Dr. Leong Ka Hou

1. The role of Respiratory
Physiotherapy in surgery
Tutor: Lei On Teng
IC: Leong Ka Hou
Rehabilitation IC (2019)

2. Respiratory impairment
 Abdominal operation(subphrenic abscess, liver operation, colectomy)
 Thoracic operation(transthoracic esophagectomy, pulmonary
lobectomy)
 Cervical operation(thyroidectomy)

3. THORACIC SURGERY
 Damage to the muscle or to the nerves as a consequence
of the incision
 Distortion of chest wall configuration(less common factor)

4. Abdominal surgery
 lower abdominal surgery is very low (2–5%)
 Upper abdominal surgery is higher (20–40%)
1. Celli B (1993) Respiratory muscle strength after upper abdominal surgery.
 Rapid shallow pattern of breathing
decreased lung volumes
 This decrease is sustained for 48 hours
after surgery (on average)
 Reduction in diaphragmatic strength
(reflex inhibition of the phrenic nerve output)
and shift to predominantly rib cage breathing

5. Respiratory movement shift
Abdominal
breath
Chest breath
1 = preoperative (control), 2 = 2–4 hours, 3 = 6–8 hours, 4 = 24 hours, 5
= 48 hours postoperative. Breathing is shifted from predominantly
abdominal (1) to rib cage (2 and 3) and back again to abdominal (4 and
5).

6. Open laparotomy VS Laparoscopy
 Hypothesis of inhibition of phrenic
nerve in open laparotomy more than
laparoscopy.
 The better postoperative outcome

7. The purpose of chest physiotherapy
• To facilitate removal of retained or profuse airway
secretions.
• To optimize lung compliance and prevent it from collapsing.
• To decrease the work of breathing.
• To optimize the ventilation-perfusion ratio/ improve gas
exchange

8. Normal clearance
 The normal human bronchial tree is lined by a thin (5 micrometers) layer of
mucus
Effective cough,
open airway,
functional mucociliary

9. Balance of branchial clearance
 粕木
Cleanarance ↓
1. Respiratory muscle
weakness,
2. Collapsing airway
Secretion ↑
1. Endobronchial
diseases(COPD)
2. Smoker

10. Classification
 Conventional Techniques
Manual handling techniques, Postural drainage (percussion and
vibration),
 Modern techniques
Active Cycle of Breathing Technique(ACBT), Cough excerise
 Instrumental techniques
Positive expiratory pressure (PEP), Continuous Positive Airway
Pressure, High-Frequency Chest Wall Oscillation (HFCWO)

11. Postural drainage
 Removes sputum from certain parts of the lungs by using gravity and proper
positioning to bring the secretions into the throat
 Best time for the treatment:
Morning(built up during the night).
1-2 hours after eating (prevent nausea and or vomiting).
Avoidance before meals (tired and decrease appetite).
 Anatomy of lung
left: upper lobe and lower
Right: upper lobe, middle lobe and lower lobe

12. Postural drainage
 Two to three times a day.
 3-15 minutes.
 Middle and lower portions
Trendelenburg position
 Upper portion
sitting (gravity)
Percussion(kinetic energy)
Vibration (pressing ribs direction during expiratory)

13. Postural drainage
 Bronchodilators, mucolytics agents, water, or saline
Reduce bronchospasm, decrease thickness of mucus and sputum
Enhancing secretion removal
Encourage diaphragmatic breathing/ cough(More effective)
Auscultate the chest
to determine the
areas of needed
drainage.
Discontinue: hypoxemia, hemoptysis

14. Contraindication for conventional
Techniques
(Manual handling techniques, Postural drainage (percussion and vibration)
 Intracranial pressure (ICP) > 20 mm Hg
 Uncontrolled hypertension
 Distended abdomen
 Esophageal surgery
 Recent gross hemoptysis

15. Modern techniques
 Active Cycle of Breathing Technique(ACBT)
 Cough excerise

16. Active Cycle of Breathing
Technique(ACBT)
 Target:
Loosen and clear secretions from the lungs
Improve ventilation in the lungs
Improve the effectiveness of a cough
Improved the outcome
of post-CABG. Include:
pain, respiratory
function.

17. Forced Expiratory Technique
(huffing and cough)
 " huffing" exercises: breathe in slowly through nose > hold
the breath (3 seconds) > exhale with open mouth (like
fogging a mirror)
 Cough: don’ t swallow and spit out the mucus.
Deep and slow deep breath
Short and force exspiratory
(small > large airway)
Cough with accessory muscle
(large airway> mouth)

18. Huffing
 Two types of huff:
Medium Volume Huff High Volume Huff
Secretions lower airways upper airways
Breath(volume) Normal-sized breath Deep breath
Action Active, long breath out
(fogged a mirror)
mouth wide and huff out
quickly( forced expiration)
End lungs feel quite empty As exhaled as possible
Try to avoid excessive coughing as this may reduce how
effective the technique is and make it excessively tiring.

19. Huffing
 Duration for ACBT should be for about 10 minutes
 Taking this exercise to reduce the duration of
Hospitalization, reduction of the rate of
respiratory infection.

20. Forced Expiratory Technique
(huffing and cough)

21. Instrumental techniques
 Positive expiratory pressure (PEP)
 Continuous Positive Airway Pressure(CPAP)
 High-Frequency Chest Wall Oscillation (HFCWO)

22. Positive expiratory pressure (PEP)
 Inhalation is at tidal volume
 It provide resistance to expiration> forced expirations
(expiration is slightly active against devices)
 Enhancing collateral ventilation> remove secretion in
collapse airways
 Vibratory therapy,

23. Positive expiratory pressure (PEP)
Acapella
lung flute
Flutter

24. Mechanism of PEP

25. Continuous Positive Airway Pressure
 Generated exhalation against a constant opening pressure
 Positive end‐expiratory pressure> prevent collapsing of
alveola

26. High-Frequency Chest Wall Oscillation

27. High-Frequency Chest Wall Oscillation
 Non-invasive, painless inflatable vest
 Mechanism: Generated vibrations(micro-high frequency (5–25 Hz),
intense)
 loosen and thin mucus separate from the wall of small airway
 HFCWO during the 20- to 30-minutes every, cough for every 5 minutes

28. Take home massage
 Respiratory physiotherapy is necessary for the patient who undergo
operation
 Purpose increasing Cleanarance(Respiratory muscle weakness,
Collapsing airway) and early intervention of the patient with
bronchial diseases(COPD), smoker
 There are three main means for respiratory Conventional Techniques,
Modern techniques, Instrumental techniques
 Respiratory physiotherapy is easy and convenience to perform for
the patient by family

29. Reference
 https://journals.sagepub.com/doi/10.1177/1750458919888818
 https://www.atsjournals.org/doi/abs/10.1164/ajrccm.153.1.8542159
 https://thorax.bmj.com/content/54/5/458
 https://www.physio-
pedia.com/index.php?title=Respiratory_Physiotherapy&utm_source=physioped
ia&utm_medium=related_articles&utm_campaign=ongoing_internal
 Text book: Delisa’s physical medicine & rehabilitation
 www.uptodate.com