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

Reason for Procedure

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

How Procedure is Performed

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

Prognosis
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

Rehabilitation
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
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

Return to Work (Restrictions / Accommodations)

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 requiringdialysis, chronic heart disease) or postoperative complications may also require work restrictions and accommodations.
Source: Medical Disability Advisor

References

Cited
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.

http://www.mdguidelines.com/pneumonectomy

ICD-9-CM: 32.2, 32.28, 32.29, 32.3, 32.4, 32.9

Definition
Lung excision is the surgical removal (excision) of all or part of the lung.Pneumonectomy is excision of the entire lung. Lobectomy is excision of one or more sections (lobes) of the lung. Segmental resection is removal of one or more sections (segment) of a lobe. Wedge resection is excision of a triangular portion of a lung across more than one segment. Most lung excisions are done to treat non-small-cell lung cancer (NSCLC). Lung excisions are also done when an individual sustains a major wound to the chest with extensive bleeding, if the bronchial tube carrying air into the lung is damaged beyond repair, for recurrent pneumonia, for persistent bleeding that fails to respond to conventional management, for suspicious nodules where a diagnosis is not clear, and for diffuse lung disease to obtain a tissue sample for diagnosis.
Source: Medical Disability Advisor

Reason for Procedure

Excision of the entire lung (pneumonectomy) is most commonly performed to remove cancer originating in the lung (primary lung cancer) that cannot be removed with a lobectomy, segmental resection, or wedge resection. Other diseases and conditions treated with pneumonectomy include chronic dilation of the airways within the lung as a result of infection(chronic bronchiectasis) and multiple abscesses of the lung. Before a decision is made to remove a lung, pulmonary function tests are performed on the remaining lung to ensure it is healthy enough to cope with increased demands. Excision of one or more sections or lobes of the lung (lobectomy) is most commonly performed to remove cancer that is confined to a particular lobe. Other diseases and conditions treated with lobectomy include bronchiectasis, giant blisters (blebs or bullae) associated with bullousemphysema, noncancerous (benign) tumors confined to the lobe, fungal infections, and congenital abnormalities. Segmental resection is most commonly performed to remove lung tissue damaged by bronchiectasis or chronic inflammation. During a segmental resection, only the segment of lung containing the diseased tissue is removed. Healthy segments are preserved. Wedge resection is most commonly performed to remove small, benign, primary lung tumors, treat localized inflammatory disease, and remove tissue for diagnostic biopsy.
Source: Medical Disability Advisor

How Procedure is Performed

Pneumonectomy, lobectomy, and segmental resection, procedures approach the lungs from the side through a thoracotomy incision. In some cases, the surgeon may choose to approach the lungs from the front through the breastbone (median sternotomy incision), but this is much less common. Wedge resection, particularly for diagnostic biopsies, may be done using thoracoscopy, which is a less invasive

procedure. For a thoracotomy, 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) may be inserted. General anesthesia is induced, and a breathing tube (endotracheal tube) is placed through the mouth and into the windpipe (trachea) to maintain an airway during surgery. After being anesthetized, the individual is repositioned onto the nonoperable side (lateral or semilateral position). Arms are secured and bony prominences (hip, ankle, elbow, shoulder) are padded to prevent pressure sores. A catheter may be inserted into the spine to deliver pain medication postoperatively (epidural analgesia). Compression stockings may be applied to keep an even flow of blood moving through the legs during surgery and to prevent formation of clots. A urinary catheter may be inserted into the bladder with the tubing 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, 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, is washed (prepped) with an antibacterial solution. 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 the individual's face and fastened to a canopy so that the entire head and neck are protected from the surgical field but exposed to the anesthesiologist. A sterile plastic adhesive drape is placed over the exposed surgical field. The surgeon cuts (incises) the individual's skin, underlying tissue, and muscle, 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 (the pleura) and gently peels it away from the lung. For a pneumonectomy, all branches of the main blood vessels entering and leaving the diseased lung (pulmonary artery and vein) are clamped, tied twice with nonabsorbable suture, and cut in two (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. A lobectomy is performed in a similar way. The bronchus is clamped and divided above the lobe or lobes to be removed. The bronchus stump is closed as previously described. The edges of the remaining lung are sutured together, and the lung is re-inflated. The chest cavity is irrigated with saline to check for leaks in the suture line of the remaining lung and to clear the chest of old blood. At this time, the surgeon also assesses the degree of expansion the remaining lung can provide. Bleeding is controlled with sutures and electrocautery. A segmental resection procedure is performed much like a lobectomy, with only a segment of a lobe being removed rather than the whole lobe. Blood vessels supplying the segment are clamped and tied with nonabsorbable suture and divided. The segment of bronchus supplying the segment is clamped, divided, and closed in the usual manner. The edges of lung are sutured together, and bleeding is controlled. A wedge resection is very similar to a segmental resection, but the portion of lung removed comes from more than one lobe segment. Chest tubes are not inserted after pneumonectomy. Following pneumonectomy, the chest cavity is allowed to fill with air and fluid. The levels are monitored, with just enough pressure placed on the heart and other

lung to keep them in their normal space without obstructing them or letting them drift to the empty side. Chest tubes are inserted after lobectomy, segmental resection, and wedge resection. Chest tubes are inserted through the skin and into the space around the lung (the pleural space). The other ends of the chest tubes are attached to sealed drainage systems that allow blood to drain from the pleural cavity while not allowing air back in. The tubes are secured to the skin with sutures. During closure, the muscle and each layer of tissue are closed withsurgical sutures. The skin is closed with sutures and the suture line covered with a thin layer of sterile gauze and secured with tape. The individual may transfer directly to the intensive care unit, rather than the recovery room, for recovery from anesthesia. Wedge resection can now be performed using a scope, much like alaparoscopic procedure. This is called a video-assisted thoracoscopic surgery (VATS). It is set up much the same as a standard wedge resection, except three small incisions are made in the chest wall. Instruments are inserted into the chest cavity, and a video camera helps to guide their use. Following the procedure, a chest tube is often left in place for a few hours. This procedure works best when only a small amount of tissue needs to be removed.
Source: Medical Disability Advisor

Prognosis
The prognosis following partial removal of a lung depends on the underlying disease or condition requiring surgery. Individuals with lungs diseased from emphysema, infection, or other conditions have reduced lung capacity before surgery. Removing part of the lung reduces this capacity even more. In general, the less of a lung removed, the better the outcome for the individual in terms of returning to work and performing activities of daily living. The prognosis following pneumonectomy for lung cancer is poor. If lung cancer is found early, before it has spread to nodes or other organs, the 5-year survival rate following surgery is 49% ("Detailed Guide"). However, lung cancer is rarely diagnosed in the very early stages when lung excision is most beneficial. As a result, the 5-year survival rate for all stages of lung cancer combined is only 15% ("Detailed Guide").
Source: Medical Disability Advisor

Rehabilitation
Individuals who undergo the excision of one or more lobes of the lungs require occupational, physical, and respiratory therapy after surgery. All therapies begin in the hospital, and occupational and physical therapycontinues after discharge. Respiratory therapy aims to increase lung capacity and decreased the risk of a buildup of lung secretions. Respiratory therapists teach individuals pursed-lip breathing to increase the airflow to the lungs. Individuals may also use an incentive spirometer. This device measures and displays the amount of air inspired to help motivate individuals to take deeper breaths. Individuals also learn to produce an effective cough and are taught which positions may help relieve shortness of breath. Occupational therapy addresses any fatigue or shortness of breath that may occur during activities of daily living. Occupational therapists may teach energy conservation techniques, in which activities such as meal preparation are broken into smaller components to make tasks more manageable. Therapists may also teach individuals to use equipment that conserves energy. Physical therapy addresses decreased endurance, strength, and range of motion. Individuals learn to stretch the shoulder and chest muscles on the side of the removed lung to help normalize posture. Individuals perform strengthening exercises to improve overall endurance and promote normal posture.

They may perform aerobic activity such as walking on a treadmill or riding a stationary bicycle to further increase endurance. Individuals learn to rate the amount of energy they expend by utilizing a rating of perceived exertion scale. This is a numbered scale that rates exercises from "very, very light" to "very, very hard." Individuals use this scale to stay within safe exercise parameters predetermined by their physicians.
Source: Medical Disability Advisor

Complications
Complications following lung surgery include collapsed lung (atelectasis), heart rhythm disturbances, air leakage from the bronchial stump (pneumothorax), hemorrhage, shifting of organs and tissue into the space formerly filled by the removed lung or lobe (mediastinal shift), lung infection (pneumonia), accumulation of excess fluid in the space formerly filled by the removed lung or lobe (pleural effusion), respiratory insufficiency,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 vessels that were cut and sutured during lung surgery.
Source: Medical Disability Advisor

Return to Work (Restrictions / Accommodations)

After the individual returns to work, work hours may be gradually increased over several weeks until individual is working a full shift, if possible. Many individuals who have had all or part of a lung removed may experience some degree of shortness of breath, even without exertion. These individuals most likely require work restrictions and accommodations that help conserve energy and reduce the requirement for oxygen. Other medical problems or permanent disabilities because of underlying medical conditions, such as diabetes, chronic renal failure requiringdialysis, or chronic heart disease or postoperative complications, may also require work restrictions and accommodations.
Source: Medical Disability Advisor

References

Cited
"Detailed Guide: Lung Cancer." American Cancer Society. 15 Sep. 2004 <http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=26>