This document discusses physiotherapy treatment for various pulmonary surgeries. It describes different types of thoracotomy incisions and their indications. It also discusses postoperative physiotherapy protocols for procedures like pneumonectomy, lobectomy, wedge resection and others. The goals of physiotherapy are to clear secretions, retain lung expansion, prevent complications and restore mobility. It covers management of chest drains and tubes as well as potential complications of pulmonary surgeries.

1. Physiotherapy in Pulmonary
surgery
Dr. Shilpasree Saha (PT)
Assistant Professor, NIHS

2. Thoracotomy
 Thoracotomy describes an incision made in the chest wall
to access the contents of the thoracic cavity (lung.
Bronchi, heart, esophagus).
 Thoracotomies typically can be divided into two:
1. Lateral (Anterolateral thoracotomies, Posterolateral
thoracotomies).
2. Anterior (transverse, vertical)
These can be further subdivided into supra-mammary and
infra-mammary

3. IndicationsFor
Surgery
I. Malignancy
II. Inflammatory conditions
III. Trauma: Stab wounds, gunshot wounds.
IV. Degenerative: Large lung bullae in selected patients
where there is compression of normal lung.
V. Congenital: Arterio-venous fistula, sequestrated lobe,
lobar emphysema.
VI. Diseases/infections

4.  Vertebral border of scapula and line of ribs (5,6,7,8) to the
anterior angle of costal margin.
 Trapezius, latissimus dorsi, rhomboids, serratus anterior,
intercostals and erector spinae are cutted.
 A rib may be removed so that when the other ribs are
retracted there is sufficient space for access to the thorax.
 Mainly used for lung operations.
Postero-lateral thoracotomy

5. Antero-lateral
thoracotomy  An antero-lateral thoracotomy is the standard approach
for a closed mitral valvotomy and is used by some
surgeons for pleurectomy.
 Serratus anterior, latissimus dorsi, pectoralis, intercostal
muscle are cutted.

6.  Patients are placed in the supine position with a small roll
under the ipsilateral shoulder. The patient’s arms are
tucked.
 The skin incision begins in close to the midline in front ,
follows the line of rib below the breast to the posterior
axillary line.
 Used for mitral valvotomy or pleurectomy.

7. Median
sternotomy
 Median sternotomy is the most widely used incision in
cardiac surgery.
 The skin incision should extend from just below the
sternal notch to a few centimeters below the xiphoid
process.
 Careful dissection behind sternal notch and xiphoid
process should be required to prevent accidental adjacent
vessels injuries.
 The sternotomy should be made on the midline of the
sternum after detecting the lateral margin of the sternum
by dipping the thumb and the index finger into the
intercostal space.

8. Usedforopenheart
surgery.
Indication of MS

9. Thoraco-laparotomy
incision
 Along the line of 7th or 8th rib and there may be an
abdominal incision as well.
 Used for access to the oesophagus.

10. TypesOfLung
Surgeries
 Pneumonectomy
 Lobectomy
 Wedge resection

11. Complications
1. Respiratory complication:
a. Infection
b. Collapse of remaining lung tissue
c. Pneumothorax
d. Broncho-pleural fistula
2. Circulatory complication:
a. DVT
b. Cardiac arrhythmia
c. Cardiac tamponade
d. Haemorrhage

13. Pneumonectomy
 The entire lung is removed.
 In a radical pneumonectomy, mediastinal lymph nodes and part of the
chest wall may also be removed.
 The resulting cavity is filled by protein rich fluid and fibrin.
 The cavity size is reduced by lateral shift of the trachea and heart, upward
shift of the diaphragm, and reduction of the intercostal spaces on the
operated side.
 Occasionally, and later, a scoliosis may develop.

14. Indications
 Carcinoma
 Bronchiectasis
 Tuberculosis
 Incision: postero-lateral thoracotomy

15. Physiotherapy
treatment
a. Gain patient confidence
b. Clear lung field
c. Teach breathing control
d. Inspiratory holding
e. Teach postural awareness
f. Arm, trunk and leg exercise
g. Mobility from the bed

16. Postoperative
Physiotherapy
 Goals:
a. Clear secretion from remaining lung
b. Retain full expansion from lung tissue
c. Prevent circulatory complication
d. Prevent wound complication
e. Regain arm and spine movement
f. Maintain good posture
g. Restore exercise tolerance

17. Treatment
protocol
 Day-0: (surgery am, treat pm):
a. Patient in half lying position
b. Breathing exercises
c. Foot and ankle exercise

18. Day-1
 Segmental expansion exercises
 Shaking or vibration if necessary
 Huffing and coughing with wound support
AT THE END OF THE DAY:
 Huffing and coughing with wound support
 Foot and ankle exercise
 Correction of posture
NEXT SESSION:
 Patient may sit out of the bed
 Shoulder and arm movement

19. Day-2
 Sitting on the edge of the bed and perform:
a. Trunk exercises- turning, bending at side, stretching
 Breathing exercises in chair sitting
 Walk around bed with trunk erect and arm swinging

20. Day-3
 Same protocol, twice a day
 Breathing and huffing is necessary

21. Day-4to
discharge
 Introduce to group therapy.
 Self care activities
 Walks more distance
 At 7th post op day, stair climbing with breathing control
 Breathing exercises
 Limb and trunk exercises
 Usually within 7-10 days, stitches come out.
 The patient is discharged after 2 weeks with strict home
exercise protocol.

22. Lobectomy
 Any of the five lobes may be removed.
 If a tumour in an upper lobe protrudes into the main
bronchus a cuff of main bronchus can be removed with
the lobe and the remaining lung and bronchus is joined to
the trachea. This is termed a sleeve lobectomy

23. Indications
 Bronchiectasis
 Tuberculosis
 Lung abcess
 Pneumonia

24. Preoperative
Physiotherapy
 BEGINS 48 HOURS TO A WEEK BEFORE SURGERY.
 Gain patient confidence
 Clear lung field
 Teach breathing exercises to expand lung tissue
 Inspiratory holding
 Teach postural awareness
 Arm, trunk and leg exercise
 Mobility from the bed

25. Postoperative
Physiotherapy
1. Half lying position with support.
2. Breathing exercises to expand all parts of remaining
lung.
3. Vibration over unoperated side.
4. Huffing with incision support.
5. Segmental expansion exercises.
6. Postural drainage by elevating the foot of the bed, if
necessary.
Day-0 (Treatment after given
analgesia)

26. Day-1
 Half lying position
 Foot and ankle exercises.
 Quadriceps contraction.
 Hip and knee bending and stretching.
 Assisted arm movement of operated side.
 Breathing exercises with inspiratory holding.
 Adding vibration to the operated side plus percussion as
required.
 Side-lying on the unoperated side, with no obstruction in
drains and upper arm supported by pillow and one more
pillow under the knee.

27. Day-2
 As first day
 Self supported huffing
 Arm exercises with full range.
 Trunk exercises.
 Abdominal contraction
 Discourage sitting crossed leg, as it occludes the popliteal
artery and vein and may result in DVT.
 At the end of 2nd day drains should removed.
 Fluid drain may be left in if there is less than 200 ml drained
in 24 hours.
 The patient can go for a short walk if necessary, with the
drainage bottle in a trolley.

28. Day-3and4
 One or two session per day.
 May introduce into group therapy.
 Trunk and arm exercises continued.
 Walking distance should increased.
 Self care activities.
 Stair climbing can be started.

29. Subsequent
treatment
 Bilateral breathing exercises
 Stitches may taken out between 7-10 days.
 Discharge between 10-12 days.

30. Segmental
resection
 A bronchopulmonary segment is removed with its
segmental artery and bronchus.
 This used to be indicated for tuberculosis but is now
rarely performed.

31. Wedgeresection
 Removal of small part of lung tissue.

32. Thoracoplasty
 This operation is performed to produce permanent
collapse of lung.
 Used to treat pulmonary TB, or chronic empyema.
 Resection of a varying number of ribs, leaving the
periosteum in position.
 4-10 ribs may be removed.

33. Complications
 Deformity
 Paradoxical breathing

34. Postoperative
Physiotherapy
 Breathing exercises
 Cough and huff using firm pressure over apical area of
thorax.
Day-0 (Treatment after given
analgesia)

35. Day-1
 Posture correction
 Active assisted arm movement.

36. Day-2
 Continue with breathing exercise and coughing.
 Posture correction.

37. Day-3and4
DAY -3
 Patient will be up and about.
 Manual resistance training for shoulder girdlearm on
effected side.
DAY -4
 Trunk exercises in sitting is added.

38. Day5-discharge
DAY-5 TO 7
 Trunk exercises in standing.
 Posture correction in walking.
DAY- 8 TO DISCHARGE
 Trunk mobility
 Thoracic cage mobility
 Posture correction should maintain for atleast 3 months
after discharge.

39. Operationof
pleura
 Pleurectomy
 Abrasion pleurodesis
 Decortication of lung

40. Pleurectomy
DEFINATION
 Removal of parietal pleura from an area of the chest wall
leaving a raw surface to which visceral layer sticks and is
performed for pneumothorax.
PT- MANAGEMENT
 Important to emphasize expansion breathing exercises
for effected side.

41. Abrasion
pleurodesis
DEFINITION
 Insertion of a powder into the pleural cavity, acts as an
irritant to the pleural surfaces, causing them to adhere to
each other.
 Performed in spontaneous pneumothorax and malignant
pleural effusion.
PT- MANAGEMENT
 Important to emphasize expansion breathing exercises
for effected side.

42. Decortication
ABRASION PLEURODESIS
 Stripping of layers of pleura that have become thickened due to
chronic inflammation from pleurisy which restricts movement of chest
wall and expansion of lung.
 In case of Unresolved empyema, whole pleura is removed to clear
away the chronic pus filled area plus surrounding fibrous tissue.
PT- MANAGEMENT
 Important to emphasize expansion breathing exercises
for effected side.

43. Drainsand
tubes
 Chest drains also known as under water sealed drains
(UWSD) are inserted to allow draining of the pleural spaces
of air, blood or fluid, allowing expansion of the lungs and
restoration of negative pressure in the thoracic cavity.
 Negative pressure is disrupted when air, or fluid and air,
enters the pleural space and separates the visceral pleura
from the parietal pleura, preventing the lung from collapsing
and compressing at the end of exhalation.
 The underwater seal also prevents backflow of air or fluid
into the pleural cavity.
 Appropriate chest drain management is required to maintain
respiratory function and haemodynamic stability.
 Two types:
a) Open
b) Closed

44. Opendrainage
 Include corrugated rubbers or plastic sheets.
 Drain fluid collects in gauze pads or stoma bags.
 They increase the risk of infection.
 E.G.- Penrose drain

45. Closeddrainage
 Consists of tubes draining into a bag or bottles.
 They include chest or abdominal drains.
 The risk of infection is less.
 Enables the lung to re-expand following pneumothorax and
lobectomy.
 Fluid is removed after any thoracic surgery to prevent pleural effusion
(expect pneumonectomy)

46. Equipments
 A tube
 A bottle with sterile water
 A suction pump

47.  The tube passes from inside the pleural cavity down
through a tight-fitting cap at the neck of the bottle to
below the level of water- under water seal.
 Air may be allowed to escape freely from a second tube
positioned high above the water in the neck of the bottle
or a suction machine may be attached to this tube.
 It is a single bottle, open to air. The patient's chest tube is
submerged under a level of water (usually about 2cm)
which acts as a one-way valve. When the patient's pleural
pressure exceeds the level of water (i.e. it is greater than
2cm H2O), the air in the tube will bubble out and escape
into the atmosphere. When the patient takes a breath in,
the negative intrapleural pressure will suck drain water up
the tube, but no additional air can enter.
Single Bottle Drainage

48. Disadvantages
 It is unsuitable for draining pleural fluid. Air will vent out of
the single bottle effortlessly, but any fluid drained will
collect in the bottle, increasing the fluid level. As the fluid
level rises, the pressure required to force air and fluid out
of the chest cavity increases; i.e. the more fluid drains out
of the patient, the deeper the tip of the tube, and the more
pressure will be required to force further fluid/gas out of
the pleural cavity.
 Fluid may reflux into the patient's chest cavity. As long as
this bottle remains well below the level of the patient's
pleural space, no fluid will get sucked up into the chest. If
the bottle is held above the level of the chest, everything
inside it may regurgitate back into the pleural cavity, with
non-hilarious consequences.

49. Two-chamber
underwaterseal
pleuraldrain
 This system separates the fluid collection chamber from
the water seal chamber. That way, there is still an
underwater seal to prevent the re-entrainment of air, and
pleural fluid can collect in the first chamber without
affecting the depth of the underwater seal.

51. Thethree-
chamber
underwater seal
drain
 This system is much like the two-bottle system, but with
an added chamber to help regulate the suction pressure,
i.e. it is specifically designed to be used with suction.

53. Pointstobenoted:
 Measured by calibrated scale in the bottle.
 200 ml of fluid being usual in first 24 hours.
 Air drainage can be seen as bubble in water.
 No bubble indicates either air in cavity has been removed
or the tube is kinked or blocked.
 Bottle draining should not placed higher than the chest
level because water could pour into pleural cavity.
1. Amount and type of drainage

54. Airleaks
 If bubble continue after the lung re-expansion, may be
due to air leak arising from a hole in the tube.
 If the patient is asked to take deep breath and cough,
bubbles appear if there is air leak.

55. Swingof water
 Water level remain same when suction is applied.
 No suction- water level falls in bottle on inspiration and
rises on expiration.
 Swing stops- lung fully expanded or tube is kinked or
blocked.

56. suction
 Tends to pull water level in bottles creating a negative
pressure which pulls water in the tube down thus creating
a suction effect.

57. Tubes  Fixedto thoracic wall by stitch.

58. Clamp
 Used on the tubes when bottle is to be changed or
moved.