Physiotherapy management in ICU of repiratory surgeries

1. ICU MANAGEMENT OF
RESPIRATORY SURGERIES
Prepared By:
HINA VAISH

2. TYPES OF RESPIRATORY
SURGERIES¹
LUNG SURGERY
• Lobectomy
• Sleeve Resection
• Segmental
Resection
• Wedge Resection
• Bullectomy
• Pneumonectomy
• Lung Volume
Reduction Surgery
• Lung Transplant
PLEURAL SURGERY
• Pleurectomy
• Pleurodesis
• Decortication
CHEST WALL
SURGERY
• Thoracoplasty
• Surgery for chest
wall deformity
1. Jennifer A Pryor, S Prasad. Physiotherapy for respiratory and cardiac problems 3 edition, pg 394-
400.

3. INDICATION FOR SURGERY
• Malignancy
• Trauma
• Disease / Infection
• Deformity

4. POST OPERATIVE
COMPLICATIONS
• Pain
• Pulmonary complications
 Post operative hypoxia.
 Atelectasis3
 Pneumonia3
 Aspiration pneumonitis3,4
 Pneumothorax
 Bronchopleural fistula.
3. François Stéphan, Sophie Boucheseiche, Judith Hollande, Antoine Flahault, Ali
Cheffi, Bernard Bazelly and Francis Bonnet. Pulmonary Complications Following
Lung Resection:Chest 2000;118; 1263-1270
4. Johnson J L, Hirsch C S. Aspiration Pneumonia :recognising and managing
potentially growing disorder. Postgrad Med 2003: 113: 99-112.

5. • Circulatory complications
DVT
Cardiac arrthymia3
Haemorrhage3
• Wound Complications5
• Joint stiffness
• Muscle Weakness
• Postural deformity
3. François Stéphan, Sophie Boucheseiche, Judith Hollande, Antoine Flahault, Ali Cheffi,
Bernard Bazelly and Francis Bonnet. Pulmonary Complications Following Lung
Resection:Chest 2000;118; 1263-1270
5.Nei S cherniack , Murray D Altose, I.Homma. Rehabilitation of patient with respiratory
diseases.

6. • Effects of Anesthetic Agents6,7
Decreases FRC
Cephald excursion of the dependent
position of the diaphragm.
Impairment of mucociliary clearance
6..Pedersen, T., Viby-Mogensen, J. and Ringsted, C. (1992), Anaesthetic practice and
postoperative pulmonary complications. Acta Anaesthesiologica Scandinavica,
36: 812–818.
7. Warner, David O. M.D. Clinical Concepts and Commentary
Preventing Postoperative Pulmonary Complications: The Role of the Anesthesiologist.
Anesthesiology: May 2000 – 92; 5 :1467-1472

7. • Effect of Surgery
Most surgeries cause a decline in lung
function.
The decline in VC is about 58% of the
pre operative value in non-resectional
thoracotomy8
Phrenic nerve injury
Laryngeal nerve injury
8. Ali j, Weisel RD, Layug AB ,et al:Consequences of post operative
alteration in respiratory mechanics. Am J Surg: 128:376-382, 1974

8. MONITORING
A. Drains
 Two types of drains are used:
1. Open Drain
A small tube is inserted into the pocket of
pus which then drains onto a dressing.
2. Closed Drains
 These are used to drain air or fluid from
the pleural cavity.

9. • Amount and Type of Drainage
• Air leak
• Swing of Water
• Suction
This tends to pull the water level up in the
bottle creating a negative pressure which
pulls the water in the tube down thus
creating a suction effect on the air or fluid
in the pleural cavity.

10. B.Lines and tubes
C.Saturation
D.Vitals
 Heart Rate
 During exercise it should not exceed 20
beats from resting values.
 Blood Pressure
 Respiratory Rate
 Pulse

11. PRINCIPLES OF PT
MANAGEMENT
• Management of pain
• Improve / Maintain Normal or Baseline
Ventilation and Oxygenation. 9,10
 Clearance of Airways
Improve Chest Expansion
Improve Cough Effectiveness
Improve Breathing pattern
9. Physical Therapy protocols,Office of Physical Therapy Affairs, MinistryofHealth,
Kuwait.With cooperation ofPhysical Therapy Department, KuwaitUniversity. (2003)
10. Julie C Reeve. Physiotherapy interventions to prevent postoperative pulmonary
complications following lung resection. What is the evidence? What is the practice?
118 NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)

12. • Improve / Maintain Musculoskeletal System within Functional
Limit. 11
 Improve ROM
 Improve Muscle Strength and Endurance
 Prevent Joint Deformities and Contractures
• Improve Circulatory System Function 11
 Prevent DVT
 Prevent Swelling
• Maintaing good posture
• Maintain normal cognitive function to avoid disorientation and
hospital related psychoses11
• Improve / Maintain Level of Functional Status with in
Patient's Tolerance.
11. Donna Frawnfelter. Principles and practice of cardiopulmonary physical
therapy, third edition. Pg502-503

13. NON INTUBATED PATIENTS PT
MANAGEMENT
• Pain management
 Medically managed by analgesics, PCA
 TENS 12
• Positioning.13
 Body positioning is a potent therapeutic intervention that promotes
oxygen transport and gas exchange in two ways:one fron the
physiological benefit accrued from specific position themselves and
other from physiological benefit accrued from changing from one
position to another.
12. Benedetti F, Amanzio M, Casadio C, et al:Control of postoperative pain by
transcutaneous electrical nerve stimulation after thoracic operations :Journal
of Cardiothoracic and Vascular Anesthesia. 12; 4:August 1998, 492
13. Dean E. Effect of Body Position on Pulmonary Function .Physical Therapy
May 1985; 65: 5 613-618

14. • Huffing and coughing (splinted)14
14. Donna Frawnfelter. Principles and practice of cardiopulmonary physical
therapy, third edition. Pg504-505

15. • Incentive spirometry15,16
15. Agostini P, Calvert R, Subramaniam H, Naidu B.2008: Is incentive
spirometry effective following thoracic surgery; 7;297-300
16. Bastin R, Moraine J, Kahn R, Melot C.1997: Incentive spirometry
performance:A reliable indicator of pulmonary function in early postoperastive
period after lobectomyChest 111:5959-563.

16. • Breathing exercises17
• Segmental breathing
• Diaphragmatic breathing
17. Soledad Chumillas et al. Prevention of postoperative pulmonary
complications through respiratory rehabilitation: A controlled clinical study.
Archives of Physical Medicine and Rehabilitation.79;1: 5-9, January 1998.

17. • Coordinate upper extremities mobility with
inspiration and expiration to improve lung
expansion 12
• Postural drainage
• Maintaining good posture
 Slouching or leaning on the affected side decreases
alveolar ventilation resulting in uneven alveolar
distribution and thus leading to areas of atelectasis.
• Chest physiotherapy is effective in preventing post
op pulmonary complications19.
18. Julie C Reeve. Physiotherapy interventions to prevent postoperative pulmonary
complications following lung resection. What is the evidence? What is the practice? 118
NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)
19. Gonzalo Varela , , Esther Ballesteros, Marcelo F. Jiménez, Nuria Novoa,and José L.
Aranda. Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary
lobectomy . 2000. European Journal of Cardio-Thoracic Surgery, 29;2: 216-220

18. • Early Mobilisation 2o
Active ,active assistive ROM of upper and
lower extremities
Mobilisation augments cardiopulmonary
function particularly when upright
• Early ambulation 20
20. Kaneda Hiroyuki, Saito Yukihito, Okamoto Miki, Maniwa Tomohiro, Minami
Ken-chiro, Imamura Hiroji. Early post operative mobilisation with walking at 4hrs
after lobectomy. Gen Thora Cardiovasc Surg. 2007;

19. INTUBATED PATIENTS PT
MANAGEMENT 21
• Positioning.
• Modified postural drainage position
• Use pulmonary hygiene techniques to mobilize
secretions such as vibration, percussion and
shaking.22
 These techniques help in dislodging the secretion and
moving them from the periphery to the central airways.
21. Clini Enrico, Ambrosino Nicolino. Early physiotherapy in the respiratory intensive
care unit. Respiratory Medicine 2005;99:1096-1104
22. Ms K. R. Stiller, R. M. Munday. Chest physiotherapy for the surgical patientBritish
Journal of Surgery 79; 8: 745–749, August 1992

20. Prercussion

21. • Endotracheal suctioning or
tracheostomy to clear retained
secretions 23
23. Bonde et al, 2002.Sputum retention after lung operation:Prospective
randomised trial shows superiority of mini tracheostomy in high risk patients.
Annals of Thoracic Surgery74:196-203

22. Endotracheal suctioning

23. Tracheostomy suctioning

24. Manual Hyper inflation

25. • Manual hyperinflation24
 Used on patient with endotracheal or
tracheostomy tube that could be attached to the
manual ventilating bag.
 Use the bag to hyperinflate the lung, then an
inspiratory pause followed by quick exhalation.
24. K Stiller, T Geake, J Taylor, R Grant and B Hall. Acute lobar atelectasis. A
comparison of two chest physiotherapy regimens Chest 1990;98;1336-1340

26. • Using sterile techniques.
• Early Mobilisation
Active , active – assisted or passive
movements of all four extremities .