Physiotherapy plays an important role after thoracic surgery to address issues like pain, reduced lung volume, impaired cough, and risk of postoperative pulmonary complications. Key physiotherapy techniques include positioning the patient, early mobilization and ambulation, lung expansion maneuvers, airway clearance techniques, and exercises to improve shoulder range of motion. Safety must be monitored during mobilization given risks of hemodynamic instability, oxygen desaturation, or exacerbating pain. The goal is to optimize lung function and mobility while preventing complications.

2. Physiotherapy after Thoracic Surgery
• Thoracic surgery has been the primary intervention used to treat
pulmonary, pleural, chest wall, and mediastinal disorders.
• The main presenting problems of postoperative patients who have
undergone thoracic surgery include:
• improper patient positioning; incision and/or chest drain pain;
ineffective cough; reduced lung volume; postoperative pulmonary
complications (PPCs), which can be non-infectious (e.g., atelectasis
and respiratory failure) or infectious (e.g., pneumonia); impaired
airway clearance; frozen shoulder on the thoracotomy side; postural
abnormalities; and persistent chest wall tightness

3. • Many thoracic surgical
procedures and traumatic
conditions require intercostal
drainage. The main aim of
intercostal chest drainage is to
remove air and/or fluid from the
pleural space to restore sub
atmospheric intrapleural
pressure, thus enabling re-
expansion of the deflated or
compressed lung.

4. • Chest tube
• The chest tube should be clear
of adequate diameter (6-11 mm
internal diameter in adults) with
a radio-opaque strip to outline
the tube itself and the side holes
should lie within the pleural
space. Any connectors should
also be clear to prevent blockage
going undetected.
• Apical tubes are positioned to
drain air while basal drains are
intended to drain fluid.

6. Underwater seal drainage
• Is used to ensure that the air removed from the pleural space during
expiration is prevented from re-entering during inspiration.
• To achieve this:
a. The pleural drain is attached to a tight-fitting connector on the
bottle neck. This is connected to a rigid tube which is submerged about
2 cm below the surface level of the water thus creating an underwater
seal.
b. The air is expelled against the hydrostatic resistance of the water and
out into the atmosphere via the vent. The vent is essential to avoid
build-up of pressure within the container.
c. Fluids will drain by gravity and not spill back into the pleural space if
the bottle is always kept below the level of the patient's chest.

7. d. Fluctuations in the level of the water column reflect the change in
pleural pressure during breathing. In self-ventilating patients the
intrapleural pressure becomes more negative during inspiration and
the fluid column will rise. During expiration the intrapleural pressure is
less negative causing the fluid level to fall.
e. A more gradual cessation of bubbling usually means that the lung
has fully re-expanded.

8. Drain removal:
• Tubes that have been used solely to drain fluid will be removed once
they are producing 10- 20 ml/hour or less.
• In the case of empyema where pus is being drained into a bag, the
length of the tube within the chest is gradually shortened, externally,
by a few centimeters until the infection has resolved.
• Air drainage tubes are removed once the lung has fully re-expanded,
and the air leak has stopped.
• To avoid unnecessary reinsertion of a chest, drain, the tube may be
clamped for a period of 12-24 hours and a radiograph taken to
confirm that the lung has not deflated without the aid of the chest
drain which may therefore be removed.

9. Physiotherapy key points for chest tube:
• a) Advice should be given on postural correction and upper limb
exercises.
• b) Care should be taken to avoid kinking, stretching or disconnection
of the tubes.
• c) Observation of changes in air leaks and drainage should be made
before, during and after physiotherapy intervention.
• d) In the presence of an air leak, positive pressure techniques are
usually avoided.
• e) In case of accidental dislodgement of an intercostal drain, the
patient is asked to immediately breathe out, and firm pressure with a
sterile dressing is applied to the insertion site at the end of expiration.
While maintaining pressure, the patient is asked to breathe normally
till medical help arrives.

10. Lung surgery:
• a- Lobectomy:
This is the removal of an entire lobe.
Generally, two intercostal drains are
placed in the pleural space at the
time of operation to evacuate air and
fluid /blood from the space. The
drains may be attached to low
continuous suction (10-20 cmH2O)
to aid re-expansion of the remaining
lung tissue. Normally the
hemidiaphragm on the affected side
will rise slightly owing to the
subsequent loss of lung volume.
• b-Segmentectomy:
Segmentectomy is the excision of
one or more of the
bronchopulmonary segments. The
subsequent loss of lung tissue is
minimal. An air leak may persist for
several days requiring an extended
period of intercostal chest
drainage.

11. • Complications of thoracic surgery:
• a) Pain.
• b) Bronchial secretions.
• c) Pneumonia.
• d) Atrial fibrillation.
• e) Wound infection.
• f) Hemorrhage.
• g) Empyema.

12. Chest trauma:
• a- Simple rib fracture:
• Rib fractures are the most common
thoracic injury and unless they are
causing chest wall instability (flail), the
main aim is to relieve pain and
prevent pulmonary complications
such as atelectasis and infection.
• Physiotherapy key points:
• 1- Patients will benefit greatly from
early mobilization.
• 2- Patients should be taught how to
support the chest wall to facilitate an
effective cough.
• 3- Taping or restriction of the chest
wall to reduce pain is not advised as
this may lead to further respiratory
complications.

13. b- Pneumothorax:
• I. Open pneumothorax:
• If an open chest wound is sufficiently
large, intrapleural pressure will remain
equal to atmospheric pressure.
• With each breath, air will be sucked in
and out of the chest wall, resulting in
marked paroxysmal shifting of the
mediastinum with each respiratory
effort.
• The subsequent hypoventilation and
decreased cardiac output can be life
threatening. In the emergency closure
of the wound by any means should be
attempted, followed by surgical
closure and insertion of an intercostal
drain.

14. • II. Tension pneumothorax:
• Injury to the lung results in a
continuing air leak ,which acts as a
one-way valve, allowing air to
progressively accumulate in the
pleural space.
• This creates positive intrathoracic
pressure leading to mediastinal shift
and compression of the remaining
lung. These increasing pressures/ if
not corrected, can invert the
diaphragm, cause subcutaneous
emphysema and ultimately a
cardiorespiratory arrest.
• Signs and symptoms include:
• Surgical emphysema,
• Absent breath sounds on the affected
side,
• Mediastinal shift and tracheal
deviation to the opposite side and acute
respiratory distress.

15. • III. Hemothorax:
• This involves accumulation of
blood in the pleural space. The
source of bleeding may be
attributed to the heart, aorta,
intercostal arteries or internal
mammary artery if a penetrating
wound was the cause.
• It is often associated with a
pneumothorax.
• If the blood has become clotted
and unable to be cleared with an
intercostal drain then thoracic
evacuation of the pleural space will
be necessary to avoid formation of
a fibrothorax or empyema.

16. Postoperative initial patient assessment:
• 1) Database information (from medical records):
• Preoperative investigations: chest X-ray, computed tomography scan,
pulmonary function tests, or 6-minute walk test.
• Surgical procedure and incision.
• Concise medical history: personal history, present history, relevant
past history (i.e., previous surgery), drug history including respiratory
and/or cardiac medications.

17. • 2) Subjective information:
• Detailed medical history: personal history, smoking history, history of
alcohol or drug abuse, chief complaint, present history, past medical
and surgical history, social history, family history
• Pain assessment: a verbal descriptor scale or a visual analogue scale
is used to measure incision or shoulder pain. The patient should be
asked about the efficiency of the postoperative analgesia method in
delivering adequate pain relief.
• Cough and sputum assessment: the patient's ability to cough and
expectorate should be assessed. The colour, volume, and consistency of
sputum should be observed.

18. • 3) Objective information:
• Clinical examination: inspection, palpation, percussion, and
auscultation
• Oxygen delivery system: level of fraction of inspired oxygen
• Type of chest drain
• Postoperative complications: pulmonary, cardiovascular, wound,
neurological, musculoskeletal, gastrointestinal, renal, and central
nervous system complications.
• Cardiovascular and respiratory status: the clinical stability of
postoperative patients should be assessed by checking their heart rate
and rhythm, blood pressure, respiratory rate, and oxygen saturation.
• Range of motion assessment: for the shoulder and trunk on the
operated side
• Biochemical data, arterial blood gas analysis, chest X-ray.

19. Postoperative physiotherapy treatments:
• Physiotherapy treatment must be started postoperatively between 4 and
12 hours after recovery from general anesthesia. The estimated session
time is 30 minutes, with 2–3 daily sessions.
• 1) Pain management:
• 2) Positioning:
• 3) Early mobilization and ambulation:
• 4) Lung expansion maneuvers:
• 5) Airway clearance techniques:
• 7) Shoulder ROM exercises and gentle scapula mobilization exercises:
• 8) Leg, trunk, and thoracic mobilization exercises:
• 9) Discharge and home program:

20. 1) Pain management:
• Pain impairs the patient's ability to take deep breaths or to cough
effectively, which could lead to reduced lung volume and sputum retention.
• The aim of physiotherapy pain relief interventions is not to substitute for
analgesic medications, but to reduce the total dose of analgesic
medications received by postoperative patients.
• Methods of pain management:
(1) Transcutaneous electrical nerve stimulation:
- TENS has multiple mechanisms of action, the first of which is closing the
gates of pain perception in the brain. The second mechanism is that TENS
stimulates the release of endogenous opioids.
- Duration from 20–30 minutes at 3-hour time intervals on the day following
surgery.
- Frequency varies from 2–100 Hz.

21. (2) Cryotherapy (cold therapy):
- The application of simple ice packs over the incision dressing during
the first 24 hours following surgery and afterwards is known to
produce remarkable relief of incisional pain and less need for narcotic
painkillers, by inducing vasoconstriction, which reduces inflammation
and swelling.
(3) Wound support:
- It is very important to support the patient’s incision and intercostal
drain site with firm but gentle pressure, taking care not to press
directly on the incision or drain site.
- One method can be done with the physiotherapist standing on the
contralateral side, with one hand placed on the anterior chest wall to
stabilize the incision from the front, and the other hand placed on the
posterior chest wall to stabilize the incision from behind, while at the
same time the physiotherapist’s forearms stabilize the entire chest
and create a “bear-hug” hold.

22. 2) Positioning:
• Positioning benefits:
• a- Enhance ventilation, perfusion, and gas exchange.
• b- Help clear excess bronchial secretions.
(1) Gravity-assisted positions to improve ventilation and gas exchange:
(a) Early upright sitting.
- Patients should not be allowed to be in a supine or in a slumped position in
bed, as these positions reduce lung volume.
(b) Lateral (side-lying) positioning.
- High side-lying with the operated lung on the top.
- After pneumonectomy, if the side-lying position is adopted for draining the
remaining lung, the patient should be positioned carefully on the operated
side, because if patient lies on the non-operated side, the bronchial stump
may be bathed with fluid if the anastomosis is not well sutured.

23. • (2) Gravity-assisted positions to assist the clearance of bronchial
secretion:
• The modified (horizontal) postural drainage position is recommended
first, instead of the classical (head down) position, in postoperative
patients, as the latter can lead to decreased arterial oxygenation and
could induce more cardiovascular stress, furthermore, it may increase
the risk of aspiration in postoperative patients with uncontrolled or
unprotected airways.

24. 3) Early mobilization and ambulation:
• The term postoperative mobilization refers to a change in the
patient’s position from the supine or slumped position in bed to
upright sitting in or out of bed (e.g., in a bedside chair), standing, or
walking.
• Mobilization, conventionally, should be started on the first
postoperative day by having the patient sit on the edge of bed or in a
chair out of bed, and then taking short steps to walk around the bed.

25. (1) Safety guidelines for early mobilization and/or ambulation:
• a- Mobilization should only be initiated for patients with clinically
stable cardiopulmonary and cardiovascular conditions.
• b- A patient’s clinical status is considered unstable if the vital signs
exceed any of the following thresholds:
• Heart rate less than 40/min or greater than 140/min.
• Respiratory rate less than 8/min or greater than 36/min.
• Oxygen saturation is less than 85%.
• Blood pressure less than 80 or more than 200 mm Hg systolic or
greater than 110 mm Hg diastolic.
• Mean blood pressure ˂65 mm Hg.
• Extremes of temperature are also highly suggestive of clinical
instability.

26. • c- Before upright mobilization, sitting balance should be checked, and
the sensory and motor functions of the lower limbs should be tested.
Once a postoperative patient is able to sit unsupported on the edge
of the bed for 5 minutes and can perform a full bilateral knee
extension along with clinically acceptable vital signs, the patient can
progress to standing and ambulation.
• d- Upon standing, it is important to check for orthostatic hypotension,
which can manifest by a drop in systolic blood pressure of ＞20 mm
Hg and a drop in diastolic blood pressure of ＞10 mm Hg, and/or in
the form of symptomatic dizziness or light-headedness.
• e- For patients’ safety, patients should start ambulation with a high
level of assistance, either by 2 or 3 personnel or by using assistive
devices such as a wheeled walker, dynamic orthotics, or a mechanical
lift.

27. • f- A graduated walking program should be adopted for mobilizing
postoperative patients. The physiotherapist must start low and go slow;
that is, to start with sessions that are short (i.e., 3–5 minutes), more
frequent (i.e., 2–3 times/day), and relatively non-intense (inducing a level
of patient effort of ＜13 on the rating of perceived exertion [RPE] scale or
at 60% of maximum heart rate [HRmax]).
• g- During all mobilization activities, careful attention should be paid to
subjective symptoms of exercise intolerance, such as shortness of breath,
chest pain, dizziness, cold sweating, leg fatigue, and pain. In such cases,
activities must be stopped immediately until hemodynamic stability returns
and then these stressful activities should be modified in subsequent
mobilization sessions.
• h- When walking a patient who is receiving supplemental oxygen, the
physiotherapist should monitor oxygen saturation the entire time, and the
amount of oxygen given to the patient must be enough to keep oxygen
saturation ≥90% during ambulation.

28. • (2) Contraindications to ambulation:
• Postoperative patients with unstable vital signs.
• Patients who are not able to follow commands.
• Patients with untreated deep venous thrombosis or pulmonary
embolism.
• Patients on high ventilatory support (i.e., a high fraction of inspired
oxygen of ˃80%, positive end expiratory pressure (PEEP) or continuous
positive airway pressure [CPAP] of more than 10 cm H2O).
• Patients with orthopedic injuries or neurological limitations to
ambulation.
• Patients with hypotension, uncontrolled arrhythmia (e.g., atrial
fibrillation).
• Uncontrolled decompensated heart failure, or recent myocardial
infarction.
• Patients with acute renal failure.

29. 4) Lung expansion maneuvers:
• After thoracic surgery, lung volume and functional residual capacity are
reduced due to anesthesia, chest wall pain, and/or recumbency.
• No individual lung expansion maneuver is significantly superior to another,
and a combined approach may be more effective than a single
intervention.
• (1) Deep breathing exercises: can be prescribed to postoperative patients
as 5 deep breaths with a 3-second end-inspiratory hold per waking hour.
(a) Thoracic expansion exercises (lateral costal breathing exercises):
- These exercises are most efficiently performed in the high side-lying
position, with the operated side on the top and the arm on the involved side
brought to abduction at the level of the head, It is important to support the
chest drain site to reduce pain.

30. (b) Deep diaphragmatic breathing:
• Deep diaphragmatic breathing should be practiced while the patient
is sitting upright, with his or her back supported and the pelvis in the
posterior tilting position.
(c) Coordinated deep breathing exercises:
• The patient may be taught to coordinate deep breathing with arm
flexion, arm abduction, trunk extension, or trunk side flexion away
from the operated side.
(d) Sustained maximal inspiration (3-second hold at total lung capacity):
• This is of great importance in facilitating more equal filling of the lung
regions.
(2) Incentive spirometry:
(3) Inspiratory muscle training:

31. 5) Airway clearance techniques:
• The inability to cough and clear airway secretions leads to an
increased risk for infection and the development of postoperative
pneumonia.
• An airway clearance technique should be started as soon as the
patient wakes on the day of surgery and/or on the first postoperative
day. It should be repeated every 30 minutes.
• We may use supported coughing, huffing, the forced expiration
technique (FET), the active cycle of breathing technique (ACBT),
modified postural drainage positioning with or without vibration, and
the positive expiratory pressure (PEP) therapy.
• Manual chest physiotherapy techniques as Shaking the chest wall
following thoracic surgery is not an appropriate choice due to the
presence of a chest wall incision, but a compressive support may be a
better choice to promote the clearance of secretions.

32. 6) Postural correction:
• Post-thoracotomy patients tend to side-flex their trunk towards the
thoracotomy side; that is, to drop the shoulder and raise the hip on the
operated side, because this is less painful.
• The patient is discouraged from adopting this protective posture and
is encouraged to keep moving the shoulder on the operated side.
• Patients should also be educated to keep both shoulders at the same
level and the trunk straight while sitting, standing, or walking.

33. 7) Shoulder ROM exercises and gentle scapula
mobilization exercises:
• After thoracotomy, approximately 80% of patients have shoulder pain
on the side of the incision, which may cause them to immobilize the
arm on the thoracotomy side, potentially leading to frozen shoulder.
• Auto assisted or active ROM exercises for the shoulder (e.g., arm
elevation) within pain limits can be started as early as possible, starting
on the first postoperative day with attention to the chest tube site.
• In addition, the scapula on the operated side can be mobilized gently
through its full range of protraction, retraction, elevation, and
depression, while the patient is in the side-lying position.
• These exercises need to be performed 3–4 times daily.
• However, shoulder abduction and external rotation are initially
avoided to prevent increased stress on the incision

34. 8) Leg, trunk, and thoracic mobilization
exercises:
• Non-resistance leg exercises (i.e., quadriceps and ankle exercises) can
be started on the first postoperative day to minimize circulatory stasis
and to prevent circulatory problems such as deep vein thrombosis and
pulmonary embolism.
• The patient can also start non-resistance arm exercises and thoracic
mobilization exercises on the first postoperative day with the aims of
increasing thoracic cage mobility, easing deep breathing with
subsequent increased lung volume.
• Thoracic mobilization exercises include thoracic extension exercises,
chest wall rotation exercises, and thoracic lateral flexion exercises. It
should be performed 5 times daily with adequate pain relief and/or
wound support.

35. 9) Discharge and home program:
• Once discharged, patients should be provided with a detailed home
program to stick with.
• A graduated walking program can be initiated following hospital
discharge, as follows. Immediately after discharge, the postoperative
patient should start walking at a moderate level of effort for about 3
times a day for 5 minutes each time for a total of 15 minutes/day.
Then, the patient should gradually increase the total walking time
each week by 5 minutes, so that he or she becomes able to walk for a
total of 30 minutes either intermittently or continuously by the first
month postoperatively