post operative physiotherapy management for flail chest or multiple ribs fracture or...
DESCRIPTION
Dr.Senthil Kumar, BPTTRANSCRIPT
1
POST OPERATIVE PHYSIOTHERAPY
MANAGEMENT FOR FLAIL CHEST
SUBMITTED BY: D. SENTHIL KUMAR
A Project work submitted to
THE TAMILNADU DR. MGR MEDICAL UNIVERSITY,
CHENNAI
in partial fulfillment of the requirements for the degree of
BACHELOR OF PHYSIOTHERAPY
AUGUST 2010
2
ACKNOWLEDGEMENT
First I would like to thank my Almighty God for his blessings to complete my project on
POST-OPERATIVE PHYSIOTHERAPY MANAGEMENT FOR FLAIL CHEST
successfully.
I also like to thank Dr. P. M. NARGUNAM, M.D (O&G) Managing Director for
providing good infrastructure and all facilities in our college.
I am grateful to thank our principal Dr.S.MAHESH, M.P.T (O&G), M.I.A.P for his
guidance and encouragement.
I also thank my guide Dr.V.KAMALASEKARAN B.P.T M.I.A.P for guiding me to
complete my project successfully.
My special thanks to my staff Dr. S.KALPANA B.P.T., M.I.A.P M.sc for his invaluable
support.
I thank our Librarian Mr. P. BOOPATHI, B.A, M.L.I.Sc, M.B.A who has helped me in
getting the reference books and materials for my project.
I take immense pleasure in extending my sincere thanks to my Parents
Mr. M.DHANAPAL and Mrs.D.MYTHILI who have helped and encouraged me to complete
my project work in success.
I also thank my Brothers Mr. C.GOPI KRISHANAN, Mr. S.JAI SELVAKUMAR,
Mr. N.MAHARAJA, Mr. V. KARUPPAN V. ISSAC, M. RAJESHKUMAR, and sister
D.GAYATHRI, for their support.
I wish to express my hole hearted thanks to MY FRIENDS for their timely help &
support.
3
CONTENTS
SL.NO TITLE PAGE NO.
1 INTRODUCTION 4
2 ANATOMY 5
3 PHYSIOLOGY 9
4 DEFINITION 14
5 AETIOLOGY 16
6 TYPES 17
7 CLINICAL FEATURES 19
8 INVESTIGATION 22
9 MANAGEMENT 24
10 PHYSIOTHERAPHY ASSESSTMENT 34
11 PHYSIOTHERAPHY MANAGEMENT 37
12 REHABILITATION 56
13 CASE STUDY 50
14 CONCLUSION 65
15 BIBLIOGRAPHY 66
4
INTRODUCTION
Trauma or Injury to the human body has been a challenging situation even to
the prehistoric man. The scope for getting injured has increased with the development
of industry, agriculture and transportation to such an extent that epidemiologically,
trauma is becoming one of the biggest killers and maimers of human beings all over
the world.
A fracture is defined as break in the structural continuity of bone. In my studies
I explained about FLAIL CHEST , it is refers to a section of the rib cage that has
broken away from the surrounding ribs .it is more common in the elderly persons. It
will occur due to chest trauma.
It is a life threating medical condition. After the post – surgery, physiotherapy
role is very important.
Physiotherapy in its various forms occupies an important place in the post –
operative treatment of various cardio-thoracic conditions. In this study, I explained
about the Anatomy and physiology of the flail chest. After that, I explained how to
give a valuable therapy to the patient by using various techniques. After that, the
complications are explained which will be produced by the flail chest. Finally, the
rehabilitation and home programme will be admist by the therapist.
5
ANATOMY RIB CAGE
Thorax forms the upper part of the trunk of the body. It permits boarding and
lodging of thoracic viscera thorax is supported by skeletal frame work and its called as
RIB or THORACIC cage. The chest wall is inherently stable with twelve Ribs
attached posteriorly to the spinal column and anteriorly to the sternum.
STERNUM
Is a flat bone forming the anterior median part of the thoracic skeleton? The
upper part corresponding to the handle is called manubrium. The middle part
resembling the blade is called the body. The lowest tappering part is xiphoid process
or xiphi sternum.
THE MANUBRIUM It is quadrilateral in shape. It is the thickest and strongest part of the sternum.
It has two notches they are jugular notch or supra sternal notch and clavicular
notch.
BODY OF STERNUM
The body is longer, narrower and thinner than the manubrium. It has two
surfaces anterior and posterior. Two lateral borders and two ends upper and lower.
XIPHOID PROCESS
It is smallest part of the sternum. It varies greatly in shape and may be bifid or
perforated. It lies in the floor of the epigastric fossa.
6
ANATOMY OF THORACIC CAGE
7
THE RIBS (COSTAE)
There are twelve ribs on each side forming the greater part of the thoracic
skeleton. The ribs are bony arches arranged one below the other between each rib
there is gap called inter costal space.
The upper ribs are less oblique than lower ribs. The first seven ribs are
connected with the vertebral column behind and with the sternum in front by means of
the costal cartilages.
The first seven ribs are called true to vertebro sternal ribs. The remaining five
ribs are called false ribs. The cartilages of 8th & 9thand 10th ribs join to next higher
cartilages they are known as vertebrochondral ribs.
The 11th and 12th ribs are free anteriorly and called as floating ribs or vertebral
ribs. The first two and last three ribs have special features and typical ribs the third to
9th ribs are typical ribs.
TYPICAL RIBS
It includes head, neck, tubercle and costal cartilages. The shaft is flattened and
curved. The shaft extends anteriorly towards these sternal ends for the costal cartilage.
The costal groove runs along the inferior surface of the rib.
8
ATYPICAL RIBS
FIRST RIB
Anterior end is larger and thicker, posterior end is comprises the head, neck,
tubercle and shaft.
SECOND RIB
The length is twice of the first rib. Shaft is sharply curved. Non-articular part of
the tubercle is small.
TENTH RIB
It closely resembles atypical rib, but it is shorter and is only a single facet on the
head, for the body of the tenth thoracic vertebra.
ELVENTH AND TWLEVETH RIBS
They are short, have pointed ends, the neck and tubercle are absent. The angle and
costal groove are poorly marked in the eleventh rib and are absent in the 12th rib.
9
PHYSIOLOGY
RESPIRATORY MOVEMENTS:
The lungs expand passively during inspiration and retract during expiration.
These movements are governed by the following two factors.
1. Increase in volume of the thoracic cavity creates a negative intra
thoracic pressure which sucks air into the lungs.
2. Elastic recoil of the pulmonary alveoli and of the thoracic wall expels
air from the lungs during expiration.
PRINCIPLE OF MOVEMENTS:
1. Each rib may be regarded as a lever, fulcrum lies lateral to the tubercle.
Slight movements at the vertebral end are greatly magnified at the anterior end.
2. Anterior end moves forward during elevation. This occurs in vertebrosternal
ribs. In this way anteroposterior diameter of the thorax is increased.
3. Along with the up and down movements of the 2nd to 6thribs, the body of
the sternum also moves up and down called "Pump handle movements".
4. During elevation of the rib, the shaft moves outwards. This occurs in the
transverse diameter of the thorax. Such movements occur in the vertebrochondralribs
and are called "Bucket handle movements".
5. Each ribs are longer than the next higher ribs. On elevation the larger lower
rib comes to occupy the position of the smaller upper rib. This also increases the
transverse diameter of the thorax.
10
MECHANICS OF RESPIRATION
11
VENTILATION
During inspiration, chest wall expands, intrapulmonary pressure falls and
becomes sub atmospheric and air from the atmosphere enters the lung. During
expiration, chest wall and the lungs shrink, intrapulmonary pressure rises and air is
forced to leave the lung. Therefore, thoracic cage expands and shrinks causing
inspiration and expiration. Thus expansion and shrinking of the thoracic cage and
lungs is called ventilation.
MECHANISM OF VENTILATION
Muscles of inspiration contract cause expansion of the thoracic cage. When the
chest wall expands the parietal pleura also tries to move along with the expanding
chest wall. In between visceral and parietal there is a thin layer of intrapleural fluid.
Because of this both the layers cannot be separated. So when chest wall
expands, visceral pleura also moves and tries to drag the lung. Lung expands due to its
elastic properties but during inspiration intra pleural pressure become more negative.
This expansion of the lung causes the dilation of the airway and alveoli system.
Within the alveoli, pressure becomes sub atmospheric. Airway tube is in direct
communications with the external atmosphere. Therefore when the intrapulmonary
pressure falls, a pressure gradience develops, air enters from the external atmosphere
into the lung.
This flow continues until intrapulmonary pressure becomes equal to the
external atmospheric pressure. This is inspiration. The muscles of inspiration stop
contracting and the lung shrinks. Intrapulmonary pressure rises and the air leaves the
12
lung. The outward continues until the intrapulmonary pressure becomes equal to the
external atmospheric pressure, this is expiration.
LUNG VOLUME AND LUNG CAPACITIES
LUNG VOLUME
TIDAL VOLUME {VT}
Tidal volume is the volume of air inspired or expired by an individual
Per respiratory exertion at rest.
Tidal volume of the young healthy adult is about 500ml.
From top end of a tidal volume inspiration phase, the subject makes a maximal
inspiratory effort. The extra air that is drawn in is the inspiratory reserve volume.
Normal value is about 2000 to 3000ml.
EXPIRATORY RESERVE VOLUME {ERV}
From the end expiratory position of the tidal volume breathing, the subject
makes the hardest expiratory effort. The extra air that comes out is the expiratory
reserve volume.
Normal value is about 1000ml.
RESIDUAL VOLUME
After even the severest expiratory effort, the lungs still contain some air, called
residual volume.Normal value is about 1500ml.
LUNG CAPACITIES
13
Inspiratory capacity {IC} = IRV + VT.
Functional residual capacity {FRC} = ERV + RV.
Vital capacity {VC} = IC + ERV.
VITAL CAPACITY {VC} or FORCED VITAL CAPACITY {FVC}
It is the volume of air breathed out by a forcible expiratory effort after a
maximal inspiration.
VC = IC + ERV
= [2500ml+3500ml] 1000ml
=3.5 to 4.5litres approximately.
The Forced expiratory volume for one second [FEV1] is the forced vital
capacity that is recorded during the first second.
TIMED VITAL CAPACITY
The term timed vital capacity means the percentage of the total VC which is
expelled in 1st, 2nd or 3rd second.
TOTAL LUNG CAPACITY {TLC}
The term total lung capacity means when all the capacities are added together.
TLC =IC + FRC
Normal value is 5.5 litres.
14
FLAIL CHEST
DEFINITION:
The chest wall moves inward with inspiration, such as multiple rib fractures.
- DONNA FROUNFELTEER
Multiple fractures of ribs can result from direct violence which may occur in a road
accident or similar trauma. - AM THOMSON
Blunt injury to the chest can result in the fracture of one or more ribs.
- BARBARA A. WEBBER
15
FLAIL CHEST
16
AETIOLOGY:
Life-threatening chest injury
Pulmonary injury
Significant blunt trauma
Motor vehicle accident
Kinetic force to chest wall and rib cage
Osteoporosis, total sternectomy and multiple myeloma
Bone disease or deterioration in older patients (Very rare)
CHEST WALL INJURIES CASES FILED IN G.H
[233 cases: Closed injuries -210&open wounds -23]
17
TYPES
LATERAL TYPE:
Multiple ribs are fractured anterior and posterior
ANTERIOR TYPE:
Anterior ends of ribs are fracture on both sides, so that the sternum along with
anterior fragment of ribs becomes floating segment.
[ANTERIOR TYPE OF FLAIL CHEST]
18
POSTERIOR TYPE:
Multiple ribs are fractured at their posterior angles, so that spinal column along
with posterior fragments becomes floating segment.
[POSTERIOR TYPE OF FLAIL CHEST]
19
CLINICAL FEATURES
Paradoxical motion
Chest Pain
Sharp pain
Decrease in breathe sound
Shallow rapid respiration
Shortness of breathe
Difficulty drawing breathe
Dyspnoea
Uneven chest expansion
Tachycardia
Cyanosis
Brusises
Tachypnea
Discoloration of the chest area
PARADOXICAL MOTION:
The characteristics paradoxical motion of the flail segment occurs due to
pressure changes associated with respiration that the rib cage normally resists.
The ambient pressure is comparison to the pressure inside the lungs. It goes in
while the rest of the chest is moving out and vice versa.
20
[PARADOXICAL MOTION]
EFFECTS OF PARADOXICAL RESPIRATION:
Imperfect ventilation leading to hypoxia
Mediastinal flutter – media sternum move towards the sound side during
inspiration and towards affected side during expiration
Movement of media sternum severe shock
Stagnation of air
Accumulation of broncho pulmonary secretion
Post traumatic insufficiency or wet lung occurs
21
INTERNAL CHANGES OF FLAIL CHEST
CHEST PAIN
May also be due to rib fractures, strain of the intercostal muscles or tumors of
the ribs.
CYANOSIS
This is the name given to blue colour of the skin and mucous membranes. There
are two types, peripheral and central.
Peripheral Cyanosis
It is due to reduced blood flow through the peripheries and is associated with cold
extremities.
Central Cyanosis
It is due to reduced oxygen saturation of the arterial blood. It is noticed in the
tongue, lips and ear lobes and it is associated with warm extremities.
DYSPNOEA
This is a state of disordered breathing, in which the patient has an unpleasant
awareness of difficulty in breathing.
22
INVESTIGATION
PHYSICAL EXAMINATION
Pain
Breathing problems
Paradoxical movement of chest wall
Unstable chest wall
Abnormal chest movement during respiration
This shows the evidence of paradoxical movements of chest wall. Brushing,
gazes or seat belt sign are visible. On inspection, and palpation may reveal the crepitus
associated with broken ribs.
CT SCAN
Computerized Tomographic scanning has an occasional but important place,
particularly in the investigation of fracture of thoracic cage.
These have been found to provide very little additional useful information for
initial evaluation of chest wall injuries
CHEST X-RAY
The antero-posterior chest radiograph will identify most significant chest wall
injuries, but will not identify all rib fractures.
Lateral or anterior rib fractures will often be missed on the initial plain film.
23
Underlying injuries ray (anteroposterior and lateral views) can assist with the
diagnosis of rib fractures and such as pneumothorax (air in the pleural cavity),
haemothorax (blood in the pleural cavity), atelectasis (collapse of lung tissue
leads to absence of gas from part or all of the lungs), pneumonia or lung
contusions.
Negative X-rays do not necessarily exclude fractures that occur in the
cartilaginous portion of the ribs, therefore physical symptoms must also be
taken into consideration when making a diagnosis.
MRI:
Provides superior soft tissue contrast in multiple imaging planes and is used to
examine the musculoskeletal, central nervous system and cardiovascular systems.
Images are better at identifying soft tissue pathology but anatomical detail less
clear. Fluid appears bright.
24
MANAGEMENT
CONSERVATIVE MANAGEMENT
DRUG THERAPY
Treatment of the flail chest initially, follows the principles of
ADVANCED TRAUMA LIFE SUPPORT.
Adequate good analgesia avoiding narcotic analgesics is of paramount
importance in patient recovery and may contribute to the return of normal respiratory
mechanics.
If analgesia is ineffective inter-costal Nerve blocks or morphine infusion may
help control pain.
Mild analgesics- Paracetamol
Pethidine -50-100mg
Morphine sulphate- 10mg
Diamorphaine- 5mg
25
SURGICAL MANAGEMENT
TRACTION FOR A FLAIL CHEST
26
SURGERY POSITION AND INCISION:
Antero –lateral flail chest injuries are approached with an antero-lateral
thoractomy with the patient in a supine position with both arms abducted 90 degrees.
Posterior –lateral flail chest are approached with an posterior – lateral
thoracotomy with the patient in lateral decubitus position and the arms abducted 90
degree.
A variety of surgical techniques have been reported in the past to stabilize the flail
chest.
1. External towel clip traction (high risk of osscous and soft tissue infections)
2. Application of over lapping rib struts
3. Intra-medullar wiring
4. Mechanical relief of fracture ribs also done by a plate and screws, but this
surgical approach may be difficult to perform in a case of osteoporosis or bone
fragmentation that can be present over a trauma.
SEAGULL WING PROSTHESIS:
The stabilization of fragmented bones is obtained by a self -retaining sea gull
wing prosthesis inserted under a sternum, with the wings allocated over the adjacent
ribs.
We use this technique in two cases of flail chest
Anterior flail chest
Lateral flail chest
ADVANTAGE:
27
This allows a fast recovery of the bone and an easier weaning from the mechanical
ventilation.
I. This does not require screws or other hardware to fix.
II. Can be easily removed after the completion of bone fixation (4 to 6 months
later)
Osteosynthesis:
Once both ends are fracture line re-expose, osteosynthesis is accomplished by
with metal plates.
[OSTEOSYNTHESIS]
TYPES OF PLATE:
Sanchez-Lloret is the rib segment stretching the lateral hooks as previous described
for Judet plates (Are frequently used). On plate is placed, it is reinforced with a heavy
“adsorbable polyfilament” suture at each ribs.
[JUDET PLATES] [SANCHEZ PLATES]
28
[SURGICAL STABILIZATION OF TRAUMATIC FLAIL CHEST]
Surgical stabilization was preferred by the patients rib fractures injuries. Ideal
when chest wall continuity must be restored.
The length of the blades metal hooks must be carefully chosen to adapt to the rib
size.
29
TYPE OF INCISION :
Posterolateral or anterolateral chest wall incision
[ANTEROLATERAL CHEST WALL INCISION]
MUSCLES INVOLVED
Trapezius
Rhomboid
Latissimus dorsi
Serratus anterior
Internal and external intercostal
30
CHEST DRAINAGE
The purpose of drains in thoracic surgery is to remove fluid or air which
expected to accumulate. Drainage may be closed or open.
CLOSED DRAINAGE
A tube with end and side holes isintroduced into the thorax via an intercostal
space. It is connected to a closed bottle via a transparent tube which ends water.
A second short tube left unconnected maintains atmospheric pressure in their
bottle. This arrangement provides a simple one-way valve. If the short tube is
connected to a suction apparatus the air pressure with the bottle will be reduced below
atmospheric. If sufficient suction is applied the negative pressure which exists
between the lung and the chest wall will be increased. The calibrated bottle allows for
easy measurement of blood loss.
The drainage bottle should be kept at a lower level than that of patient’s chest
to prevent siphoning of fluid and back into pleural cavity. After other types of lung
desection two drains, one placed at the apex of the pleural cavity and the other at the
base are used.
OPEN DRAINAGE
A tube in the pleural cavity connects directly to the air. This arrangement is
only safe when the pleural cavity has become rigid and immobile. This is used only to
drain achronic empyma where infection is localized from the rest of the pleura by
fibrosis. This is a rarely indicated following pulmonary surgery.
31
MECHANICAL VENTILATION
Mechanical ventilation can be effective immediately after trauma to assure a
cardio respiratory stabilization and can be prolonged in patients with associated
broncho pulmonary disease, but a fast weaning from the ventilation is preferable if a
surgical fixation can be done.
HUMIDIFIER
Humidification is the moistening of the air or gases we breathe. Artificial
humidification is essential for the maintenance of adequate ventilation.
During normal respirations the inspired air is warmed and humidified by the
mucus membranes so that it is fully saturated at body temperature when it reaches the
trachea. If there not sufficient moisture available to replace that used up in
humidifying the inspired air, cilial activity is decreased. Dehydration also makes the
bronchial secretions thick and viscid. The combination of these tenacious secretions
with depressed cilial activity makes expecotoration difficult.
Humidity is the invisible moisture or water in the form of individual molecules
in its vaporous or gaseous state.
32
SUCTIONING If a patient is unable to clear secretions by coughing, suctioning is
Indicated. As it is an invasive procedure with significant risk, suctioning must be
performed using very careful technique.
1. Preparation
Check that the suction apparatus is functioning properly and is
connected, the suction is turned on, and the vacuum level is set between
80 and 120 Cm H2O.
SUCTIONING
Make sure the oxygen flow is turned on and attached to the self-inflating
breathing bag.
Position the patient properly and less contraindicated: Nasotracheal and
pharyngeal suctioning are usually performed with a patient in the semi-
fowler position with the patients neck hyperextended, whereas patients
with a trechestomy or endotracheal tube are suctioned in the supine flat
position.
Have water soluble lubricants available if the patient is to be suctioned
nasotracheally. Put on protective eye wear.
33
Layout of the sterile field containing gloves, catheter, and container for
sterile.
Using sterile technique put on gloves, fill container with sterile water,
and attach catheter to suction.
2. Pre-oxygenation
Using a self-inflating breathing and a mask or artificial air way
connector, hyperventilate the patient with 100% oxygen.
3. Levage (Optional)
Instill 5 ml of sterile normal saline solution (Nacl) directly into the
endotracheal or tracheostomy tube.
4. Suction
Using sterile technique throughout:
Wet the catheter in the sterile solution or with the water soluble lubricant if
nasotracheal suction is to be performed.,
Insert the catheter (with no suction applied) into the airway until resistance
is met or until a reflex cough is triggered.
Pull the catheter back slightly and then withdraw the catheter in a twirling
motion while applying suction (should not take longer than 5 to 10
seconds).
Re-oxygenate the patient with 100% oxygen.
Clean secretion from catheter by suctioning some of the sterile water.
Repeat process if necessary until there are no more secretions.
34
PHIYSIOTHERAPY ASSESSMENT
SUBJECTIVE
Name :
Age :
Sex :
Occupation :
Address :
CHIEF COMPLAINT:
Pain
Inability to move trunk
Inability to breathe normally
HISTORY OF THE PATIENT
Past medical history:
Hyper tension
Ishaemic heart disease
Diabetic melitius
Asthma
Present medical history:
Medication for present complaint
Social History:
Work environment
Home environment
35
Personal history:
Smoking
Alcoholism
Vital Signs:
Heart rate
Respiratory rate
Blood pressure
Body temperature
Pulse rate
ON OBSERVATION
Level of awareness:
Alert? Responsive? Lethargic? Co-operative?
Body Built:
Obese
Normal
Cachetic
Chest wall measurement:
Axilla
Nipple
Xiphoid level
Chest Shape:
Barrel chest
Pectus excavatum
Pectus carniatum
36
Pattern of Breathing:
Fish Mouth Breathing
Shallow Breathing
Cynosis:
Peripheral
Central
Clubbing
ON PALPATION
Pain
Tenderness
Edema (pitting or non-pitting)
Peripheral pulse
ON AUSCULTATION
Normal breath sound:
Tracheal, Bronchial, vesicular, Broncho-vesicular
Percussion (unaffected side):
Chest wall mobility and expansion:
Heart sound:
ON EXAMINATION
Range of motion:
Shoulder and trunk
Investigation:
X-ray, CT scan, MRI
37
PHYSIOTHERAPY MANAGEMENT
AIMS:
To improve breathing pattern
To improve ventilation
To decrease pain
To assist in the removal of excessive bronchial secretions
To ensure adequate ventilation of all areas of the lungs and to help preventing
consolidation / atelectasis
To maintain full joint range and muscle length by passive movements – If the
patient is unable to perform active exercise
To maintain mobility and blood circulation by free active exercise, when
possible
To ensure the maintenance of a good posture by accurate positioning and
advice
To help rehabilitate patient to as full and independent life
38
Aggressive pain management techniques, such as epidural analgesia, need to be
employed before patients have physiotherapy. The aim of physiotherapy for a patient
with multiple fractured ribs is to minimize any compromise of the respiratory system.
An initial assessment is carried out to obtain a set of baseline objective markers
from which to develop a treatment programme; these include respiratory rate, oxygen
saturation, breathing pattern, peak expiratory flow rate, arterial blood gases, and
auscultation (listening to chest sounds).
Treatment is carried out at a minimum of twice a day for the first three days and
then on an 'as required' basis. At each session the patient is reassessed and the initial
objective markers re-tested.
Relaxed Position For Breathless Patient
Accurate positioning to drain specific areas of lung may be limited, if possible at all,
and may simply consist of tilting the bed or mattress from side to side (particularly if
patient also has thoracic injuries), tilting the bed head up and head down may also be
helpful provided the are no contra-indications.
39
RELAXED POSITION FOR BREATHLESS PATIENT
40
BREATHING EXERCISE
Patients generally use a pattern of breathing that is more efficient for them.
There are several techniques of teaching breathing exercise. The term "Breathing
exercise" is misleading as it implies that the patient is physically exerting himself.
Patient should be taught a more relaxed and economical pattern of breathing.
GOALS OF BREATHING EXERCISE
To decrease the work of breathing.
To improve alveolar ventilation.
To improve airway clearance by improving cough.
To increase strength, co-ordination and efficiency of respiratory
muscles.
To assist in relaxation.
To maintain mobility of the thorax.
To enable patient to manage shortness of breath attacks.
DIAPHRAGMATIC BREATHING EXERCISE
It is the normal mode of respiration. One method of diaphragmatic breathing
concentrates on forward movement of whole abdominal wall. Another technique
combines forward movement of upper abdominal wall with some lateral movement of
the lower ribs.
41
DIAPHRAGMATIC BREATHING
42
POSITION OF THE PATIENT
Relaxed half lying or sitting.
TECHNIQUE
1. The physiotherapist places both hands over the abdomen. The patient gently
breaths in, concentrating on allowing the abdominal wall to swell, gently or forcibly
under the slight pressure of the physiotherapists hands. On breathing out he feels his
abdomen slowly sinking back to rest. The patient can practice by resting both hands
over the abdomen. The upper chest and shoulder should remain relaxed throught. The
expiratory phase is completely passive. Any prolonged or forced expiration may
increase airway obstruction. Careful verbal command should be given.
2. The physiotherapist places the hand on the anterior costal margins and upper
abdomen to feel the movement occurring. He starts by gently breathing out, while
relaxing the shoulders and upper chest and feeling the lower ribs sinks down and in
towards the mid-line. When the patient has mastered the breathing pattern, then
progress in sitting, standing, exercising positions.
ADVANTAGES
Improves ventilation.
Improves oxygenation.
Increase tidal ventilation.
Eliminate accessory muscle activity.
Decrease respiratory rate.
Improve distribution of ventilation.
Reduce the work of breathing.
43
PURSED- LIPS BREATHING EXERCISE
Pursed- lips breathing improves ventilation and oxygenation and relieves
respiratory symptoms.
One method recommends passive expiration.
Another method advocates abdominal muscle contraction to prolong
expiration.
TECHNIQUE
Position the patient comfortably.
The therapist should place the hand over the mid-rectus abdominis area to the
detect the activity during expiration.
Instruct the patient to inhale slowly. Ask the patient to purse the lips before
exhalation.
Instruct the patient to relax the air out through the pursed lips and refrain the
abdominal muscle contraction.
When abdominal muscle activity is detected ask the patient to stop exhaling.
When the patient has learned the technique he is asked to perform the same
while standing, sitting and exercising.
44
[PURSED- LIPS BREATHING EXERCISE]
ADVANTAGES
Increase tidal volume.
Increase alveolar ventilation.
Increase oxygenation.
Reduce the work of breathing.
45
INTERMITTANT PRESSURE BREATHING (IPPB )
Serious impairment to ventilation results and the patient frequently requires
intubation and intermittent positive pressure ventilation (IPPV).
The IPPV will also act as a form of internal splintage thus helping to prevent
paradoxical breathing. Ventilation (full or assisted) may be continued for
approximately ten days or until the rib stabilize.
In the spontaneously breathing patient, intermittent positive pressure breathing
is the maintenance of a positive air way pressure throughout inspiration, with air way
pressure returning to atmospheric pressure during expiration. It has been suggested
that IPPB may be of value in patient with chest wall deformities or pronounced
inspiratory muscle weakness who cannot voluntarily generate transpulmonary
pressures and inspiratory volumes great enough to produce sufficient expiratory flows
to aid effective expulsion of secretions.
INTERMITTANT PRESSURE BREATHING (IPPB)
46
PRACTICAL PROCEDURE:
The position of the patient depends on the condition for which the IPPB is
being given. It may be effectively used in the sitting, high side lying or side lying
positions. The patient should comfortable and able to relax the upper chest and
shoulder girdle.
The patient is told to close his lips firmly around the mouthpiece and breathe in
through his mouth. The patient should relax during inspiration allowing air from the
ventilator to inflate his lungs. Expiration should be quiet and relaxed.
The patient relaxes his upper chest and shoulder girdle and the physiotherapist
places his hands on the anterior costal margins to encourage gentle movement of the
lower chest.
Treatment time and frequency with IPPB depend on the individual case, but it
is likely to be between 10 to 20 minutes.
INCENTIVE RESPIRATORY SPIROMETRY
It is a form of low level resistance training that emphasizes sustained maximal
inspiration. The patient inhales through a spirometer that provides visual or auditory
feedback as the patient breathes in as deeply as possible. Incentive spirometry
increases the volume of air inspired and has been used to prevent alveolar collapse in
post operative conditions and to strengthen muscles in patients with neuro muscular
disorders.
47
PROCEDURE:
Place the patient in a comfortable position (Supine or semi upright)
Have the patient take three to four slow, easy breaths.
Have the patient maximally exhale with the fourth breath.
Then have the patient place the spirometer in his mouth and maximally inhale
through the spirometer and hold the inspiration for several seconds.
[INCENTIVE RESPIRATORY SPIROMETRY]
INSPIRATORY MUSCLE TRAINING [IMT]
Inspiratory muscle training is currently used in pulmonary rehabilitation to
increase the strength and endurance of the inspiratory muscles. To train a muscle
to improve its functional ability, the muscle must be subjected to a stress greater than
its usual load and the training must be directed at developing specific functional
attributes of the muscle.
48
Endurance training of the inspiratory muscles is thought to promote an
increase in the proportion of fatigue-resistant fibres in the diaphragm, an increase in
the metabolic capability of the muscle, and a reduction in the susceptibility of muscle
fibres to the deleterious effects of exercise. Improvement in the strength and
endurance of the inspiratory muscles has enhanced the resistance to inspiratory muscle
fatigue and improve ventilatory function.
[INSPIRATORY MUSCLE TRAINING [IMT]
The work of breathing is reduced and respiratory reserves are increased. This
increases the muscle strength and endurance. Two techniques have been used. They
are;
1) Isocapnic hyperventilation.
2) Inspiratory resistive or resistance breathing.
49
1. ISOCAPNIC HYPERVENTILATION
Patient is asked to breath at the highest rate they can manage for 15 to 30
minutes. Rebreathing circuit is used in to prevent hypocapnia. It increase the
endurance of inspiratory muscle.
2. INSPIRATORY RESISTIVE OR RESISTANCE BREATHING
There are two devices. They are
a) A non-linear device.
b) A threshold IMT device.
With a controlled rate of breathing in a non-linear device, patient inspire
through a narrow tube that offers a non-linear airway resistance for one or three daily
periods of 15 to 30 minutes. Size of orifice is adjusted to provide level of resitance.
With a threshold IMT device a reliable inspiratory pressure load is provided. The load
is adjusted according to a desired % the patient's maximal inspiratory pressure [PI
max].
RELAXED SITTING
The patient is made to sits with his back kept straight. The forearms are made
to rest on thighs and the wrist is relaxed.
50
CONCEPTUAL FRAMEWORK OF RESPRATORY
MUSCLE TRAINING
Respiratory muscle training
Increased strength and endurance of respiratory muscle
Delay the onset of Improve ventilation
respiratory muscle fatigue
Prevent/deter the onset of Improve tissue oxygenation
respiratory insufficiency and *Cognition
fatigue *Perception
*Psycho-motor function
Improve clinical Improve sense of
signs and symptoms wellbeing
Improve activities of Improve quality of
daily living life
51
MOBILIZATION EXERCISES
It is essential to teach the patient to keep the shoulders in level, head erect and
spine straight. The patient with tightness of the trunk muscles on one side of the body
will not expand that part of the chest fully during inspiration. So, exercises which
combine stretching of these muscles with deep breathing exercises will improve
ventilation on the side of the chest.
TO MOBILIZE THE ONE SIDE OF THE CHEST
While sitting, have the patient bend away from the tight side to lengthen tight
structures and expand that side of the chest during inspiration.
Then have the patient push the fisted hand into the lateral aspect of the chest, as
he or she bends towards the tight side and breathes out. Progress by having the patient
rise the arm on the tight side of the chest over the head and side bend away from the
tight side.
This will place an additional stretch on the tight tissues.
52
CHEST MOBILIZATION EXERCISES
53
TO MOBILIZE THE UPPER CHEST AND STRETCH THE
PECTORALIS MUSCLE
While the patient is sitting in a chair with hands clasped behind the head, have
him or her horizontally abduct the arms (elongating the Pectoralis muscles) during a
deep inspiration.
Then instruct the patient to bring the elbows together and bend forward during
expiration.
TO MOBILIZE THE UPPER CHEST AND SHOULDER
With sitting in a chair, teach him to reach with both arms overhead [180 degree
bilateral shoulder flexion and slight abduction] during inspiration.
Bend forward at the hips and reach the floor during expiration.
To Increase Expiration During Deep Breathing While The Patient Is Supine
Have the patient “breath in” while in a crook lying position. Then have the
patient pull both knees to his chest (one at a time at project the low back) during
expiration.
SITTING
Trunk turning with arms relaxed
Trunk bend sideways
Trunk bending forwards with breathing out and trunk raising with
breathing in.
54
Range of Motion Exercises
Understand that passive range of motion exercises are merely a stopgap
measure used while the patient recovers from his injury. During passive range of
motion exercises, the patient's limbs will be manipulated by a third party to ensure that
the muscles do not atrophy to an unreasonable degree. Passive range of motion
training will typically be performed on the extremities (arms and legs) daily or twice
daily for the duration of rehabilitation, according to information from Medical-
Dictionary.com.
Elbow Bends
Perform elbow bends to allow the patient's arms to remain mobile throughout
the recovery period from a flail chest. To perform elbow bends, grip the patient's arm
(keeping it by his side) and turning it so that the palm is facing toward the ceiling.
Initiate the movement by bending the arm gently at the elbow until the fingertips
lightly touch the shoulder. Repeat this drill 10 to 20 times per session on both sides of
the body. After performing that variation, extend the arm out laterally to the side,
keeping it at a 90-degree angle to the body and repeating the drill again to work the
elbow through another range.
[RANGE OF MOTION EXERCISES]
55
Knee Bend
Perform knee rotations to keep the lower body limber during the immobile
portion of the recovery period. Manually grip the lower leg, bending it at the knee
until the foot is fully rested on the bed with the leg at a 45-degree angle. Initiate the
movement by gently pushing inward at the knee, creating rotation at the hip and
bringing the knee across the body to brush against the other leg or the bed. Reverse
the movement, pushing the knee to the outside to work the hip joint in both directions.
Move slowly to avoid accidentally injuring the patient, repeat the drill for 10 to 20
times in both directions before switching and repating the exercise with the other leg.
[HIP FLEXION EXERCISES]
THORACIC EXPANSION EXERCISES
Thoracic expansion exercises are deep-breathing exercises emphasizing
inspiration. The patient is instructed to take in deep breath to inspiratory reserve;
expiration is passive and relaxed.
At high lung volume the expanding forces between alveoli are greater than at
tidal volume and assist in re-expansion of lung tissue.
56
Three or four expansion exercises are usually appropriate before pausing for a
few seconds for a period of breathing control.
Thoracic expansion exercise can be encouraged with proprioceptive stimulation
by placing a hand either the patient's or the therapist's, over the part of the chest wall
where movements of the chest is to be encouraged.
[THORACIC EXPANSION EXERCISES]
ADVANTAGES
Increase in chest wall movement.
Increase in lung volume.
Assist clearance of secretion along with rhythmic vibration
57
FREE EXERCISES
THERABAND ARE USED TO DEVELOP ARM STRENGTH. LEG STRENGTH AND STABILITY IS DEVELOPED THROUGH
A VARIETY OF STANDING EXERCISE,.
PATIENTS ARE CLOSLEY MONITORED WITH A HANDHELD
PULSEOX, TO MEASURE BLOOD OXYGEN CONTENT AND
HEART RATE.
Cardio-Vascular Benefits And Respiratory Development.
58
REHABILITATION
The post operative rehabilitation may be longer and more complicated.
Physical therapy is indicated in those individuals with fractured ribs who present with
a compromised respiratory system, advanced age, or functional limitations associated
with postural muscles.
THE GOALS OF REHABILITATION
To decrease pain
Prevent respiratory complication and restore function
They should instruct patients in Deep-breathing exercises to promote full lung
expansion relieve inter-coastal muscle spasm and mobilize lung secretions. Finally
shoulder and trunk gentle stretching exercises may relieve discomfort and promote
chest expansion. Functional shoulder mobility and improved posture.
PHASE 1
DAY OF OPERATION
Breathing exercises – half lying position
Assisted cough
DAY 1
Posture correction – push the head side ways against manual resistance towards
the affected side and to push the shoulder down and back.
Active assisted arm movements - both sides
DAY 2
59
Breathing exercises and coughing
Posture – align the head, shoulder and thoracic spine with scapular retraction
without the guidance of the therapist
DAY 3
Manually resisted exercises for the shoulder girdle and arm on the affected side
are added
DAY 4
Trunk exercises in sitting are added
DAY 5 – 7
Trunk exercises in standing
Posture correction in walking
DAY 8 (To discharge from hospital)
Trunk mobility and thoracic mobility exercises
Good posture
PHASE 2
This is an out patient programme
The patient visits the department two weeks following his discharge until
tweleve weeks, thrice a week
Exercises are given for 30 to 45 min accompanied by checking the vital signs
periodically.
A gradual warm up session for 05 to 10 min is given
FOLLOW UP: Regular Check-up
HOME ADVICE:
60
To avoid sternal discomfort, all patients will benefit from splinting the
incisions with a hand or pillow when laughing, coughing and sneezing.
Patient should be instructed to avoid lifting, pushing and pulling objects until 4
to 6 weeks post surgery when the ribs is well healed.
Patients is encouraged to gradually increasing walking, with a goal of 30
minutes of ambulation 1 to 2 times per day at 4 to 6 days post surgery.
Continue exercise for posture, upper extremity and trunk mobility and ribs
protection are also important component of the home exercise program.
61
CASE STUDY
NAME : Mr. Ramakrishnan
AGE : 28
SEX : Male
OCCUPATION : Driver
ADDRESS : No: 4, South Mada Street,
Mylopore, Chennai
CHIEF COMPLIANTS : Pain over right side
Inability to move trunk
Inability to breathe normally
HISTORY
Past medical history : Hyper tension
Present medical history : Underwent surgery
Personal History : Smoking
Vital signs :
Heart rate : 76 beats/ min
Respiratory rate : 13 breaths/ min
Blood pressure : 150/90 mm/Hg
Body temperature : 101.4 F
Investigations :
X – Ray, C T scan, MRI
ON OBSERVATION
Level of awareness : Responsive
Body built : Obese
Chest Shape : -
Breathing pattern : Shallow rapid breathing
Cyanosis : Negative
Clubbing : Absent
62
INCENTIVE RESPIRATORY SPIROMETERY
SELF ASSISSTED DIAPHRAGMATIC BREATHING EXERCISES
63
ON PALPAT0ION
Pain : Present
Tenderness : Grding 3
Peripheral pulse : Present / normal
ON AUSCULATION
Breath sound : Non vesicular
Investigation : X-ray – Anterior rib fractures (6, 7 and 8)
Surgical Management
Right surgical stabilization
Right Antero lateral thoractomy is done
Problem List:
Pain
Decreased movement – especially the shoulder on the operation side
Decreased mobility
Poor posture
TREATMENT PLAN
Medical management:
Adequate good analgesia (Morphine 10mg)
Inter costal nerve blocks
64
PHYSIOTHERAPY MANAGEMENT:
AIMS:
To relieve pain
To improve breathing pattern
To improve ventilation
To loosen secretion
MEANS:
Breathing exercises
IPPB
Pursed lips breathing
Inspiratory muscle training
Mobilization exercise
HOME ADVICE:
Practice exercises in home
Avoid carrying weight
Maintain good posture
Maintain dietary supplements
Avoid risk factors (alcohol, smoking)
65
CONULISION
Thus the thoracic surgeries, as explained above lead to wide variety of
complications. These postoperative complications both local and general are known to
occur frequently.
However, the good news is that, they can be prevented. Proper pre-operative
assessment with efficient medical and physiotherapy care will aid in preventing these
complications. Post operative physiotherapy is therefore indispensable. It helps to
bring back the patient to the optimum normal condition.
It is therefore, the duty of the physiotherapist to reduce and prevent post
operative morbidity as well as to make the patient to lead a normal life.
66
BIBLIOGRAPHY
Human Anatomy – Volume 1 -B.D. Chaurasia
Gray’s Anatomy –Williams and Warwick
Rose and Wilson. Anatomy and Physiology in health illness
–Anne Waugh, Allison Grant.
Concise medical physiology –Sujit .K.Chaudhuiri
Davidson’s Principles and Practice of medicine -Christoper, Edwin, John,
Nicholas
Tidy’s Physiotherapy -Starurt B. Porter
Principles and Practice of Cardiopulmonary physical therapy
-Donna Frownfelter,
Elizabeth Dean
Cash;s textbook of Chest, Heart and Vascular disorders for Physiotherapist’s
- Particia A. Downie
Physiotherapy for Respiratory and Cardiac Problems
- Barbara A. Webber,
- Jennifer A.Pryor
Textbook of physical rehabilitation –Susan O. Sullivan
Therapeutic exercises, foundation and technique -Carolyn Kishner,
Lylln allen Colby
General thoracic surgery - S. Thomas W. Shields,
Joseph Locicero,
Ronald B. Ponn
67
Project by,
Dr. D. Senthil Kumar, B.P.T
Chennai, Tamil Nadu, India
Project designing, Production and Marketing by,
C. Gopi Krishnan, B.E
Chennai, Tamil Nadu, India