Week 8

Question 1

Describe the 4 most common thoracic surgical incisions.

Answer 1

thoracotomy (along the line of the ribs)
mini-thoracotomy (partial thoracotomy)
clam shell (both chest walls and through sternum)
median sternotomy (along sternum)

Question 2

What is video-assisted thoracoscopic (VAT) surgery?

Answer 2

a key hole procedure that allows insertion of a long, thin tube with a camera attached and small surgical instruments to perform surgeries without the need for a full thoracotomy

Question 3

What is a lung biopsy?

Answer 3

where a small piece of tissue is removed for a diagnostic test

performed via a fine needle biopsy, a surgical lung biopsy or bronchoscopy (aka transbronchial)

Question 4

What are the 3 types of lung resection? At what point will these affect a persons lung function?

Answer 4

wedge resection (where a small part of a lobe is removed)
lobectomy (removal of a whole lobe)
pneumonectomy (removal of a whole lung)

pneumonectomy is when we start to see effects on a patients lung function

Question 5

What happens to the space left behind after a pneumonectomy?

Answer 5

immediately the space is filled with air following the surgery, over time this fills with fluid at a rate of approx. 2 rib spaces per day with 80-90% of space filled with fluid at 2 weeks post op

Question 6

What effects does a pneumonectomy have on a patients lung function?

Answer 6

reduced FVC, FEV1 (forced expiratory volume) and gas diffusion capacity

generally SOB experienced on exertion and reduced exercise capacity

Question 7

What is the purpose of a talc pleurodesis?

Answer 7

to ‘stick’ open a lung following a persistent or recurrent pneumothorax or pleural effusion

Question 8

What is the purpose of a chest tube (aka intercostal catheter/ICC)?

Answer 8

a tube placed in the chest after thoracic surgery to drain air, fluid and blood out of the chest and promote re-expansion of the affected lung

Question 9

What are some common postoperative pulmonary complications (PPC’s)?

Answer 9

decreased ventilatory drive & gas exchange (due to anaesthesia)

reduction in lung volume (due to drowsiness, pain and altered chest wall dynamics)

decreased FRC due to immobility/prolonged supine positioning

slowing of mucociliary clearance (due to dehumidification) leading to retained secretions, exacerbated by a painful cough

impaired surfactant production and sign mechanism leading to atelectasis

all of the above leave patients susceptible to pulmonary infection, pneumonia, hypoxaemia & respiratory failure

Question 10

When is a lung volume reduction surgery (LVRS) indicated?

Answer 10

used to be utilised to remove parts of the lung that are affected by emphysema

no longer used as much due to ineffectiveness long term as published in 2003

Question 11

What is a coronary artery bypass grafting (CABG) surgery? What additional implications does this surgery have for physiotherapy?

Answer 11

a bypass surgery for an occluded coronary artery due to coronary artery disease

often grafts are harvesting from the individual i.e greater saphenous vein, left internal thoracic artery or radial artery so this area will also be painful (careful with handling & monitor venous pooling)

also a median sternotomy is required for the surgery so we need to maintain symmetrical movements of the arms to allow proper closer of the incision

Question 12

What constitutes heart failure?

Answer 12

when the heart is unable to supply sufficient cardiac output to support a physiological circulation due to a structural or functional abnormality

Question 13

What is the purpose of a Ventricular Assist Device (VAD) and what are the implications for physiotherapy?

Answer 13

to facilitate ventricular function during heart failure to bridge someone to a transplant

it is a continuous flow device so the patient is unlikely to have a pulse, so we cannot use this as a way to monitor the patient’s status

Question 14

What kinds of respiratory complications can be seen following cardiac surgery?

Answer 14

atelectasis (due to surfactant washout & alveolar collapse caused by cardiopulmonary bypass, compression from pleural effusion and resorption atelectasis from bronchial secretions)

pneumonia (due to infection)

pulmonary oedema (secondary to fluid overload or cardiac failure)

hemidiaphragm paralysis (left) (due to damage to the phrenic nerve during cooling)

Question 15

What kinds of circulatory complications can be seen following cardiac surgery?

Answer 15

venous thromboembolism (due to immobility and other risk factors such as age, obesity, cardiac failure, blood disorders)

Question 16

What kinds of cardiovascular complications can be seen following cardia surgery?

Answer 16

heart rhythm disturbance (particularly atrial fibrillation)

hypertension & hypotension

fluid overload (due to pulmonary oedema and/or pleural effusion)

cardiac failure

Question 17

What are the symptoms of atrial fibrillation?

Answer 17

heart palpitations, light headedness, chest pain, dizziness, fatigue, SOB, weakness

Question 18

In atrial fibrillation, what ventricular rate is of concern to physios?

Answer 18

a ventricular rate of >120, mobility is contraindicated and therapy should focus on circulation & breathing exercises only

a rate of 90-120 mobility should be done with care

<90 will be treated as normal and should not be symptomatic

Question 19

When is an intra-aortic balloon pump (IABP) indicated and what are the implications for physio treatment?

Answer 19

patient unable to wean off the cardiopulmonary bypass

the device is triggered by pressure changes of ECG so NO percussion to be used over the leads

also the apparatus is inserted through the femoral artery so no hip flexion beyond 15 degrees to avoid moving the balloon and damaging the aorta

Question 20

List the movements we want to avoid after a median sternotomy.

Answer 20

avoid unilateral pressure through the upper limbs (i.e. asymmetrical movements)

avoid reaching backwards

avoid any excessive pressure through upper limbs in general

always using pain as a guide