Surgical Management of Cardio & Pulmonary Disorders Flashcards
What is a Thoracotomy?
Surgical procedure = incision made between the ribs to access the lungs or other structures of the thorax
Examples: Pneumonectomy, lobectomy, lung reduction surgery, single-lung transplant, some double-lung transplants
Approach = anterior, lateral, posterior
Possible Complications of thoracotomy include:
phrenic nerve laceration
complete motor innervation to the diaphragm and sensation to the central tendon aspect of the diaphragm
PT implications of thoracotomy include:
Chest tubes, Chest PT, Thoracotomy side shoulder ROM, Breathing Re-training, Incentive spirometry, Bed mobility, Transfers, Early progressive ambulation
Pneumonectomy =
Surgical removal of one lung
Most common reasons for Pneumonectomy:
Lung Cancer
Congenital abnormalities
Traumatic lung injury
Chronic lung infection = tuberculosis, fungal infections, abscesses
Thoracocentesis =
A technique used to remove fluid or air from the pleural space
It can be used as both a diagnostic tool and a therapeutic intervention
Typically used with ultrasonography to pinpoint location, and effectiveness of treatment
Most common reasons for Thoracocentesis:
Large pleural effusions
Heart failure
Liver cirrhosis
Nephrotic syndrome
Pleural effusion =
excess amount of fluid around the lung in the pleural cavity
Medical Surgical Management: Thoracic Surgical Procedures
Posterolateral Thoracotomy Muscles Impacted
Lung Volume Reduction Surgery (LVRS)
Video-assisted thoracoscopic surgery (VATS)
Posterolateral Thoracotomy Muscles Impacted:
Latissimus Dorsi, Serratus, Rhomboid Major
Lung Volume Reduction Surgery (LVRS):
used for the treatment of pulmonary malignancy, infection, and trauma
used to diagnose pulmonary disease
Video-assisted thoracoscopic surgery (VATS):
a minimally invasive surgical technique used to diagnose and treat pulmonary conditions, thoracoscope used for image, small surgical instruments used via a small incision in the chest wall
VATS -> aortic procedures, aortic valve replacement (AVR)
VATS Surgical Approach
- Less surgical time/less anesthesia time
- Less painful
- Smaller wound = decreased chance of wound infection
- Faster recovery/shorter hospitalization
- Less invasive internally
Anterolateral Thoracotomy Muscles Impacted:
Pectoralis Major/Minor, Serratus Anterior
Commonly used for cardiac procedures, pulmonary resections, esophageal procedures
Lateral Thoracotomy Muscles Impacted:
Latissimus Dorsi, Serratus Anterior, Obliques, Pec Major
Commonly used for pneumonectomy, lobectomy, wedge resection
Chest Tubes =
Fluid or Air Removal:
Placed between ribs = Pleural space between parietal & visceral layers
Used post-surgical for air and fluid removal
Pneumothorax = creates a negative pressure for air removal
Chest tube placement =
through the chest wall to drain intra-pleural fluid or blood in the chest post thoracic surgery or chest trauma
Jackson-Pratt Drain (JD)
placed in wounds during surgery to prevent the collection of fluid underneath the incision site or used for persistent fluid leaks after surgery
closed, air-tight drainage system which operates by self-suction
drain(s) promote healing by keeping excess pressure off the incision and decreasing the risk of infection.
Lung Bullectomy =
Bullectomy: surgical removal of a bullae, which is a dilated air space in the lung parenchyma measuring more than 1 cm
Most common cause of a lung bulla is chronic obstructive pulmonary disease
Lung Volume Reduction Surgeries (LVRS) =
Surgical treatment for the symptoms of emphysema in which approximately 30% of the damaged lung tissue is removed in an attempt to improve the mechanics of respiration
Surgery is generally performed by either a median sternotomy or video-scope assisted thoracoscopy (VATS)
Optimization of Diaphragm after LVRS =
Reduces lung volume, improves elastic recoil
Results in a less expanded thoracic cage, improved mechanical function of the muscles of respiration, particularly the diaphragm and the mobility of the rib cage
With removal of localized emphysematous areas, lung expansion & recoil of more normal lung tissue may occur = improving ventilation/ perfusion
Lung Transplant Candidates =
FEV1 < 30%
Have a condition for which lung transplant is considered an effective treatment
Have severe/progressive lung disease that no longer responds to medical tx
Be physically capable of undergoing surgery and subsequent treatments
Stopped smoking or abusing alcohol, drugs—including pain meds
Have adequate financial resources
Have an acceptable support system
Motivated/compliant with therapy
Lung Transplant =
‘Clamshell’ incision = Bilateral thoracotomies
Lung transplant PT Implications:
Splinted cough, bilateral shoulder ROM, Chest PT, Breathing exercises diaphragm & rib cage mobility, Incentive spirometry, Bed mobility, Transfers, Posture, day 1 ambulation
The primary indication for heart or lung transplantation is =
terminal cardiopulmonary disease
Heart and Lung Transplantation indication =
Combined heart-lung transplantation remains the only definitive therapy for patients who have both end-stage heart failure and end-stage lung failure
Most common indication is congenital heart disease (CHD) followed by idiopathic pulmonary arterial hypertension (IPAH)
Donor Organs =
The availability of donor organs dictates the pace of the transplant
The list of candidates awaiting transplantation is maintained by the
United Network for Organ Sharing (UNOS)
Pharmacological agents are used to medically manage organ transplant candidates until a donor organ is available
Donor organs are matched to the recipient using a specific organ allocation system
Candidates for transplantation are evaluated by a transplantation team member and must meet certain eligibility criteria =
Cardiopulmonary Exercise Test is primary indicator used to guide transplant listing
Patients eligible are classified as: Class I, IIa, IIb, III based primarily on CPET along with other factors such as ventilation status, obesity, age
A Physical Therapist evaluates the patients cardiac and/or pulmonary system limitations as well as musculoskeletal condition, exercise capacity, ventilator function, and mucociliary clearance
Preoperative rehabilitation program:
(heart and lung transplantation)
Patient and family education
Cardiovascular endurance training
Musculoskeletal strength
Flexibility training
Breathing retraining
The goal of the pre-operative rehabilitation, is to:
improve or prevent deterioration of the candidate’s physical condition and to assure the ability to increase post-operative physical function
Factors considered when an organ becomes available:
Blood type
Body size: within 10%
Medical urgency
Survival
Location of donor and recipient
UNOS
UNOS computer system generates a “match run” =
a rank-order list of candidates to be offered each organ
Organ preservation time:
kidney = 24-36 hours
pancreas = 12-18 hours
liver = 8-12 hours
heart/lung = 4-6 hours
Heart-Lung Transplant Procedure - donor
No significant valvar stenosis or insufficiency
Chest X ray free of significant infiltrate
Free of systemic infection
No evidence of malignancy
Heart-Lung Transplant Procedure - recipient
Sternotomy
Cardiopulmonary bypass
Heart excised followed by each lung leaving the main stem bronchus intact
Donor heart-lung bloc placed
Aortic, inferior vena cavam superior vena cava anastomosis
Considerable time taken to weak patient form bypass and initiate ventilation to allow for homeostasis
Heart-Lung Bypass Machine =
pump returns oxygenated blood to the aorta and delivers it to the rest of the body
Functions as the heart and lungs during surgery
Maintains circulation of blood and oxygen
Maintains appropriate temperature
Bloodless field for thoracic surgery
Reasons for Lung Transplant =
COPD
Pulmonary fibrosis
Pulmonary hypertension
Cystic fibrosis
Lung transplant post-op care =
ventillatory support
hemodynamic monitoring
immunosuppressive therapy
monitor for s/s of infection and rejection
emotional support
First 3 months post lung transplant =
ICU -> P Rehab -> Home Health -> OP Rehab
Close daily to weekly monitoring by lung transplant team
Domino effect Heart and Lung Transplantation =
donor = deceased
patient 1 = has malformed but viable heart and bad lungs
patient 2 = has a bad heart
donor heart and lungs given to patient 1
old heart from patient 1 given to patient 2
Common Immunosuppressants =
Azathioprine
Basiliximab
Belatacept
Prednisone
Immunosuppressive medications are used to:
prevent rejection and infection
Acute rejection =
both cellular and/or antibody mediated occur when the immune system is not adequately suppressed, thus causing inflammation that can damage the new tissue over time
For all thoracic transplant patients, vital signs should be monitored:
Hemodynamic Response = heart rate, BP, RR, RPE, SpO2 and/or SaO2
Heart rate of a heart transplant recipient will not increase linearly with activity progression secondary to denervation
Cardiac Denervation =
Disappearance of neural input to the sinoatrial node
Loss of efferent and afferent nerve signaling into and out of the heart = Heart Transplant recipients unable to experience the sensation of angina due to ischemia
Loss of ventricular sensory input = hypotension and bradycardia
Potential impact on inotropic responses = decreased strength of heartbeat
Exercise capacity in denervated HTx recipients seems to be diminished =
denervated hearts must rely on circulating catecholamine to adjust to increased needs of exercise
HR increases more slowly than normal to reach a lower maximal HR
HR decrease during recovery from exercise at a slower than normal rate
Abnormal cardiac output (CO) response to exercise
Exercise prescription for a patient after heart transplantation =
critical to have a sufficient warm-up and cool-down period to allow the denervated heart to accommodate to the change in activity level and maintain cardiac output
This accommodation occurs during the warm-up phase by an increase in stroke volume provided by the contracting muscles of the new heart and by increases in circulating catecholamines (a type of inotrope)
Breathing and pacing exercises to allow for increased gas exchange in lung transplant pts
Inpatient treatment and goals =
focus on improving impaired gas exchange, ineffective airway clearance, patient positioning, pain reduction, and reducing mobility restrictions
Outpatient treatment and goals =
focus on strengthening large skeletal musculature, weight-bearing exercise, continues aerobic conditioning, resolution of any musculoskeletal problems, home exercise program, education and independence with self-monitoring
The Physical Therapist should be alert for transplant complications, which can often manifest themselves initially in the exercise response:
decrease in SaO2/SpO2
reduced exercise tolerance = SOB, dizziness, fatigue
abnormal increase/decrease in HR or RR
Frequent complications of the transplant patient include:
rejection, infection, steroid myopathy, osteoporosis, and malignancy
Surgical Management of CHF =
Cardiac Transplantation
Left Ventricular Assist Device (LVAD)
Cardiomyoplasty
Left Ventricular Assist Device (LVAD) =
Successfully used as an alternative to cardiac transplantation
Used for patients with end-stage heart failure who are not candidates for cardiac transplantation
Mechanical pump that typically assists the LV, can be used to assist the RV
Used to bridge a patient waiting for a heart transplant = not available, patient not strong enough
Research to date has shown that exercise testing and training for patients with an LVAD =
are safe and effective in improving physiologic and functional status
Cardiomyoplasty: Left or Right Ventricular Muscle Flaps
Latissimus dorsi or trapezius muscle
> wrap around LV/RV
> attached to a pacemaker
> pacemaker stimulates flap to contract
> contracts the LV/RV
major problem = muscle fatigue
General Post-Operative Issues =
General Anesthesia: anaphylaxis, aspiration, peripheral nerve damage, nausea and vomiting, respiratory distress, hypoxic tissue damage
Blood & Fluid Loss
Blood Transfusion
Pain
Infection
Chest tubes
Mobility
Post-Surgical Observation
Incisional care = Watch for redness, drainage, edema, heat
