologue: active and passive drainage of the pleural cavity

Postoperative thoracic surgery poses the problem of draining the pleural cavity after closure of the thorax. Two phases in the draining process can be identified. Immediately after closure of the chest, there is a need to drain air to allow lung expansion and volume oscillation during the breathing cycle. Gas drainage ought to be performed by having the tip of the chest tube where the gas bubble is going to collect during the suction process, namely in the less dependent portion of the chest

Mechanics

Thoracic surgery that requires resection of a portion of lung or of a whole lung profoundly alters the mechanical and fluid dynamic setting of the lung-chest wall coupling, as well as the water balance in the pleural space and in the remaining lung. The most frequent postoperative complications are of a respiratory nature, and their incidence increases the more the preoperative respiratory condition seems compromised.3 There is an obvious need to identify risk factors concerning mainly the

Lung Fluid Balance and Tissue Mechanics in Physiologic Conditions

The pressure existing in the interstitial space of the lung is subatmospheric,15 about −10 cm H2O, reflecting, as much as for the pleural space, a strong draining lymphatic action, in the face of a low permeability of the capillary endothelium providing fluid filtration (Fig. 7). A subatmospheric interstitial pressure keeps the endothelium well glued to the epithelium, and in this way the volume of the extravascular water is kept at a minimum so that the overall thickness of the air-blood

The Postoperative Residual Pleural Space

As described in the analysis of Fig. 5, complete gas removal is a major cause of lung over distension that in turn leads to the 3 main postoperative respiratory complications: air leak, hydrothorax, and lung edema. To avoid over distension, a gas bubble has to remain in the chest in the immediate postoperative period after placing a suction tube. Gas is slowly reabsorbed (∼1%/d) from the chest; washing the cavity with oxygen would speed up the reabsorption process. Within the gas bubble,

Suggestions: how to improve pre- to early postoperative evaluation

Because surgeons are attaining considerable technical refinement,42 there is an obvious need to also refine the identification of risk factors for respiratory distress to reduce morbidity and mortality. The postoperative period seems to be the most critical period, when cofactors of respiratory morbidity may be present.

To prevent over distension, knowledge of the elastic properties of the lung would be useful. To follow the time evolution of the lung fluid balance, 2 methods can be suggested.

Respiratory Mechanics

  • In emphysema, lobectomy and pneumonectomy result in over distension of the remaining lung, thus implying a greater risk of air leak.

  • In fibrosis, pleural pressures become remarkably subatmospheric implying a greater risk for persistence of the gas bubble (potentially misinterpreted as air leak) and formation of hydrothorax.

  • Respiratory work increases after lobectomy and pneumonectomy, because lung compliance decreases in inverse proportion to the volume resected.

  • The increase in respiratory work

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    Studies reported in this review have been sponsored by funding from Italian Ministry of University, University Milano-Bicocca, ASI (Agenzia Spaziale Italiana).

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