Lobectomy

1. Lobectomy
Submitted by- Tasneem Zafar
Submitted to- Dr. Jamal Moiz
Submission date- 29th, December 2020
Subject- Physiotherapy in cardiopulmonary condition(BPT 402)

2. Introduction
• Lobectomy is the surgical operation where the lobe of the lung is removed.
Lobectomy remains the treatment of choice for patients with early-stage lung
cancer.
• The surgery can be performed via thoracotomy or VATS(video assisted
thoracoscopic surgery) or RATS(robotic assisted thoracoscopic surgery).
Indications
• Bronchiectasis
• Tuberculosis
• Lung abscess
• Carcinoma

4. Procedures
• Patient is given anesthesia before the procedure and will be placed on mechanical ventilator with a
breathing tube inserted into the throat.
• Thoracotomy- incision will be made on the side of the body at the front of the chest around the
nipple and wrap around the back to the area under the shoulder blade.
• VATS or RATS- three or four small cut will be made around the area of the lobe. A thoracoscope , a
small tube with a light and tiny camera is inserted in to the chest cavity
• Following dissection of the fissure and hilar structures, the branches of the pulmonary artery and
veins to the lobe are isolated and ligated. The bronchus is usually stapled but can be sewn. At
completion of the operation, the remaining lung is reinflated.
• Some air leak is common and usually settles within a few days. One or two intercostal drains are
inserted. The patient does not routinely need intensive care and postoperative ventilation is best
avoided. The 30-day mortality rate is 2–3%, with morbidity such as chest infection or cardiac
arrhythmia at around 10%. The average length of stay is around 5–7 days.

5. Complications
• Respiratory
• Infection of lung tissues
• Consolidation/collapse of remaining lung tissues
• Pneumothorax
• Broncho-pleural fistula
• Circulatory- DVT, cardiac arrhythmias
• Wound
• Joint stiffness
• Muscle weakness
• Postural deformity

6. Pre operative physiotherapy
• Gain the patient confidence
• Clear the lungs field
• Teach respiratory control and inspiratory holding
• Teach postural awareness
• Teach arm, trunk and leg exercises
• Teach mobility around the bed

7. Post operative physiotherapy
1.pain management
Pain impairs the patient’s ability to take deep breath leading to reduced lung
volume and sputum retention. Pain induces sympathetic stimulation, restrict
shoulder and scapula ROM
TENS- it is effective as an adjunct to analgesic medication. It relieve ipsilateral
shoulder pain, minimize dose of analgesics, and incision pain.
It can be applied for 20-30 minutes at 3 hour interval on the day following surgery.
Frequency can be either high-frequency or low-frequency, but alternate frequency
of 2-100 Hz is more effective due to its synergistic effect with analgesic.
Cryotherapy- application of simple ice packs over the incision dressing during the
first 24 hours following surgery and afterwards reduces remarkable decrease in
incision pain. It can be used before or during coughing to reduce aggravation of
incision pain.

8. 2.Wound support
• Support the patient’s incision and intercostal drain sites with firm but gentle pressure, but do not
pressure directly on the incision or drain site. this reduces pain and allow the patient to breathe in
deeply and cough with little discomfort.
• Physiotherapists standing on the contralateral side, with one hand placed on the anterior chest wall
to stabilize the incision from the front, and another hand placed on posterior chest wall to stabilize
the incision from behind, while at the same time the physiotherapists forearms stabilize the entire
chest and create a bear hug hold.
• Another method for wound support can be done by patient by placing the hand of the unoperated
side across the front of the thorax as far as possible resting firmly over the incision and drain sites,
while the other hand reinforces the hugging hold by clasping the opposite elbow and pulling it
against the thoracic wall. Alternatively patient may be taught to hold a pillow firmly against the
incisions while coughing or to wear an external thoracic support.

9. 3. Positioning
Positioning patients after thoracic surgery utilizes gravity to provide 2 major
benefits-
Gravity assisted position to improve ventilation
Early upright position- upright position in and out of the bed as soon as possible
after patient is woken up, with endotracheal tube still in place. This position
increase diaphragmatic excursion, improve ventilation and increased lung volume
and capacity.
If patient can not sit upright, they should be positioned to high side lying position
with operated lung on the top. This insure adequate V/Q mismatch and adequate
expansion of the operated lung.
Gravity-assisted position to assist the clearance of bronchial secretions-
modified(horizontal) postural drainage position is recommended first, instead of
classical (head down) position, in post operative patients, as latter can lead to
decreased arterial oxygenation.

10. 4.Early mobilization and ambulation
• Early mobilization , with sitting in bed at 3.5 hours after surgery, maintaining a
sitting position for 30 minutes, and then ambulation in the fourth hour led to
better recovery. Patient is considered Unstable if vital sign exceed following
threshold: HR <40/min or >140/min, RR<8/min or >36/min, po2 <85% and BP
<80/200 mm hg or >110 diastolic. CRT>4.5sec suggest poor peripheral
perfusion.
• Once a patient is able to sit on the edge of the bed for 5 min and can perform
full bilateral knee extension along with clinically vital signs, they can bee
progressed to standing and ambulation. Session with short(3-5 min), more
frequent(2-3/day) and non intense (60% HRmax) is suggested. Stair climbing is
initiated 4th or 5th day if patient walk considerable distance on flat surface.
• In case of shortness of breath, chest pain, dizziness, cold sweating, leg fatigue
and pain, mobilization should be stopped until hemodynamic stability returns.
After mobilization patient’s re-assess vital sign for any abnormal responses.

11. 5.Lung expansion manoeuvres
• Deep breathing exercise can be practiced in erect position, in a high side lying
position or in a modified postural drainage position. As periodic deep breathing
is important , recommended protocol is 5 deep breath with a 3 sec hold per
every waking hour.
• Thoracic expansion exercise(lateral costal breathing exercise)- unilateral TTEs
is performed in high side lying position with operated side on the top and arm
brought to abduction at the level of the head. PT placed hand on incision site
and patient is instructed to breathe in slowly and deeply to push PT hands up, to
hold his breath for 2-3 sec and finally exhale from mouth.
• Deep diaphragmatic breathing patient is sitting upright, with back supported and
pelvis in posterior tilting position. Patient is asked to relax the upper chest and
breath in from nose by expanding lower chest and abdominal region and then to
gently exhale.
• Deep breathing exercise coupled with arm or trunk movement- patient is asked
to coordinate deep breathing with arm flexion, arm abduction, trunk extension
away from operated side, while coordinating exhalation upon returning to
starting position.

12. Lung expansion manoeuvres
• Sustained maximal inspiration- holding one’s breath for 3 second after reaching deep inspiration.
• Incentive spirometry the patient is asked to breathe in slowly and deeply for as long as possible
through the mouth piece of the device to maximally distribute the ventilation, and then hold the
deep breath for period of 5 second, which is then followed by normal expiration.
• Inspiratory muscle training- Brocki et al. has shown that addition of IMT to standard postoperative
physiotherapy improved hypoxemic status in high-risks patient after lung cancer surgery, but no
additional benefits for preserving respiratory muscle strength.

13. 6.Airway clearance technique
It include coughing, huffing, the forced expiratory technique(FET), active cycle of breathing
technique(ACBT), modified postural drainage position and positive expiratory pressure(PEP). It
should be started as soon as patient wakes on the day of surgery. It should be repeated every 30 min.
Supported coughing- patients sits upright, tilt the chin up, support the wound with pillow, take a deep
breath combined with extension, and momentarily hold the breath, then carries out series of sharp
expiration while leaning forward.
Huffing- take medium size breath and then with mouth and glottis open breath out forcefully and
slowly.
FET- combination of 1-2 forced expiration (huff) and a period of breathing control.

14. • ACBT- patient should start with breathing control for 20-30 second, then
practice TEEs 3-4 times then re-start breathing control again(20-30 sec or 6
breaths) and finally practice FET. The whole cycle should be repeated 2-3 times
every waking hours.
• PEP- for PEP application patient sits upright or leans slightly forward with
elbow supported on the table and hold the mouthpiece firmly. Then the patient is
asked to larger than normal breath with a short breath hold(3-5 sec) and to
exhale through the PEP device with active but not forced expiration against an
expiratory resistor. Resistance range from 6-25 cm h2O, 10-20 breath/cycle and
4-8 cycle/sessions for maximum of 20 minutes.

15. 7. Postural correction
patient tend to side-flex their trunk towards the thoracotomy side, i.e. to drop the
shoulder and raise the hip on the operated side. Patient is encouraged to keep both
shoulders at the same level and the trunk straight while sitting, standing, or
walking.
8. Shoulder ROM exercises and gentle scapula mobilization
exercises
auto-assisted or active ROM exercise for shoulder (arm elevation) within pain
limits can started as possible on the first postoperative day. Scapula on the
operated side can be mobilized gently through its full range of protraction,
retraction, elevation, and depression while the patient is in side-lying position. It
can be practiced 3-4 times daily. Shoulder abduction and external rotation are
initially avoided to prevent increased stress on the incision.

16. 9. Leg, trunk, and thoracic mobilization exercises
Non-resistance exercise(quadriceps and ankle exercises) and Non-resistance arm
exercises and thoracic mobilization(thoracic extension exercise, chest wall rotation
exercise and thoracic lateral flexion exercise )on first post op day can be started.
10. Discharge and home programme
After discharge patient is advised to continue regular breathing exercises, to
gradually increases their mobilization and daily activities and practice an airway
clearance technique. After discharge walking should be 3 times a day for a total of
15min/day. Then increase walking time each week by 5 minutes, so patient will be
able to walk 30 minutes either intermittently or continuously by first month
postoperatively.

17. Summary
• Lobectomy is the surgical operation where the lobe of the lung is removed. Lobectomy remains the
treatment of choice for patients with early-stage lung cancer.
• The surgery can be performed via thoracotomy or VATS(video assisted thoracoscopic surgery) or
RATS(robotic assisted thoracoscopic surgery).
• Indication are Bronchiectasis, Tuberculosis, Lung abscess and Carcinoma.
• Rehabilitations protocol include pain management, wound support, airway clearance technique,
lung expansion maneuver, mobilization, and arm, leg and trunk exercise.

18. References
• Essential of physiotherapy after thoracic surgery: what physiotherapists need to know, narrative
review- Ahmad Mahdi Ahmad
• Bailey & Love’s Short Practice of Surgery, 27th edition.
• Donna Frownfelter, Elezebeth dean