Resrictive Pulmonary Disorders



Restrictive pulmonary disorders are characterized by the inability of the lungs to expand fully as a result of extrapulmonary and/or pulmonary disease or restriction. In other words, the patient has difficulty taking in a deep breath.

Acute and Chronic Causes of Restrictive Pulmonary Disorders

There are a variety of acute or chronic disorders directly involving structures of the pulmonary system or extrapulmonary disorders that can cause restrictive pulmonary dysfunction.

Resrictive Pulmonary Disorders

Pulmonary Causes

Diseases of the lung parenchyma such as tumor, interstitial pulmonary fibrosis (e.g., pneumonia, tuberculosis, asbestosis), and atelectasis Disorders of cardiovascular/pulmonary origin, such as pulmonary edema or pulmonary embolism Inadequate or abnormal pulmonary development (bronchopulmonary dysplasia)

Extrapulmonary Causes

Chest wall pain secondary to trauma or surgery Chest wall stiffness associated with extrapulmonary disease (e.g., scleroderma, ankylosing spondylitis) Postural deformities (scoliosis, kyphosis) Ventilatory muscle weakness of neuropathic or myopathic origin (e.g., spinal cord injury, cerebral palsy,Parkinson’s disease, muscular dystrophy) Pleural disease Insufficient diaphragmatic excursion because of ascites or obesity.

Pathological Changes in the Pulmonary System

Pulmonary function may be altered as a result of pulmonary or extrapulmonary conditions.  Cardiopulmonary factors contributing to these changes are decreased pulmonary compliance caused by inflammation or fibrosis (thickening of the alveoli, bronchioles, or pleura), pulmonary congestion, and decreased arterial blood gases (hypoxemia).

Management Guidelines: Post-Thoracic Surgery

Although any number of acute or chronic disorders can be the underlying cause(s) of restrictive lung dysfunction, only management after thoracic surgery is addressed in this section. Patients with cardiac or pulmonary conditions that require surgical interventions are at high risk for restrictive pulmonary complications after surgery. Thoracotomy, an incision into the chest wall, is necessary during many types of pulmonary surgery including lobectomy (removal of a lobe of a lung), pneumonectomy (removal of a lung), or segmental resection (removal of a segment of a lobe of a lung). Cardiac surgeries, such as coronary artery bypass graft surgery, replacement of one or more valves of the heart, repair of septal defects, or heart transplantation also require thoracotomy.

Factors That Increase the Risk of Pulmonary Complications and Restrictive Lung Dysfunction After Thoracic Surgery

The post-thoracotomy patient experiences considerable chest pain, which leads to chest wall immobility, poor lung expansion, and an ineffective cough. In addition, pulmonary secretions are greater than normal after surgery. Therefore, the patient is more likely to accumulate pulmonary secretions and develop secondary pneumonia or atelectasis.

General Anesthesia

Decreases the normal ciliary action of the tracheobronchial tree Depresses the respiratory center of the central nervous system, which causes a shallow respiratory pattern (decreased tidal volume and vital capacity) Depresses the cough reflex

Intubation (Insertion of an Endotracheal Tube)

Causes muscle spasm and immobility of the chest Irritates the mucosal lining of the tracheobronchial tree, which causes increased production of mucus Decreases the normal action of the cilia in the tracheobronchial tree, which leads to pooling of secretions

Incisional Pain

Causes muscle splinting and decreases chest wall compliance, which in turn causes a shallow breathing pattern. Consequently, lung expansion is restricted and secretions are not adequately mobilized. Restricts a deep and effective cough. The patient usually has a weak, shallow cough that does not effectively mobilize and clear secretions.

Pain Medication

Although pain medication administered postoperatively diminishes incisional pain, it also Depresses the respiratory center of the central nervous system Decreases the normal ciliary action in the bronchial tree.

Resrictive Pulmonary Disorders

General Inactivity, Postoperative Weakness and Fatigue

Pooling of secretions, particularly in the posterior basilar segments of the lower lobes, because of inactivity Decreased effectiveness of the cough pump because of postoperative weakness and fatigue

Other risk factors not directly related to the surgery

Patient’s age (_ age 50) History of smoking History of COPD or restrictive pulmonary disorder because of neuromuscular weakness, Obesity, Poor mentation, and orientation.

Thoracic Surgery: Operative and Postoperative Considerations during Management

Many factors contribute to a patient’s postoperative impairments, any one of which influences postoperative management. A patient who has undergone thoracotomy for a pulmonary or cardiac condition typically is hospitalized for a week or less.  Therapeutic interventions begin on the first postoperative day and include breathing and coughing exercises, shoulder ROM, posture awareness training, and a graded aerobic conditioning program.

Co-morbidities and Related Dysfunction

In addition to the primary pulmonary or cardiac pathology (e.g., a malignant tumor, lung abscess, coronary artery disease) the patient also may have related cardiopulmonary conditions, such as angina, congestive heart disease, chronic bronchitis, or emphysema. The patient with a long history of cardiac disease may have preoperative pulmonary dysfunction such as hypoxemia, dyspnea on exertion, orthopnea, or pulmonary congestion. Such co-morbidities and related pulmonary or cardiac dysfunction can complicate postoperative rehabilitation.

Surgical Approach

Pulmonary surgery typically involves a large posterolateral, lateral, or anterolateral chest incision. A standard posterolateral approach, for example, is performed by incising the chest wall along the intercostal space that corresponds to the location of the lung lesion. The incision divides the trapezius and rhomboid muscles posteriorly and the serratus anterior, latissimus dorsi, and external and internal intercostals laterally. Postoperatively, the incision is painful, and the potential for pulmonary complications is significant. Many patients, quite understandably, complain of a great deal of shoulder soreness on the operated side. Loss of range of shoulder motion and postural deviations are possible because of the disturbance of the large arm and trunk musculature during surgery. The most common incision used with cardiac surgery is a median sternotomy. A large incision extends along the anterior chest from the sternal notch to just below the xiphoid. The sternum is then split and retracted so the chest cavity can be exposed. After completion of the surgical procedure, the sternum is closed with stainless steel sutures. Postoperatively, there is less incisional pain after a median sternotomy than after a posterolateral thoracotomy, but deep breathing and coughing are still painful. After a median sternotomy, a patient tends to exhibit rounded shoulders and is at risk for developing shortened pectoralis muscles bilaterally.

Additional Considerations

After any type of thoracotomy one or two chest drainage tubes are put in place at the time of the surgery to prevent a pneumothorax or a hemothorax. While these tubes are in place, crimping, clamping, or traction on the tubes must be avoided during postoperative interventions. Fatigue occurs easily during the first few postoperative days, so treatment sessions should be short but frequent. The duration of treatment sessions should be increased gradually during the patient’s hospital stay. Check the patient’s chart regularly to note any day-today changes in vital signs or laboratory test results. Always monitor vital signs such as heart rate and rhythm, respiratory rate, and blood pressure prior to, during, and after every treatment session.



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