What is the management of an adult patient with a possible history of smoking after undergoing Video-Assisted Thoracic Surgery (VATS)?

Post-VATS Management

Implement multimodal pain control with regional anesthesia (paravertebral or erector spinae plane block) combined with scheduled paracetamol and NSAIDs, with opioids reserved strictly for breakthrough pain only. 1

Pain Management Protocol

Regional Analgesia (First-Line)

• Paravertebral block is the preferred regional technique for VATS due to superior efficacy in reducing postoperative pain and opioid requirements 1
• Erector spinae plane block is equally recommended as a first-choice alternative, providing effective analgesia with potentially fewer complications than thoracic epidural 1, 2
• Serratus anterior plane block serves as an alternative when first-choice blocks are contraindicated or technically difficult 1
• Continuous catheter infusion is preferred over intermittent bolus techniques for sustained analgesia 2

Scheduled Systemic Analgesia

• Administer paracetamol pre-operatively or intra-operatively and continue at regular intervals postoperatively as the foundation of multimodal analgesia 1, 2
• Initiate NSAIDs or COX-2 inhibitors pre-operatively or intra-operatively and continue postoperatively unless contraindicated by renal impairment, heart failure, or bleeding risk 1, 2
• Transition to oral medications as soon as the patient tolerates oral intake 2
• Avoid high-dose NSAIDs in patients with renal impairment, heart failure, or bleeding risk 2

Rescue Analgesia Only

• Use opioids exclusively as rescue analgesics for breakthrough pain, not as primary analgesics 1, 2
• For immediate post-procedure breakthrough pain, intravenous fentanyl in divided doses is preferred 1
• Consider patient-controlled analgesia only if frequent rescue dosing is required, but this should not replace the multimodal foundation 2

Pulmonary Complications Prevention

High-Risk Patient Identification

• Current smokers have significantly increased risk of postoperative pulmonary complications (PPCs) and represent the only independent risk factor on multivariate analysis 3
• COPD diagnosis is associated with increased complications (OR 2.54) 4
• Smoking pack-years >50 units significantly increases complication risk (OR 5.27) 4
• Older age contributes to postoperative pneumonia and prolonged hospitalization 5

Active Pulmonary Management

• Initiate aggressive chest physiotherapy from postoperative day 1 for all patients 3
• Adequate pain control is essential to prevent splinting, atelectasis, and impaired participation in respiratory physiotherapy 2
• Monitor closely for signs of PPCs including shortness of breath, chest tightness, or difficulty with deep breathing 6

Postoperative Monitoring

Expected Outcomes

• Median chest drainage duration: 2 days (range 1-33 days) 4
• Median hospital length of stay: 4-6 days 7, 4
• Earlier chest tube removal (median 3 days) and shorter hospital stay compared to thoracotomy 7

Complication Surveillance

• PPCs occur in approximately 7.4% of VATS lobectomy patients and are associated with significantly longer hospital stay, higher ITU admission rates (23.8% vs 0.5%), and higher mortality (14.3% vs 0%) 3
• Overall 30-day morbidity rate is approximately 31% for VATS segmentectomy 4
• Reoperation rate is approximately 4.7%, with indications including hemothorax, prolonged air leak, segmental torsion, and empyema 4
• Pneumonia and persistent air leak complications are more common following VATS compared to intercostal drain alone for pneumothorax treatment 7

Immediate Evaluation Triggers

• Seek urgent evaluation for new or worsening pain that interferes with breathing or movement, as this may indicate complications 6
• Report any associated neuropathic pain immediately, as it requires specific multimodal management rather than opioids alone 6
• Evaluate respiratory symptoms such as shortness of breath or chest tightness immediately 6

Smoking-Specific Considerations

• Patients with smoking history require more careful perioperative management due to prolonged surgical duration and extended postoperative oxygen requirements 5
• Patients who never smoked consume significantly less morphine equivalent analgesics (coefficient: -17.48 mg) on postoperative days 0-2 compared to those with smoking history 8
• Vigorous preoperative smoking cessation is urgently needed to reduce PPC risk, as current smoking is the only modifiable independent risk factor 3

Mobilization and Recovery

• Implement aggressive early mobilization once pain is adequately controlled 2
• Average time to resume normal activity is shorter with VATS compared to thoracotomy 9
• Rate of return to normal lifestyle exceeds 81% at 2+ years post-VATS 9