PT in thoracic surgery

1. JAMIA MILLIA ISLAMIA
PHYSIOTHERAPY IN CARDIOPULMONARY
CONDITIONS (BPT 402)
PHYSIOTHERAPY MANAGEMENT
FOLLOWING THORACIC SURGERY
Submitted to: Dr. Jamal Moiz
Submitted by: Shikha Sharma
BPT 4th YEAR
Roll No. 17BPT034
CPRS
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2. TYPES OF THORACIC INCISION
 Posterolateral thoracotomy
 Anterolateral thoracotomy
 Median sternotomy
 Left thoraco-laprotomy
 Video-assisted thoracoscopic incisions
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3. PRE AND POST OPERATIVE PHYSIOTHERAPY
 THORACOTOMY(excluding pneumonectomy):
 PRE-OPERATIVE PHYSIOTHERAPY:-
 Objectives:-
1. Full range of motion and adequate circulation: Special attention to the
operated side shoulder. The patient should practice elevation and
abduction of the shoulder atleast three times a day.
2. Correct posture: It is maintained by teaching postural awareness and a
correct sitting position.
3. Adequate ventilation is maintained: Patient is taught breathing exercise
to hyperinflate the remaining lung tissue and aid the secretion clearance.
4. Improve general mobility: To start with begin mobility in the bed.
5. Effective coughing technique
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4.  Effective coughing technique:
1. Try to make the patient understand the importance of coughing.
2. Teach the incision supporting technique while coughing or performing any other vigorous
activity to the patient.
3. Patient can perform the coughing technique by stabilising the area around the chest.
4. If the physiotherapist is assisting the procedure, he can stand either on the affected side
supporting the incision area or on the good side and stabilising the whole chest, creating a
'bear-hug'.
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5. • POST-OPERATIVE PHYSIOTHERAPY:-
 Patient assessment:
•Surgical procedure and incision.
•Concise relevant history of present condition.
•Relevant past medical history including previous surgery.
•Social history
•Drug history, speicific note of respiratory medicines, example:
inhalers.
SUBJECTIVE:
•Ask open-ended questions: How do you feel?
•Ask about pain control: Can the person cough?
OBJECTIVE:
•Cardiovascular status(CVS): blood pressure, heart rate and rhythm.
•Oxygen delivery system
•Blood gas or oxygen saturation
•Respiratory rate
•Chest X-ray
•Method of pain control
•Number and type of drains
•Auscultation
•Ability to cough
•Range of motion of shoulder on incision side. 5

6.  Post operative complications:-
 Pain
 Intercoastal drains in situ
 Decreased air entry
 Retained secretions
 Decreased mobility
 Decreased shoulder movements on operated side.
 Poor posture
 Post operative plan:-
 Ensure the patient has adequate analgesia.
 Breathing exercises:
1. Deep inspiratory exercises with inspiratory holds and sniffs in lying and side
lying; operated side on top.
2. Diaphragmatic breathing involves concentration on full range movement of
the diaphragm to prevent pleural adhesion formation.
3. Active cycle of breathing technique(ACBT)
4. Patient should be encouraged to carry out at least two full cycles every waking
hour to maintain improvements gained in lung function.
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7. • Lateral costal shakings below the incision.
• Elevation of the foot of the bed to aid drainage of secretions .
• Huffing and coughing with good support in forward lean sitting or over the edge of
the bed.
• Full range active/assisted arm exercises.
• Active leg, foot and ankle exercises.
• Trunk, shoulder girdle exercises and postural correction.
 Post operative regime:-
• DAY OF OPERATION:-
Oxygen therapy is usually administered for the first few hours after the patient
return to the ward.
Active/assisted shoulder movements must begin immediately.
The patient should be able to co-operate with the breathing exercises with
support.
• DAY 1:-
Ensure the comfortable side-lying
position of the patient.
Make patient perform unrestricted
anterior and posterior chest wall
movements.
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8.  Patient should be encouraged to practice:
 Breathing exercise
 Coughing exercise
 Limb and shoulder girdle exercise
 Posture correction regularly throughout the day.
 Frequency: 3 treatment sessions through the day.
 Support the patient in sitting position with pillows.
• DAY 2:-
 Chest PT frequency: 2-3 times/day.
 As soon as the drains are off suction, mobilisation is performed around the room and stair
climbing added as more as position.
• DAY 3 TO DISCHARGE:-
 Assess the patient on daily basis.
 Progression in postural exercises is followed.
 Patient is discharged on 8-10 days postoperatively.
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9.  PNEUMONECTOMY:-
 PRE-OPERTIVE PHYSIOTHERAPY:-
 Objectives:-
1. Instruct patient not to lie on his good side for approximately 10 days
after the operation.
2. In all probability the patient would find that his respiratory pattern is
embarrassed by lying on his remaining lung.
3. Huffing must be taught to the patient.
• POST-OPERATIVE PHYSIOTHERAPY:-
 Complications:-
1. Pain
2. Decreased air entry on the good side
3. Retained secretion
4. Decreased shoulder movement on the operation side.
5. Decreased mobility
6. Poor posture
7. Decreased exercise tolerance
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10.  Postoperative treatment plan:-
1. Ensure adequate analgesia.
2. Diaphragmatic breathing exercises with inspiratory holds and sniffs in sitting or
half-lying.
3. Unilateral shaking on the good side during expiration phase.
4. Huffing with good support of the incision.
5. Full AAROM of shoulder, active leg, foot
and ankle exercises.
6. Early mobilisation with controlled breathing
pattern.
 Postoperative regime:-
1. Oxygen administration for first few hours.
2. Physiotherapist must check for deficit between apex and radial pulse.
3. It is necessary to position the patient in side lying if the remaining lung required
drainage.
4. Discharge is about 10 days postoperatively, also need further support at home.
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11.  PLEURODESIS, PLEURECTOMY AND DECORTICATION:-
 PREOPERATIVE PHYSIOTHERAPY:-
 Objectives:-
1. Patient is taught breathing exercises emphasizing on diaphragmatic
contraction and coughing techniques.
2. Encourage patient to cooperate with physiotherapist post operatively.
• POSTOPERATIVE PHYSIOTHERAPY:-
 Postoperative regime:-
1. Care of the drainage tubes together with costal and diaphragmatic breathing
exercises.
2. Special efforts must be made to regain maximum rib and diaphragmatic
movement.
3. Encourage patient to sit out of bed on the first day and commence walking
as early as possible.
4. Walking, stair climbing and general exercises should continue until
discharge.
5. Outpatient physiotherapy is advised if the patient is young and has gone
pleurectomy for pneumothorax, and thoracic movement, lung function and
exercise tolerance is not satisfactory.
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12.  THORACOPLASTY:-
 PREOPERATIVE PHYSIOTHERAPY:-
1. Preoperative physiotherapy plan is similar to other surgical procedure.
 POSTOPERATIVE PHYSIOTHERAPY:-
 Postoperative complications:-
• Postural deformity
 Postoperative treatment:-
• On operation day : Application of a firm
‘Paradoxical pad’ to prevent the paradoxical
movement of the upper chest.
• Day 1:Deep breathing exercises, huffing
and coughing , AAROM shoulder
movements and correction of posture.
• The best position for coughing is forward-sitting.
• Day 2/3:Breathing exercises, mobilisation and trunk exercises are also added in the
plan.
• Following days :Posture correction exercises should be performed in front of the
mirror.
• Outpatient physiotherapy program : It is followed until the patient achieve
postural control.
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13.  PECTUS CARINATUM AND PECTUS EXCAVATUM:-
 POSTOPERATIVE PHYSIOTHERAPY:-
 Postoperative plan:-
1. Maintain clear airways, lung expansion,
2. Prevent lung collapse and consolidation.
3. Prevent the tendency to ‘kyphose’.
4. Avoid side lying.
5. Promote shoulder girdle and arm exercises bilaterally.
6. Postural correction.
7. The patient should either be flat in bed or sit in an upright chair with a
lumbar pillow to prevent kyphosis.
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14.  HIATUS HERNIAAND OESOPHAGEAL RESECTIONS:-
 PREOPERATIVE PHYSIOTHERAPY:-
 Objectives:-
1. Full ROM and adequate circulation
2. Correct posture
3. Adequate ventilation
4. General mobility
5. Coughing technique
6. Postural drainage of the affected area.
 POSTOPERATIVE PHYSIOTHERAPY:-
 Objectives:-
1. Patient having extensive thoraco-abdominal incisions may require
administration of entonox during physiotherapy treatment.
2. Patients who have undergone repair of a hiatus hernia or a Heller’s
operation will be returned to the ward.
3. Do not force coughing and avoid tipping the foot of the bed.
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15. REFERENCES
 Tidy’s physiotherapy, Thirteen Edition, Edited by Stuart B. Porter.
 Cash’s Textbook of General Medical And Surgical Conditions For Physiotherapists.
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