Independent Learning PackageAcute2005

Answers 1. Partially compensated respiratory acidosis 2. Fully compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Uncompensated respiratory acidosis 5. Fully compensated metabolic acidosis 6. Uncompensated metabolic alkalosis 7. Partially compensated respiratory alkalosis 8. Uncompensated metabolic acidosis 9. Fully compensated respiratory acidosis 10. Partially compensated metabolic acidosis A a Gradient AaDO2 • Determines state of the respiratory system • Looks at the difference between alveolar and arterial O2 levels • Identifies if there is a problem with diffusion of O2 across the capillary walls. D A-a O2 = P alveolar O2 - P arterial O2 = PAO2 - PaO2 PAO2 = PI O2 - PACO2 PI O2 = FIO2 x (Atmospheric Pressure - H2O Vapour) e.g. = 0.21 x (760 - 47) = 0.21 x 713 = 150 PACO2 = PaCO2 Respiratory Quotient = divide by 0.8 or e.g. multiply by 1.2 RQ = 40 0.8 = 50 PAO2 = 150 - 50 = 100 DA - a O2 = 100 - 100 or 85 = 0 - 15 mmHg 45 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

RESPIRATORY CONDITIONS This section will require you to revise pre-clinical information on acute and chronic respiratory conditions as well as respiratory failure and chest trauma. The aim is to link your theoretical knowledge with the patient’s clinical presentation and the appropriate physiotherapy management. It is recommended that the following topics be revised. Chronic Obstructive Pulmonary Disease Asthma Suppurative Lung Disease - Bronchiectasis, Cystic Fibrosis Infective Lung Diseases Pneumonias Tuberculosis Interstitial Pulmonary Disease Lung Cancer Respiratory failure Chest trauma Other topics such as - pulmonary embolism, pleural effusion, pulmonary fibrosis, alveolar proteinosis, aspergillosus, and lung abcess will assist your understanding. Review case study tutorials presented on management of the CAL patient and chronic sputum producers CHRONIC OBSTRUCTIVE DISORDERS Asthma CASE 1 A 50 year old female is admitted to a Medical Ward via Casualty PMHx : Asthma since 45 years old - 3 previous hospital admissions, never ventilated Non smoker Nil other relevant O/E : Fatigued looking, agitated SOBAR ++ - unable to speak in short sentences Laboured breathing Accessory muscle use ++ Not cyanosed BP - 170 / 90 PR - 130 b / min RR - 32 b / min 46 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CXR : Hyperinflated, poor inspiratory effort Clear lung fields Auscultation : Quiet chest ↓ BS throughout both lung fields No added sounds ABG’s : On R/A pH - 7.47 PaCO2 - 28 PaO2 - 60 HCO3 - 24 Three hours later in the Ward on 30% O2 ABG’s : pH - 7.33 PaCO2 - 58 PaO2 - 65 HCO3 - 24 Three days later the patient RTW following mechanical ventilation in ICU O / E : SOBOE - breathless after showering, 200 m on the flat non distressed Accessory muscle use at rest Audible expiratory wheeze Tight moist cough - has difficulty expectorating CXR : Hyperinflation ↓ lung volumes ( L ) > ( R ) Patchy changes in ( L ) base Auscultation : Widespread inspiratory and expiratory wheezes Nil BS bibasally Vital Signs BP - 130 / 90 RR - 22 Temp - 38.1o C PR - 95 b / min ABG’s pH - 7.42 PaCO2 - 38 PaO2 - 90 HCO3 - 25 QUESTIONS RELATING TO CASE 1 47 1. Briefly review the components of asthma and drug management 2. Discuss the significance of the patient’s past medical history 3. What do the auscultation findings reflect? 4. Interpret the ABG’s and consider the condition that they reflect. 5. What are the danger signs for this patient? © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

6. Discuss how you would undertake the assessment of this patient. 7. Discuss the ABG’s that were taken three (3) hours later. 8. What condition is now evident? 9. Outline the aims of treatment and techniques that may be appropriate at this stage? 10. On discharge from ICU consider the medications the patient may be receiving. 11. What is your interpretation of the objective findings 12. In view of the findings outline your treatment aims. 13. Discuss the techniques you would use to address these aims. 14. Outline the issues that you would consider prior to discharge. ANSWERS TO CASE 1 1. Asthma Components • Reversible airflow limitation • Airway inflammation – involving in particular mast cells, eosinophils, T lymphocytes, macrophages, neutrophils and epithelial cells. • Airway hyper-responsiveness – exaggerated bronchoconstriction triggered by a wide range of non-specific stimuli Drug Management • Preventors - decrease the inflammation - inhaled corticosteroids - becloforte, pulmicort, flixotide • Relievers - relief of bronchospasm - Short-acting ß2 agonists - ventolin (salbutamol), bricanyl (terbutaline) - anticholinergic - weak bronchodilator, potentiates the effect of ventolin - atrovent (ipatropium bromide) • Symptom Controllers - Long-aacting β2 severe asthma - serevent (salmeterol), oxis (eformoterol) • Combination Medications - Combivent (atrovent + salbutamol), Seretide (flixotide + serevent) • Antibiotics when needed to treat superimposed infection 2. Significance of past medical history Only three (3) admissions therefore her asthma is usually well controlled and the fact that she has never been ventilated reflects the severity of the disease. 48 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

3. Auscultation findings Reflect the lack of movement of air and that the patient is fatiguing. 4. ABG interpretation and condition : pH - ↑ - alkalosis Uncompensated respiratory alkalosis PaCO2 - ↓ - alkalosis with a severe hypoxaemia HCO3 - - normal PaO2 - ↓ - severe hypoxaemia ABG’s reflect hyperventilation i.e. blowing off their CO2 and severe hypoxaemia. 5. Danger signs for this patient • the quiet chest • ↓ PaO2 • hypoxaemia • fatigue • tachycardia 6. Patient Assessment C/O : limited or impossible due to fatigue and SOB O/E : Observation - no assessment of response to verbal instruction Palpation - assess response to tactile input Auscultation - limited due to patient’s shallow breathing pattern →stretch facilitation to encourage deeper breaths Ensure O2 is kept on at all times. 7. ABG interpretation - 3 hours later pH - ↑ alkalosis Uncompensated respiratory PaCO2 - ↓ alkalosis acidosis with moderate to severe hypoxaemia HCO3 - normal PaO2 - ↓ Hypoxemia even with supplemental oxygen 8. The condition now evident is : TYPE II RESPIRATORY FAILURE PaCO2 > 50 mmHg Fatigued with shallow breathing ⇒ ↑ CO2 49 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

9. Aims of treatment and techniques 50 ¾ Need to talk to the Medical Staff ¾ Positioning - high supported sitting or forward lean sit - Supportive therapy ¾ Humidification - to assist with the supplemental O2 DO NOT RELAX THE ACCESSORY MUSCLES AS THE PATIENT IS RELIANT ON THEM 10. Possible medications on discharge from ICU Bronchodilators - nebulised ventolin + / - atrovent - long acting bronchodilator e.g. serevent (salmeterol) or theophylline (xanthine derivative) ↓ inflammation - use of inhaled + / - oral corticosteroids inhaled - becloforte or becotide - beclomethosone (puffer) - pulmicort - budesonide (turbuhaler - TH) - flixotide - fluticasone propionate (turbuhaler) oral - prednisone or prednisolone Infection / retained secretions - a number of antibiotics to specifically treat the organisms isolated following the M / C / S sputum 11. Interpretation of the objective findings There is mucous plugging with X ray evidence of consolidation at the ( L ) base. The auscultation findings may reflect the patient not breathing deeply enough for breath sounds to be heard. 12. Treatment Aims Consider the patient report of difficulty clearing secretions and being unable to expel them and the airways are excitable. • Relaxation • ↑ air entry • ↑ efficiency of breathing pattern’ • ↑ removal of secretions 13. Techniques to address the aims • Treat after bronchodilation • Positioning - high supported sitting or ( R ) sidelying • Active cycle of breathing technique – using breathing control and when able relaxed deep breathing • Consideration of autogenic drainage (AD) • Assisted cough - use of AP sternal compressions • Humidification or nebulisation if secretions are tenacious © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

14. Issues to be considered prior to discharge i) Awareness of the Asthma Management Plan and ways of coping with acute exacerbations ii) Education regarding appropriate techniques : e.g. breathing exercises, appropriate puffer technique and use of peak flow meter if patients SOB limits their activity education is needed regarding recovery positions and breathing control iii) Advice regarding exercise - this is particularly important if exercise is a stimulus and the airways are sensitive until a threshold is reached. Prior to exercise the preventors should be used so that the relievers are available during the activity. WARM UPS and COOL DOWNS are essential in view of the reactive airways SHORT BURSTS OF ACTIVITY are best such as swimming or cricket 51 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CHRONIC OBSTRUCTIVE DISORDERS Bronchiectasis CASE 2 A 56 year old man is admitted to a Medical Ward via Casualty PMHx : Severe pneumonia in childhood ~ Bronchiectasis IHD Current Medications : Ventolin qid Atrovent tds Pulmicort bd Amoxil Anginine prn O/E : Barrel shaped chest Cyanosis Clubbing SOBOE Productive cough - ↑ production of mucopurulent, slightly blood-stained secretions Auscultation : ↓ BS throughout both lung fields Scattered crackles and wheezes throughout lung fields LL > UL CXR : No local lesions Fibrosis and peribronchial thickening in the lower lobes ABG’s : On Room Air pH - 7.41 PaCO2 - 37 PaO2 - 68 HCO3 - 25 Patient re-admitted 2 months post acute admission for a pre-operative work up for a ( R ) hemicolectomy Post operative presentation: C/O : Wound pain 3/10 ↑ to 7/10 with deep inspiration and coughing O/E : ↓ expansion of the chest wall ( R ) side Spontaneous cough weak and moist Auscultation : ↓ BS bibasally - ↓ ( R ) > ( L ) Widespread coarse crackles especially ( R ) base CXR : ↓ lung volumes particularly ( R ) side ( R ) LL consolidation / collapse 52 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

QUESTIONS RELATING TO CASE 2 1. Discuss the causes of bronchiectasis 2. Outline the pathophysiological changes that occur with this disease process. 3. What do the patient’s medications reveal about his ischaemic heart disease? 4. Discuss the influence of haemoptysis on physiotherapy management. 5. Describe the impact of the auscultation and X ray findings on physiotherapy management. 6. What is the aim of treatment in this initial admission? 7. Discuss the techniques that may be utilised with this patient. 8. Why would the patient be admitted for a work up pre operatively? 9. Consider the effect of the wound on lung mechanics. 10. What are your primary concerns regarding the patient’s post op presentations? 11. What changes would you have to make to your treatment post-operatively? 12. Discuss your treatment of this patient. 13. After a few days outline the changes to your management. ANSWERS TO CASE 2 1. Causes of bronchiectasis - Congenital or Acquired Congenital - Cystic Fibrosis Cilial dysfunction syndrome Primary ciliary dyskinesia Kartagener’s syndrome Young’s syndrome Primary hypogammaglobulinaemia Acquired - Post infection / pneumonia Pertussis Measles Tuberculosis Obstruction Inhaled foreign body Carcinoma Immune deficiency 53 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

2. Pathophysiological changes of bronchiectasis Abnormal and permanent dilatation of the bronchi with destruction of the muscular and elastic components of the bronchial wall associated with inflammation ⇓ Contractile force exerted by surrounding undamaged lung ⇓ hypertrophy and hyperplasia of the tissue in the area and loss of elasticity Inflammation ⇒ peribronchial alveolar tissue damage ⇓ fibrosis and obliteration of distal bronchi ⇓ altered airway anatomy ⇓ impaired mucociliary clearance ⇓ predisposes to airway colonisation persistent (chronic) infection results 3. Medications and Ischaemic Heart Disease (IHD) The patient is only on anginine, a short acting coronary artery vasodilator, for his IHD. As there are no long acting agents used the IHD is less severe. 4. Haemoptysis and Physiotherapy Management 54 The patient’s sputum was slightly blood stained and it needs to be ascertained whether it was fresh or old blood. Streaks of blood through purulent sputum is common ⇒ Rx would not cease but results recorded in the patient’s file. Frank haemoptysis ⇒ a sign of erosion of pulmonary vessel – needs to be monitored - not treat with percussion and vibrations for 5 – 10 days to allow healing. Large amounts of free flowing frank haemoptysis can be life threatening and require embolisation of the bronchial artery. Most episodes are self-limiting. 5. Impact on Physiotherapy Management Auscultation : identifies the Lower Lobes as the primary focus of management © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

X Ray : confirms changes in the Lower Lobes 6. Aim of Rx SECRETION REMOVAL as there is an increase in the amount of sputum and it is mucopurulent 7. Techniques for Secretion Removal • Postural Drainage (PD) Cilia are ineffective or absent and combined with bronchial dilatation ⇒ sputum retention Performed with a tip as the IHD is not severe - the patient should be questioned in the initial subjective to establish the stability of IHD and prior to each Rx medication sheets need to be checked and the patient questioned regarding chest pain • Active cycle of breathing technique (ACBT) combined with percussion and vibrations • Autogenic Drainage (AD) may enable the patient to manage more independently • Flutter or PEP may also encourage independence in management • Demand could be increased as the patient condition improves If exercise or mobilising assists secretion removal consider utilising this first 8. Pre-op work-up The aim is to maximise the patient’s condition preoperatively to ensure the lungs are as clear as possible. Rx would be intensive with 2 physiotherapy sessions as well as independent management with ACBT or AD or Flutter. The patient would also be encouraged to undertake an exercise or walking programme. Pre op instruction would also be undertaken to ensure the patient had a thorough understanding of the post op management. 9. Effect of wound on lung mechanics Midline or transverse incision ⇓ Restrictive lung deficit ⇓ ↓ lung volumes ↓ FRC ⇓ atelectasis 55 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

10. Primary concerns regarding post op presentation ¾ POOR PAIN RELIEF ⇒ unable to cough ¾ Secretions at the ( R ) base ⇒ potential for superimposed pathology ¾ Hypoventilation 11. Rx changes post operatively ¾ Improve pain relief ¾ Positioning - alternate sidelying with the bed flat if able to be tolerated, depending on SOB ¾ Not tip for PD immediately post operatively due to: • Pain • Pressure on the wound site ¾ May not tolerate percussion and vibration in the initial stage post-operatively 12. Rx post operatively • Positioning in high supported sitting • ACBT with staged basal expansion or relaxed deep breathing • Incentive spirometry • Concentrate on huffs or FETS • Flutter valve or PEP mask • Autogenic drainage - if able to change lung volumes Frequency of Rx would be increased initially at least x 4 / day or 2nd hourly with overnight Rx if available 13. Changes to treatment after a few days With good pain control ⇒ ↑ demand with ↑ mobilising Frequency of Rx - ↓ to 2 or 3 times a day 56 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CHEST TRAUMA Case 3 A 50 year old man has received a stab wound , # ( R ) Ribs 4 - 7 and a pneumothorax during a fight. PMHx includes smoking 40 / day and a heavy alcohol intake. He is on the surgical ward with 2 ICC’s with UWSD. O/E : Pain 4 / 10 at rest and 6 / 10 with movement PCA pethidine RR 26 b / min BP 150 / 80 HR 90 b / min FIO2 0.35 % via mask SpO2 90 % Ausc - ↓ BS throughout ( R ) lung field No added sounds DAY 2 0800 hrs Patient is tired, agitated and confused ABGs pH 7.47 PaO2 58 PaCO2 32 HCO3 23 RMO orders an increase in the FIO2 to 0.40 % humidified 1000 hrs FIO2 0.40 % humidified SpO2 88 % Repeat ABG’s pH 7.33 PaO2 65 PaCO2 50 HCO3 24 QUESTIONS RELATING TO CASE 3 1. Discuss the aspects of the patient’s presentation that may impact on assessment and treatment. 2. Outline your concerns in relation to the objective assessment. 3. What are the aims of treatment for this patient Day 1 ? 4. List the precautions relating to ICC’s. 5. Outline your Rx of this patient. 6. Discuss what is happening on Day 2. 7. How might your Rx options vary on Day 2? 57 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS TO CASE 3 58 1. Impact of patient’s presentation on assessment and Rx • Smoking history • Alcohol intake → potential for DT’s • Effect on pain perception 2. Objective Assessment • Concern re appropriate use of PCA as pain rating remains high • ↑ inspired O2 but SpO2 remains low • Need to encourage use of PCA throughout Rx session • Auscultation - with the high pain rating is the patient able to take deep breaths sufficient for added sounds to be heard 3. Aims of Rx Day 1 i) ↑ ventilation ii) prevent secondary respiratory infection iii) prevent circulatory complications iv) mobilise patient 4. ICC Precautions : In bed i) Note the swinging (S), bubbling (B) and draining (D) with tidal breathing, deeper breaths and cough ii) Check the insertion site - ensure there is no ooze and the extent of the dressing iii) Check the tube is not kinked by the taping or the bed Moving - Whether clamps are to be with the patient depends on Consultant’s protocol i) Keep the bottle below the level of insertion – ensure fluid does not flow back into the chest - potential for empyema ii) Keep the bottle level when mobilising – ensures tube remains underwater and accurate measures of drainage can be gained iii) If the bottle breaks / disconnected kink the tubing, alternatively if the tube is dislodged apply pressure over insertion site 5. Rx ↑ Ventilation • Positioning - high supported sitting • Breathing exercises - Staged basal expansions but due to the pain breathing control may be necessary first and ACBT may be a more © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

effective approach • Incentive Spirometry • Mobilise + / - assistance • PEP mask may assist the atelectasis • IPPB may assist if the patient is unable to take a deep breath on his own • Supported cough - with a towel binder 6. Day 2 At 0800hrs the patient is demonstrating signs of TYPE I RESPIRATORY FAILURE. Signs and symptoms of Type I Respiratory Failure: • ↓ pO2 < 60 mmHg • ↑ Vital signs - ↑ RR ↑ PR ↑ BP • Hypoxaemia • Restless • Confused and agitated • Plucking at sheets At 1000 hrs the patient has deteriorated despite an ↑ in inspired O2, and the SpO2 is less. This indicates that the patient is tiring. ABG’s indicate Type II Respiratory Failure with an ↑ pCO2, as he is tiring. Signs and symptoms of Type II Respiratory Failure • Drowsiness • Flushed face • Peripheral vasodilation • Bounding pulse • Eventual coma 7. Changes to Rx At the review at 0800 hrs consideration of the introduction of BiPAP. BiPAP - bi-level positive airways pressure varying inspiratory and expiratory pressures - + ive pressure keeps the alveoli open Possible starting pressures - INSP - 8 cm H2O pressure - EXPIR - 3 cm H2O pressure At 1000hrs with Type II Respiratory Failure evident, medical reviews would be ongoing and ventilation would be under consideration. 59 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CARDIAC CONDITIONS Revision of : Anatomy and Physiology of the heart Lectures on ¾ Cardiac Disease I, II and IIIconditions ¾ Physiotherapy Management of Cardiac Conditions ¾ Exercise Testing and effects of exercise ¾ Exercise in Disease States If you feel confident about your knowledge in this area attempt the questions first and then revise the lectures to supplement your answers REVISION QUESTIONS 1. When treating, what complaints from your patient would raise your concerns regarding a cardiac problem? 2. What other conditions would you need to differentiate these from? 3. Draw the normal ECG waveform and indicate what each of the waves represents. 4. When treating a patient in the ward, what signs would alert you to the possibility that your patient may have developed ST depression or a worsening of ST depression? What would your actions be? 5. What do you understand by the term CCF? Apart from myocardial ischaemia and arrhythmias we need to consider heart failure. To ensure you understand the mechanism of heart failure, revise the Frank Starling Curve. 6. Consider (L)VF and (R)HF under the following headings: (L)VF (R)HF Causes Signs & Symptoms Treatment Implications for Physiotherapy Management Different degrees of disability as a result of LVF are encountered in clinical practice. It is necessary to consider what limitations each individual’s condition may place upon your treatment. 60 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Before considering the following patient examples consider the ECG waveforms for the following arrythmias, their impact on physiotherapy management and those that require CPR to be performed a) ST Depression b) AF - Atrial Fibrillation c) VT - Ventricular Tachycardia d) VF - Ventricular Fibrillation Consider the following patient examples and the limitations upon your management. Patient 1 A 65 year old man who usually has controlled (L)VF has had a (L) hemicolectomy yesterday. His pain is well controlled ( 2/10 with movement ), BP is 140/75 and his fluid balance is +ive 2 000 mls. On assessment he is on oxygen 2 litres via nasal prongs, is slightly SOB on exertion, with no swelling of ankles. Auscultation revealed decreased BS bibasally with fine end inspiratory crackles. Patient 2 A 72 year old female who has (L)VF which limits her activity to light household tasks and shopping (with rests) but is unable to lift a washing basket. At night she needs to sleep on 3 pillows, despite maximal medication and her legs are now swelling consistently. Yesterday she was admitted to hospital with increasing SOB (SOB at rest) and a cough productive of green sputum. X ray and auscultation findings confirm a (R)ML pneumonia. Now he is on 40% oxygen, antibiotics and physiotherapy has been requested. Would you consider compressive therapy for her swollen legs? Patient 3 A 62 year old male in ICU with a chest infection and a history of (L)VF. He is very SOB despite oxygen of 50% the patient is cyanosed and auscultation reveals coarse crackles and prolonged expiratory wheezes. His condition deteriorates and he is now productive of large amounts of pink frothy sputum. Outline the changes to your management. 61 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CARDIAC CONDITIONS ANSWERS 1. Patient complaints → concerns regarding cardiac condition • Chest feels tight / pain • Dizzy spells - possibly myocardial ischaemia • SOB - walking upstairs; while eating; with conversation or needs two pillows to sleep • Asking for non routine medication 2. Differentiation of chest pain • Gastric irritation / indigestion • T4 syndrome • Thoracic Aortic Aneurysm 3. Normal ECG Waveform Characteristics of Normal ECG - Review Web Lecture Notes i) HR - 60 – 100 beats / minute ii) Regular R-R intervals iii) Presence of P waves - one for every QRS iv) P-R interval between 0.12 – 0.2 sec v) RS narrow 2 mm vi) ST Segment - straight - important because the heart must stay contracted – if heart damaged vii) “T” wave • P wave represents atrial depolorisation • QRS complex occurs as the ventricles are depolorised • The wave for atrial repolorisation is lost within the QRS complex • T wave is the result of ventricular repolorisation 62 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. ST Depression Developing or worsening ST Depression • SOB • Angina - variety of presentations possible - crushing, tightness, central, • radiating to jaw or arms, parasthesia • Pallor • Sweaty • Dizziness (indicates myocardial ischaemia) Actions • Monitor - take pulse, stay with the patient • Report to nurse looking after the patient • Document accurately • Modify treatment- delay/ don’t mobilize/ don’t demand 5. CCF Failure of either ventricle to pump sufficiently to deliver adequate blood to metabolizing tissues or pulmonary circulation. SVC RA IVC → RV ⇒ LUNGS ⇒ LA LV⇓ ⇓ Brain Liver Peripheral Tissues 6. LVF and ( R ) HF Table on the following page 63 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

LVF Causes IHD - Coronary Artery Disease (CAD), MI Signs and Symptoms HT ( R ) HF Treatment Aortic Stenosis, Cardiomyopathy, myocarditis Implication for Anaemia - dec. Hb ==> increase pump to sup Physiotherapy Management activity ==> heart failure with exercise Pregnancy, alcoholism, renal failure, thyrotoxi SOBOE Cardiomegaly Orthopnoea PND Pulmonary Oedema X Ray findings - Bat wing distribution of infil glass appearance, Kerly B lines, pleural effusio Auscultation - fine end inspiratory crackles Uncontrolled - pink frothy exudate Treat the underlying causes Diuretics - pull fluid off , dec.preload Anti-hypertensives - dec.perip. vascular resista Vasodilator therapy Blood transfusion for anaemia watch fluid bala Rest - Morphine and Oxygen Consider controlled Vs. uncontrolled failure Increased SOB with uncontrolled CCF due to s oedema in bases ==> use of accessory m. and s breathing ==> inc.oxygen cost of breathing bu supply oxygen to muscles Not well controlled - no tipping, use high sitti no demand ventilation cannot clear oedema, treat s’imposed in frequent rests Uncontrolled pulmonary oedema - emergency No role for physiotherapy © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

pply normal RHF icosis, beriberi Chronic respiratory disease - chronic hypoxia Pulmonary thromboembolism esp. multiple ltrate, ground Valvular Disorders - Valvular pulmonic stenosis on Primary pulmonary hypertension (L)VF , MI ance ance Effects seen in peripheral circulation stiff lungs + - increased JVP > 2 cm shallow - SOA - dependent oedema ut dec.CO to - Organomegaly - hepatomegaly, splenomegaly ing - Ascities - abdominal pain nfection Diuretics - to inc. fluid output, dec. preload y Digoxin - inc. contractility Bed rest Oxygen If chronic respiratory disease with infection - treat the underlying infection Failure increased by hypoxia ==> manage underlying resp.disorder Demand if not too SOB If not well controlled - no HDT (if very necessary check with Unit) - not position supine, flat or prone - no inspiratory holds - no TED stockings - no isometrics - avoid paroxysmal cough 64

Arrthymias • ST Depression – diagnostic of myocardial ischaemia • Atrial Fibrillation - AF – Irregular R-R intervals; no P waves; wavy; irregular baseline • Ventricula Tachycardia – VT – Broad bizarre QRS complex • Ventricular Fibrillation – VF – Chaotic line; no discernible waves or complexes Impact on physiotherapy management • ST Depression - if appears or ↑ during Rx – cease Rx - may need to ↑ FiO2 during Rx • AF – Patient usually has underlying heart disease therefore care with positioning and demand ventilation - Do not ↑ HR to MHR during Rx • VT – Cease physiotherapy Rx - Medical Rx - O2 therapy, lidnocaine, countershock • VF - Cease physiotherapy - Commence CPR Commence CPR - VF and asystole i.e. no QRS omplex ⇒ No Cardiac Output Patient 1 - Controlled LVF post-op Often post op patient’s may have an increased fluid load (increased preload) due to fluid replacement intra and post operatively. As this patient is SOB on exertion, we need to watch the fluid balance for fluid overload and for renal dysfunction postop. Most post surgical interventions can be performed - breathing exercises, limb exercises with care not to increase the SOB, incentive spirometry ( no problem with inspiratory holds) and mobilisation using oxygen. When mobilising oximetry would provide an objective assessment of the effects of increasing demand and would be useful as demand is further increased. 65 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Patient 2 - Mild LVF with a productive ( R ) ML pneumonia The patient has the combined problems of SOB on exertion and a chest infection. Treatment implications: ¾ effects on breathlessness - consider frequency and duration of treatment - possibly short frequent treatments with rests between ¾ not anatomical Postural Drainage positions - modified positions - high sitting, high side lying - not flat, no tipping ¾ secretion removing techniques - assess effects of percussion and vibration ¾ minimal demand - foot and ankle exercises but not vigorous arm and leg exercises until breathlessness decreases. Noting the fluid balance will give a further indication as to when activity can be increased. ¾ demand ventilation should only be introduce once the patient is stabilised. ¾ humidification may make clearance of secretions easier and the mucous membranes may be dry due to the diuretics. Compressive therapy to her swollen legs would cause a large increase in preload, increasing venous return and thereby worsen the heart failure. Diuretics will assist to decrease the oedema. Patient 3 - Uncontrolled LVF Treatment implications ¾ treat superimposed infection and aim to keep the patient comfortable. ¾ short treatments ¾ position in forward lean sitting or high supported sitting ¾ secretion removal techniques of percussion and vibration ¾ humidification to assist expectoration ¾ air entry techniques - e.g. ACBT and SBE not appropriate ⇒ patient unable to change lung volumes ⇒ autogenic drainage is unsuitable for secretion removal. ¾ may need assistance to clear secretions - suction via Geudels airway or via the nasopharynx to clear secretions in the upper airways Condition deteriorates with failure so severe that oedema has crossed into the alveolus. Physiotherapy is not indicated and management would consist of mechanical ventilation, PEEP and diuretics. Repeated suctioning of the ETT will worsen the oedema as the negative pressure will draw more oedema across the alveolus. 66 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

SURGICAL PRE & POST OPERATIVE ASSESSMENT Review your lectures on Surgical Conditions and consider the following questions in your preparation for Case Scenarios. Pre-operative Assessment : 1. Discuss the criteria you would use to decide the patients requiring pre-operative assessment in a large surgical ward 2. Consider the chart information you need to have in assessing your pre-operative patient? 3. Outline your pre-operative assessment. 4. List possible factors that could increase the risk of DVT or PE. ANSWERS : 1. Criteria to decide patients requiring pre-operative assessment Require pre-op assessment ♦ “At risk” patients ♦ High risk surgery ¾ Elderly ¾ Immunocompromised ¾ Premorbid lung pathology i.e. productive cough, fibrotic changes, restrictive conditions, CAL ¾ Malnourished ¾ Long procedures i.e. longer than 3 hours → ↑ risk post-op ¾ Upper abdominal or thoracic surgery - particularly if resection of lung tissue is involved ¾ Underlying malignancies ¾ Recent URTI ¾ Immobile ¾ Neurological probleams - i.e. spinal cord injury ¾ Obesity ¾ Smoking history ¾ PMHx respiratory or circulatory complicationswith previos surgery Ensure you understand the reasons why thes factors increase the risk of post-op complications 67 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

2. Chart information necessary for a pre-operative assessment ♦ Patient details - name, DOB, address, NOK, occupation, social history ♦ PMHx, PSHx,, HxPC ♦ Planned procedure ♦ Anaesthetic work-up ♦ Results of investigations - CXR, RFT, ABG, ECG, US Scan, CT Scan, MRI, Endoscopy, routine bloods, coagulation profile, Barium studies 3. Physiotherapy pre-operative assessment ¾ Check chart, patient history, investigations ¾ Chest assessment and institute chest treatment if indicated ¾ Teach - appropriate breathing exercises - SBE with IH’s or RDB - circulation exercises - supported cough or huff - bed mobility and transfers - with assistance and independently - specific exercises for procedures - UL exercises for thoracic surgery ¾ Explain - physiotherapist’s role regarding chest, circulation, mobilisation, specific exercises - post-operative presentation / incision(s) - rationale for breathing and circulation exercises hourly post-op - early mobilisation programme i.e. generally Day 1 post-op - need for adequate post-op pain relief for effective physiotherapy treatment Provide TED stockings pre-op deending on hospital protocol 4. Factors causing ↑ risk of DVT / PE • Prolonged immobility with surgical or medical illness • Coagulation abnormalities such as DIC (Disseminating Intravascular Coagulopathy) • ↑ age > 40 years of age • Presence of malignancy especially liver and pancreas • Obesity • Vascular surgery or damage to blood vessels • Orthopaedic surgery - in particular hip joint or pelvis • Immobility - paralysis, unconscious, CVA, orthopaedic post-op limitations • Hypertension • Diabetes • OCP (Oral Contraceptive Pill) - less significant with lower doses now utilised • Operations lasting longer than 30 minutes 68 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Post-operative Assessment : 1. Outline intra-operative events that would impact upon your post-operative treatment? 2. List the chart information you need before assessing your post-op patient? 3. a) Name the most common drugs used for post-operative pain relief. b) How are these drugs usually administered? c) When should pain relief be ordered for a surgical patient? d) List some complications of narcotic analgesia. e) What drugs are commonly ordered concomitantly? 4. What factors before, during and after surgery predispose surgical patients to respiratory complications? 5. a) Describe a thorough Calf check. b) If the calf is more tender and painful on one side what is your action? c) If a DVT is diagnosed what is the medical treatment? d) How will you modify your treatment? 6. Outline the effects that post-operative physiotherapy has on the respiratory and circulatory system? 7. List the techniques used post-operatively to prevent respiratory and / or circulatory complications? 8. a) When should you mobilise a post-operative patient? b) List the considerations prior to mobilisation? 9. Discuss the type of patients who may benefit from an incentive spirometer? 10. When would you perform secretion removal techniques on a surgical patient? 11. Briefly outline the differences in physiotherapy management for the following post-op patients a) 2 hours post-op Hysterectomy b) 12 hours post-op Open Cholecystectomy c) 24 hours post-op Laparotomy d) 3 days post-op AAA repair. 12. a) How do you prepare your patient for discharge? b) Consider the information that the patient needs for discharge? 69 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

1. Intra-operative events include : ♦ Change to the planned procedure - laproscopic procedure becomes open ♦ Large blood loss → low Hb post-op ♦ Cardiac complications - ECG changes intra-op, silent MI ♦ Labile BP, intra-operative CVA ♦ Contamination of the field e.g. faecal contamination ♦ Other tissue damage - nerves, tendons, arteries or muscles sacrificed ♦ GA complications - epidural at wrong level, ( R ) main bronchus intubation, epidural / spinal CSF leak ♦ Aspiration Consider how each of these factors would effect your post-operative management 2. Chart information prior to post-operative assessment includes : ¾ Operation notes outlining the actual procedure ¾ Incision/s - structures that have been cut through ¾ Any specific post-op orders ¾ Length of time in recovery ¾ Analgesia - epidural, PCA, Narcotic infusion, IV or IM narcotic ¾ Medical or surgical reviews required since theatre ¾ Any initial post-op complications - poor pain control, low urine output (UO), SOB, fluid overload, wound ooze, bleeding, post-op pyrexia ¾ Any investigations undertaken since surgery (Hb) ¾ Anaesthetic Record From the bed chart: ¾ Vital signs - PR, BP, temperature, SpO2, Supplemental O2 ¾ Fluid balance ¾ Medications chart / Narcotic infusion sheet ¾ Acute observation chart / VAS (Visual Analogue Scale) 3. a) Post-operative analgesic medications : ♦ Narcotics - Fentanyl, Morphine, Pethidine, Omnopon, Endone, MS Contin ♦ Local Anaesthetics - Marcaine, Bupivacaine ♦ Mixed Analgesics - Digesics, Capadex ♦ Simple oral analgesics - Panadol, Panadeine, Asprin ♦ NSAIDS - Indocid, Toradol, Naprosyn ♦ TENS ♦ Gas - Nitrous oxide 70 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

b) Common routes of administration : ¾ Epidural – Continuous infusion or patient controlled. ¾ PCA - Patient Controlled Analgesia ¾ Narcotic Infusion - Continuous IV infusion ¾ IM injection - Intra-muscular injection ¾ Oral ¾ Intercostal nerve block Ensure you know the medications given via each of these routes c) Pain relief should be given so that pain is controlled at all times. Epidural and continuous infusions provide continuous pain control and the rate can be adjusted by the anaesthetist to improve pain control if it is not adequate. The patient is carefully monitored, particularly BP and the RR to ensure they are not narcotised. Patient Controlled Epidural Analgesia (PCEA) is being utilised in some centres. With this technique a continuous infusion is delivered and the patient receives a bolus (additional dose) when they press the button. With a PCA the patients administer their own analgesia. Education of the patient is required to ensure the patient receives adequate pain relief. It is possible to combine a small continuous background infusion with a PCA to provide adequate relief in the initial post-op period when the patient is drowsy and unable to self-administer medication regularly. With all PCA’s encourage your patient to provide themselves with some pain relief at the beginning of your assessment and regularly throughout the Rx to ensure the relief is maximised prior to mobilisation d) Complications of narcotic analgesia : ¾ Postural Hypotension / dizziness ¾ Drowsiness ¾ Nausea / vomiting ¾ Itch ¾ Syncope ¾ Respiratory Depression NOTE : Local anaesthetics used in epidurals can → significant side effects e.g. Lower limb numbness or weakness ⇓ ask in subjective questioning about pins and needles, numbness, weakness or heaviness THIS IS AN ISSUE OF SAFETY - THESE QUESTIONS MUST BE ASKED 71 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

If there are some changes, an objective evaluation must be undertaken : If numbness or pins and needles are present - an objective assessment of light touch in a dermatomal distribution must be undertaken to define the level involved If weakness or heaviness is present - an objective evaluation of muscle strength must be performed. i) Static quads and inner range knee extension over your arm with an isometric hold - look at the quality of the movement, the range, the ability to hold and the eccentric control. ii) Hip and knee flexion - ensure you are supporting the limb for safety. Look at the quality of the movement through the range, the range of movement and eccentric control. Numbness may not prevent the patient from mobilising, but the effect of weakness on movement control may delay mobilisation e) Drugs ordered concominantly ♦ Anti-emetics - Maxalon i.e. metoclopramide - Stemetil i.e. prochlorperazine - Zofran i.e. ondansetron 4. Factors predispose to respiratory complications Pre-operative : • PMHx - pre-existing lung disease • Smoking • Obesity • Poor nutrition • Elderly • Pain • Emergency vs Elective procedure • Immobile • Neurological problems • Recent URTI • PHx respiratory complications post-op 72 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. Factors predispose to respiratory complications : Continued Intra-operative : • GA vs Spinal anaesthesia • Length of procedure - longer than 3 hours → ↑ risks • Type of procedure - ↑ risk upper abdominal and thoracic surgery • Intra-operative complications → delay mobilisation e.g. cardiac complications • Aspiration Post-operative : • Poor pain control • Aspiration • Anxiety and lack of co-operation • Factors that delay mobilisation - nausea, low BP, dizziness, low Hb • Prolonged intubation and ventilation 5. Calf Check; Action if positive findings; Medical Management of DVT; Modifications to Physiotherapy Rx a) Description: ¾ Ensure TED stockings are rolled down or removed to perform check ¾ Essential to compare the sides ¾ Check colour of the limb ¾ Observe if any swelling, redness ¾ Compare temperature - changes will be very subtle ¾ Palpate bulk of the calf Only if no positive signs perform a Homan’s test - passive ankle dorsi-flexion (DF) Ensure differentiate between stretch of calf and calf pain - if pain with DF with knee extension - flex the knee and perform DF, if still painful you have a positive sign as it is the Soleus that compresses the vascular structures b) Action if one calf tender and painful ¾ Report abnormal findings to nursing staff and medical staff immediately ¾ Document findings in the patient’s medical record ¾ Patient will remain RIB till reviewed by medical staff Presence of DVT confirmed by either Doppler Ultrasound or Venogram 73 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

5. DVT Management (Continued) c) Medical Management of DVT ¾ IV Heparin - anti-coagulation for 5 – 7 days ¾ Change to Warfarin prior to discharge for longer term management 6 to 12 months ¾ Monitor coagulation profile via regular APTT ¾ Streptokinase or Urokinase can be used but more commonly for management of PE d) Modification to physiotherapy Rx ¾ Patient usually remains RIB for 24 to 48 hours or until coagulation levels are therapeutic - check with medical staff for specific orders ¾ Restart exercise on the involved limb after 24 hours, while exercises can be continued throughout on the other limb ¾ Mobilisation recommenced within 24 - 48 hours after checking with medical staff 6. Effects of post-op physiotherapy on respiratory function : Changes that occur in the respiratory system due to surgery are: ™ Central inhibition of the respiratory centre in the bran stem ™ Drying effect on the cilia due to anaedthetic gases ™ ↓ in cilia beat frequency ™ ↓ in mucociliary flow ™ Weakness in the respiratory muscles related to - GA - pre-operative medication - post-operative pain relief ™ Loss of surfactant related to - Monotonous breathing pattern - Lack of sighs during anaesthesia and or mechanical ventilation ™ Diaphragmatic dysfunction ™ Absorption atelectasis from ↑ O2 consumption during surgery ™ Pain inhibition ™ Poor coughing due to splinting 74 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

6. Effects of post-op physiotherapy on respiratory function : Continued All of these will cause the following effects : ¾ ↓ in dynamic lung volumes FVC, FEV1 and in static volume VC - thus producing a Restrictive lung deficit ¾ The lungs will become less compliant ⇒ greater effort to expand ¾ Alveolar hypoventilation - mostly commonly results in atelectasis ¾ Secondary infection / pneumonia may occur Post-op physiotherapy techniques therefore aim to : ¾ Reinflate areas of collapsed lung tissue ¾ Prevent further collapse ¾ Prevent the progression to post-operative infection If volumes of air are delivered sequentially, some collapsed alveoli fill and eventually as more volume is delivered all alveoli open. This indicates that a slow inspiration, building up the size of the breath each time then holding at the end to maintain a high trans- pulmonary pressure i.e. an inspiratory plateau will help reverse or prevent atelectasis. Techniques such as SBE’s with inspiratory holds are based on this principal Effects of post-op physiotherapy on circulatory function ¾ Identifying patients at ↑ risk of DVT / PE and providing appropriate prophylaxis - circulation and lower limb exercises After lower limb exercises, normal blood flow is regained for 30 – 60 minutes ⇒ hourly exercise is essential ¾ Circulation slows following surgery for up to 7 days ⇒ continue circulation and lower limb exercises throughout this period 7. Techniques for prevention of post-operative circulatory complications include ♦ Hourly circulation exercises ♦ TED stockings ♦ Sequential Compression Device - SCD ♦ Early post-op mobilisation ♦ Prophylactic heparin or fragmin 75 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

7. Techniques for prevention of post-operative respiratory complications include : ♦ Adequate pain relief prior to intervention ♦ Good positioning - sitting the patient upright or standing will ↑ FRC ♦ Appropriate deep breathing exercises - Staged Basal Expansion +/- Inspiratory Holds or Relaxed Deep Breathing - to ↑ ventilation ♦ Mobilisation ♦ Demand Ventilation - arm and leg exercises, SOOB ♦ Incentive Spirometry ♦ Supported cough - to clear retained secretions ♦ Other secretion removal techniques - ACBT, FET, modified postural drainage, percussion and vibration ♦ Humidification - to aid cilia function ♦ IPPB or CPAP may be indicated when a patients respiratory condition is deteriorating 8. Post-operative mobilisation a) Commenced ¾ Day 1 - depending on the nature of the surgery - no complications that would delay mobilisation - e.g. low BP, low Hb b) Considerations prior to mobilisation : ¾ Adequate pain relief ¾ Anti-emetics - if nauseated ¾ Stable vital signs - particularly BP as narcotics ⇒ postural hypotension ¾ Normal limb power and sensation if epidural insitu ¾ Check wound prior to any movement ¾ Check HB particularly if vascular or large or extensive surgery ¾ Organise attached equipment - move all drips and drains to one side ¾ Arrange mobile drip pole ¾ Give appropriate instructions to the patient and assist appropriately with transfers ¾ Sit patient on the edge of the bed for a few moments until dizziness has cleared ¾ Arrange for a second person to assist with first walk ¾ Arrange an appropriate walking aid for first walk - Forearm support frame (FSF) ¾ Organise a chair for the patient to sit out in after the walk - before transferring the patient ¾ Organise appropriate footwear + / - dressing gown for the walk. It is essential that the patient feels their dignity is recognised and respected 9. Patients benefit from incentive spirometer : ¾ High risk patients ¾ Patients unlikely to carry out ward programme independently ¾ Patients who cannot achieve good air entry with alternative techniques ¾ Patients having thoracic or cardiac surgery - due to CPB If hyperinflation is evident an incentive spirometer should not be given. Incentive spirometers should not be given indiscriminaely – little research validation 10. Perform secretion removal techniques on surgical patients : 76 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

¾ At risk patients with pre-op productive chests the require secretion removal techniques e.g. bronchiectatic or chronic bronchitic patients ¾ If other modalities have not cleared the retained secretions ¾ Post-op chest infections Options include : ♦ Modified postural drainage ♦ Percussion and vibration ♦ Flutter or PEP Mask / Mouthpiece ♦ Active Cycle of Breathing - ACBT ♦ IPPB Careful assessment should be made of each patient to ensure selection of the most appropriate respiratory techniques. 11. Physiotherapy Management of the following patients : a) 2 hours post Hysterectomy • Do not change position - keep supine or sidelying • Commence post-op deep breathing exs, (DB exs), circulation exs (assist/active) and supported cough - may need therapist to support the wound • Patient will be very drowsy - use stimulating voice • Remind the patient to continue hourly exercises - reinforced by Nursing Staff b) 12 hours post Open Cholecystectomy • Position in high supported sitting - check wound, vital signs, pain relief • Continue appropriate DB exs - SBE + / - IH, RDB, DV, Incentive Spirometry, circulation exs, supported cough • Remind patient to continue hourly exs c) 24 hours post-op Laparotomy • Continue Rx as outlined above + may mobilise for the first time d) 3 days post AAA Repair • Continue Rx as outlined above • Focus on independence in transfers, mobility and ward exercise programme • Commence discharge programme and advice 12. Discharge a) Preparation for discharge • Continue abdominal exs + / - pelvic floor • Reinforce for continued wound support to assist in the wound healing process • Continue breathing exs or specific exercise programme as appropriate b) Advice • Ergonomic advice - specific to the patient’s situation • Advice regarding return to driving, sports and hobbies • Educate the patient to avoid straining • Teach appropriate lifting techniques to avoid late herniation of abdominal incision 77 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY Before considering some cases it is necessary to review your understanding of surgical procedures, equipment and potential complications post operatively. Review Introduction to Surgery General Surgery I and II SURGICAL PROCEDURES 1. HIATUS HERNIA REPAIR - the top end of the stomach is pulled down through the diaphragm and the hiatus is reinforced. It may be performed from above the diaphragm via a thoracotomy or from below via an upper midline incision. The patient is nursed with the head elevated and the forward lean sitting is avoided. 2. OESOPHAGECTOMY - removal of part or all of the oesophagus and the stomach is pulled up and re-anastomosed to the end of the oesophagus. When an Ivor Lewis procedure is performed two (2) incisions are made – an upper abdominal to mobilise the stomach and a thoracotomy for resection of the lesion and construction of the anastomosis. Some centres are now performing thorascopic-assisted oesophagectomies so that there is only one abdominal incision and 4 or 5 port incisions posteriorly for dissection of the oesophagus. An extension of this has seen thorascopic and endoscopic assisted oesophagectomies in which there are only port incisions and a neck incision for the re-anastomosis. 3. GASTRIC / DUODENAL SURGERY - most commonly performed for complications arising from gastric or duodenal ulcers or gastric carcinoma. a) Vagotomy - i ) Trunkal - the vagus nerves are divided within the abdomen to diminish gastric ii ) Selective - only the fibres to the stomach are divided iii ) Highly selective - only the fibres to the acid secreting parietal cell mass are divided. b) Pyloroplasty - The pyloric muscle is divided and the defect is sutured transversley leaving a larger gastric outlet. It is therefore a drainage procedure carried out after a trunkal or selective vagotomy when the stomach muscles become paralysed and defective gastric emptying occurs. c) Nissen Fundoplication - performed when anti-reflux surgery is indicated. The gastric fundus is mobilised and loosely wrapped around the lower oesophagus and sutured, preserving the vagus nerve. The “wrap” returns a portion of the lower oesophagus to the abdomen. This eliminates acid reflux and heals oesophagitis. This procedure is now often performed via the laproscope. The post operative protocol may dictate that no nausea or vomiting is allowed and physiotherapy intervention has to take this into account. 78 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

d) Partial Gastrectomy - i ) Bilroth I - 1/3 or 2/3 of the stomach is resected and the stomach remnant is sutured to the duodenum. ii ) Bilroth II - wider stomach resection removing the acid secreting portion and part of the duodenum. The stomach is re-anastomiosed to a loop of the first part of the jejunum and a blind ending duodenal pouch is fashioned. e) Total Gastrectomy - is removal of all of the stomach, closure of the duodenum & anastomosis of the oesophagus to the jejunum (Roux-en-y-oesophagojejunostomy) 4. OPEN CHOLECYSTECTOMY - removal of the gallbladder from the liver bed. It is performed via a Kocher's incision or (R) paramedian incision. An intra-operative cholangiogram (IOC) can be performed to minimise the potential of a stone in the duct system being missed. The cystic duct is catheterized with a T-tube, radio-opaque solution is injected into the ducts and X-rays taken. The T-tube may be left in for 10 days to prevent stenosis of the common bile duct, to drain any remaining gallstones and to prevent inadvertent biliary leakage into the peritoneal cavity. This procedure is now commonly performed as laproscopic procedure. 5. WHIPPLE'S PROCEDURE/PANCREATICODUODENECTOMY – usually performed for cancer of the head of the pancreas. This is a long procedure involving a large incision and removal of the pancreas, common bile duct, part of the stomach and duodenum with re-anastomosis of the remaining portions. 6. SEGMENTAL OR PARTIAL COLECTOMY - removal of part of the colon, commonly for treatment of carcinoma, ulcerative colitis, Crohn’s disease and diverticular disease of the colon. 79 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

a) Hemicolectomy (right, transverse or left) is a resection of a segment of colon with an end to end anastomosis. There is no stoma formed. b) Anterior resection with anastomosis (restorative resection) - involves removal of the sigmoid colon and upper rectum with an end to end anastomosis and is performed for lesions in the upper rectum and lower sigmoid colon. c) Abdominoperineal resection (APR) - removal of the rectum and anus via a laparotomy and anal incisions. Patients usually have anal and abdominal drains with the formation of a permanent colostomy post-operatively. d) Hartman’s procedure - is a modification of a restorative resection. Instead of anastomosis after the resection, the proximal end is converted into a left iliac colostomy. The distal end within the pelvic cavity is simply oversewn. At a later date this may be reversed. 7. TOTAL COLECTOMY AND PROCTOCOLECTOMY (with ILEOSTOMY) - involves excision of the whole colon, either alone or in conjunction with the rectum (proctocolectomy). The procedure is indicated in the treatment of ulcerative colitis and malignant changes in polyps. A one-stage proctocolectomy is an extension of an APR involving excision of the rectum and entire colon via abdominal and perineal approaches. The patient has a permanent ileostomy. In a two-stage procedure the total colectomy is performed first, an ileostomy is formed and the proximal cut end of the rectum is closed. In the next stage the rectum and anus are removed. Occasionally, if the rectum is free or relatively free of disease, the ileum may be anastomosed to the rectum. 80 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

8. STOMAS - are artificial openings between the colon and the skin of the abdominal wall. The mucosa of the colon is stitched to the cut edges of the skin in the opening in the abdominal wall that has been made to receive it. Flatus and faeces are then discharged through the opening onto the surface of the abdomen and collected into a plastic (coloplast) bag. There are a number of different types of stomas:- i) terminal colostomy - a permanent colostomy, formed when the divided end of the colon is brought out to the surface of the abdomen eg following APR ii) side colostomy - formed when the anterior wall of the colon is sutured to the abdominal wall via a small hole made in the colon. Used for relief of distal colonic obstruction and to ‘protect’ an anastomosis initially post-operatively, to ensure it is not placed under any pressure and cause leakage; eg following anterior resection. iii) loop colostomy - created by exteriorizing a loop of colon and passing it over a glass rod. The glass rod is withdrawn after 5-7 days and the externalised colon falls back into the abdomen. A variation of the loop colostomy is the double-barrel colostomy. iv) defunctioning colostomy - is sometimes necessary to ensure that no faeces can pass into the distal colon. In this case, the colon is transected and the two ends, proximal and distal, are brought out through separate openings in the abdominal wall. v) ileostomy - a procedure which creates a cutaneous fistula from the lower part of the ileum. Colostomies- Terminal Side Loop Defunctioning 9. TOTAL ABDOMINAL HYSTERECTOMY (TAH) - removal of the uterus with or without removal of ovaries and fallopian tubes (bilateral salpingo-oophorectomy BSO) 10. WERTHEIM'S HYSTERECTOMY - involves a TAH, BSO and removal of lymph nodes from the pelvic region. This is a prolonged and extensive procedure. 11. CYSTECTOMY - removal of the bladder. May be partial or complete. 12. ILEAL CONDUIT - reconstruction of renal drainage by connecting the ureters to a piece of ileum which is externalised through the abdominal wall. 81 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

INCISIONS : 82 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY A summary of information relating to equipment is outlined. Table 1 EQUIPMENT FUNCTION PRECAUTIONS Naso-Gastric Tube - Is a flexible tube used to drain bile - often pinned to pillow - do not pull and gastric contents from the stomach out when sitting pt forward. Oxygen mask when the GI tract is inactive. - ensure is well secured to pts nose with IV Drip - used pre-op in pts with GI obstruction appropriate tape, and will not slip out to prevent aspiration or regurgitation when mobilising. Wound Drain - used post-op in pts with marked ileus - switch off NG feeds when tipping or to decompress the gut; unconscious / suctioning your pt. to avoid aspiration. semi conscious pts to prevent - remember that NG feeds can often be aspiration; and in pts with marked abdo disconnected to mobilise the pt. – be distension and vomiting post-op. sure to reconnect them once the pt. Has - the tube is either on free drainage, returned to the bed or chair. regular aspiration, or low pressure suction. - check the correct concentration is - also used for enteral feeding of pts - a being delivered to the patient. narrow, softer feeding tube can be - keep O2 on during Rx inserted for this purpose. - use appropriately if PRN Face mask (or nasal prongs) attached to - mobilise post-op pts with O2 (if the pt. for delivery of supplemental approp.) oxygen. -replace O2 mask or nasal prongs if Pts. On a narcotic infusion post-op will removed to mobilise pt. routinely receive supplemental O2 to - ensure burette is not empty - esp. help overcome the effects of respiratory prior to mobilising pt. depression. - do not fill / adjust IVAC - call N/staff - to increase pts PaO2. - care with arm exercises when there is Peripheral venous line inserted for a problem with patency of the drip - post-op administration of maintenance / only then is backflow likely to occur. replacement fluids and medications. - care with bed mobility - limit (Following abdo surgery, most pts movements of joints close to insertion remain NBM until normal GI function has re-appeared - usually 2 - 4 days. of IV ->risk of tissuing -rupture vein wall Appliances that afford a channel of exit from a wound. - pt. c/o pain at drip site report ASAP - Used to prevent accumulation of post- thrombophlebitis may occur. op fluid - where it would be detrimental - drips should be changed ~ 2 - 3 days. for fluids to collect. - do not pull out during the course of See below for description of wound your treatment drains listed earlier in the text. - as infection can be a problem ensure safe, appropriate handling of this equipment. See below for more information re specific drains. 83 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Redivac Drain - is a glass or plastic bottle with a rubber stopper . A vacuum is created in the bottle which allows drainage to proceed. The drain is inserted through a small stab wound away from the suture line ( to minimise the risk of wound infection). Take care with handling not to “devac” by pulling or standing on the tube. The Bellovac drain is a similar design with a drainage tube attached to a bellows. Yeates Drain is a small drain exiting a wound directly, comprising a row of tiny drainage tubes in series - which have been described as having the appearance of pan-pipes. The surgeon often applies a coloplast bag over the drain to act as a collecting duct. Care should be taken to avoid compressing the drain - as in a supported coughing manoeuvre. These drains may be used in Head and Neck surgery. Axiom Drain is a large calibre drain with multiple perforations, attached to low pressure suction. The drain sits on the pelvic floor and drains the fluid that accumulates there. This drain is used after major bowel surgery eg. Anterior resection, where there is anticipated high blood loss. This drain is always under suction - do not disconnect the suction to mobilise without doctors permission. In the following table there is a summary of information relating to post operative complications and the implications for physiotherapy. Ensure you understand these conditions and the reasons for the modifications to treatment. :Table 2. COMPLICATION DEFINITION SIGNS & SYMPTOMS INTERVENTION Wound Dehiscence - partial or total disruption of - discharge of sero- - always check wound any or all of the layers of the sanguineous peritoneal prior to sitting /moving operative wound. fluid (fluid composed of patient Rupture of all the layers of serum and blood) In an emergency the abdo. Wall and extrusion - dry dressings suddenly - lie patient flat, elevate of the viscera is - become wet feet if necessary evisceration. - patient reports feeling of - hold patients stomach - Occurs in 1 - 3% of all something giving way using clean sheet, towel or abdominal operations. - Pain pillow case, ideally +/- O2 Associated with : - bleeding from wound - summon help - distension of the abdomen with coughing or -patient is usually returned - paralytic ileus movement to theatre ASAP to have - increased intra-abdominal - increased pulse rate the whole wound repaired. pressure - Hypotension - malnutrition and general debility - malignant disease excessive vomiting, hiccups or coughing - inadequate surgical closure - faulty catgut. Occurs ~ end of week 1. 84 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Paralytic Ileus Cessation of movement of - no bowel sounds Medical management :- the gut / peristalsis not - no flatus / faeces NBM; NG tube left in Post-operative regained for a prolonged - vomiting or re-inserted; Haemorrhage post-operative period. - hiccups IV fluids: Due to : - abdo distension ++ parenteral feeding. (Internal) - rough / excessive - severe abdo pain ++ Pt should mobilise to Peritonitis handling of colon or ileum - tendency towards bi- decrease collapse and during surgery basal collapse start bowels moving - Ascites - peritonitis - pneumoperitoneum need encouragement + ? Abdominal massage - Post-operative bleeding - decreased BP for gut motility - associated with : - increased PR -organ removal - pallor and sweating In an emergency : - resection of part of the - dizziness and thirst - lie patient flat gastrointestinal tract - pain ++ - elevate patients feet if - vascular surgery - increased abdo girth necessary - increased drainage in - summons help if necessary bottle / bag - remain with patient until help arrives. Inflammation or irritation - severe abdo pain +++ of the peritoneal cavity - - nausea and vomiting Medical management : - with associated infection. - fever NG tube; IV fluids: Due to : - abdo tenderness antibiotics. - acute abdo infections - abdo rigidity - time PT Rx with pain - perforations - tendency towards bi- relief - gangrene of the bowel basal collapse - maintain pulmonary - anastomotic leakage - tendency towards function / prevent - closed / crush injury paralytic ileus complications. - elevated temperature - short, frequent Rx - increased pulse rate - positioning patients in - increased white cell high sit may be difficult count (WCC). - consider standing - consider long term re- Increase in non-infective - large abdomen conditioning program. peritoneal fluid in the - SOB Medical management: peritoneal cavity. Due to - tendency towards bi- - will depend on the :- malignancy basal collapse underlying cause. - right heart failure Maintain the patient’s - renal failure pulmonary function / - portal hypertension prevent collapse. Short, frequent Rx. The aim of the following cases is to integrate your theoretical knowledge and the patient’s clinical presentation. Once again attempt to answer the questions before referring to the answers. If you are unsure of the rationale discuss this with your supervisor. 85 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY Case 1 A 64 year old man is admitted to a general surgical ward for a Laproscopic Cholecystectomy PMHx : Ex-smoker - ceased 20 years ago Previously 10 / day for 20 years Obese Mild asthma since childhood → ventolin prn, becloforte bd Seen in Pre Ac for pre operative assessment. Admitted fasting on the day of surgery. OT Laproscopic procedure unsuccessful → Open Cholecystectomy Post op orders : NBM - N/G tube insitu IV fluids as charted Analgesia as charted Hourly UO measures → notify if <30 mls / hr for more than 4 hours Bellovac drain insitu Day 1 Post op : C/O : Adequate analgesia - 1 / 10 at rest and 3 / 10 with movement Nausea, dizziness in the upright position Nil SOB Nil sputum post op - moist cough, difficulty expectorating O/E : Non-distressed ↓ Lateral costal expansion ( R ) base ↓ BS ( R ) > ( L ) base Coarse expiratory crackles ( R ) LLposterior segment Weak pain inhibited cough QUESTIONS 1. Review the laproscopic procedure. 2. Discuss the proposed advantages of this type of surgery compared to an open procedure. 3. Outline the potential complications of a laproscopic procedure. 4. Consider possible causes of the conversion of the procedure from laproscopic to open. 5. What incision would be utilised for the open procedure? 86 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

6. Discuss the post-operative risk factors for this patient. 7. What purpose does the N/G tube serve? 8. Review the purpose and precautions with regard to IV lines and wound drains. 9. Discuss the links between the assessment findings and the patient presentation. 10. Prioritise the aims of treatment for this patient Day 1 11. Discuss your treatment of this patient. 12. What procedure might be performed post-operatively to investigate the presence of any remaining stones? 13. Discuss the potential serious complication of this procedure. 14. In more detail outline other causes of this complication; the signs and symptoms associated with it and problems encountered in treating this condition. ANSWERS 1. Laproscopic procedures involve the insufflation of the abdomen with gas via a large needle to create a pneumoperitoneum. One such needle is the Hassan needle that is inserted just below the umbilicus. This gas allows improved visualisation of structures. Smaller port holes are then created to enable access for the equipment. Four (4) or five (5) ports are usually utilised. 2. Proposed advantages of the laproscopic procedure: • No large incision • Decreased pain • Shorter length of stay • Less respiratory compromise 3. Potential complications of laproscopic procedures • Abdominal distention • Shoulder tip pain - due to irritation of the diaphragm - Rx TENS opposite C4 • Surgical emphysema • Pneumothorax 4. Conversion from laproscopic to open proceduremay be due to : • the presence of adhesions from previous surgery, obstructing the view • the presence of fat the makes visualisation very difficult. • technical difficulties of the surgery itself. 87 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

5. Incision for the open procedure Kochers or ( R ) subcostal incision ( R ) upper paramedian incision 6. Post-operative risk factors 1) Obesity 2) Respiratory conditions 3) Less impact from smoking as ceased for a long time 7. Purpose of the N/G tube To drain bile and if the patient is nauseated the tube is able to be aspirated to prevent vomiting. Review the precautions in Table 1.pg 82 8. Purpose and precautions for IV lines and drains - Review Table 1. - pg 82 9. Links between assessment findings and patient presentation ↓ BS ( R ) base is consistent with the area of the incision and the potential for pain inhibition Fine crackles ( R ) post basal segment represent atelectasis rather than overload as the UO > 30 mls / hr and the patient is not SOB. Weak cough due to pain inhibition but patient reports pain with movement of only 3/10. This suggests that the pain at 3/10 is significant as it is impacting on his ability to clear his secretions. 10. Prioritised aims of treatment Day 1 1. Ensure pain relief is optimised → cough not pain inhibited 2. ↑ ventilation 3. Facilitate removal of secretions 4. ↑ post-op mobility 88 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

11. Patient Rx • Maximise pain relief prior to treatment • Positioning - high supported sitting - in bed or sitting out of bed • Breathing exercises - Staged basal expansion with inspiratory holds - if response is not maximised demand ventilation can be utilised - Unilateral facilitation at the ( R ) base • Vibrations on expiration to assist with mobilisation of secretions • Supported cough with A-P sternal compression to assist with mobilisation of secretions in upper airways. • Leg exercises to prevent venous stasis - patients undergoing laproscopic surgery may be at increased risk of DVT due to the pressure of the gas on the large veins. • Mobilisation - to increase ventilation and stimulate the circulation 12. An ERCP : Endoscopic retrograde cholangiopancreatography - is performed to assess the presence of any remaining stones. The procedure involves the endoscope being passed through to the duodenum and then a dye being inserted to enable the drainage of the liver, pancreas and biliary tree to be outlined and viewed by Xray. 13. Potential serious complication of an ERCP is pancreatitis. Pancreatitis is a disease characterised by inflammation of the exocrine portion of the pancreas (ie digestive enzymes attack the pancreas) Ranges from mild disease with oedema of the pancreas to the severe form being haemorrhagic or necrotising pancreatitis. Acute - characterised by exudation of neutrophils and interstitial oedema Severe - coagulation necrosis of the gland and surrounding tissue ⇓ loss of structural integrity and possibly frank bleeding The release of vasoactive substances from the inflamed pancreas itself produces a shock like state. This can lead to respiratory failure and ARDS, as a consequence of interstitial capillary leakage and decreased surfactant production. Pleural effusions may occur along with basal collapse due to severe abdominal pain and distension. The consequent V/Q inequality reflects significant pulmonary dysfunction. The CXR of these patients demonstrates the characteristic ground glass appearance with some demonstrating pleural effusions and lower lobe collapse esp. on the ( L ). 89 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

14. Causes of pancreatitis: - Metabolic - alcoholism ; hyperparathyroidism - Toxic - alcohol poisoning - Mechanical - impaction of gall stones → obstruction of the pancreatic duct - Infections - Trauma - MSOF - Idiopathic - Post ERCP - Pregnancy - Hyperlipidaemia Signs and symptoms include : - Pain - increases in severity as inflammatory changes in the gland progress - Abdominal distension - Severe nausea and weakness - Increased pulse rate - Elevated Serum Amylase - generally above 1 000 Somogyi units Most commonly patients with pancreatitis are nursed on a surgical ward and should be monitored carefully by physiotherapy. Problems that may be encountered in treatment: - Pain - often narcotics are indicated prior to commencing treatment if the patient is not on patient controlled analgesia (PCA) - Bibasal collapse or distended abdomen - positioning in high supported sitting may be intolerable, they may prefer to stand or lean over a table - Haemodynamic instability - Alcoholic - non co-operative with treatment / DT’s or they may have pre- existing respiratory problems - Increased risk of clotting or bleeding 90 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ABDOMINAL SURGERY Case 2 A 58 year old man is admitted to a Colorectal ward prior to surgery. Routine Admission for a ( R ) Hemicolectomy HPC : 10 kg weight loss over last 4 / 12 PR bleeding / melena Lethargy Abdominal pain → “cramping“ sensation, worse at night, worsening over last 1/12 PMHx : Smoker 20 / day for last 40 years CAL - RFT’s FEV1 / FVC = 1.6 / 2.9 Hypertension OT : ( R ) Hemicolectomy Post op orders : NBM IV fluids Analgesia via epidural Hourly UO measures Routine post op observations Day 1 post op : C/O : Inadequate analgesia pain 7/10 at rest Itchy Nausea and vomiting O/E : Distressed RR - 30/min Accessory muscle use +++ ↓↓ lateral costal expansion BS - absent in the bases with no added sounds Weak ineffective cough Calf check √√ Wound - nil ooze Day 3 post op Abdominal distension ++ ↑ temperature 39 0C ↑↑ WCC - 20 Abdominal pain ++ - 9/10 at rest 91 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

QUESTIONS 1. Outline the risk factors for this patient 2. What factor stands out for you in the patient’s post-operative Day 1 presentation? 3. Make a prioritised list of the patient’s Day 1 problems. 4. What are the aims of treatment Day 1? 5. On Day 3 what condition has become evident? 6. Discuss the evidence in the patient’s presentation that supports this condition 7. Outline the medical management of this condition 8. Discuss the physiotherapy treatment of this condition ANSWERS 1. Risk factors for this patient ¾ Weight loss - malnourished → less resistance to infection ¾ Smoking history - a 40 pack year history ¾ ↓ Respiratory function tests - ↓ respiratory reserve ¾ HT ¾ ↓ mobility + lethargy → ↑ DVT risk 2. The factor that stands out in the patient’s Day 1 post-operative presentation is : The level of distress reflected in the pain rating as well as the respiratory rate and accessory muscle use 3. Day 1 prioritised problem list : • Poor pain control • Respiratory distress • Hypoventilation → bibasal collapse • Potential for secretion retention • Potential for circulatory compromise 92 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. Day 1 : Aims of Treatment 1. Before treatment pain relief must be optimised. It may be that the patient needs to be reviewed by the pain team and changes made to his medication prior to the commencement of Rx 2. Ventilation 3. Facilitation of secretion mobilisation and removal 4. Increase muscle pump action through foot and leg exercises and mobilisation 5. On Day 3 the signs reflect PERITONITIS Inflammation or irritation of the peritoneal cavity with associated infection. 6. Signs and symptoms of peritonitis : • Severe abdominal pain - 9/10 • Abdominal distension • ↑ Temperature - 390C • ↑ WCC - 20 Other features include : a tendency to bibasal collapse and for paralytic ileus Potential causes of peritonitis : perforation during surgery or an anastomotic leak 6. Medical management : Insertion of a N/G tube ⇒ NBM with IV fluids and antibiotics 8. Physiotherapy Treatment ♦ Time treatment with pain relief or encourage use of PCA throughout Rx ♦ Maintain pulmonary function and prevent complications ♦ Short frequent treatments ♦ Positioning may be difficult - may not tolerate high supported sitting ♦ In view of ↓ condition pre-operatively a long term re-conditioning programme would be appropriate. Another abdominal procedure is an APR - Abdomino-Perineal Resection which involves excision of the rectum where the carcinoma is low in the rectum and an Anterior Resection is not an option. This procedure involves both abdominal and perineal dissection, therefore the patient will have two incisions - an abdominal lower paramedian or median incision, as well as a rectal incision. There will be a drain in the abdomen + / - a perineal drain. Patients will be unable to sit on their rectal wound and drain, therefore modified positioning for treatment will be necessary. High side-lying is an option. When coughing the patient it may be necessary to support the rectal wound with a rolled up towel, if pain or discomfort is a problem. The patient will have a permanent colostomy. Remember to respect the patient’s privacy and comfort. Ensure that the bag is emptied of wind, air or faeces prior to treatment or mobilising. Do not lie the patient prone. 93 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003