R e s e a r c h A r t i c l e T h e T r e a t m e n t o f S ta b b ed C h e st s at N g w e l e z a n a H o s p it a l , K waZ u l u - N atal A B ST R A C T : A study was undertaken at Ngwelezana hospital to determine the requirements fo r a cost effective physiotherapy service fo r patients with stabbed chests. Forty male patients between the ages o f 16 and 60 who had sustained unilateral penetrating stab wounds to the chest which required intercostal drainage were randomised into one o f two groups on admission to Ngwelezana hospital. The patients in group I received physiotherapy immediately after insertion o f the intercostal drain, while the patients in group 2 received physiotherapy 12 to 24 hours after insertion o f the drain. Mean duration o f intercostal drainage in group I was 2.35 days while that o f group 2 was 7.55 days. This represented a significantly shorter drainage time fo r the patients who had been treated immediately after insertion o f the drain. Patients were discharged from hospital on the day that the intercostal drain was removed. No complications were experienced by the patients in group 1 while fo u r patients in group 2 developed an empyema. The cost o f the patients in group 2 exceeded the costs o f those in group 1 by R78 728.00. It is thus imperative that patients admitted with stabbed chests should have physiotherapy immediately after insertion o f the intercostal drain. KEYWORDS: BREATHING EXERCISES, CHEST TRAUMA, PHYSIOTHERAPY THULILE NGUBANE, S. DE CHARMOY, C. EALES. INTR O D U C TIO N N gw elezana Hospital is situated six k ilo ­ m etres w est o f Em pangeni and approxi­ m ately 200 kilom etres north o f Durban in K w aZulu - Natal, South A frica. It has a bed occupancy o f 758 beds and serves the follow ing districts and areas as a secon­ dary hospital: Ngoye district, Nseleni area, K w aM bonam bi area, Nseleni area, M tun- zini area and the Em pangeni district. This am ounts to thirteen referral hospitals and nineteen clinics. The hospital, at the tim e o f this study, was staffed by 73 medical doctors and one physiotherapist. M uckart et al (1995) reported that the pattern o f penetrating torso traum a in KwaZulu - Natal had changed consider­ ably in the last decade. The incidence of stab wounds had declined by 30% while the incidence o f gunshot w ounds had increased by 800%. It is notew orthy that this survey was conducted in the Durban M etropolitan area which is the largest city in Kw aZulu - Natal. W hile conducting this study it was the au tho rs’ perception that the incidence o f stab w ounds rem ains high in the m ore rural areas such as the areas which N gw elazana hospital serves. In a four year audit on stab w ounds in Zim babw e the follow ing was found: the mean age o f the patients was 30 years; 83 percent o f the stabbing occurred at night while the other 17 percent occurred during the day. T hey also rep o rted on the anatom ical site o f the stab w ounds and found that 51 percent occurred in the chest with the rem ainder involving the thorax, upper lim bs, head and neck. The authors o f this audit reported a zero per­ cent m ortality rate and com m ented on the benign nature o f the thoracic stab w ounds (M uguti et al, 1995). Physiotherapy was not considered a treatm ent option or was not reported on in the audit. Stab w ounds in the South A frican context seem to be more severe as they are associated with p ro lo n g ed th o ra cic d rain ag e tim es, increased infection rates and morbidity. T hese factors take up valuable resources, beds and staff and delay the return o f the patient to normal functioning (Senekal and E ales, 1995). The treatm ent o f choice for patients presenting at N gw elezana with stabbed chests includes pain m edication, broad spectrum antibiotics, insertion o f an inter­ costal drain and physiotherapy. The aver­ age intercostal d rainage tim e fo r the patients in the hospital is betw een 4.72 and 5.27 days. Since the early 1970’s research has been undertaken in South A frica, to determ ine the role o f physiotherapy in patients with penetrating injuries to the chest. A ccord­ ing to Fairlie (1973), the aims o f physio­ th e rap y in p a tie n ts w ith p e n e tra tin g injuries to the chest are: to facilitate d rai­ nage o f air/fluid in the pleural cavity; to ensure adequate ventilation and re-expan­ sion o f all areas o f the lung; to prevent the accum ulation o f secretions; to prevent pos­ tural com plications associated with the presence o f an intercostal drain and to main­ tain full shoulder range o f m ovem ent. The treatm ent techniques used in the 1970’s and today by physiotherapists are the same. Breathing exercises are used when patient co-operation can be obtained. T runk exercises are used to m ove the intrapleural contents tow ards the site o f the drain thus facilitating intercostal drain drainage. In addition the trunk exercises m aintain m uscle length and strength pre­ v e n tin g the d e v elo p m en t o f p o stu ral deform ities. T hese exercises may be com ­ b in ed w ith the b re ath in g ex ercises. General aerobic exercises such as running on the spot, clim bing stairs and star jum ps are used to increase respiratory rate, tidal volum e and heart rate thus facilitating ventilation and perfusion. C oughing is interspersed with all the above exercises to clear any accum ulated secretions and facilitate drainage due to an increase in intrapleural pressure generated by cough­ ing (Fairlie, 1973; H ayes-G regson, 1973). Fairlie (1973), Rodseth et al (1978) and Senekal and E ales (1995) all com pared two groups o f patients with penetrating w ounds to the chest. T he first group C O RRESPO N D EN CE: T hulile N gubane C h ief Physiotherapist Chris Hani Baragw anath Hospital P.O. Box Bertsham 2013 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 1 23 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. ) receiv ed their physiotherapy treatm ent im m ediately after insertion o f the inter­ costal drain. The other group w ere only treated by a physiotherapist betw een 8 and 60 hours after intercostal drain inser­ tion. For all three o f the studies the two groups received exactly the sam e treat­ ment, only the tim ing o f the treatm ent was different. In all three studies the d u ra­ tion o f intercostal drainage, length o f stay in hospital and prevalence o f tem pera­ tures was significantly less for the group who received im m ediate physiotherapy treatm ent. L ung function tests, forced vital capac­ ity (FVC), forced expiratory volum e in 1 second (FEV i) and the FE V i/FV C ratio, show ed no significant difference between the groups (Fairlie, 1973; Rodseth et al, 1978; Senekal and Eales, 1995). There w as h o w ev er a sig n ifican t differen ce between m easurem ents taken w hile the intercostal drain was in situ, and once it had been rem oved (Senekal and Eales, 1995). T his finding is not unexpected as pain due to the intercostal drain is likely to inhibit m easurem ents w hich require forced expiration. Due to the rem aining high incidence of stabbed chests in the N gw elezana area, and the fact that there is only one p h ysio ­ therapist, it was considered im portant to repeat the study o f Senekal and E ales (1995). A study was designed to d eter­ mine w hether there w ould be a difference in outcom e in patients w ho received chest physiotherapy im m ediately after insertion o f the intercostal drain com pared to those patients who received chest physiotherapy 12 to 24 hours after insertion o f the inter­ costal drain. M ET H O D All patients adm itted to the wards from casualty with one under w ater drain for either a pneum othorax, a haem othorax, or a haem opneum othorax w ere considered for inclusion in the study. Patients were excluded from the study if they had m ore than one underw ater drain, a docum ented history o f tuberculosis, a tension p n eu ­ m othorax o r a sucking chest wound. T his study w as co n d u c ted at the N gw elezana H ospital in K w aZulu - Natal over a period o f three m onths. Forty male patients betw een the ages 18 and 60 years w ith unilateral penetrating stab w ounds to the chest w ere included in the study. The patients participating in this study w ere all haem odynam ically stable on adm ission. A ll patients had a chest x-ray taken on adm ission w hich was repeated after inser­ tion o f the intercostal drain and at inter­ vals dictated by the clinical progress of the patient. The patients w ere divided into two groups according to the referral method. T he patients assigned to group 1 (n = 20) w ere referred for physiotherapy by the doc­ tors im m ediately after insertion o f the intercostal drain. For the patients in group 2 (n = 20) physiotherapy com m enced 12 to 24 hours after insertion o f the inter­ costal drain. U nder norm al circum stances all patients adm itted for stabbed chest injuries are treated by the physiotherapist som etim e during the day follow ing adm is­ sion. M ost adm issions occur at night. For the purposes o f this study the doctors w orking in the casualty unit w ere all asked to refer the patients as soon as the intercostal drain had been inserted. Some o f the doctors com plied with this request w hile others did not. T hose doctors who did refer patients imm ediately contributed to the patients in group 1 w hile those who did not refer at all, contributed to the patients in group 2. Com parisons betw een the two groups w ere m ade using the follow ing param e­ ters; age o f the patient, duration o f inter­ costal drainage and hospitalisation, num ­ ber o f physiotherapy treatm ents, radio­ logical resolution and the presence o f com plications. The physiotherapy treatm ent consisted o f the follow ing regim en: In sitting: 1. U n ilateral lateral co stal breath in g , posterior basal breathing, diaphrag­ matic breathing. 2. Both hands behind the head; bend trunk forw ard and rotate to touch opposite knee with forehead. This was com bined with inspiration and expira­ tion and repeated 10 times. 3. A rm s at side, alternate trunk side flex ­ ion. R epeated 10 tim es to both sides. 4. H ands on shoulders w ith elbow s held out to the side, patient moves to touch left knee with right elbow and vice versa. R epeated 10 tim es to both sides. F o r exercises 2, 3 and 4 above expira­ tion occurred on trunk flexion and inspi­ ration on trunk extension. 5. Coughing 6. Brisk walking on the spot (lifting knees to the level o f hips) for one m inute 7. Repeat above deep breathing exercises. 8. Coughing In standing: 1. Arm elevation with inspiration fol­ lowed by flexion and toe touching on expiration - repeated ten times. 2. Arm s at sides, alternate trunk side flexion - repeated ten tim es to both sides. 3. A rm s yard - circular m ovem ents of the arm s - repeated ten times. 4. D eep breathing exercises - unilateral lateral costal b re ath in g , p o sterio r basal b reath in g and d iaphragm atic breathing. 5. C oughing 6. Stride standing, arms yard, bend and touch right foot with left arm , return to starting position and then vice versa - repeated to both sides ten times. 7. B risk w alk in g on the spot - two m inutes. B risk w alking around the w ard - two minutes. R unning up and dow n stairs - two m inutes. 8. R epeat deep breathing exercises. 9. C oughing follow ed by blow ing up a balloon six times. For exercises 1, 2 and 6 expiration occured during trunk flexion and inspira­ tion during trunk extension. Patients w ere also encouraged to walk around, cough and to do deep breathing exercises on their own between treatments. T he above treatm ent was continued tw ice daily until discharge o f the patients in both groups. All patients w ere dis­ charged w hen radiological resolution of the initial injury was dem onstrated and the intercostal drain had been rem oved. D ischarge occurred on the sam e day as rem oval o f the intercostal drain. RESULTS A N D DISCUSSION W hen com paring the two groups they w ere relatively well m atched for age. The age range for the patients in group 1 was 17 to 34 years with a m ean age o f 25.5 years w hile that o f group 2 was 16 to 60 years with a m ean age o f 31.85 years (see Table 1). A lthough there is a discrepancy in m ean ages betw een the groups it was not considered to be significant (p > 0.05). The patients in group 2 w ho developed com plications w hich prolonged their ho s­ pital stay, fell w ithin the m ean age range o f the patients in group 1. It seem s that the age o f the patient did not contribute to the developm ent o f com plications. T h e resu lts sh ow ed a sig n ifican t im p ro v e m e n t in the gro u p rece iv in g physiotherapy im m ediately after insertion o f the intercostal drain (group 1) (Figure 1). 24 SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 1 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. ) TABLE 1: RAW DATA FOR ALL PATIENTS IN THE STUDY GROUP 1 GROUP 2 PATIENT NO. AGE NUMBER OF LENGTH OF AGE NUMBER OF LENGTH OF TREATMENTS STAY TREATMENTS STAY 1 26 6 3 30 44 22 2 24 4 2 19 12 6 3 31 6 3 16 22 11 4 27 2 1 23 10 5 5 27 44 2 33 16 8 6 26 4 2 21 12 6 7 26 6 3 22 8 4 8 25 4 2 60 10 5 9 24 4 3 50 12 6 10 19 4 4 24 10 5 11 27 6 3 60 10 5 12 30 6 3 46 16 8 13 21 4 2 22 36 18 14 20 2 1 25 12 6 15 31 4 2 21 12 6 16 34 4 2 42 10 5 17 23 6 3 42 8 4 18 24 6 3 26 10 5 19 17 4 2 35 8 4 20 28 2 1 20 24 12 Mean 25.5 4.4 2.35 3 1 .85 15.1 7.55 Median 26 4 2 25.5 12 6 S.D. ±4.3 ±1.4 ±0.8 ±13.65 ±9.6 ±4.8 FIGURE 1: MEAN NUMBER OF TREATMENTS AND LENGTH OF STAY PER GROUP No. of Treatments Length of Stay T h ere w as a sig n ifican t d ifferen ce (p < 0.01) betw een the two groups with regard to the m ean duration o f intercostal drainage and hospital stay (group 1 = 2.35 ± 0.8 and group 2 = 7.55 ± 4.81). It is im portant to rem em ber that patients w ere discharged im m ediately after rem oval o f the intercostal drain. These results are in agreement with those o f Fairlie, 1973; Rod- seth et al, 1978; Senekal and Eales (1995). Four of the twenty patients in group 2 developed com plications w hile none o f the patients in group 1 developed a com ­ plication. Patients 1,3 , 13 and 20 in group 2 all developed an em pyem a resulting in a prolonged hospital stay. T hese findings are again in agreem ent with those found by Senekal and Eales (1995). In term s o f physiotherapy cost, if one considers that in 1997 a single p hysio­ therapy treatm ent as described above cost R 52.50 then the total cost o f physiother­ apy alone for the patients in group 1 was R 4 620.00 (88 * R52.50) and for those in group 2 R16 380.00 (312 * R52.50). In term s o f hospital stay, the cost o f a hospi­ tal bed at N gw elezana in 1998 is R757.00 per day m eaning that the difference in hospital cost betw een the two groups was R78 7 2 8 .0 0 (47 days * R 7 5 7 .0 0 = R35 579.00 for group 1 and 151 * R757.00 = R 114 307.00 for group 2). W hile com pleting this study the fo l­ low ing subjective observations were made. Firstly, all the patients adm itted for stab w ounds w ere adm itted at night tim e. This finding is in agreement with Fairlie (1973); H ay se-G reg so n (1 9 7 3); M ug u ti et al (1995); Senekal and E ales (1995) who all found that the m ajority o f patients with stabbed chests w ere adm itted at night. Secondly, the patients who had had treat­ m ent the previous night (on adm ission) were up walking around the next day while those who had not had treatm ent w ere still very reluctant to move. It w ould seem then that the results above confirm those o f the Senekal and Eales (1995) study. T he results also sug­ gest that early, “aggressive” physiotherapy is a financial m ust for this patients po pu ­ lation in the present South A frican finan­ cial clim ate. The saving o f R 78 728.00 could be used to em ploy a further physio­ therapist thus enhancing the physiotherapy service provided to the com m unity that N gw elezana serves. REFERENCES Fairlie A. P hysiotherapy in the m anagem ent o f the stabbed chesl. South A fric an Jo u rn a l o f P h ysiotherapy 1973, 29: 5 - 10. H ayse - G regson JM . T he treatm ent o f pene­ trating stab w ounds o f the chest. South A frican Jo u rn a l o f P h ysio th era p y 1973, 28: 7 - 1 5 M uckart DJJ, M eum ann C, B otha JB C . The changing pattern o f p enetrating torso traum a in K w aZ ulu/N atal - a clinical and pathological review. South A frican M e d ica l Jo u rn a l 1995, 85: 1172 - 1174. M uguti GI, Z ishiri C, D ube M. Stab w ounds in B ulaw ayo, Z im babw e: a four y ear audit. The C entral A fric an Jo u rn a l o f M ed icin e 19 9 5 ,4 1 : 380 - 385. Rodseth CP, H arw in S, L isus K, B aigrie RDH. Im m e d ia te p h y sio th e ra p y in p e rfo ra tin g w ounds o f the pleural cavity and underlying lung. South A fric an M edical J o u rn a l 1978, 54: 8 1 4 - 8 1 6 . Senekal M, E ales CJ. B ecker PJ. Penetrating stab w ounds to the chest - w hen should chest p h y sio th e ra p y c o m m e n c e ? S o u th A fric a n J ournal o f Surgery 1995, 33: 61 - 66 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 1 25 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. )