Rehabilitation is one of the important aspect in pre and post surgery care. This presentation is mainly focusing on the "thoracic and abdominal rehabilitation" and also gives details about assessment and management of "intercostal drains".

1. Physiotherapy in
surgery
KHUSHBOO BHATT (PT)
MPT in cardiorespiratory
physiotherapy, Bangalore

2. Introduction
Surgery is now available for those previously
denied it because of disease or debility.
Many operations can now be performed via
laparoscopy or thoracoscopy, including aortic
aneurysm repair and heart surgery
Minimal access techniques use fibreoptic
endoscopes, which provide illuminated fields of
vision and allow keyhole surgery by instruments
inserted through several small stab incisions.
These changes have altered requirements for
physiotherapy. Sicker patients who are now able
to have surgery require extra input, and policies of
early discharge demand rapid rehabilitation.

3. All could doubtless benefit from direct physiotherapy, but most physiotherapists select for assessment only those at
risk due to:
• smoking history, especially current smokers who have a six-fold greater incidence of postoperative complications
• surgery to the upper abdomen or chest
• prolonged preoperative stay
• prolonged anesthesia
• the presence of lung or heart disease
• obesity or malnourishment
• advanced age
• excessive anxiety
• emergency surgery

4. General
respiratory
complications
after surgery
• Lung complications occur in
25-50% of patients undergoing
major surgery.
• Atelectasis
• Infection
• hypoxemia

5. Atelectasis

6. Hypoxaemia
• Hypoxaemia may not be significant and many patients leave hospital happily ignorant of
its existence.
• For others it can impair healing, promote infection and contribute to postoperative
confusion
• When present for a few hours it is related to the anaesthetic. When present for several
days it is related to the surgery and postoperative factors
• Patients at risk may suffer nocturnal hypoxaemia for up to five nights after surgery

7. Chest infection
• Intubation overrides defense
mechanisms and anaesthetic agents
impair ciliary action.
• This predisposes to chest infection,
especially in smokers
• Signs may emerge some days after
surgery, e.g. crackles on
auscultation, purulent bronchial
secretions, malaise, fever and
sometimes tachypnoea.
• If pneumonia develops, mortality can
reach 30-40% .

8. Other chest complications
• Intubation can cause bronchospasm in susceptible patients
• Toxic levels of opioids can cause respiratory depression.
• Vital capacity can drop by 40-50% because of pain, leading to impaired cough.
• DVT
• Fatigue
• Anxiety
• Depression
• Fluid imbalance
• Hypertension
• Neurological complications

9. DEEP VEIN
THROMBOSIS
• Deep vein thrombosis (DVT) is a blood clot that
develops surreptitiously, usually during surgery.
• Causes are calf compression, immobility, fluid
loss, manipulation of blood vessels, the surgical
stress response which upsets clotting and
depression because of the serotonin effect on
platelet aggregation.

10. SIGNS
• Tenderness, swelling and warmth of the calf,
or sometimes pain on dorsiflexion (Homan's
sign), any of which must be reported.
• Diagnosis can be confirmed by ultrasound
or Doppler imaging.
• DVT becomes serious if it breaks free and
causes pulmonary embolism by lodging in
the pulmonary vascular bed.
• Patients most at risk are those who:
• are elderly, obese, or have malignant,
vascular or blood disorders
• are undergoing lengthy surgery, especially of
the knee, hip or pelvis, which involve distortion
and traction of blood vessels
• have had a previous history of DVT.

11. Preoperative management
• Advice on positioning, mobilization and chest clearance has
shown a reduction in postoperative complications, increased
Sa02 and improved mobilization.
• Pain assessment and management
• Prevention of DVT by compression devices and bandaging,
exercises, positioning,drug mx.
• Anxity management

12. Postoperative management
• Assessment
• Positioning
• Breathing exercises and clearance techniques
• Bed mobility
• Mobilization
• Prevention of DVT by compression devices and bandaging,
exercises, positioning,drug mx.
• Self management and discharge planning

13. Thoracic surgery

14. Operation on the lung
Operation on the pleura
Operations on the
oesophagus

15. Common types of
thoracic incision:
• Posterolateral thoracotomy
• Anterolateral thoracotomy
• Median sternotomy
• Left thoraco-laparotomy

16. Operations on
the lung
Pneumonectomy
Lobectomy
Segmental resection
Wedge resection
Lung volume reduction
surgery

17. Operation on
the pleura
Pleurectomy
decortication

18. Complication of
pulmonary surgery

19. Operations on
the
oesophagus
Oesophageal
resection
Repair of
oesophageal

20. Complications of oesophageal surgery
• All the complications of pulmonary sx apply to oesophageal
surgery .
• In addition chyothorax (effusion resulting from the serving of the
thoracic chyle duct)

21. Intercostal
drains
• When thoracotomy has been performed
and the pleura opened ,it is necessary to
insert chest drains, which is called
intercostal drains.
• Most patient will require two intercostal
drains,
• One sited in the apex to drain air and one
in basal area to drain post-operative
bleeding.

22. Procedure
Introduced through a stab
incisions
In intercostal space below the
level of thoracotomy
Positioned within the chest
cavity
Secured with purse-string
suture for tight seal
Apical drain is generally sited
anteriorly and basal posteriorly

24. Drains
• The idea is to create a one-way mechanism that will let
air/fluid out of the pleural space and prevent outside
air/fluid from entering into the pleural space.
• This is accomplished by the use of an underwater seal.
The distal end of the drainage tube is submerged in
2cm of H2O.
• Normal intrapleural pressure is negative. However, if air
or fluid enters the pleural space, intrapleural pressure
becomes positive.
• Air is eliminated from the pleural space into the
drainage chamber when intrapleural pressure is greater
than +2cmH20.
• Thus, air moves from a higher to lower pressure along
a pressure gradient. The drainage chamber has a vent
to allow air to escape the chamber, and not build up
within the chamber.

25. Amount and Type of drainage system:
• 1 bottle
• The simplest form of underwater seal drainage systems.
• This system can drain both fluid and air.
• The distal end of the drainage tube must remain under the
water surface level.
• There is always an outlet to the atmosphere to allow air to
escape.
• It is suitable for use with a simple pneumothorax, when the
vent is left open to the atmosphere, or following a
pneumonectomy when the tubing is clamped and released
hourly
• 2 bottle
• This system is suitable for the drainage of air and fluid.
• The first chamber is for collection of fluid and the second is
for the collection of air.
• As the two are separate, fluid drainage does not adversely
affect the pressure gradient for evacuation of air from the
pleural space.
• A separate chamber for fluid collection enables monitoring
of volume and expelled matter.

26. 3 bottle
• Suction is required when air or fluid needs a greater pressure gradient
to move from the pleural space to the collection system. Suction may
be applied via a third bottle or a suction chamber.

27. Assessment of chest drains
• As part of a physiotherapy objective assessment a specific examination of a chest drain should be
performed. Important aspects that should be noted include the following;
• Location
• Pain
• Swing/Oscillation -
• Normal – reflects the changes in pleural pressure on breathing (if not on suction). Will gradually
lessen and stop as lung re-expands.
• If drain is not swinging; Gradual : lung re-expanded, Sudden : ?obstructed or ?lung collapse, Check
for suction : Wall suction – no swing
• Draining- Denotes volume of fluid draining from pleural space.
• Dependent on pathology; Post op – mostly occurs in first few hours, Fluid – slow drainage,
Pneumothorax – minimal. If amount in bottle is excessive, its more difficult for air to be expelled. If
there is a lack of drainage – check for kinks or obstruction

28. • Bubbling- Reflects the amount of air draining out of the pleural space.
• Usually occurs during expiration or coughing. May also occur on inspiration
if big air leak present.
• Large volume air leaks may require suction to remove air; if persistent may
require pleurodesis.
• Continuous bubbling – means there is a connection between the lung and
intra pleural space. If bubbling stops check for; Kink, Blockage,
Disconnection.
• Suction- Application of a negative pressure (3-5kPa) to restore negative
pressure in the pleural space. Typically used if there is a large volume of
air or fluid to be removed from the pleural space
• CX
• Auscultation

29. Complications of Chest Drains
• Failure to enter the pleural space
• Infection at insertion site or intrapleurally
• Penetration / lacerations to lungs
• Penetration of peritoneal space - laceration of the diaphragm
• Haemorrhage
• Blocked drains
• Pleural sepsis
• Subcutaneous emphysema
• Pain – chest wall/ neck / shoulder

30. Take care...
• Familiarize yourself with the location of the clamps in case of emergency
• gravity drainage
• Keep bottles/drains below the level of the patient’s chest – if you need to move the
patient from lying to sitting this should be done on the side the chest drain is on
• Clamping should be avoided if at all possible – clamping can cause a tension
pneumothorax which leads to compression of the heart and a mediastinal shift which
can be fatal.
• If you knock over the chest drain: put it back upright, check the levels and inform the
nurse on duty so she can perform the necessary tests to make sure it’s still working
properly.
• Need to carefully plan any movements to avoid disconnection during activity
• If there is a suction port attached to the chest drain and you need to mobilize the
patient you have to get surgical permission to temporarily disconnect the suction

31. When do you clamp?
• Post pneumonectomy
• Changing bottle
• Break in circuit
• It is never appropriate to clamp chest drains for mobilisation / transport of patients.
NEVER clamp in tension pneumothorax or if still bubbling.

32. What to do if disconnect?
Part of the system becomes
disconnected or drain/bottle breaks;
• Clamp the tubing close to the patients
chest
• Reconnect with sterile tubing or new
drain
• Unclamp and restore drainage
• Report the incident
Tubing becomes disconnected from
the patient
• Ask patient to exhale and press
gauze against the wound at end
exhalation
• Ask patient to breathe normally
• Call for medical help but stay with
patient and maintain pressure on the
wound
• Observe the breathing rate and chest
symmetry
• Reassure the patient and give them
oxygen if they become distressed

33. Criteria to
remove drains
Less than 100ml of drainage in 24hours
Minimal swing
Chest X-ray establishing full lung
expansion
Breath sounds present over the whole
thorax on auscultation
No air leak

34. Pain control in thoracic surgery
• Epidural anesthesia
• Paravertebral block
• Patient controlled analgesia (PCA)
• Transcutaneous nerve stimulation
• Oral analgesia

35. Physiotherapy in
thoracic surgery

36. Preoperative care
• The provision of preoperative chest physiotherapy is not
routine, but it has been shown to be benefit in high risk patients.
• Pre-existing COPD are prone to increased secretions

37. Postoperative care
AIMS:
Patient
education
Maximization of
lung volume
Prevention of
sputum
retention
Sputum
clearance
Maintenance of
shoulder range
of movements
Early
mobilization

38. Modalities of physiotherapy
• From initial assessment and problem identification a treatment
plan can be formulated.
• Breathing exercise
• Forced expiration
• Supported cough
• Positioning
• Early mobilization
• Adjunct physiotherapy

39. Breathing exercises
• ACBT
• Can be repeated 2-3 times or until
patient become non-productive.
• Fatigue
• Thoracic expansion exercise
• Respiratory holds

40. Forced expiration
• It helps in clearance of excess bronchial secretions.
• An effective FET should sound like forced sigh. It depends on-
• Mouth open
• Glottis open
• Abdominal wall contracted
• Chest wall contracted
• If done at low volume, will aid removal of secretions peripherally situated. High lung
volumes will clear secretions from proximal airways.

41. Supported cough

42. Positioning
• Major function of positioning is to improve
FRC postoperatively.
• Improve gas exchange
• Improvement in oxygenation
• Segmental drainage
• Pnumonectomy pt. Should not be positioned
on their unoperated side, this can result in
bronchopleural fistula, due to space fluid
washing over the bronchial stump.
• They can be treated in sitting for the first 4
days unless advised by medical team.

43. Early
mobilization
• Mobilization should commence as
soon as is safely possible and
functional residual capacity is
maximally improved in standing.
• Pt must be cardiovascularly stable
and not requiring high amount of
oxygen before mobilization.
• Intercostal drain is on suction then
mobility can be restricted to bed side
marching and squatting.

44. Shoulder
exercises
• Operated side shoulder
movements should be
assessed,
• Auto-assisted exercises is
necessary to begin with
• Practice more than 3 times per
day

45. • Incentive spirometry
• Mini-tracheostomy
• Heated humidification
• Continuous positive airways
pressure (CPAP)
• Intermittent positive airways
pressure breathing (IPPB)
Adjuncts to physiotherapy

46. Abdominal
surgery

47. • The effect of an upper abdominal incision seems to strike at the root of normal respiration
• laparoscopic cholecystectomy take longer than laparotomy and entail tilting the head
down and pumping CO2 into the peritoneum. This impairs diaphragmatic function and can
refer pain to the right shoulder.
• Full-incision surgery of the upper abdomen is more problematic than either chest or lower
abdomen. It is associated with more pulmonary complications than chest surgery
• Bowel resection leads to significant loss of exercise tolerance. Up to 40% maximal
workload is lost, which directly relates to loss of employment thus reinforcing the need for
rehabilitation.

48. • An abdominal aortic aneurysm (AAA) means that the vessel has bulged to twice its
normal size. Severe abdominal pain and backache suggests a contained rupture, which
leads to complete rupture after 2-3 hours.
• A long midline or flank incision leads to prolonged paralytic ileus, large fluid shifts and
significant pain.
• There is a risk of cardiovascular instability, and patients are not usually mobilized for at
least 2 days.
• Patients who have had an aortofemoral graft should avoid hip flexion on the affected side
for 3 days. They may mobilize before they are allowed to sit.

49. Complication of abdominal surgery
• Paralytic ileus: Loss of gut activity silences bowel sounds and is normal for the first day or two.
• It becomes problematic if prolonged, and causes distension if swallowed air is held up in the atonic colon,
exacerbating diaphragm dysfunction and requiring a nasogastric tube.
• Pain: Analgesia tends to be taken less seriously than after sternotomy, even though pain after laparotomy is often
worse because most activity requires some abdominal muscle contraction.
• Malnourishment: Abdominal surgery IS usually associated with poor nutrition due to: -
-malabsorption associated with preexisting gut pathology
- preoperative fasting
- the catabolic effects of surgery
- intestinal handling which affects the delicate mucosal lining
- postoperative nausea and precanous appetite
- unfamiliar food.
Poor nutrition reduces mobility, predisposes to infection, depression, muscle weakness, pressure sores and
prolonged hospital stay, and delays wound healing

50. Thank you