Physiotherapist role in Thoracic Surgery


Pre-operative care

The provision of pre-operative chest physiotherapy is not routine, but it has been shown to be of benefit in highrisk patients. For example, Nagasaki et al. (1982) demonstrated that pre-operative physiotherapy for elderly patients and those with COPD reduced postoperative pulmonary morbidity. Patients with pre-existing COPD are prone to increased bronchial secretions (Massard and Wihlm 1998) and may require chest clearance prior to surgery. Physiotherapy may be requested by the patient’s medical team following bronchoscopic findings (i.e. sputum retention). The pre-operative care may vary from simple education in postoperative techniques to more intensive chest clearance.


Postoperative care

Postoperative complications commonly present as a restrictive pattern with reduced inspiratory capacity, reduced vital capacity (VC) and reduced FRC (Craig 1981). There are changes in defence mechanisms owing to anaesthesia and reduced cough effort (Scuderi and Olsen 1989) that can lead to retention of secretions. Postoperative physiotherapy aims to minimise the risk of non-infectious and infectious pulmonary complications (Scuderi and Olsen 1989), the most common being atelectasis and pneumonia. Other common problems are loss of joint range in the shoulder on the incision side and reduced mobility. Therefore, the main aims of

physiotherapy are:

patient education;

maximisation of lung volume;

prevention of sputum retention;

sputum clearance;

maintenance of shoulder range of movement;

early mobilisation.

Patient assessment

The initial assessment of the patient leads to identification of specific problems. Without an accurate assessment an appropriate treatment plan cannot be initiated (Pryor and Webber 1998). Re-assessment is then an ongoing process to judge the effectiveness of treatment, to identify new problems and to modify a treatment plan.

The initial patient assessment notes

Database: obtained from medical notes

• Pre-operative information: pulmonary function tests and

arterial blood gases

• Surgical procedure and incision

• Concise relevant history of present condition

• Relevant past medical history including previous surgery

• Social history

• Drug history, specific note of respiratory medicines, e.g. inhalers

Subjective: information the patient tells you

• Ask open-ended questions: How do you feel?

• Ask about pain control: Can the person cough?

Objective: information based on examination of the patient and tests carried out

• Cardiovascular status (CVS): blood pressure, heart rate and rhythm

• Oxygen delivery system and FIV1

• Blood gases or O2 saturation

• Respiratory rate

• Chest X-ray

• Method of pain control

• Number and type of drains

• Auscultation

• Ability to cough

• Range of movement of shoulder on incision side


From the initial assessment and problem identification a treatment plan can be formulated. The amount of chest physiotherapy required will vary from patient to patient. The patient’s individual requirements will primarily dictate how often and for how long treatment is needed. Consultant preference and hospital protocols may also influence this (Stiller and Munday 1992).

Breathing exercises

The active cycle of breathing technique (ACBT) used in sitting may be sufficient to maintain effective airway clearance (Pryor and Webber 1998). ACBT consists of cycles of breathing control and thoracic expansion exercises followed by the forced expiratory technique (FET). The thoracic expansion exercises can be combined with inspiratory hold and vibrations. In patients with reduced breath sounds, atelectasis and/or sputum retention positioning in conjunction with ACBT may be indicated. The whole cycle should be repeated 2–3 times or until the patient becomes non-productive. In early postoperative patients, fatigue may be an issue and treatment should be terminated at this point. The thoracic expansions should be slow deep breaths in through the nose and sigh out through the mouth. The end-inspiratory hold can improve air flow to poorly ventilated regions (Hough 2001); the breath hold should be encouraged Forced expiration

The FET is used to help in the clearance of excess bronchial


reduced lung volume;

retention of secretions;

increased work of breathing;

poor breathing control/pattern;

ineffective cough;


The FET is used to help in the clearance of excess bronchial


An effective FET should sound like a forced sigh. It is

dependent on:

mouth open;

glottis open;

abdominal wall contracted;

chest wall contracted.

Crackles may be heard if secretions are present. FET performed to low lung volumes will aid removal of secretions peripherally situated. High lung volumes will clear secretions from proximal airways (Pryor and Webber 1998). Supported cough A cough is created by forced expiration against a closed glottis. This causes a rise in intrathoracic pressure. As the glottis opens there is rapid, outward airflow and shearing of secretions from the airway walls.

Early mobilisation

Mobilisation should commence as soon as is safely possible as functional residual capacity is maximally improved in standing (Jenkins et al. 1988). Dull and Dull (1983) proposed that early mobilisation in uncomplicated patients could render breathing exercises unnecessary. Patients must be cardiovascularly stable and not requiring high concentrations of oxygen before mobilization can begin.

Shoulder exercises

The shoulder on the operated side should be checked for range of movement. The patient should practice elevation and abduction of the shoulder at least three times a day. Auto-assisted exercises may be necessary to begin with. Any limitation of range should be more formally assessed and treated.

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