| A pneumonectomy is the surgical removal of an entire lung, performed primarily for the treatment of lung cancer. Before a decision is made to remove a cancerous lung, pulmonary function tests are performed on the lung that will remain to ensure it is healthy enough to cope with the increased demands to be placed on it. Surgery is considered the only treatment that may cure the condition. Not all individuals with lung cancer are candidates for pneumonectomy, especially if the cancer has already spread to the lymph nodes or other organs at the time of diagnosis.
Smoking and certain working environments markedly increase the risk for lung cancer and the need for pneumonectomy. Accounting for more than 1 in 4 cancer deaths nationally, lung cancer is the single largest cause of death from cancer among men and women in the US (Prager 1415). Occupational exposures that increase the risk of lung cancer are asbestos, nickel chromates, coal tar, radioactive copper, arsenic, and radioactive emissions from radon.
Symptoms of lung cancer do not typically develop until the cancer is advanced and has possibly spread (metastasized) to other organs; the growth of lung tumors may take place silently over a period of ten to forty years, depending on the type of cells involved. The first symptom seen may be cough with bloodstained sputum or lung cancer may first be detected as a mass seen on routine chest x-ray.
Lung tumors are divided into two broad categories: small cell carcinoma and non-small-cell carcinoma. Small cell cancers are considered more deadly because of more aggressive cell division and replication that lead to rapid tumor growth and metastases; small cell cancer will spread through the lymph nodes and blood to other organs such as the liver, bone, brain, kidneys, and pancreas. Non-small-cell cancers include adenocarcinoma, bronchoalveolar, squamous cell, and large-cell carcinomas. |
Source: Medical Disability Advisor
| Pneumonectomy is performed to treat lung cancer when tumors cannot be treated effectively with removal of an affected lobe (lobectomy), removal of the tumor mass with segmental resection of lung tissue and nearby lymph nodes, radiation therapy alone or chemotherapy alone. Lung cancer will most likely to be treated with pneumonectomy in individuals who have had no metastases to lymph nodes at the time of diagnosis. Pneumonectomy may also be used to treat chronic bronchiectasis and multiple abscesses of the lung. |
Source: Medical Disability Advisor
| To perform a pneumonectomy, the surgeon usually approaches the lungs from the side through a thoracotomy incision. In cases in which a central mass is found, the surgeon may choose to approach the lungs from the front through the breastbone (median sternotomy incision), but this approach is much less common.
For a thoracotomy approach, the individual is at first positioned on the back (supine position), and secured to the table with a safety belt across the upper thighs. Monitoring equipment is secured (temperature probe, ECG leads, and a pulse oximeter finger cot to measure the level of oxygen in the blood). Intravenous lines are inserted for administration of fluids, medications, and blood during and after surgery. A special line to monitor arterial blood gases (oxygen and carbon dioxide) is also inserted. General anesthesia is administered and an endotracheal tube is placed through the mouth and into the windpipe (trachea), in order to maintain an airway and facilitate breathing.
After being anesthetized, the individual is repositioned onto the non-operable side (lateral or semi-lateral position). (In some cases, the surgeon may decide to divide the breastbone in half to provide better access to the lungs. In this case, the individual remains positioned on the back.) Arms are secured and bony prominences (hip, ankle, elbow, etc.) are padded to prevent pressure sores. A catheter may be inserted into the spine to be used for the delivery of pain medication postoperatively (epidural analgesia). Compression stockings may be applied to keep an even flow of blood moving through the legs during surgery, and prevent clot formation. A urinary catheter is inserted into the bladder and the tubing is hooked to a drainage bag in order to monitor kidney (renal) function during surgery. A nasogastric tube may be passed through the nose and into the stomach to drain accumulated stomach secretions. A conduction pad may be secured on the thigh to prevent burns when blood vessels are cauterized with the electrocautery machine. The surgical area is washed (prepped) with an antibacterial solution, including the entire rib cage on the surgical side, from the middle of the back to the middle of the chest and stomach, and from the neck to below the hip. The individual is covered with sterile, moisture-proof surgical drapes, leaving the surgical area exposed (the entire rib cage on the surgical side). The head portion of the drape is lifted off of the individual's face and fastened to a canopy so that the entire head and neck is protected from the surgical field but exposed to the anesthesiologist. A sterile plastic adhesive drape is placed over the exposed surgical field.
The individual's skin, underlying tissue, and muscle are cut (incised), usually between the fourth and fifth ribs. A rib may be removed to provide a better view. The ribs are separated with a rib retractor. The retractor is slowly cranked open, separating the ribs and exposing the diseased lung. The surgeon uses scissors to open the membrane that surrounds the lung (pleura) and gently peel it away from the lung. All branches of the main blood vessels entering and leaving the lung (pulmonary artery and vein) are clamped, tied twice with nonabsorbable suture, and divided. The main air tube (bronchus) going from the windpipe (trachea) to the diseased lung is clamped and divided. The lung is removed from the chest. A piece of pleura may be used to cover the bronchus stump. The bronchus stump is then closed with nonabsorbable suture. The chest cavity is irrigated with sterile salt water (saline) to check for leaks in the bronchus stump, and to clear the chest of old blood. Bleeding is controlled with sutures and electrocautery.
Chest tubes are not inserted after pneumonectomy as they are inserted after other lung surgeries. Following pneumonectomy, the chest cavity is allowed to fill with air and fluid. The levels are monitored so that just enough pressure is placed on the heart and other lung tissue to keep them in their normal space, without obstruction or drifting. During closure, the muscle and each layer of tissue is closed with surgical sutures. The skin is closed with sutures and the suture line is covered with a thin layer of sterile gauze and secured with tape. The individual may be transferred directly to the Intensive Care Unit for recovery from anesthesia rather than transferring to the Recovery Room. |
Source: Medical Disability Advisor
| The prognosis following pneumonectomy for lung cancer is usually poor; the exception may be in bronchoalveolar carcinoma if it is found as a single mass. If lung cancer is found early before it has spread to lymph nodes or other organs, the 5-year survival rate following surgery is 35 to 51% (Sekido 1427). However, the 5-year survival rate for all stages of lung cancer combined is 14%.
Recurrence in the lungs after pneumonectomy is rare although the cancer may reappear in other organs.
Following pneumonectomy, an individual may be able to return to work. As the disease progresses, however, the individual may become permanently disabled. |
Source: Medical Disability Advisor
| Individuals who undergo pneumonectomy will require occupational, physical, and respiratory therapy after surgery. All therapies will begin in the hospital, with occupational and physical therapy continuing after discharge from the hospital.
The goal of respiratory therapy is to increase lung capacity and decrease risk for buildup of lung secretions. To accomplish this, the respiratory therapist may draw on a variety of breathing and coughing techniques.
Occupational therapy addresses any fatigue or shortness of breath that may occur during activities of daily living. The therapy sessions may include learning to use equipment such as a shower chair to decrease the energy expended during bathing, or energy conservation techniques, in which activities of daily living such as meal preparation are broken up into smaller components to make tasks more manageable.
Physical therapy addresses decreased endurance, strength, and range of motion. For example, the individual may learn to stretch shoulder and chest muscles on the side of the removed lung to help normalize posture, and strengthen the diaphragm by lying on the back and performing abdominal breathing exercises. The patient learns to rate the amount of energy expended in order to stay within safe exercise parameters. |
Source: Medical Disability Advisor
| Complications following pneumonectomy include collapsed lung (atelectasis), heart rhythm disturbances, air leakage from the bronchial stump (pneumothorax), hemorrhage, shifting of organs and tissue into the empty chest cavity (mediastinal shift), lung infection (pneumonia), accumulation of excess fluid in the empty chest cavity (pleural effusion), respiratory failure, and death.
A ruptured bronchial stump requires immediate surgery, as does hemorrhage caused by slippage of a suture from one of the major pulmonary blood vessels that were cut and sutured during the pneumonectomy. |
Source: Medical Disability Advisor
| Individuals who have had a pneumonectomy without experiencing serious postoperative complications or disabilities may be able to return to work part time 6 to 10 weeks after surgery. Hours of work may be gradually increased over the next several weeks until the individual is working a full shift, if that is possible. Individuals with chronic lung disease will most likely require work restrictions and accommodations that aid in conserving energy and reducing the load on the remaining lung. Most individuals with only one lung will experience some degree of shortness of breath even without exertion. Individuals may not be able to perform heavy work due to the decreased ability to exchange gases through the remaining lung tissue.
Other medical problems or permanent disabilities because of underlying medical conditions (such as diabetes, chronic renal failure requiring dialysis, chronic heart disease) or postoperative complications may also require work restrictions and accommodations. |
Source: Medical Disability Advisor
| Prager, Diane, et al. "Bronchogenic Carcinoma." Textbook of Respiratory Medicine. Eds. Jay Murray and John F. Nadel. 3rd ed. Philadelphia: W.B. Saunders, 2000. 1415-1416.Sekido, Yoshitaka. "Surgical Management." Textbook of Respiratory Medicine. Eds. Jay Murray and John F. Nadel. 3rd ed. Philadelphia: W.B. Saunders, 2000. 1427-1432. |
Source: Medical Disability Advisor
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