Chest Physiotherapy

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<p>Chest Physical Therapy for the Postoperative or Traumatic Injury PatientCOLLEEN M. KIGIN, MS</p> <p>Techniques of chest physical therapy have been used since the early 1900s to decrease postoperative pulmonary complications. Through investigations since the 1950s, documentation as to the efficacy of chest physical therapy in actually reducing postoperative pulmonary complications has been published. However, the careful documentation of techniques employed (such as full Trendelenburg's position versus a modified position and vibration of particular force and fre quency) has not been done. Also, because of an inability to specify the risk factors of postoperative pulmonary complications occurring in particular pa tients or to qualitate the occurrence of these complications, it is difficult to establish what treatment is most efficacious. This article is a critical review of investigations to date with recommendations for further research stemming from this review. Key Words: Respiratory dysfunction, Treatment techniques, Physical therapy.</p> <p>Operative procedures and the care of trauma victims have been recorded for centuries, with open chest surgery performed in Galen's time.1 As a result of advances over the past two centuries in mechanical ventilation, anesthesia, and infection control the estimated number of surgical procedures in the United States in 1979 was 23,858,000. Included in this number were 445,000 cholecystectomies, 166,000 open heart operations, and 813,000 respiratory procedures.2 The incidence of trauma has also been increasing in the United States and, in 1979, accounted for 65,000 hospital beds, and 22,000,000 bed days.3 Although operative procedures are vast in number, sophisticated in techniques, and remarkable in results, they continue to harbor significant risks. Respiratory failure is either a major cause or a major contributing factor in 50 percent of postoperative deaths.1 Treatment to prevent or modify respiratory complications has been a major focus of care for the operative patient. Since 1915, physical therapy has been widely used to prevent or reverse respiratory complications of surgery and trauma.4-9 The purpose of this paper is to review physical therapy used for postoperative or traumatic injury patients. This review will define and critically review postoperative pulmonary complications (PPC), and evaluative and therapeutic procedures used for the above types of patients. Needed investigations in chest physical therapy (CPT) will be proposed.</p> <p>Miss Kigin is Director, Chest Physical Therapy and Co-Director, Respiratory Care, Department of Anesthesia, Massachusetts General Hospital, Boston, MA 02114 (USA).</p> <p>POSTOPERATIVE PULMONARY COMPLICATIONS Anesthesia and medication result in some degree of respiratory depression in postoperative patients.10 Transient hypoxemia, first noted by Overholt in the 1930s, is a common finding in the early postoperative hours.11, 12 Supplemental oxygen, deep breathing, and coughing are routinely used to prevent PPC. Despite these preventive efforts, patients develop PPC (including atelectasis, which makes up 90 percent of PPC).1 Pasteur, in 1908, was the first to recognize atelectasis in the postoperative patient.13 Atelectasis, of Greek derivation meaning lack of expansion, is synonomous with alveolar collapse. Palmer stated, in 1952, that atelectasis was the most common PPC and it remains so today.14, 15 The primary causes of atelectasis include hypoventilation caused by obstruction of airways by secretions, decreased activity of the respiratory muscles, and decreased expiratory reserve volume.15 Preoperative medications, anesthetic agents, and drugs given in the intraoperative period decrease lung compliance, which contributes to diminished lung volume and atelectasis.16 Because surgery of the extremities results in fewer PPC than do abdominal and thoracic procedures, it appears that anesthesia is not the primary cause of postoperative atelectasis.17 Other factors that may contribute to atelectasis include supplemental oxygen delivered to a patient at low lung volumes,18 increased abdominal girth that restricts lung expansion,17, 19 and changes in negative pressure in the thorax.20 PHYSICAL THERAPY</p> <p>1724</p> <p>Physiologic changes resulting from atelectasis include increased alveolar surface tension caused by deficient amounts of surfactant in the atelectatic area. 20, 21 Surfactant, produced by type II pneumocytes, improves lung compliance, which decreases the need for high inspiratory pressures. 22 With persistent atelectasis and the subsequent decrease in surfactant, increased inspiratory pressures are needed to reinflate the atelectatic area. 23 Although atelectasis is not an infective process, prolonged atelectasis and decreased mucociliary transport can result in bacterial infection, or pneumonia. 17, 21 A summary of postoperative pathophysiologic changes outlined by Tisi is found in Table l. 15 Other PPC, less common than atelectasis, are pneumonia, aspiration, adult respiratory distress syndrome, and pulmonary embolus. 19</p> <p>TABLE 1 Postoperative Pathophysiologic Changes in the LungFactors Mea sured Lung Volume TLC Type sur gery Thoracic Abdomi nal upper lower Extrem ity Ventilatory Pattern VC Changea ERV RV</p> <p> no TV</p> <p>(50-70%) (5-40%) no RR</p> <p>( 60%) ( 25%) no Compli ance</p> <p>FACTORS CONTRIBUTING TO PPCTisi, in 1979, divided into four groups the factors contributing to PPC (Fig. 1). 15 A patient with one or more of these factors is considered at high risk for developing PPC. Although the figure offers predisposing characteristics, no criterion has 100 percent sensitivity. Peters noted, in 1980, that the diversity of criteria for high risk classification adds to the variety of conclusions from studies of PPC. 24 A variety of signs and symptoms can identify PPC. Some authors choose only one criterion (radiography), 6, 14 others choose a combination of factors (radiography, temperature changes, breath sound changes, and pulmonary function changes). 5, 8, 25-32 These variable criteria for PPC result in widely differing complication rates for similar patients. Table 2 summarizes the criteria and incidence of PPC. 33 Gas Ex change</p> <p>Sigh Mecha nism</p> <p>Po 2</p> <p>A-aPo 2</p> <p>TLC = VC = ERV = RV = TV = RR = Po2 = A-aPo2 = = = no =a</p> <p>total lung capacity. vital capacity. expiratory reserve volume. residual volume. tidal volume. respiratory rate. partial pressure of arterial oxygen. alveolar to arterial oxygen gradient. increase. decrease, no change.</p> <p>TREATMENT OF PPCA variety of treatments has developed through the years, but as recently as 1980 there was no consensus of the superiority of any procedure for the nonintubated patient. 24, 33 The literature offers no more definitive information for the intubated patient group than it does for the nonintubated. This article will provided discussion about investigations in both groups.</p> <p>tential respiratory complications in the patient with chronic lung disease and the patient undergoing thoracic surgery. Weighting of high risk factors has been attempted to identify preoperatively the patient likely to develop PPC. 17 The results, however, were not conclusive. L General Factors smoking history obesity age (&gt;50) II. Disease Related Factors history COPD including emphysema and bronchitis history restrictive lung disease including neuromuscular disease HI. Type Anesthesia (listed least risk to greatest) general anesthesia spinal anesthesia IV. Type Surgery (listed least risk to greatest) nonabdominal, nonthoraeic (</p>


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