Thoracic surgery does not induce large fluid shifts and intravascular fluid losses compared to other surgical procedures.

Collapse and re-expansion of lung parenchyma, heterogeneous pulmonary compliance in lateral decubitus position, elevated positive pressure ventilatory pressures, or increased pulmonary arterial pressures during single-lung ventilation may induce pulmonary edema that should be monitored and managed postoperatively.

Avoiding fluid overload through judicious, if not restricted, crystalloid and colloid administration intraoperatively and postoperatively is therefore critical in all thoracic patients, especially in patients with limited pulmonary reserve, or with cases requiring increasing pulmonary resection, where the remaining lung is subjected to the entire cardiac output. Fluid restriction while maintaining adequate end-organ perfusion is essential.

Transient hypotension and decreased urine output may be seen due to relative rather than absolute hypovolemia in patients with high thoracic epidural analgesia and should be managed with judicious fluid administration, decreasing epidural dosing as well as its concentration of local anesthetic, and occasionally using low dose vasopressor administration.

Principles of analgesia include [7]:

Thoracotomy incisions may be very painful (Fig. 2.1), impairing adequate mobilization, inspiration and expectoration, leading to atelectasis, retention of secretions, infection or worse. Inadequate analgesia contributes to a significant number of postoperative complications in these patients. Inadequate control of pain on postoperative days 1 and 2 is an independent predictor of chronic post-thoracotomy pain. It is thus imperative to control pain effectively and immediately.

The use of high thoracic epidural anesthesia is associated with improved pain control and decreased risk of pulmonary complications (such as pneumonia, atelectasis, prolonged mechanical ventilation, and re-intubation from respiratory failure), compared to patient-controlled analgesia and narcotic administration [8]. There is also a reduction in opioid consumption.

Thoracoscopic incisions are generally far less painful; however, chronic pain may occur due to levering a trocar on the rib and neurovascular bundle above. Preemptive analgesia with intercostal nerve blocks and local infiltration is an essential adjunct to multimodal oral and intravenous analgesia.

Over-sedation should be avoided when switching patients to oral or subcutaneous narcotics, as this may lead to subsequent hypoventilation and hypercarbia.

Risk factors for poor postoperative pain control include: preoperative patient preparedness, high opioid tolerance, young age, psychological factors (e.g., preoperative anxiety, depression, neuroticism), chronic pain, incision type (thoracotomy > VATS), and rib resection [9–13].

Chest tubes are routinely placed in virtually all operations whereby the parietal pleura has been entered to allow for evacuation of air, detection and management of air leaks, and drainage of hemothorax, chylothorax, enteric content, or other types of pleural effusions.

Principles of chest tube placement include being positioned for optimal drainage (fluid: posterior and basal; air: apical and anterior), with tube caliber directed at expected output (large-bore chest tube for sanguinous fluid; pigtail for air and serous fluid).

Postoperatively, the patient is asked to voluntarily cough or perform a Valsalva’s maneuver and the water sealed chamber is observed for bubbles (Fig. 2.2). The fluid level in the water chamber should move up and down with deep respiration and coughing.

Persistent air leak can be detected by suddenly placing (or increasing) the chamber on suction and observing a sudden rush of air through the system. For patients with small air leaks, the chest tube can be clamped for a couple of hours and then unclamped while on vacuum suction to observe the sudden rush of air; however, clamping overnight is neither necessary nor advisable.

It is imperative for patients to maintain the ability to deliver an effective cough (pulmonary toilet) and to maintain good bronchial hygiene.

Incisional pain can lead to significant chest wall splinting, preventing proper airway clearance of secretions and mucus plugs. This is further exacerbated by a strong smoking history and chronic bronchitis.

Early ambulation, fluid restriction, aggressive pain control, chest physiotherapy, and prevention of over-sedation with narcotic medications all contribute to a better pulmonary recovery in the postoperative period.

Nasotracheal suctioning, flexible bronchoscopy, mechanical ventilation may be required, especially in patients with poor preoperative pulmonary function.

Other supportive therapies include (as necessary):

The Thoracic Morbidity and Mortality (TM&M) classification is a system to standardize and grade the presence and severity of surgical complications after non-cardiac thoracic surgery (available at: http://​www.​ottawatmm.​org[18])