The document discusses physiotherapy for patients undergoing thoracic surgery. It defines several common postoperative pulmonary complications including atelectasis, pulmonary edema, pulmonary embolism, and pneumothorax. It also reviews surgical procedures for conditions like lung cancer, aneurysms, and abdominal surgeries. The role of physiotherapy in the preoperative, operative, and postoperative periods is to prevent complications, improve lung function, and aid recovery through techniques like breathing exercises, positioning, and mobilization.

1. Physiotherapy
in surgical condition II:
Thoracic Surgery
Tadsawiya Padkao, PT, M.Sc.
Faculty of Allied Health Sciences
University of Phayao

2. PURPOSES
• To learn definitions, cause, clinical manifestations
for pulmonary disease related to surgery
• To review the types and procedures for operations
• To study the post-operative pulmonary
complications
• To analyze the management of cardiopulmonary
dysfunction secondary to acute surgical conditions
Padkao 2

3. Atelectasis
• Atelectasis or partial lung
collapse is the collapse of
normally expanded and
aerated lung tissue at any
structural level involving or
part of the lung
• Cause: Anesthesia,
prolonged bed rest,
secretions, foreign objects,
direst compression
• Clinical manifestation:
Breathing difficulty
Padkao 3

4. Pulmonary Edema
• Pulmonary edema or pulmonary congestion is excessive
fluid in the lung that may accumulate in the interstitial tissue,
in alveoli or in both.
• Cause: cardiac – heart failure, renal failure, ARDS, drug
rxn/narcotic (heroin) toxic inhalation, near drowing.
• Clinical manifestation: restlessness and anxiety, cough,
slight dyspnea, wheezing, pink frothy sputum.
Padkao 4

5. Padkao 5

6. Pulmonary Embolism
• The lodging of a blood clot
in a pulmonary artery with
subsequent obstruction of
blood supply to lung
parenchyma.
• Cause: Deep vein
thombosis
• Clinical manifestation:
nonspecific symptom
because depend on the
clot location.
Padkao 6

7. Padkao 7

8. Rib fracture
• Single rib fracture cause
only minor discomfort
• Multiple rib fracture often
lead to severe respiratory
compromise
• VC, FRC and cough are
reduced which lead to
atelectasis hypoxemia
and pneumonia
Padkao 8

9. Padkao 9

10. Pneumothorax
• Defined as an accumulation of
air or gas in the pleural cavity
caused by defect in the visceral
pleural or chest wall.
• Type: tension pneumothorax
(above figure), open
pneumothorax, traumatic
pneumothorax (below figure),
latrogenic pneumothorax
• Cause: A penetrating injury,
Blunt trauma, medical procedure,
lung disseases
• Clinical manifestation: Very vary
depeng the accumulate.
Padkao 10

11. Inspiration
Padkao 11

12. Expiration
Padkao 12

13. Hemothorax
• Hemothorax is a collection
of blood in the space
between the chest wall and
the lung (the pleural cavity)
• Cause: chest trauma,
cancer
• Clinical manifestation: Very
various depend on the
collection
Padkao 13

14. Pleurisy
• Defined as an inflammation of
the pleural
• Type: wet and dry pleurisies
• Dry pleurisy is the two layer of
membrane may become
congested and swollen
• Wet pleurisy: empyema
• Cause: infection, injury, tumor,
complication of lung disease
(pneunonia,TB,lung abscess)
• Clinical manisfestation: sharp
chest pain (inspiration), cough,
fever, tachynea
Padkao 14

15. Empyema
• Defined as an
accumulation of pus
• Cause: complication of
pleuricy or pneumonia,
bronciectasis, lung
abscess, chest surgery
• Symptom: dyspnea,
coughing, ipsilateral pleural
chest or shoulder pain,
malaise, tachycardia,
couhg and fever
Padkao 15

16. Padkao 16

17. Pleural Conditions
• Most pathological
condition of pleural
space are treated with
intercostal drainage
• Pleurectomy
• Pleurodesis
• Decortication
• Thoracoplasty
Padkao 17

18. Pleurectomy / Decortication
Padkao 18

19. Lung Cancer
• Malignancy of the epithelium of the respiratory tract
is the most frequent cause of death
• Risk factors: cigarette smoking, environmental
tobacco smoke, occupational exposure, previous
lung disease, nutrition, genetic susceptibility
Padkao 19

20. Segmentectomy
• Wedge resection is perform
if the tumor is confined to
one area of the lung.
• This procedure removes
only the tissue affected
• Should a larger section
need to be removed, the
procedure is called a
segmentectomy
Padkao 20

21. Lobectomy
• A lobectomy removes an
entire lobe. By moving the
entire lobe, the lobectomy
hopefully removes all
traces of cancer cells.
Surrounding lymph nodes
may be removed at the
same time in a procedure
called a lymphadenectomy
Padkao 21

22. Pneumonectomy
• A pneumonectomy is
the surgical removal of
a lung, usually as a
treatment for cancer.
Padkao 22

23. Lung Volume Reduction Surgery
• The basic concepts of this procedure involve
reducing the volume of functionally disturbed and
overexpanded bullous lung tissue so that the
intrinsic “spinginess” to the lung can be restored.
Padkao 23

24. Bullectomy
• A bullectomy is the surgical
resection of one or more
bullae.
• A bulla is an airspace that is
greater than one centimeter
in diameter that formed as a
result of pulmonary tissue
destruction.
Padkao 24

25. Aneurysm
• Defined as abnormal stretching
(dilatation) in the wall of artery,
vein and heart diameter at
least 50% greater than normal
• Cause: Artherosclerosis,
Marfan syndrom, Infection
agent
• Clinical manifestation: depend
on the side and position
- Aortic aneurism: MI,
stroke
- Abdominal aneurysm:
abdominal pain, sign of rupture
(abdominal heartbeat)
Padkao 25

26. Padkao 26

27. Ventricular aneurysms
• Ventricular aneurysm is
a complication of a
heart attack
(myocardial infarction).
It is a ballooning of
section of blood vessel
in the heart that first
appears several days
of weeks after an acute
myocardial infarction.
Padkao 27

28. Abdominal aneurysms
• Dilatation usually begins
below the renal arteries
and extend to aortic
bifurcation.
• The area of dilatation is
clamped above and below,
the aneurysm sac opened,
a graft inserted and sax is
closed over the graft.
Padkao 28

29. Rupture diaphragm
• Severe compression of
the lower thorax or
upper abdominal can
rupture the diaphragm.
Padkao 29

30. Abdominal surgery
• Splenic surgery
• Hepatic surgery
• Gastric, duodenal and gallbladder surgery
• Renal surgery
Padkao 30

31. While the patient is deep asleep and pain-free (general anesthesia), the surgeon makes an incision into the abdomen and examines the
Padkao
abdominal organs. Different incisions are sometimes used depending on the circumstance. Common incisions include a vertical 31
midline incision, and right or left upper or lower quadrant transverse incisions. Tissue samples (biopsies) can be taken and diseased
areas can be evaluated. When the treatment is complete, the incision is closed with either sutures or skin staples.

32. Incision and suture
• Posterolateral thoracotomy incised lattisimus dorsi, serratus
anterior, external and internal intercostals, trapezius and
rhomboid
• Median sternotomy involves longitudinal division of sternum
and the aponeuroses of the pectoralis major
Padkao 32

33. Posterolateral
Medial Sternotomy Thoracotomy Incisional
Incisional Line Line
Padkao 33

34. Cardiopulmonary Bypass Circuit
Padkao 34

35. Complications of bypass
• Prolonged bypass induces cytokine activation and
an inflammatory response
• Results in:
– Red cell damage and haemoglobinuria
– Thrombocytopenia
– Clotting abnormalities
– Reduced pulmonary gas exchange
– Cerebrovascular accidents
Padkao 35

36. Padkao 36

38. Role of Physiotherapy
• Continued advance in minimal access surgery,
combined with improved anesthesia and pain
management of surgical patient, reflect the
necessity for ongoing evaluation of physiotherapy
practice in this field
• Treatment should never be routine but in response
to individual patient assessment and based on the
best clinical evidence
Padkao 38

39. Role of Physiotherapy
• Pulmonary complication occur to 60% of patients
who undergo cardiac, thoracic or upper abdominal
surgery
• Chest physiotherapy is advocated to prevent and
treat pulmonary complication
Padkao 39

40. Operative management
• Preoperation
- NPO 8 hr before operation
- Medication
- Instrumentation preparation
- Cleaning
- Premedication
• Perioperation
- Aneathesia
- Operative procedure
• Postoperation
- Record vital signs: every 15 min during first 2 hrs, every 30 min during
2-4 hrs after operation and every 60 min during 4-12 hrs after operation
- Prevent or correct complication
Padkao 40

41. Anesthesia
• General anesthesia
• Spinal anesthesia
• Epidural aesthesia
• Nerve block
• Local anesthesia
Padkao 41

42. General Anesthesia
• FRC may be lowered by up to 30% at 24 hours
postoperatively and remain reduced for several days
• Dependent lung collapse occurs within 15 minutes and
last for up to 4 days postoperatively
• Narcosis reduces the sensitivity of the respiratory
center and decrease the efficiency of the elimination of
CO2
• A decrease in CO potentially reduces pulmonary blood
flow and alveolar perfusion, thus increasing
physiological dead space
Padkao 42

43. General Anesthesia
• V/Q mismatching is accentuate by supine,
respiratory depression and reduce cardiac output
• Mucocillary clearance cease altogether after 90
minutes of GA
• The cough reflex is damped
Padkao 43

44. Postoperative Complication
• Atelectasis
• Wound complications
• Pulmonary oedema
• Myocardial infarction
• Cardiopvascular problem
• Deep vein thrombosis
• Acute renal failure
• Reduced gut mobility
• Nausea and vomiting
• Psychosis
• Peripheral nerve injuries
• Myalgia
Padkao 44

45. Postoperative Complication
• VC and FRC ↓
• The deterioration in lung function generally reaches
a maximum within 48 hours after operation
• Abnormal breathing pattern
• After abdominal surgery, marked diaphragmatic
dysfunction occurs and last week (Simonneau et al,
1983)
• Ineffective cough
Padkao 45

46. Thrombophlebitis
Padkao 46

47. Pain nanagement
• Transcutaneous electrical nerve stimulation (TENS)
• Drug therapy
- Oral analgesia: 2-3 days after major surgery
- NSAIDs
- Opiods
- Patient-controlled analgesia (PCA)
- Nitrous oxide
Padkao 47

48. Incision and suture
• These may vary according to individual surgeon’s
preference
• Transverse abdominal incisions can less strain on the
wound than vertical incisions
• Face and neck suture tend to heal in 3-5 days
• Leg and foot tend to heal in 14 days
• Abdominal and chest wound tend to heal in 7-10 days
• Median sternotomy is less painful a thoracotomy or
abdominal incision
Padkao 48

49. Preoperative Physiotherapy Management
• Patient Selection
– Incision site
– Pre-existing respiratory problems
 Infection
 Restrictive defects
 Obstructive f=defects
 Obesity
 Age
 Smoking
 Patient motivation
 Nutritional status
 Functional status and intercurrent disease
 Alcohol and drug dependency
Padkao 49

50. Preoperative physiotherapy
• For
- Development rapport with patient
- Assess the patient and estimate degree of surgical risk
- Describe the general preoperative, intraoperative and
postoperative course
- Review specific procedure relevant to PT
- Provide the rationale for, describe, demonstrate and have
the patient practice and provide feedback on the treatment
- For patients at risk, review the use of conventional airway
clearance interventions
Padkao 50

51. Post-operative Physiotherapy
• For
- Enable patients to recover from episodes of hospital care
as quickly and safety as possible.
- Optimize the results of surgical procedure.
- Prevent costly postoperative complication.
- Teach patients how to successfully manager their own
long-term recovery process.
- Facilitate safe, early discharge policies and effective post-
discharge care.
- Provide effective and cost-efficient health care
management based on the individual needs of the patient.
Padkao 51

52. Post-operative Physiotherapy
• Positioning
• Manual techniques
• Cough and suctioning
• Breathing exercise
• Swedish pleurisy
exercise
• Mobilization
• IPPB
• CPAP
Padkao 52

53. Breathing Exercise
• The localized breathing exercise
increase lung volume achieved
promotes an increase in airflow
through collateral channels
• Deep breathing is more gas to
the basal than apical and holding
with glottis open for three
seconds at maximal inspiration
produces a greater rise in PaO2
than deep unsustained breath
• 3 TEE with SMI every walking
hour are preferable to patients
Padkao 53

54. Swedish Pleurisy Exercise
• Aim: - Increase chest expansion
- Remove fluid in pleural cavity
• Principle: Move the shoulder associated with
each pleura lines also related to respiration
• The movement of the shoulder ∝Insp. Or Exp.
Is a pumper, which accelerate fluid removing or
reabsorption.
Padkao 54

55. Method
Side lying to NO ICD side
1. Side lying, mid position:
Sh. Abduction – I – nose  Sh. Adduction – E – mouth
2. Side lying, lean backward:
Sh. Abduction – I – nose  Sh. Adduction – E – mouth
3. Side lying, lean forward:
Sh. Flexion – I – nose  Sh. Extension – E – mouth
First period: 15 time/set, 4 set/day
Padkao 55

56. Breathing Exercise
• Alveoli are likely to remain patent for 1 hour after reinflation
• The most efficient regiment of prophylaxis against
respiratory complication after abdominal surgery is deep
breathing exercise for low risk patients (Hall JC et al, 1996)
• Incentive spirometer appear to be more effective than no
physiotherapy intervention in the prevention of postoprative
pulmonary complications (Tomas J and McIntoch JM, 1994)
Padkao 56

57. Incentive Spirometer
• The use of device
designed to encourage
a reproducible
sustained maximal
inspiration made with
glottis open
Padkao 57

58. Incentive Spirometer
• Lung function can be increased significantly when
incentive spirometer and inspiratory muscle training
are used before and after operation (Weirer P et al,
1997)
• The addition IS to PT did not further reduces
pulmonary complication or hospital stay (Gosselink
R et al., 2000)
Padkao 58

59. Intermittent Positive Pressure Breathing(IPPB)
• A form of assisted or controlled
respiration produced by a
ventilatory apparatus in which
compressed gas is delivered
under positive pressure into a
person's airways until a preset
pressure is reached. Passive
exhalation is allowed through a
valve, and the cycle begins again
as the flow of gas is triggered by
inhalation
Padkao 59

60. Continuous Positive Airway Pressure (CPAP)
• The mechanism is an
increase in collateral
airflow to collapsed
lung regions due to
maintenance of
positive end-expiratory
pressure (PEEP)
thereby assisting
reinflation and removal
of secretions.
Padkao 60

61. CPAP
• Provision of CPAP decrease the risk of respiratory
distress requiring reintubation and the need for
artificial ventilation (Fagevik OM et al., 2002)
• The addition of CPAP to a traditional physiotherapy
post-operative treatment regimen after upper
abdominal surgery did not significantly affect
physiological or clinical outcomes (Denely L et al.,
2001)
Padkao 61

62. Mobilization
• The upright position is
advocated to counter the
effects of the reflex phrenic
nerve inhibition, surgical
trauma and decrease
diaphragm performance
that follow upper abdominal
surgery
• Mobilization refer to a
progressively increased
activity level
Padkao 62

63. Foot Leg Exercise
• Ankle exercise may be
helpful in prevent
phlebitis and improving
venous return in
patients who are
confined to bed
Padkao 63

64. Clearance of bronchial secretions
• Support cough
• Huff
• FET
• ACBT
• Percussion and vibration
• Suction
Padkao 64