**4. Impacts of postoperative pain on patients after thoracic and breast surgery**

Postsurgical pain after surgery, sub-optimal or untreated pain has profound impacts or negative effects on patients. Pain after surgery usually and directly impedes respiratory function, mobilisation, delays recovery, increase duration of hospitalisation and hospital care costs of patient [6, 23–26].

The severity of pain is usually increased due to tension on the incision as a result of movement or mobilisation, deep breathing, and/or coughing [10, 11]. As a result, postoperative altered or impaired pulmonary function as well as postoperative pulmonary complications in postoperative patients is common and becomes the main clinical impact especially after thoracic surgery due to pre-existing lung disease, surgery-related loss of parenchyma, and inadequate postsurgical pain management [9, 27].

The surgical wound continuously moves as patients breathe, move, and cough, which worsens pain. Directly, pain impedes patient's performance of deep breathing which consequently limits inspiration, decreases lung compliance, and decreases functional residual capacity, thereby leading to postoperative atelectasis and hypoxemia [8, 10]. Likewise, ineffective coughing results in retention of secretions resulting in developing postoperative pneumonia [9, 11]. Furthermore, the development of shoulder pain causes patients to splint shoulder and decrease shoulder movement which impairs and causes gradual loss of both active and passive shoulder function [13, 28].

For most women who had undergone breast surgery, the impact of acute pain varies and may be dependent on whether the surgery is breast conserving or mastectomy with or without reconstruction. Additionally, psychosocial, physiological, and other individual risk factors contribute to the impact of pain on breast surgery patients [29]. A long-term impact of acute pain after breast surgery is the occurrence of persistent pain, which could result in negative health status and poor quality of life. If acute pain after breast surgery is inadequately managed, it may negatively impact sleep, work, interpersonal relationships, and activities of daily living [30].

### **5. Factors influencing acute pain after thoracic and breast surgery**

Pain after breast and thoracic surgery is usually influenced by several factors that can be mainly categorised into patient factors, surgical approach, and analgesics technique factors [8, 14]. Previous studies have been conducted to examine determinants of pain after thoracic surgery. These are, however, mainly focused on determinants of post-thoracotomy pain syndrome or long-lasting pain after thoracic surgery [31].

#### **5.1 Patient factors**

A few studies have been done to determine how patient factors influence postsurgical pain intensity and response. Reports from the previous literature regarding gender differences and pain perception revealed female patients are less tolerant of noxious stimuli, frequently complain of severe and diffuse pain, and have higher risk for developing chronic pain than male patients [32, 33].

#### *Non-Pharmacological Management of Acute Pain after Breast and Thoracic Surgery DOI: http://dx.doi.org/10.5772/intechopen.109863*

Age has also been identified in existing literature as a significant predictor of post-operative pain. The pharmacokinetics of pain medications can be affected by advanced age as the older adults are more sensitive to systemic opioids. For instance, a previous study revealed that elderly patients required 40% less amount of thoracic epidural analgesia because of the difference in thoracic epidural spread in the elderly [34]. A study conducted on 1231 patients to identify the risk factors contributing to postoperative pain in a referral hospital in developing country revealed younger age, female gender, and emergency surgery [35].

Another study conducted in a university hospital in Northeast Ethiopia showed American Society of Anaesthesiologists' Physical Status Classification System class I and II, general anaesthesia, and incision length exceeding 10 cm as risk factors contributing to postoperative pain [36]. Although younger age, being female, a history of depression and anxiety, and the lack of preoperative education about pain management are more likely to increase risks of severe acute post-surgical pain, a recent literature suggests that these risks have not been evidenced in thoracic surgery patients [37]. Furthermore, increased body mass index (BMI) has been recorded in a previous study to influence severity of pain as well as delay recovery after surgery [38]. To date, current evidence has been focused on predictors of persistent pain after thoracic and breast surgery with less attention to acute pain.

Since pain experience is subjective, sensory, and emotional, psychological factors can influence pain perception and pain experience. Pre-operative anxiety, depressive mood, and catastrophising have been shown to lower pain thresholds, thus predicting a more severe post-operative pain [14]. For this reason, assessment and management of patients' preoperative anxiety, depressive mood, catastrophising, and others negative moods become another essential role for nurses in preoperative preparedness. These require establishing good rapport and relationships with patient and family member, including implication of cognitive behavioural strategies and distraction techniques [14, 37].

Previous pain experience may influence the ways of thinking and responding or coping with pain after surgery. Patients who are vigilant or too concerned about pain and have negative thought or expectation about pain may influence the way they respond to pain or report worst pain after surgery. Furthermore, the past pain experience together with socio-cultural factors influences people on constructing certain assumptions, beliefs or myths, and attitudes about pain and pain medication [39]. In addition, experiences of pain medication used as well as existing pain before the present surgery and the previous surgeries have been recorded in literature as factors influencing pain after surgery. Use of opioids, anti-depressant, anti-convulsant, and the existing pain preoperatively, especially at a previous surgical site, are revealed as the predictors of moderate to severe postoperative pain [5].

The way people express pain or give meaning to their pain experience is partly influenced by their cultural background. Cultural stereotype conformed or shared by members of the same group passed from generation to generation affects pain expression in diverse ways. Often a patients' response to pain reflects whether they are members of a stoic or emotive culture. Stoic patients, mostly from African and Asian cultures, scarcely express their pain but "grin or bear it". In particular, the stoic culture promotes not drawing attention to ones' self, especially in a negative light [40]. Additionally, openly complaining or being assertive are considered inappropriate in a stoic culture while behaving in a dignified manner is considered appropriate. For this reason, although an individual feels pain, it is not culturally appropriate to express it [40]. Moreover, African and Asian patients will avoid making demands

or questioning or bothering healthcare providers with complaints about pain. Meanwhile, emotive patients, mostly from Western cultures, are likely to verbalise their pain, prefer to have support around with an expectation that people react to their pain by validating what they are feeling [40].

Lastly, in some religion, pain acceptance hinged on a person's religious faith. For instance, Muslim patients may accept or reject pain medication based on their belief, and they could also consider their pain as God's blessing or believe that God can give them the ability to bear the pain. Meanwhile, Buddhists patients show stoicism when they experience pain and pain is viewed as common and accepting suffering leads to spiritual growth [40].

#### **5.2 Surgical factors**

The intensity of postoperative pain that a patient experience can be in part due to the technique used for the surgery [11]. Oftentimes, surgical methods or approaches that require more incisions or dissection of chest wall muscles can increase the postoperative pain intensity [11, 36]. Thoracic surgeries have been performed using several surgical techniques, and approaches mainly open thoracotomy and videoassisted thoracic surgery (VATS) [27, 41]. Although with open thoracotomy, reducing the size of the incision, using an appropriate muscle closing technique, or avoiding incising the latissimus dorsi may help reduce surgical tissue injury [11], VATS was created to limit the size of surgical incision and to avoid intercostal nerve damage in order to reduce pain after surgery [8, 11]. Thus, a longer incision and extended tissue trauma in open thoracotomy is expected to cause higher pain intensity compared with VATS [10]. Nevertheless, in women undergoing breast surgery, surgical techniques that require axillary lymph node dissection are predictive factors for severe postoperative pain [42].
