Removal of secretions

The most efficient way to remove secretions following thoracic surgery is by coughing. Many patients who have had surgery have impaired coughing due to pain and chest wall and diaphragmatic weakness. Excessive fluid restriction is often used in the management of lung resection cases, and this also leads to difficulty in clearing thickened secretions. Physiotherapy, particularly assisted inspiratory and expiratory therapy, is successful in most patients. A number of patients require nasotracheal suction to remove secretions, and in a small number frequent attempts are necessary. Bronchoscopy may be required. Formal tracheostomy is another major intervention but should be avoided unless other methods have failed. Insertion of an endotracheal tube and ventilation are occasionally successful but are frequently associated with further complications such as nosocomial infection.

Minitracheotomy permits a 4-mm flanged cannula to be inserted through the cricothyroid membrane under local anesthesia, allowing secretions to be adequately removed without delaying recovery (Jackson ef a/ 1991). The patient usually remains conscious and is able to eat and drink. Most importantly, the patient is able to cough and insertion of a catheter through the minitracheotomy elicits a cough reflex. Percutaneous dilation and open tracheostomy are rarely carried out to deal with thicker secretions.

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