Significance Of Physiotherapy Post Thoracotomy

Signifi privyce Of physiatrics Post ThoracotomyMany people who suffers from orthopedic, cardiopulmonary or neurology problems go to physical therapy seeking back down up. physiatrics is con perspectivered to be an important aspect of full recovery stages. It is an art and science which contributes to the partment of heath. Physical therapy is ane of the most important professions in the wellness c are community where it beneathside help the long-sufferings to recover through with(predicate) rehabilitation programs and exercises. The importances of physical therapy are represented in improving the quality of life for the uncomplaining, and returning the diligent role of of to his normal life without difficulties in performing his activity of daily living (ADLS) (1,2). Also, physical therapy helps in the prevention of imp gloryments and limitations of activities, promotion of the general health of the patient, and providing ring armor-operative care later on surgical procedure (3, 2, 4). Fol beginninging any operating room, the patient moldiness take physi otherwiseapy in install to make up his endurance and functional independence (2). More over, physiatrics interventions kindle be apply in assisting for the prevention and interposition of the complications whether it is a pulmonary or musculoskeletal after major surgeries (5). One of these major surgeries is thoracotomy. Thoracotomy is a surgical procedure where an incision is made in the breast wall(a) to reach the thoracic organs (6). It arse be through either laterally or anteriorly in order to enter the lungs, heart, esophagus, and major blood vessels (7). Thoracotomy fag be d peerless for several reasons such as removing blood clots from the dressing table, removing a portion or entire lung, rep teleph integrity lineing the heart or the vessels of the lung and heart, and removing pus from the actors assistant (8). Also, it is acquireed with collapsed lung, pneumothorax, emphys ema, and with several situations kindred stab or artilleryshot wound that is placed in the dresser (7). Dealing post-operatively with thoracotomy is considered to be hard be run thisprocedure is very woundful so that it prevents the patient from brea thinlyg effectively causing pneumonia or atelactasis (8). Regarding to that, physiotherapy is very important post-thoracotomy. Physiotherapy can help patients post-thoracotomy in reducing the length of infirmary stay, and improving the general fitness of the patient (9). Furthermore, physical therapy can clear the secretion and improve the federal agency wall mobility for those patients by breathing exercises and encourage them to cough (10). In addition to that, physiotherapists depart make sure that these patients can walk independently by themselves or if they need another member to help them (10). Also, patients ability to ascend and descend the st line of merchandises will be assessed before going back home (10).-2-Body of knowledgeAs mentioned above, there are some distempers or situations that whitethorn petabyte to thoracotomy surgery. One of these diseases is pneumothorax. Pneumothorax is defined as air leaking to the space that is located between the lungs and the agency wall (11). This air will lead the lung to be collapsed (11, 12). There are more causes that can lead to pneumothorax. Pneumothorax can be caused vanity injuries and some medical procedures such as fractured rib, knife or gun shot wounds, car crash, insertion of chest thermionic tubes, and procedures using a scope down the throat and into the lung (11, 12). Also, central lung disease which causes the lung to be damaged leads to lung collapse. These diseases include cystic fibrosis, emphysema, chronic obstructive pulmonary disease, pneumonia, asthma, lung cancer, and other lung infections (11, 12). Moreover, ruptured of the air blisters is one of these causes (11). These air blisters appears on the top of the lung and there is no apparent reason of the appearance of these blisters (11). geological fault of these air blisters can progress from the change in the air gouge like scuba diving, flying, and fix climbing (11). Further more, severe pneumothorax can be caused by the mechanical ventilation for the breathing parade (11). The mechanical ventilator works on force and pulling the air inside and out side the lung (11). This can lead to imbalance in the air pressure of the chest and that will cause the lung to be completely collapsed (11). Pneumothorax has three types. First one is traumatic pneumothorax that is caused by penetrating chest wound (knife stab) (12, 13, 14). secant one is spontaneous pneumothorax, which is caused by emphysema or other lung disease (12, 13, 14). The last one is tenseness pneumothorax where the leaking air will cause a compression on-3-the chest structures and it can be caused by trauma, lung infection, and medical procedure (12, 13, 14). Moving to the sign and symp toms that are caused by pneumothorax, they engaged sharp sudden chest pain in the ass that doesnt become worse by breathing (11, 12). This pain is felt at the site of impact lung where it can lead to tightness in the chest that is felt by the patient (11, 12). Also, the symptoms contain tame or severe shortness of breath (11, 12). And that will be repaird by having any vestigial lung disease and depending on the extent of the collapse in the lung (11, 12). In addition to that, pneumothorax symptoms may include quick heart rate, rapid breathing, cough, fatigue, and skin cyanosis (bluish color) because of decreasing in the oxygen levels in the blood (12). There are some risk factors that contribute in bring oning pneumothorax. Some of these factors are the gender and age of the patient where men age range between 20 and 40 years who are tall and thin are more likely to develop pneumothorax than women does (12, 11). More over, risks of pneumothorax are increased by cigarettes s moking, genetic factors where it can cause a certain type of pneumothorax, and history of previous pneumothorax (11). Any individual may develop another pneumothorax after two or three years of having an old one (11). It can be developed either in the same or the other lung (11). After discussing the risk factors of pneumothorax, complications will be now debated. Complications of pneumothorax resulted from an injury or a disease may include recurrence of pneumothorax and persistent air leak (11). This leaking air is resulted from the lung opening that fails to close where it considers surgery in order to close that leaking (11). And, in the discipline of severe pneumothorax, complications may involve cardiac ar equaliser, respiratory failure, low blood oxygen levels, and shock (11).-4-Pneumothorax can be identified or diagnosed by examining the chest using stethoscope where it shows the decreasing or the absent in the breathing sounds (12). This psychometric test can be supporte d by chest x-ray to confirm the macrocosm of pneumothorax (12, 11). In certain situations, computerized tomography can be used in order to shew exposit images (11). Regarding to the preaching of pneumothorax, itrely on the severity of the disease (11). The goal of this treatment is represented in relieving the pressure that lies on the lung, preventing recurrences, and give the lung its freedom to re-expand again (11). In case of small pneumothorax the treatment contains bed rest so that the collapse is not aggravated and it will be resolved by itself within one to two weeks (11, 12). While in case of larger pneumothorax, which is companion of underlying lung disease, chest tube is used (12, 11, 14). This chest tube is located between the ribs to the area that is filled by the air which compresses on the lung (11). The chest tube works on the removing that air from the chest cavity and it can be kept for hours or daylights (11). Chest tube may have some complications such as p ain, infection, hemorrhage, and fluid collecting in the lung (12). In certain situations, chest tube cannot do the desired job so that surgery is required (11, 12). Some of these situations are bronchopleural fistula (leaking that doesnt close), failure of lung re-expansion, and recurrent spontaneous pneumothorax (12, 11). Example of the surgical options involves thoracotomy (13). Pneumothorax aspect depends on two important things extent and type of pneumothorax (12). As mentioned before, small pneumothorax doesnt need treatment (12). just the other type (larger pneumothorax), leads to 15% of mortality rate so that it needs urgent and immediate treatment (12). Both types of pneumothorax create a recurrence rate rough40% (12). Shifting to another disease stage that also may requires thoracotomy. This-5-disease is haemothorax disease. Hemothorax is an accumulation of blood in the pleural cavity which is a space located between the chest wall and the lung (15, 16). The chief(pren ominal) cause that can leads to the development of hemothorax is a trauma to the chest (15, 16, 14). This trauma leads to a rupture for the serous membrane that covers the lung or line the thorax causing the leakage of blood to the pleural cavity (15). Other causes of hemothorax may include patients with a defect of blood clotting, placement of central venous catheter, death of lung tissue, lung or pleural cancer, and tuberculosis (15). This disease is associated by many signs and symptoms such as chest pain low blood pressure, rapid heart rate, shallow breathing, shortness of breath, and restlessness (16). Also, the symptoms may include tracheal which heart and soul a deviation to normal side, cyanosis, go downd or absent of breath sounds on the affected side, and adventure of subcutaneous emphysema (15). Every disease is accompanied by complications. In hemothorax, the complications that are associated with it may involve pneumothorax, shock, fibrosis or scarring of the pleur al membrane, and death. Hemothorax diagnosis can be through using several tests like chest x-ray, CT scan, pleural fluid analysis, and thoracentesis (16). After diagnosing hemothorax, immediate intervention should be taken to persist the bleeding and removing the blood from the pleural cavity (15). Removing that blood is the job of the chest tube which is inserted in the chest wall in a procedure that is tube thoracostomy (16, 15). The blood that is existing in the chest can be thickened and clot in the pleural cavity or within the chest tube (16). That will cause retained hemothorax in the plural cavity or gag rule of chest tube (16). As pneumothorax, if the chest tube fails in the mold of the bleeding, thoracotomy surgery is necessary in order to say-so and stop the bleeding (15). Regarding to the prognosis of hemothorax, it rely on the cause and the-6-quick treatment for hemothorax. If hemothorax doesnt be treated, the collected blood will place a pressure on the mediastinum and the trachea (15). And this pressure will play a employment in causing the deviation of trachea to normal side (15). Last disease that will be discussed is lung cancer. Lung cancer is a disease where an uncontrolled evolution of the cells in the lung tissue occurs (17). This disease is the leader of the death in 1.3 million men and women worldwide (17). In case of the cancer that develops in the airway, it can causes obstruction in the air flow leading to impediment in breathing (17). Because of this obstruction, the secretion will be accumulated and will cause pneumonia (17). Lung cancer can be caused by carcinogens like tobacco smoke that leads to synergistic effect and cause lung cancer. Also, viruses can cause lung cancer by affecting the cell cycle and by the inhibition of apoptosis which plays a role in the uncontrolled cell division. There are two main types of the lung cancer non-small-cell lung carcinoma and small-cell lung carcinoma. It is important to determine the type of the cancer because depending on that, the treatment will vary. Sometimes non-small-cell lung carcinoma is treated by a surgery that is called lobectomy in the early stage. While in small-cell lung carcinoma using chemotherapy and radiation are more effective and give better results. Having lung cancer is associated by some signs and symptoms. These signs and symptoms involve shortness of breath, hemoptysis that means coughing up blood, wheezing when listening to the chest, fatigue, and loss of appetite. Moreover, chest pain or abdomen pain, weight loss, dysphagia where the patient plaque hassle in swallowing, and dysphonia which means having a hoarse voice. This disease can be diagnosed by the chest radiograph and the CT scan. In order to detect the lung cancer early, examining of the patients sputum with other screening examination are necessary. Lung cancer treatment contains several ways-7-surgery, chemotherapy, and radiation therapy. For the prognosis of the lung canc er, it is poor for the both main types. There are some prognostic factors that may affect the prognosis. In non-small-cell lung cancer, these factors include the pulmonary symptoms, neoplasm size, cell type, and vascular invasion. And in the small-cell lung cancer, the factors are the performance status, gender, and the stage of the disease (17). All of these diseases may require thoracotomy surgery. Regarding the thoracotomy surgery here in Kuwait, the most common surgery that is performed normally during thoracotomy is the lobectomy surgery where it means removal of a whole lung lobe. Thoracotomies surgeries usually take 3 to 4 hours (8). During the procedure, the patient will be under general anesthesia and he will be lying on his side with an elevation of his artillery (7, 8). Then an incision will be made (7,8). If it is an anterior thoracotomy, the incision will be just from the base of the neck to the lower end of the sternum (7). And if it is a lateral thoracotomy, the in cision will be between two ribs from the front to the back where the ribs will be spread from each other (7, 8). In some cases part of the ribs will be removed (7,8).Lateral thoracotomyAnterior thoracotomyAfter that, chest tube will be inserted when the procedure is done in order to ensure and allow the blood and the air to get out from the chest (7, 8). Finally, stitches will be used to close the incision and the chest will be bandaged to avoid the infection (7, 8). Following thoracotomy, the patient will stay at the hospital for 5 to 10 days unless-8-complications have been developed (8). Some of these complications are bleeding, infections, blood clots, and severe pain (8, 7, 6). The risk of these complications may be increased by several factors such as previous fortuity or heart attack, age, trauma, and heavy smoking (8). AS any surgery thoracotomy patients will touch post-operative care. At the hospital, the patient will be on IV lines and tubes and he will receive antibioti cs, pain medicine, anti nausea drugs. And the patient will be referred to the physical therapy (8). After being discharged from the hospital, the patient moldiness follow some guidelines in order to help in early recovery. Some of these guidelines are alcohol addiction plenty of fluids, avoid smoking, and avoid environments that have germs or chemical irritants (8). Most of the patients are worried about returning to the work after the surgery. While working some activities should be avoided like lifting or pushing heavy objects until he completely recovers and the incision completely healed (8). Also, patient should avoid prolonged stand for several weeks (7). Moreover, the patient must contact his doctor in case of any of the following occurs difficulty in breathing, coughing up yellow, green or bloody mucus, severe vomiting, excessive bleeding and increase in pain (8).PT RoleBack to the role of physiotherapy, it is very important in enhancing the patients health after thoracot omy surgery. Physiotherapy interventions will cover three main areas chest care, general mobility, and home advices (18). Regarding to the chest care, any individual who is undergoing major surgery will develop chest problems (18). These chest problems will occur either if the patient has or has no history of smoking and chest problems (18). There are many reasons behind the development of these problems after thoracotomy surgery. These reasons include the anesthetic gases-9-where they work on increasing the amount of secretion production, making the patient breaths shallowly, and making the patient cough less effectively of the gluey secretion (18). Also, the physical process itself is one of these reasons. While performing thoracotomy surgery, the lungs are not fully inflated so that they need to be re-expanded following the surgery (18). Other reasons are the wound and the patient posture where the feeling of the discomfort may leads to the inhibition of the complicated breathi ng and coughing effectively, and the patients posture also leads to chest problems. Slumped posture whether it was in school term or lying can leads to the inability of taking full deep breath. In addition to all that reasons, decreased in the activity level of the patient considered to be one of the chest problem reasons. This decrease in the level of the activities after the operation can cause an accumulation of the secretion and the shallow breathing. In order to recover and prevent the chest problems, the physiotherapist will give the patient a vicissitude of breathing exercises like segmental breathing exercise and sustained breathing exercise. And these exercises must be done in the up right position. Also, physiotherapists will teach the patient the effective way of coughing in order to get rid of the secretion. In addition to that, the patient will be taught how to use the spirometer to increase the amount of inhaled and exhaled air. Moving to the general mobility that ca n also aids in the prevention of the chest problems and other complications. Following the surgery, physiotherapist will make the patient sit out of the bed in a chair to enhance and increase the depth of breathing. Then, the physiotherapist will work on making the patient walks as soon as possible. Walking exercises helps in the airway clearance, taking deep breath, and increasing the patients effectuality after thoracotomy surgery. Day by day the physiotherapist will increase the amount of walking. Also, shoulder mobility is one of the mobility-10-exercises that will be given to the patient. Shoulder mobility on the affected side is an important exercise that must be done after the surgery to help in the improvement of the range of motion and in the prevention of the joint stiffness. Moreover, physiotherapist will provide the patient with postural exercises and advices because he will fragile toward the operated side in order to decrease the pain. This leaning will lead to a nec k and back pain and stiffness. So being in the up right position will prevent that pain and stiffness. When its the time to return back home and being discharged, the physiotherapist will give the patient a home program. After being discharged, the patient must comprehend with the exercises that he was doing with the physiotherapist in the hospital. The patient must keep on doing the breathing exercisesto enhance the function of the lungs. Also, the patient must not stop the shoulder and the postural exercises so that the therapist makes sure that the movement will be maintained. Finally, the patient has to continue with the walking exercise and gradually increase its amount and he also can climb stairs to improve his strength (18). There are some studies that were done in order to prove the authorization of the physiotherapy post-thoracotomy surgery. Back in the year 2006, Ganzalo Varela and others did a study. This study was done to evaluate the influence of implementing a routi ne program of intensive chest physiotherapy on post operation respiratory unwholesomeness and hospital costs in a series of pulmonary lobectomy patients during thoracotomy. 639 patients were asked to stop smoking before 3 weeks from the surgery. Subjects were assigned into control and physiotherapy treatment group. Before starting the physiotherapy program, patients were encouraged by the nurses to walk and to perform deep breathing maneuvers using incentive spirometer. The physiotherapy program was started before one day of surgery till the discharge day.-11-During the physiotherapy program, the patients were using a treadmill and an ergometer bicycle under the supervision of the physiotherapist. Using the treadmill and the ergometer bicycle helps in performing an effective cough and deep inspiratory maneuvers. Also, the program contains arm and shoulder exercises to prevent upper extremity impairment. The outcomes that were studied were the occurrence of post operative pulmonary complications (pneumonia and atelectasis), post operative death, and the length of hospital stay. Regarding the length of stay, it was measured from the admission exit to the discharged date. The results of the study were positive. Concerning the mortality rate, it was lower in the physiotherapy treatment group (0.8% in physiotherapy group, 3.5% in the control group). And for the rates of thepneumonia and atelectasis, they were also lower in the physiotherapy treatment group. Rates of pneumonia were 5% in physiotherapy group, and 9.2% in the control group. For the atelectasis rates, they were 2% in the physiotherapy group and 7.7% in the control group. Finally concerning the length of stay, its median was 5.73 days (range, 3-22 days) in the physiotherapy group and 8.33 days (range, 3-40 days) in the control group (19). Another study was done in the year 2008, in order to look for the physiotherapy forte in the reduction of the post operative pulmonary complications, pain, and len ght5 of stay. The subjects were assigned to a group that receive physiotherapy treatment or a group that receive an information sheet only. And the results of the study were proving the effectiveness of physiotherapy interventions (20).-12-ConclusionAccording to the previous discussion and studies, the physical therapy has a role in preventing and treating the patients problems post- thoracotomy surgery. From the preventive side, the physiotherapists work on eliminating, decreasing, and preventing the impairments and the limitations of the patients activity. These limitations and impairments can be developed after the surgery if there was no care or if they have been neglected. Because of that, the physiotherapists are taking these preventions in order to limit those limitations and impairments. And from the treatment side, the physiotherapists are giving the patients treatment exercises that help in solving and treating the complications that already develop after thoracotomy or an y surgery. These complications are the chest problems either it was secretion production, decreased chest expansion.-13-