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Chest Physical Therapy in Surgery Key point The major high-risk factors for developing PPC include: Advanced age Smoking Obesity Obstructive pulmonary disease REVIEW Chest physical therapy in M. Fagevik Olsén surgery: a theoretical model about Dept of Physical Therapy Sahlgrenska University Hospital who to treat S-413 45 Gothenburg Sweden Fax: 46 313424341 E-mail: monika.fagevik- Educational aims [email protected] To highlight high- and low-risk factors for PPC. To present overview data showing how the respiratory system is affected by different surgical interventions. To present a model to determine which treatment is most suitable for each individual patient. Summary Chest physiotherapy is common for patients undergoing different types of surgery in order to avoid PPC. However, do all patients require treatment, is it possible to predict those patients at risk and is it possible to select the optimal treatment for each patient? This paper aims to address these questions and to propose a model that can be utilised for determining how much physical therapy is needed. Since the early 1900s, physiotherapists physiotherapy, but, during development, new have treated surgical patients to prevent treatments and regimens have been created. post-operative pulmonary complications (PPC) Different manual treatment methods, includ- [1]. Chest physiotherapy originated in the UK ing percussion, clapping, vibrations and and, in 1915, one of the first articles was pub- shaking, have been, and in some parts of the lished describing breathing exercises to restore world still are, common [3, 4]. Position chang- respiration following damage to the pleura, ing for bronchial drainage to decrease the risk lung and diaphragm [2]. The techniques of atelectasis is another method employed for included deep breathing exercises in the recum- the prevention of pulmonary complications bent position and, if necessary, with the body [3–5]. bent laterally away from the injured side. The Over the last few decades, treatments have treatment required support from an “operator” changed, becoming more active, whereby the who, for example, placed his or her hands on patients are encouraged to carry out a larger the area of the thorax where the collapse was. part of the training by themselves [6, 7]. The use The earliest time at which the exercises were of deep breathing exercises has developed with commenced was 5 weeks from the day of the the introduction of different breathing devices, injury [2]. including incentive spirometry and positive These techniques, albeit modified, have expiratory pressure (PEP), to facilitate breath- been used since the conception of chest ing post-operatively and to accelerate the Breathe | June 2005 | Volume 1 | No 4 309 REVIEW Chest physical therapy in surgery return to pre-operative respiratory status [6–9]. Risk factors Figure key Another development in the care of post-opera- ■ Hysterectomy n=20 tive patients is the change of routines concerning Patients undergoing surgery are at varying risks of ■ Bowel n=82 mobilisation. The previous long-term immobility developing PPC. Some of the major contributing ■ Fundoplication n=35 ■ Upper gastrointestinal after surgery has been replaced by early mobi- factors are listed as follows. n=32 lisation, which is now a main aim of treatment [2, ■ Gastroplasty n=47 10]. ■ Heart n=55 To avoid PPC, patients undergoing major sur- Advanced age ● Thoracoabdominal n=35 gery often receive pre-operative information from The pulmonary system changes during adult life- ● Laparoscopic hysterectomy n=20 a physical therapist, including breathing exercis- time. For instance, closing volume and functional ● Laparoscopic es with or without breathing devices, techniques residual capacity (FRC) increase linearly with age fundoplication n=20 for facilitating mucus flow (e.g. forced expiratory and closing volume exceeds expiratory reserve ● Laparoscopic vertical technique) and the importance of early mobilisa- volume, giving rise to smaller airway collapses in banded tion. Post-operatively, treatment continues persons aged ≥44 years in the supine position gastroplasty n=20 ● Laparoscopic gastric according to the patient’s respiratory status. and at ~65 years in the sitting position [11, 12]. bypass n=20 However, do all patients require treatment, Many trials confirm that the older the patient and and is it possible to predict those patients at risk the greater the surgical procedure, the greater the and thereby select the optimal treatment for each morbidity and mortality after major surgery. The A key for figures 1–3 showing all lines with the associated patient? The aims of this article are to point out high-risk age level is reported to be from 55 years operation and number of high- and low-risk factors for PPC, present [13]. patients studied. overview data showing how the respiratory sys- tem is affected by different surgical interventions and to present a model to determine which treat- Smoking ment is most suitable for each individual patient. Smoking causes major changes in the pulmonary system, e.g. reduction in lung capacity, increased shunt, production of mucus and impairment of 100 the normal mechanics of mucus clearance, such ■ ■ ■ as ciliary activity, leading to productive coughing 98 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ [4, 14]. There is a connection between frequent ■ ■■ ■ 96 ■ ■ ■ smoking and increased risk of PPC [12], and a ■ ■ ■ % ■ 2 ■ level of >20 pack-years (1 pack-year = 1 package 94 ■ ■ a,O ■ a day for 1 year) has been suggested to imply a S ■ 92 higher risk of PPC [15]. ● ● 90 ● 88 Figure 1 Pre-op 1 2 3 5 6 ■ Sa,O2 before and after different 100 ● open procedures. Time days 90 ■ ■ ●■ 80 100 ● ■ ■ ■ 70 ● 90 ■ ■ ■ ■ ● ● ■ ● 60 ■ 80 ■ ■ ● ■ ● ● ■ ● ■ ● 50 ■ ● 70 ■ ● ■ ■ ● ■ ● ■ 40 ● 60 ● ● ■ values pre-operative PEF % of ■ ■ ● 30 50 ■ ■ Pre-op 1 3 6 ● Time days 40 ● Figure 2 ● FVC % of pre-operative values pre-operative FVC % of Figure 3 Changes in FVC after different 30 Changes in forced PEF after different open and open and laparoscopic Pre-op 1 3 6 procedures (pre-operative value Time days laparoscopic procedures (pre-operative value is is 100%). 100%). 310 Breathe | June 2005 | Volume 1 | No 4 Chest physical therapy in surgery REVIEW Obesity activity. Immobilisation leads to decreased lung Obesity is defined as a body mass index (BMI) volumes, which increases the risk of developing >30, and very severe obesity as a BMI >40 [16]. PPC; the less erect the body is, the lower the gas Obesity impairs lung volumes, decreases respira- level in the lungs [5]. However, during slumped tory compliance and increases respiratory sitting, lung values are equivalent to those in the resistance [17–19]. Obese subjects have been supine position [26]. Mobilisation is also an reported to have up to twice the normal total re- important treatment in evacuating sputum, spiratory work values [19]. In the post-operative which accumulates during the period of impaired period, the decreased ventilation in overweight ciliary activity [4]. persons implies a higher risk of development of PPC compared to persons of a normal weight [13, Pain 20, 21]. It is well known that post-operative pain limits the ability to take deep breaths and to be active; how- Obstructive pulmonary diseases ever, even after adequate pain relief, the Obstructive pulmonary disorders affect the re- impairment of pulmonary function is still consid- spiratory system by causing inflammation in the erable, leading to the hypothesis that there is a airways, mucus hypersecretion and bron- non-analgesic-dependent dysfunction of inspira- chospasm [4]. The airway obstruction includes tory and expiratory muscles after upper both reversible factors, such as inflammation, abdominal surgery [27, 28]. Some analgesics, bronchospasm or mucus plugging, and ir- such as morphine, also cause a dose-related ven- reversible factors, such as fibrotic airway walls or tilatory depression [27]. damaged alveoli [4]. Patients suffering from active obstructive diseases are, therefore, at a high risk of developing PPC after major surgery [13]. Respiratory changes Operation site and risk of PPC Abdominal surgery is associated with a higher risk How extensive are the changes in lung function, of PPC than non-abdominal surgery, e.g. and how high is the risk of developing PPC when orthopaedic surgery, and upper abdominal sur- consecutive series of patients undergoing abdom- gery implies a higher risk than lower [13, 21, 22]. inal and/or thoracic surgery are followed after Upper abdominal surgery induces a marked surgery? diaphragmatic dysfunction lasting ~1 week post- Over a period of 13 years, a series of trials operatively and is not affected by pain relief. The including different types of surgery have been per- cause of the dysfunction has been suggested to formed at Sahlgrenska University Hospital be the main cause of the post-operative restrictive (Gothenburg, Sweden). Respiratory function and Figure 4 pulmonary pattern [23, 24]. risk of PPC were initially evaluated after upper Risk of PPC after changes in FVC abdominal surgery: gastroplasty; fundoplication; after different open and Duration of anaesthesia/surgical bowel procedures; and a miscellaneous group, laparoscopic procedures. procedure The longer the anaesthesia lasts, the higher the morbidity and mortality rate [13, 22]. An import- 100 ant factor is that more complicated surgery is 90 associated with a longer duration of anaesthesia 80 [22]. WIGHTMAN [25] discusses this in a trial where 70 the incidence of PPC was higher in patients whose 60 operation lasted >30 minutes, but, after further 50 analysis, the group had a higher incidence of PPC PPC % 40 independent of the duration of the operation. The 30 result was assumed to be related to the type of 20 operation performed rather than the length of 10 anaesthesia. 0 nd. yst. eart Fu H Bowel Post-operative immobilisation H Lap. GBP Surgery is, in most cases, followed by a post-opera- Gastropl. Lap. VBG Thoracic Upper GI Lap. hyst. tive phase of immobilisation and decreased Lap. fund. Breathe | June 2005 | Volume 1 | No 4 311 REVIEW Chest physical therapy in surgery including gastrectomies, whipples and different A gynaecological ward kinds of pancreas surgery [20].
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