Role of Respiratory Physiotherapy in Preventing Pulmonary Complications Following Thoracotomy - Coursework Example

Role of respiratory physiotherapy in preventing pulmonary complications following thoracotomy. Aims and objectives: The aim of this study is to evaluate the role of respiratory physiotherapy in preventing pulmonary complications following thoracotomy surgeries. The objectives are to assess the effects of positioning and various chest physiotherapies in decreasing the pulmonary complications following various thoracotomy surgeries so that these aspects can be applied clinically to prevent and manage pulmonary complications efficiently, thereby to decrease the mortality and morbidity associated with them. Introduction Pulmonary complications after thoracotomy are common. Up to 65% of patients may have an atelectasis, and 3% may develop pneumonia (Pasquina et al 2003). They are the result of progressive changes in the respiratory status of the patient and play a significant role in postoperative morbidity and mortality (Leo et al 2006). They also prolong hospital stay and increase healthcare costs (Pasquina et al 2003). Thoracotomy is performed for various surgeries like resection of pulmonary and esophageal tumors, operations on the lung like pneumonectomy, lobectomy, segmental resection, wedge resection and lung-volume reduction surgery, operations on the pleura like pleurectomy and decortication, operations on the esophagus and on the heart (Porter 2003). The pulmonary complications are usually delayed, occurring 48–72 hours after thoracotomy (Leo et al 2006). The commonly seen complications are adult respiratory distress syndrome, pneumonia, atelectasis, pulmonary embolism, pulmonary edema, asthma and respiratory failure (Leo et al 2006). Since pulmonary complications increase the morbidity and mortality of patients following surgery, many studies have been done to look into means of preventing these complications. Leo et al (2006) evaluated the benefits of identifying these complications early in the course of post-operative care after thoracotomy, so that appropriate interventions can be delivered to prevent and manage these complications. They used a multifactorial score called FLAM score to identify postoperative patients at higher risk for pulmonary complications at least 24 hours before the clinical diagnosis. The FLAM score was based on 7 parameters, namely, dyspnea, chest X-ray, delivered oxygen, auscultation, cough, quality and quantity of bronchial secretions. The researchers concluded that changes in FLAM score could be detected atleast 24 hours before the clinical diagnosis of pulmonary complications, giving as opportunity for the clinicians to take action much before overt symptoms. Algar et al (2002) identified previous chest physiotherapy, length of the surgical procedure and predicted pulmonary function as factors determining the development and adverse outcomes of pulmonary complications. Epstein et al (1993) opined that reduced Vo2 during cardiopulmonary exercise testing was a predictor for increased risk for cardiopulmonary complications after lung resection. Whatever is the prediction of development of pulmonary complications following thoracotomy, preventive chest physiotherapy is commonly used postoperatively to prevent pulmonary complications like atelectasis and pneumonia following thoracotomy surgeries. Reeve et al (2007) evaluated the current physiotherapy management of patients undergoing thoracotomy and the factors influencing practice among different providers. They studied these aspects by distributing a postal questionnaire to senior physiotherapists in all thoracic surgical units throughout Australia and New Zealand. From the response, it was evident the 80% of physiotherapists who attended to thoracotomy patients commenced physiotherapy on the first post-operative day. The usual treatment interventions were deep breathing exercises, the active cycle of breathing techniques, cough, forced expiration techniques and sustained maximal inspirations. The main aims of physiotherapy are appropriate patient education, maximisation of lung volume, prevention of sputum retention, assisting sputum clearance and facilitating early mobilisation. Modalities of chest physiotherapy useful for post-operative patients Breathing exercises and forced expiration: These exercises are intended to clear the airway of secretions. They are usually done in sitting position. The active cycle of breathing technique consists of cycles of breathing control and thoracic expansion exercises followed by forced expirations from mid-lung to low-lung volumes. The breathing exercises can be combined with vibrations and inspiratory hold. Inspiratory hold should be at the peak of inspiration for 2-3 seconds. The whole cycle is repeated until the patient becomes non-productive or is fatigued. The deep breaths should be through the nose and expirations through the mouth. For improvements in lung function, these exercises must be performed every hour, atleast 2 cycles per hour. Various studies have demonstated the benefits of breathing exercises in preventing complications after thoracic surgeries. Westerdahl et al (2005) investigated the effects of deep-breathing exercises on pulmonary function, atelectasis, and arterial blood gas levels after coronary artery bypass graft surgery. They concluded that deep-breathing exercises did have a positive effect on the lung functions post-operatively. Those who underwent these exercises had significantly smaller atelectatic areas and better pulmonary function on the fourth postoperative day compared to a control group performing no exercises. Breathing exercises can be done with a mechanical device, blow bottle device or an inspiratory resistance-positive expiratory pressure mask. However, the effects of all the 3 techniques are the same (Wester et al, 2003). The breathing exercises can be clubbed with incentive spirometry where in the patient puts his mouth around the plastic device and inhales as much air as he can. How far this is useful when used with breathing exercises is a much debated topic. Park et al (2006) studied the effects of deep breathing exercises with incentive spirometer on the pulmonary ventilatory function of pneumothorax patients undergoing a thoracotomy. They concluded that deep breathing exercises with or without spirometry had the same effect for recovering the pulmonary ventilatory function after a thoracotomy. Fig. 1: Incentive spirometer (Incentive Spirometry, UWHealth) Forced expiration is used to clear excessive bronchial secretions. This can be done as a part of breathing exercises as described above. An effective FET will sound like a forced sigh. Supported cough: Cough is created by forced expiration against a closed glottis. Cough causes rise in intra-thoracic pressure because of which, when the glottis opens, the air flow outside rapidly, therby dragging the secretions of the airways along with it. For effective cough, the wound needs to be supported by means of the hand on the unoperated side or using a towel to support the wounded part (Porter 2003). Postural drainage therapy: In this technique, the patient is placed in various positions to facilitate the secretions to drain with the help of gravity. The position of the patient is based on the segment or lobe from where the mucous secretions are intended to be drained. To further assist drainage using this technique, percussions and vibrations are used. Percussion or chest clapping is done by percussing on the chest wall with cupped hands, one after the other in a rhythmic manner. This technique loosens the mucous and open bronchial airways. This is performed for atleast 2 minutes in each position. After percussion, vibration is applied to the area in the position. Vibration is applied by the therapist by tightening all the muscles of the arms and shoulders so that they vibrate and this force is consequently conducted through the hands of the therapist to the chest of the patient. Vibrations are delivered when the patient is expiring through pursed lips after a deep inspiration. After each positional therapy, the patient is asked to sit up and cough to bring out expectoration. Various studies have evaluated the benefits of positional therapy post operatively to prevent pulmonary complications. Choi et al (2007) evaluated the effect of head-down tilt on intrapulmonary shunt and oxygenation during one-lung ventilation in the lateral decubitus position and opined that head tilt in lateral decubitus position caused a significant increase in shunt and a decrease in percent change of arterial oxygen tension, without causing dangerous hypoxemia. Changes in body position from standing to high sitting can decrease functional lung capacity and hence functional expiratory volume in the first minute. Bala et al () studied the effects of body positions on lung capacity. They studied the lung capacities standing, high sitting and long sitting (60° inclination) position using spirometry. The researchers found that there were no differences in the FEV1 and FVC values between the high sitting, long sitting and standing positions and hence long sitting position could be adopted as an alternative treatment position especially for those with poor sitting balance, postural hypertension, fall tendencies and vertebral metastasis. Fig. 2: Postural drainage position for lateral basal segments of upper lobes (Image bank, The Point) Fig.3: Postural drainage position for superior segments of lower lobes (Image Bank, The Point) Fig.3: Postural drainage position for anterior segments of the upper lobes (Image Bank, The Point) Fig.4: Postural drainage position for anterior segments of the lower lobes (Image Bank, The Point) Heated humidification: Humidification helps loosen the thick pulmonary secretions and thus assist in easy expulsion. Following thoracotomy, the secretions thicken due to anesthesia, infection and dehydration (Porter 2003). Physiotherapy masks: The physiotherapy masks that are used are continuous positive airways pressure (CPAP), positive expiratory pressure (PEP) and Inspiratory resistance positive expiratory pressure (IR-PEP). CPAP is useful in those patients with poor arterial blood gases and reduced lung volume. It is delivered either continuously or intermittently. It improves functional residual capacity and arterial oxygen along with decreasing the work of breathing. IPPB is useful in patients who have lost lung volume and are easily fatigable because it improves lung volumes and reduces the work of breathing. Wennberg et al () studied the efficacy of these 2 breathing techniques in patients who underwent thoraco-abdominal resections. They concluded that CPAP as a breathing technique was much more useful that IR-PEP and decreased the risk of respiratory distress requiring reintubation and need of artificial ventilation. Ingwersen et al (1993) studied the incidence of post-operative complications after thoracic surgery with 3 different physiotherapy masks. They opined that all the 3 types of treatments were equally effective when used as supplement with other standard chest physiotherapy. Though many studies have shown the benefits of reparatory therapy following thoracic surgeries, there is no clear evidence in the form of randomised control trials to evaluate the benefits. Pasquina et al (2003) did a systematic analysis on the benefits of respiratory physiotherapy after cardiac surgery. They opined that there is not much evidence whether prophylactic respiratory physiotherapy prevents pulmonary complications after cardiac surgery. Conclusion Pulmonary complications following thoracotomy are common post-operatively. Respiratory physiotherapy is effective in preventing many of these complications by expulsion of mucus secretions, thus improving functional lung volume and oxygenation and decreasing atelectasis and infections. References Algar, F.J., Alvarez, A., Salvatierra, A., Baamonde, C., Aranda, J.L., López-Pujol, F.J., 2002. Predicting pulmonary complications after pneumonectomy for lung cancer. European Journal of Cardio-Thoracic Surgery, 23(2), p. 201-208. Choi, Y.S., Bang, S.O., Shim, J.K., Chung, K.Y., Kwak, Y.L., Hong, Y.W., 2007. Effects of head-down tilt on intrapulmonary shunt fraction and oxygenation during one-lung ventilation in the lateral decubitus position. The Journal of Thoracic and Cardiovascular Surgery, 134 (3), p.613-618 (RCT). Epstein, S.K., Faling, L.J., Daly, B.D., Celli, B.R., 1993. Predicting complications after pulmonary resection. Preoperative exercise testing vs a multifactorial cardiopulmonary risk index. Chest, 104, p.694-700. Available at http://www.chestjournal.org/cgi/content/abstract/104/3/694 [Accessed 14 Dec 2007] Hew, W.K. F, Rajaratnam Bala, S., Lee, C. L., Poon, K. H., Tham, C. C. J., Yeung, T.L.M., . The effect of different body positions on FEV1. Ingwersen, U.M., Larsen, K.R., Bertelsen, M.T., Nielsen, K.K., laub, M., Sandermann, J., Bach, K., Hansen, H., 2005. Three different mask physiotherapy regimens for prevention of post-operative pulmonary complications after heart and pulmonary surgery. Intensive Care Medicine, 19(5), p. 294-298 (RCT). Incentive Spirometry, UWHealth. 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