MANAGEMENT OF PATIENTS WITH RESTRICTIVE
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.
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.
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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