Physiotherapy Treatment of Surgical Chest Conditions B y M A R G A R E T R . W H IT E , M .C .S .P ., L ec tu re r, D e p a rtm e n t o f P h y sio th e rap y , U n iv e rsity o f C a p e T ow n. F ro m the p o in t o f view o f th e tre a tm e n t o f Surgical C hest co n d itio n s by P h y sio th e rap y , th is a rtic le c an o n ly h o p e to sta te b ro a d o u tlin e s o f tre a tm e n t w hich will have to be modified a nd v aried acc o rd in g to th e type o f case— a n d the p e rsonality o f th e p a tie n t— to be trea te d . A n a tte m p t has been m a d e to classify th e types o f case su itable fo r surgery u n d e r very w ide headings. A c o m m o n co n d itio n and its n o rm a l tre a tm e n t a n d p ro g ressio n has then been chosen w ith som e c o m m e n t on m o d ification in tr e a t­ m ent a cc o rd in g to different ty p es o f case. C o n c e n tra tio n has been placed o n basic tec hniques w hich sh o u ld th u s act as a guide fo r th e tre a tm e n t o f o th e r m o re c o m p lica te d chest conditions. F o r th e p u rp o se o f this a rticle surgical chest co n d itio n s can be divided in to 3 b ro a d s e c tio n s : 1. N o n T .B . C ases 2. T .B . C ases 3. H e a rt Cases B efore sta rtin g to discuss tre a tm e n ts it m u st alw ays be rem em bered th a t th e P h y sio th e rap ist is o n ly o n e m em ber o f a team , a n d th e m o re closely th e m em b e rs o f th a t team w o rk to gether, th e m o re effective a re th e results. P e rh a p s in T h o ra c ic surgery m o re th a n in a n y o th e r b ra n c h o f surgery the p a tie n t’s c o n d itio n varies fro m h o u r to h o u r, a n d fo r fully effective tre a tm e n t it is essential th a t th e P h y sio th e ra p ist is k e p t inform ed o f a n y c hanges th ro u g h o u t the day. I . E xcluding h e a rt surg ery p e rh a p s th e g re atest m a jo rity o f surgical chest cases to -d a y falls in to th e B ronchiectatic a nd Carcinoma groups, a n d in this a rticle the p re a nd p o st operative tre a tm e n t o f one o f th e m o s t u su a l o p e ratio n s, Lobectom y, w here a Thoracotom y is p e rfo rm e d , will be discussed. T o p re p a re th e p a tie n t fo r o p e ra tio n a m in u m u m o f three p re op e rativ e sessions is re q u ire d , a lth o u g h o ne w eek’s p re p a ra tio n is m o re d esirable. C e rta in c o n d itio n s will, o f c o u rse, re q u ire longer p re operative tre a tm e n t. F o r exam ple, B ro n c h ie cta sis w here, in a bad case, som e weeks o f care fu lly supervised P o s tu ra l D ra in ag e will be n ecessary to c le ar th e c hest b efore o p e ra tio n , thus helping to p re v en t p o st o p e ra tiv e c ollapse caused by an overflow o f secretions in to n e ig h b o u rin g b ro n c h i. N o t o nly d oes th e p a tie n t need to be in stru cte d in b re ath in g I c o n tro l, c orrect c o ughing, etc., b u t it is a g reat help to him to get to k n o w th e w ard ro u tin e a n d th e m em bers o f staff w ho will be c arin g fo r him a fte r o p e ra tio n . H e will th u s learn to have confidence in th e m a n d k now ho w th ey can help him as well as lea rn in g h ow to help him self. A sim ple e x p la n a tio n o f w here his scar will be, w hy he has to cough a n d h ow his chest will be su p p o rte d w hen coughing, will all be fo u n d helpful a n d re -a ssu rin g to the patient. Pre-operative T reatm ent c an be divided in to 5 m ain g ro u p s: To teach (1) c o rre c t b re a th in g c o n tro l b o th D ia ­ p h ra g m a tic a n d localised a nd c o rre c t co u ghing (2) m a in te n a n c e o f p o stu re (3) localised a rm m o v em en ts (4) fo o t a nd leg exercises w ith e m phasis o n im p o rta n c e o f m o ving a b o u t in bed (5) a n d supervise th e c o rre c t P o s tu ra l D ra in a g e p o sitio n s in cases w here th is is necessary. (1) C o rrect B reathing C ontrol. . F>r st c orrect E xp ira to ry B re a th in g will h ave to be ta u g h t in o rd e r to help to e m p ty th e chest o f P o st o p e rativ e sec­ retions, follow ed by careful Inspiratory localised bre ath in g , earing in m ind th e type o f o p e ra tio n to be perfo rm e d . December, 1960 F o r P neum onectom ies— D ia p h ra g m a tic C o n tro l a n d careful localised b re a th in g to th e base o f th e lung o n th e so u n d side a re m o st im p o rta n t. F o r L obectom ies, as well as d ia p h ra g m a tic c o n tro l, all areas o n the o p e ra tio n side will h a v e to be tre a te d so th a t th e re m a in in g lu n g tissue will re-expand fully, as soon as possible, to fill th e w hole o f the sp a c e on th e o p e ra tio n side. Teach how to cough. S h o rt s h a rp e x p ira tio n s w ith c o n ­ tra c tio n o f th e a b d o m in a l m uscles should first be ta u g h t a n d p ra ctised . I t is th e n explained how th is is p ra ctic a lly a c o u g h . N e x t, co u g h in g is pra ctised m ak in g sure th a t th e c o u g h com es rig h t fro m th e base o f the chest. 2. M a intenance o f P o stu re T h e type o f d e fo rm ity likely to arise a fte r th o ra c ic o p e r­ a tio n varies a cc o rd in g to th e o p e ra tio n perfo rm e d . F o llo w in g Thoracotom y (eith er fo r lo b ec to m y o r fo r pn e u m o n e cto m y ) the p a tie n t ten d s to lift th e h ip o n th e o p e ra tio n side w hile p u ttin g all th e w eight on th e hip o n th e so u n d side. T h e sh o u ld e r on th e o p e ra tio n side is d ro p p e d w hile th e a rm is held tig h tly in to th e side, th u s p ro d u c in g a C c urve aw ay fro m th e side o f th e o p e ra tio n . T h e p a tie n t sh o u ld be ta u g h t (a) a lte ra tio n o f w e ight-bearing on e ac h h ip ; (b) w ith th e elbow s b ent d o w n-pressing o f e lbow o n the sound side; (c) b a ck ra isin g v e rte b ra by ve rte b ra. A m irro r th a t can be placed a t th e e nd o f th e bed is in v alu a b le in teaching, m a in ta in in g and c o rre c tin g p o stu re . 3. L ocalised A rm M ovem ents Sm all localised a rm m o v em en ts sh ould b e ta u g h t pre- op e rativ e ly as th e re tra c to rs o f scapulae a re o ften c u t th ro u g h a t o p e ra tio n , a n d the p a tie n t is generally frig h te n ed a n d unw illing to m ove th e a rm im m ediately po st-o p e rativ e ly . T e a c h — (a) R e tra c tio n o f sc a p u la e (b) A b d u c tio n o f a rm a nd fo rw a rd flexion (w ith elb o w b e n t a n d h a n d resting on sh o u ld e r to begin w ith) (c) E le v a tio n o f a rm w ith th e assista n ce o f th e o th e r h a n d to begin w ith. 4. F o o t and L eg E xercises T h e im p o rta n c e o f these exercises need o n ly be m en tio n ed in passing, th e y a re ro u tin e p o st o p e rativ e tre a tm e n t. T h e p a tie n t a fte r T h o ra c o to m y is o ften so a fra id to m ove a t all th a t special in stru c tio n in th e im p o rta n c e o f m o ving a b o u t in bed a n d re -a ssu ran c e th a t no h a rm will result, a n d th a t it c a n o nly do good, saves a c ertain a m o u n t o f p o st-o p e ra tiv e tension. 5. C o rre ct P o s tu ra l D ra in ag e I f p o stu ra l d ra in a g e is to be efficient, m u ch e m phasis m u st be placed on th e im p o rta n c e o f c o rre c t b re a th in g d u rin g th e p o stu ra l d ra in a g e sessions. O n e m ig h t a lm o st say th a t o n e h a lf o f th e success o f P o s tu ra l d ra in a g e lies in seeing th a t th e p a tie n t c o n c e n tra te s o n E x p ira to ry d ia p h ra g m a tic b re a th in g w hile p o stu rin g , th u s g reatly assisting th e e xpec­ to r a tio n o f sp u tu m . T h e o th e r h a lf-lies in C orrect P ositioning a n d Percussion w ith localised b re ath in g . I t is o u tsid e th e scope o f this a rtic le to d e scribe in d e ta il each P o s tu ra l D ra in a g e p o sitio n , b u t th e R e d X have pu b lish ed a leaflet illu stra tin g these po sitio n s, and M iss W . T . T h a c k e r, M .C .S .P ., h a s pu b lish ed a n excellent b o o k le t o n th e subject. T h e p a tie n t m a y o ften need e n c o u ra g e m e n t a n d e x p la n a tio n o n th e im p o rta n c e o f co u g h in g a n d e x p e c to ra tio n . T h e y m u st h a v e no fine feelings o n th e m a tte r o f sp ittin g , it is w h a t is re q u ire d . W h en th e b ro n c h ia l tree is efficiently d ra in e d o f to x ic secretio n s th e p a tie n t’s w h ole d e m e a n o u r, m en ta l and physical, show a d ra m a tic im provem ent. T h ese p re -o p e ra tiv e b ro n c h ie c ta tic p a tie n ts sh o u ld ta k e p a r t in a general lim b e rin g u p class w hich includes b re a th in g exercises a nd p o stu ra l tra in in g , a n d sh ould th e re fo re b e well p re p a re d fo r o p e ra tio n . P o s t O p erative T rea tm e n t A s th e type o f case u n d e r c o n sid e ra tio n is th a t o f L o b e c to m y it m ight be well to c o m p a re th e p o s t o p e rativ e tre a tm e n t a n d p ro g ress o f a case o f L o b e c to m y fo r B ro n - chietasis w ith o n e fo r C a rcin o m a. Page 7P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 8 P H Y S I O T H E R A P Y December, 1960 I n B ronchielasis th e p a tie n t is u su ally y o u n g w ith a good prognosis. H e will be expected to p ro g ress quickly to a full active life. C a re sh ould be ta k e n to explain to him th a t he is n o lo n g e r a n invalid a n d th a t he c a n now go o u t a n d ta k e p a rt in a n y type o f active exercise h e fancies. So o ften these p a tie n ts have lived a sheltered in active existence d u e to th e re stric tio n s a n d e m b a rra s sm e n ts th a t th e c o n s ta n t cough a n d s p u tu m have fo rced u p o n them . It is diffic u lt fo r th em to realise th a t th ey c a n — and sh o u ld — lead a h e alth y a n d m o d e ra te ly energetic life w hen they recover fro m th e im m e d ia te p o st o p e rativ e effects. T h e ir p ro g ress in h o spital sh o u ld be swift, th ey sh o u ld be a ble to a tte n d an exercise class 7 to 10 days a fte r o p e ra tio n a n d be discharged a n y tim e a fte r 14 days. In Carcinoma th e p a tie n t is u sually o ld er a n d in p o o r general h e alth . I t is k n ow n th a t he h as n o t a long expectancy o f life a n d th a t— a t least generally— this h a s been a p a lliative o p e ra tio n . P ro g re ss will, th ere fo re, be so m e w h a t slow er a nd he will n o t b e expected to p ro g ress to full a ctiv ity so quickly, p a rtic u la rly in th e o ld er age g ro u p . T h o u g h it is, o f course, de sirab le to have him d ischarged as so o n as possible, so th a t he m ay re tu r n to his h o m e s u rro u n d in g s a t th e first o p p o rtu n ity . T hese p a tie n ts tend to be b re ath le ss a n d , the p n e u m o n e cto m ie s p a rtic u la rly , sh ould alw ays be ta u g h t w a lking w ith c o n tro lle d b re a th in g , a n d also sta ir clim bing w ith c o n tro lled b re a th in g as a ro u tin g befo re they leave h ospital. F ro m th e p re o p e rativ e in stru c tio n s it follow s th a t o u r P ost O perative A im s are: T o 1. 2 . 3. 4. 5. T o c lear th e chest o f secretions, a n d o b ta in full lung ex p an sio n a nd fu n c tio n as soon as possible m a in ta in c o rre c t p o stu re m a in ta in full a rm fu n c tio n e n c o u ra g e fo o t a n d leg exercises fo r c irc u la to ry purp o ses re tu rn th e pa tie n t to as full n o rm a l a ctivity as possible— as soon as possible. T o o b ta in these results o n th e evening o f o p e ra tio n the p a tie n t sh ould be visited, if c onscious, and c o rre c t b re ath in g c o n tro l sta rte d a n d the p a tie n t en co u ra g ed to try to cough. I t is the first 2 o r 3 days th a t a re m ost vital in p re venting post o p e ra tiv e c o llapse o f lung, and it is essential to see th a t th e p a tie n t uses his d ia p h ra g m , thus m oving his chest a n d helping e arly e x p e c to ra tio n o f sp u tu m . I t is a t th is stage th a t th e c o -o p e ra tio n o f th e n ursing staff is so essential. T h ey to o m u st realise th a t th e p a tie n t m ust be en co u ra g ed to c ough a n d spit a t re g u la r intervals, a nd th e y to o m u st k n o w how to su p p o rt his chest, th u s giving him confidence to c o u g h deeply. T h e n u rsin g sta ff m ust n ever be given th e idea th a t “ co u g h in g th e p a tie n t” is purely th e P h y s io th e ra p ist’s jo b . P ost Operative Postural Drainage In a case o f b ro n c h ie ta sis, th is sh o u ld b e sta rte d the m o rn in g a fte r o p e ra tio n a n d carried o u t m o rn in g a nd a fte r­ n o o n u n til th e X -ra y show s th a t th e lungs a re c le ar a nd fully re -expanded. I f th ere is still a n a r e a - o f bro n c h ie ta sis o n th e o p p o site side, th e p a tie n t will h ave to -c o n tin u e to do p o stu ra l d ra in a g e fo r the affected area. T h e p a tie n t will p ro b a b ly have 2 tubes, an apical a n d a low er tu b e, in his p leu ra l c avity fo r th e first 24 to 28 h o u rs, o r u n til all d ra in a g e o f th e p leural space is finished. O nce th e tu b es a re rem oved th e p a tie n t can get u p a n d activity sh o u ld be p rogressed as ra p id ly as p ossible. T h e p a tie n t sh o u ld be visited at least 4 tim es fo r th e first tw o o r th re e p o st o p e rativ e days, the fir s t a n d third visits being fo r p o stu ra l d ra in a g e (w hich includes supervision o f c o rre c t b re a th in g ) a n d c o rre c tio n o f p o stu re follow ing d ra in a g e ; the second a nd fo u rth visits prin cip ally to supervise c o rre c t b re a th in g a n d c o u g h in g w ith s u p p o rt a t th e site o f o p e ra tio n . Support While Coughing T h is s u p p o rt can be given w ith th e p a tie n t leaning b ack a g a in st the pillow w hen th e o p e ra to r’s h a n d s a re placed ab o v e a n d below the scar (the e xact p o sitio n varies a ccording to w h a t th e p a tie n t finds m ost c o m fo rtab le ). W hen the This hygienic P h y sio th e ra p ist Uniform has so many good points! S a nforise d, M e rce rise d w h ite twill A d ju sta b le n e c k lin e ------ ------- - to the specification o f the U n iv e rs it y P h y sio th e ra p y S e ctio n B re a st p o c k e t " - '" ' L o n g s le e v e s ...... .............. D e ta cha b le belt T w o hip pocke ts, o n e w ith concealed inside p o c k e t . . . B u t t o n fro n t .. D E L I L A H GARMENT OF QUALITY AND STYLE by T H E H O U S E OF E N S I G N M anufactured by The AFRICAN CLOTHING FACTORY ( Ltd. P.O. B O X 1098 CAPE T O W N a n d obtainable front good clothing stores everywhere R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, i9 6 0 P H Y S I O T H E R A P Y Page 9 . t is sitting aw ay fro m the pillow s to c ough, su p p o rt be given m ore a d eq u a te ly fro m th e so u n d side, with Ch n o p e ra to r's a rm u n d e r th e sound a rm o f th e pa tie n t, nss the p a tie n t’s chest s u p p o rtin g the chest wall below fhp scar while the o th e r a rm goes acro ss th e p a tie n t’s back d s u p p o r t s the chest a b o v e th e scar. It is m ost im p o rta n t Hvit the p a tient should have th is chest su p p o rt w henever nossible fo r th e first few p o st o p e ra tiv e days. H e is th u s Assisted a nd given confidence to c ough m o re deeply a nd adequately^ t0 a |] a re a s o f th e o p e ra tio n side are ■ilso conce n tra ted u p o n , th u s o b ta in in g m o b ility o f the chest a n d full re -expansion o f th e re m a in in g lung tissue as soon as possible. P o stu re , a rm a n d leg exercises are checked. Once the lung is well re -expanded (usually a b o u t the third o r fo u rth day) th e n u m b e r o f tre a tm e n ts c a n be d e c r e a s e d to 2 a day, a n d o nce th e p a tie n t is a tte n d in g class 1 o th e r tre a tm e n t sh ould b e sufficient. In cases o f c arc in o m a , p o st o p e ra tiv e p o stu ra l d ra in a g e may n ot alw ays be required, th o u g h w hen in d o u b t it is safer to give p o stu ra l d ra in a g e th a n to o m it it, pro v id ed the surgeon has been c onsulted, k W ith regard to other N on T.B . conditions, th e m eth o d o f 'tr e a tm e n t is very sim ilar, except th a t generally sp eak in g there is less likelihood o f p o st o p e ra tiv e collapse as the chest secretions are less. 2. T.B. Cases In T.B. Cases th e m ost c o m m o n surgical pro c ed u re s are: (a) D ecortication follow ing E m p y em a — w here m axim um em phasis is placed on intensive localised bre ath in g exercises, to en co u ra g e lu n g ex p an sio n o u t to the chest wall a t th e e arliest p ossible m o m e n t; (b) Thoracoplasty— p e rfo rm e d to c ollapse the affected area o f lung, usually in th e u p p e r lobe. H e re the m ain o bject is to prevent defo rm ity w hich can arise so q u ickly d ue to m u sc u la r a nd skeletal inbalance. C areful p re -o p e ra tiv e in stru c tio n is essential, p a rtic u la rly in c o rre c tin g b o d y lean, a n d neck a n d head de v ia tio n fro m m idline. C a re m u st be ta k e n to see th a t the fu n c tio n o f th e base o f th e lung o n the o p e ra tio n side is m ain tain ed . (c) L o b e c to m y an d P neum onectom y— w here the sam e rules a p p ly as in th e case a lre ad y discussed. 3. H e a r t C ases— c a n be sub-divided in to: (a) S im ple O perations— w here the pa tie n t is up o n the th ird to th e fifth d a y ; i.e. u n c o m p lica te d M itral V a lv o to m y P a te n t D u c tu s A rteriosus. (b) M o re com plex operations— w here th e p a tie n t is n o t u p until th e 10th to the 14th day. i.e. (1) A ll a o rtic C o n d itio n s— A o rtic Stenosis A o rtic In c o m p e te n c e C o -a rc ta tio n o f A o rta (2) All o p e ra tio n s w here a ventricle is opened F a llo t’s T e tralo g y , A tria l S eptal D efect, P u lm o n a ry V alve Stenosis, V e n tral S eptal D efect. H e a rt c o n d itio n s d o n o t generally re q u ire as m uch a tte n tio n as th e c o n d itio n s previously discussed, as on th e w hole, th ere a re few er c hest secretions. T h e c h ie f p o in ts to rem e m b e r a re to regain a n d m a in ta in m o b ility o f the th o ra x a n d to c le ar th e c hest o f secretions as e arly as possible. Acknowledgements: "P hysiotherapy f o r C hest D iseases"— M iss J. M . W. R eed, M .C .S .P . ‘P ostural D rainage"— M iss W. T h a c k e r, M .C .S .P . L ecture on Surgical H e a rt Conditions— M iss S. E vans, M .C .S .P . (delivered a t P aris C ongress). M y th a n k s are d u e to M iss M . H . S. R o p e r, M .C .S .P ., fo r re a d in g these no tes and fo r helpful suggestions. THE ENTRAX TRACTION UNIT CLAMPS TO AN Y USUAL PLINTH Please write for details C O M P R E H E N S IV E A D J U ST M E N T T h e E N T R A X allow s for th e a lte rn a tiv e s y ou will need. M o b ility a n d d ire c tio n o f pull fro m e ith e r th o ra x o r pelvis. C h an g ed in 2 m inutes. T h e t h o r a c i c h a r n e s s enables e ith e r a p o ste rio r p ull, a n te rio r pull, o r b o th co m b in e d . U p to 200 lbs. L a te ra l a d ju s ta b ility o f the p o in ts o f p ull to suit v a rio u s b uilds, w ith b o th t h o r a c i c a n d p e l v i c h arness. C ervical trac tio n . A fully a d ju sta b le h a lte r is included. T h e fittings fold qu ick ly u n d e r e nds o f p lin th w ith ­ o u t d e ta ch in g , a ffording a c l e a r c o u c h t o p im m ediately. Tflu h u d D iitn b u io z^ .(PTY.) LTD. ‘Cape Y ork” , 252 Jeppe S t., Johannesburg Telephone 23-8106P .O . B ox 3378 a n d a t President H ouse, 20 Barrack Street, Cape Town. P .O . B ox 195. Telephone 41-1172 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )