Prolonged chest tube placement

Present illness

A 73 year-old man smokes one pack a day for more than 30 years. His hypertension and type 2 DM. During a health check-up, CXR revealed lung nodule at RUL. Subsequent CT-guided biopsy revealed adenocarcinoma of lung. PET-CT showed a 3.8 cm lesion with soft tissue density and FDG uptake at posterior segment of right upper lobe of lung. Another 1.3 cm lesion was also found at lateral basal segment of LLL of lung. Other lymph node are found normal. The clinical stage is cT2N0M0, stage IB. Due to poor lung function, (FEV1: 1.09L; FEV1/FVC = 53.17%), surgery is postpone. After steroid and bronchodilator administration, his FEV1 imrpoves from 1.49L to 1.92L. FVC becomes 3.75L, FEV1/FVC becomes 51%. After VATS lobetomy, RUL is excised. 7 days after surgery, his lung still can't fully expand. Chest tube has been placed for 7 days because persistant force air leak (pneumothroax). Leg edema has been noted. Subcutaneous emphysema develops and extends.

Order

1. Vital signs measurement, bid prn
2. On diet as tolerable (DM diet)
3. Chest tube (ES -10cm H2O) => Free drain => (ES -10cm H2O)
   Due to extension to subclavicle region
   
4. Wound change dressing, qd
5. Coaching
6. O2 via nasal canula 1~3 L/min, qd prn
7. One touch finger sugar, qd AC check
   
8. Glimepiride (Amaryl): antidiabetic agents: sulfonylurea
   2mg 0.5 tab po qd
   
9. Theophylline
   200mg 1 tab po bid
   
10. Prednisolone
    5mg 2tab po qd
    
11. Bambuterol (Bambec): beta2-agonist
    10mg 1 tab po hs
    
12. Hydrochlorothiazide + Losartan (Hyzarr)
    12.5mg 1 tab pd qd
    Hydrochlorothiazide: diuretics: thiazide
    Losartan: antihypertensive agent: (angiotension antagonist, ARB)
13. Tamsulosin (Flomax): sympatholytics: alpha-blocker
    1 tab po hs
    
14. Pseudoephedrine + Loratadine (Clarinase)
    Pseudoephedrine: Adrenergic agonists: Decongestants
    Loratadine: H1 blocker
    
15. Celebrex
    1 tab po bid prn if pain
    

Past history
1.COPD
2.Hypertension
3.Type 2 DM (HbA1c 7.5%)

Personal history
Tobacco: 1PPD for > 30 years

Discussion

Prolonged chest tube placement

• Infection: wound infection or retrograde infection from the wound (germs enter the thoracic cavity from the cut where chest tube is inserted into thoracic cavity) . Pneumonia may occur.
• Steroid may weaken his immunity and he may predispose to infection. Stop steroid and change to long-acting beta agonist.
• Change wound dressing more frequent
  

COPD exacerbation

• Pneumothroax may occur if his COPD exacerbates.
  

Leg edema

• Fluid status
  

Blood sugar