Cardiothoracic Surgery Physical Therapy Book PDF

2024-2025 Physical therapy for Cardiothoracic surgery Dr. Wessam abdelftah Dr. Marwa elhelali Dr. Alyaa abd allah Zaid 2024-2025 1st edition ...

2024-2025 Physical therapy for Cardiothoracic surgery Dr. Wessam abdelftah Dr. Marwa elhelali Dr. Alyaa abd allah Zaid 2024-2025 1st edition  HORUS UNIVERSITY IN EGYPT FACULTY OF PHYSICAL THERAPYQUALITY ASSURANCE UNIT Vision The Faculty of Physical Therapy at Horus University strives to be a local and regionalcompetitor in educational programs, distinguished by scientific research that supports sustainable development and community service. Mission The aim of the faculty of Physical Therapy at Horus University is to prepare competent graduates in the field of physical therapy, capable of providing high- quality competitive healthcare through the provision of an excellent academic environment and advanced educational programs that encourage self-learning, continuous learning, and systematic scientific research; thereby contributing to development and solving societal problems. Strategic Goals 1. Improving institutional performance efficiency to ensure quality performance. 2. Achieving excellence in the educational program and enhancing graduatecompetitiveness. 3. Enhancing the scientific research system and supporting excellence and innovation. 4. Providing exceptional community services and contributing to environmentaldevelopment for sustainable development. 5. Qualifying the faculty for accreditation according to the standards of theNational Authority for Quality Assurance and Accreditation in Education. 1  Table of content Items Page Chapter I: Introduction Structure and function of heart and lung 4 Cardiac surgeries 6 Thoracic surgeries 11 Cardiothoracic Incisions 17 Chapter II: Expected postoperative complications. 20 Chapter III: Assessment of cardiothoracic surgery patients. 37 Chapter IV: Rehabilitation program Preoperative physical therapy rehabilitation program. 48 Postoperative physical therapy rehabilitation 54 program. Chapter V: Care units. Intensive care unit. 74 Coronary care unit. 112 2 Definition: The specialty of cardiothoracic surgery deals with disorders that affect the organs located in the thorax, or chest, primarily the esophagus, heart, and lungs. Since the Second World War, this relatively new specialty has rapidly developed, with the first successful open-heart surgery using the heart-lung machine occurring in 1953. Many times, the procedures are complicated and time-consuming, requiring the use of advanced equipment to assist the surgeon and accurate postoperative rehabilitation for the patient. In addition to the diagnosis and treatment of fetal damage to the heart and lungs, these operations are also used to diagnose and treat disorders of other structures, such as trachea, esophagus, diaphragm or thymus gland, which may be required in the case that myasthenia gravis is detected. Designed to preserve or enhance cardiovascular health, physical therapy or cardiothoracic rehabilitation is a medically supervised program that is recommended as a crucial therapy approach for individuals following cardiothoracic surgery. It has several positive impacts on functional capacity, skeletal muscle and endothelial function, and quality of life. Cardiothoracic rehabilitation has advanced over the past few decades and associated with a lower in mortality and improving all patient’s quality of life. The process of prescribing exercises can be fairly complicated, particularly for people who have had heart surgery. Finding the right "dose" of exercise to maximize benefits and minimize side effects is the most challenging aspect of the exercise regimen. Risk assessment and clinical evaluation are monitored, this allows for objective measurements of the cardiovascular, metabolic, and respiratory responses to exercise and helps to customize a program for each patient. 3 Structure and function of the heart and lungs: The heart, a fist-sized organ, is the pump that circulates blood throughout your body. It is the primary organ of your circulatory system. Tissue and muscle comprise this powerful organ. The four muscular sections (chambers) of your heart are responsible for temporarily holding blood before pumping it. Your heart beats due to electrical impulses that pump blood through these chambers. Your heart's function is controlled by your brain and nervous system. Figure (1): Outside of the heart (a muscular organ that pumps blood to your body) 4 Your heart’s main function is to move blood throughout your body. Blood brings oxygen and nutrients to your cells. It also takes away carbon dioxide and other waste so other organs can dispose of them. Your heart also maintains your blood pressure, controls the rhythm and speed of your heart rate. On the other hands, the organs and tissues that make up your respiratory system are what enable you to breathe. It consists of your mouth, nose, and lungs as well as the tubes (airways) that join them. Your ribcage protects your respiratory system, and your muscles and blood vessels support it. Together, these components allow your body to absorb oxygen during inhalation and excrete carbon dioxide during exhalation. Many conditions can affect the organs and tissues that make up your respiratory system. Irritants and germs you breathe in from the air including viruses, bacteria and fungi that cause infections can cause some of these conditions. Others are the result of damage or genetic diseases. Figure (2): Respiratory system. 5 Cardiac surgeries 1-Open heart surgery: 6 Figure (3): Open heart surgery Figure (4): Open heart surgery 7 2-Closed heart surgery: Congenital Aquired Patent Mitral ductus stenosis artiosis Aortic Coarcitation stenosis of aorta 8 Figure (5): Examples of closed heart surgeries Figure (6): Examples of closed heart surgeries 9 Figure (7): Open versus closed heart surgeries 10 Thoracic surgeries: 1- Flail chest or fracture ribs: Trauma can result in a medical emergency known as a flail chest. Your chest wall becomes unstable when three or more ribs are shattered in two or more places. You can't breathe deeply because you're in pain. Figure (8):flail chest 11  Figure (9): Flail chest 2- Stove in chest Is a complicated and uncommon kind of flail chest injury in which the chest is crushed by the flail segment. Because of the high death rate at the scene, it is usually the result of severe physical trauma to the chest wall and is infrequently seen in imaging or emergency medicine. It may develop from a traumatic flail chest over the course of days or weeks. 3- Pneumothorax (collapsed lung) A pneumothorax is a medical condition in which air enters human chest cavity and presses against his lung, resulting in a partial or complete collapse. It can be brought on by injuries, medical procedures, or underlying medical conditions. Breathing difficulties, chest pain, or blue skin, lips, or nails are all symptoms that require the closest emergency department. Figure (10): Pneumothorax 12  Figure (11): Left sided tension pneumothorax 4-Haemothorax: is the presence of blood in the pleural space. Figure (12): Chest haemothorax 13 5-Intercostal drainage Figure (13): Intercostal drainage 14  6-Carcinoma lung Figure (14): Lung cancer surgery 7- Laparoscopic thoracic surgery 15  Figure (15): Laparoscopic thoracic surgery 8-Haemopneumothorax: is when blood (hemothorax) and air (pneumothorax, or collapsed lung) enter pleural space at the same time 9-Lung contusion and laceration: Lung contusion is a bruise of the lung, caused by chest trauma, while laceration is a cut or tear of the lung tissue. 10-Injury to heart, great vessels and bronchus 11-Empyema, Pleural empyema refers to a pus collection in the pleural cavity is often unilateral which mostly occurs as a complication of pneumonia or perforated esophagus 12-Other types of thoracic surgery  Rib resection  Decortication  Window operation  Pulmonary tuberculosis  Tuberculoma  Bronchiectasis or bronchiectasis sicca  Aspergillosis  Broncho-pneumonia  Lung abscess 16 Cardiothoracic Incisions Median Sternotomy Median sternotomies are the most commonly performed thoracic incisions. It is typically utilized for open cardiac surgery, including heart transplants, CABG, and valve replacements. The xiphoid process and the substernal notch are the sites of the incision, which is then made through the sternum to reach the thoracic cavity. It is an often-utilized incision that offers good access to the mediastinum and thoracic cavity, however it may increase the risk of severe scarring and persistent chest pain. Thoracotomy An incision made to reach the thoracic pleural area is called a thoracotomy. The posterolateral incision, anterolateral incision, and axillary incision are the three primary subtypes. 1-Anterolateral incision There are several surgeries for cardiac, pulmonary, and oesophageal pathologies that can be performed with the anterolateral thoracotomy incision. The incision divides in the pectoralis major and serratus anterior on its approach, running from the lateral border of the sternum to the mid-axillary line at the fourth or fifth intercostal space. 2-Posterolateral incision Posterolateral thoracotomy is mostly utilized for chest wall resection, oesophageal surgery, and pulmonary resections (pneumonectomy or lobectomy), providing access to all of the thoracic viscera. The patient is placed in the lateral decubitus posture while the incision is being made. It extends laterally to the anterior axillary line, beginning in the space between the scapula and the mid-spinal line. The incision crosses the latissimus dorsi and serratus anterior muscles, then the rhomboids and trapezius, before entering the thoracic cavity. 3-Axillary incision A muscle-sparing method of accessing the thoracic cavity for pneumonectomy and pneumothorax procedures is called an axillary thoracotomy. Through the fourth or fifth intercostal space, the incision is created between the anterior border of the latissimus dorsi muscle and the posterior border of the pectoralis major muscle. The incision has minimal exposure to the thoracic viscera but reduces muscle injury and provides acceptable cosmetic results. 3-Pacemaker Incision The pacemaker, a device that controls the electrical activity of the heart, is inserted using the pacemaker incision. Usually, the left infraclavicular area is incised by 4–5 cm. The three most 17 common forms of incisions are deltopectoral, oblique, and horizontal. The pacemaker is inserted into the subcutaneous "pocket" that is formed when the incision is made. 4- Book thoracotomy. 5-Extension of an anterolateral thoracotomy. Figure (16): Common cardiothoracic incisions. ① Midline sternotomy, ② Pacemaker scar, ③ Posterolateral thoracotomy, ④ Anterolateral thoracotomy, ⑤ Axillary thoracotomy 18 Figure (17): Book thoracotomy and extension of an anterolateral thoracotomy 19 Chapter II: Expected postoperative complications. cardiothoracic surgery complications Pre operative risk factor age sex ESL BMI initial laboratory results (CK-MB, CRP, Hb, K+, HbA1C) LV ejection fraction LA and LV diameter CCS and NYHA scores arterial hypertension AF (paroxysmal and persistent) diabetes dyslipidemia myocardial infarction in the past coronary vessels angioplasty cardiac arrest implanted heart stimulator endocarditis intraoperative risk factors surgery type myocardial protection protocol spontaneous return of heart rhythm after removing aortic cross-clamp number of defibrillations required to restore normal heart rhythm maximal defibrillation power fluid balance from the operating room perfusion time aortic cross-clamp time reperfusion time time of ischemia CPB parameters (Hb, pH, pCO2, pO2, K+, Ca2+) intraoperative levozymendan infusion\ 20 21  acute post operative complications Acute complications following cardiac surgery can be serious and require immediate attention. Here are some common acute post-operative complications: 1. Bleeding: This can occur at the surgical site or internally and may require additional surgery to control. 2. Infection: Infections can develop at the incision site, in the lungs (pneumonia), or in the bloodstream (sepsis)1. 3. Arrhythmias: Irregular heart rhythms, such as atrial fibrillation, are common and can increase the risk of stroke. 4. Myocardial infarction (heart attack): This can occur due to blood clots or reduced blood flow to the heart. 5. Respiratory complications: These include difficulty breathing, pneumonia, or the need for prolonged mechanical ventilation 6. Kidney dysfunction: Acute kidney injury can result from reduced blood flow during surgery. 7. Stroke: This can occur due to blood clots or reduced blood flow to the brain. 8. Low cardiac output syndrome: This is characterized by the heart’s inability to pump enough blood to meet the body’s needs, leading to organ dysfunction. 9. Pericardial effusion: Accumulation of fluid around the heart, which can compress the heart and impair its function. 10. Gastrointestinal complications: These can include nausea, vomiting, or bowel dysfunction 11. Dyspnea due to incision Pain ,decrease lung expansion disturb mechanism of respiration, Depression of respiratory system due to anathesia in brain apnea(cessation of respiration ) 12. pneumonia due to using Neuromuscular blocker ( relaxation of respiratory muscle and loss pharynx and larynx )loss harmony increase incidence of secretion accumulation due to Impaired cough & Impaired mucociliary action 13.phrenic nerve damage 22   Phrenic nerve damage Diaphragmatic dysfunction often occur. postoperatively in patients undergoing cardiac surgery. Phrenic nerve injury commonly occurs from cold cardioplegia or mechanical stretching during open-heart surgery. Internal mammary artery (IMA| dissection may reduce blood supply to ipsilateral intercostal muscles and may cause mechanical injury to the phrenic nerve. The consequences of post-cardiac surgery diaphragm dysfunction vary from asymptomatic radiographic abnormalities to severe pulmonary dysfunction requiring prolonged mechanical ventilation and increased morbidity and mortality. Unilateral diaphragmatic paralysis (DP) reduces pulmonary function by about 25%. Bilateral DP is more sinister as it can reduce the respiratory function by up to 60% resulting in failure to wean from ventilator support. Even if the patient is extubated, it increases chances of atelectasis. pneumonia, and lung collapse. Most patients with post-cardiac surgery diaphragmatic dysfunction improve with conservative measures such as chest physiotherapy, prevention and treatment of pneumonia, treatment of underlying chronic obstructive pulmonary disease (if present), and overall care. Rarely, diaphragmatic plication may also be required in such patients. Normal diaphragmatic function could he expected to return after 6-12 months 23  Chronic complication as a result of (prolonged bed ridden) Prolonged time spent in bed after operation can generate several physiological disorders and effects on most of body systems Cardiovascular System Three major complications of cardiovascular system: A) Orthostatic Hypotension also called postural hypotension. B) Bed sores also called pressure ulcers , decubitus ulcers. C) Deep venous thrombosis (DVT). A. Orthostatic Hypotension Def: It is a decrease of systolic blood pressure at least 20 mm Hg or a decrease in diastolic blood pressure at least 10 mm Hg within three minutes after changing the position It occurs 24 after 3 weeks of bed rest when the patient change his position from horizontal position to up right position that will lead to Excessive pooling of blood in the lower extremities by the effect of gravity leading to Decrease in circulating blood volume detected by baroreceptors which will stimulate sympathetic nervous system leading to Increase of the heart rate more than 20 beats/min leading to Decrease diastolic ventricular filling leading to Decrease of cardiac output leading to Decrease of cerebral perfusion ( decrease blood goes to the brain) So the patient will have a feeling of nausea, headache, lightheaded, dizziness, blurred vision, fatigue, tremors, palpitations, impaired cognition and Vertigo soon after standing which will lead to Increase the risk of falling.Example: change position from supine position to standing position or even from sitting to standing position In a healthy and mobile person, the rapid fall in blood pressure that occurs upon standing is immediately detected by the baroreceptors, which quickly inform the cardiac canter to increase the sympathetic stimulation of the heart. Prevention: There are three simple ways to prevent postural hypotension: 1) By raising the head of the bed gradually and maintain this position for a while until the patient feels okay. 2) If a tilting table is available, the patient should be tilted gradually to standing upright position and maintain this position for a while. 3) Ankle pump exercise You can perform ankle pump exercise from lying down position or from sitting position according to the patient condition. B. Bed sores (pressure ulcers) (decubitus ulcers) 25 Def: damage and injury of the skin and the under lying soft tissues caused by constant prolonged pressure on the skin over lying prominent bony areas as a result of prolonged recumbent position or wheel chair sitting for along time. The most affected areas: 1- The back of the head( occipital region) and the ears. 2- The shoulders and the elbows. 3- The lower back, tail bone (coccyx) and buttocks. 4- The medial or inner side of the knees 5- The greater trochanter area. 6- The heel and the ankle Areas of pressure ulcers in different positions: Chronic complication as a result of (prolonged bed ridden) Causes of development of pressure ulcers: 26  1- pressure: prolonged constant pressure leads to decrease blood flow to this area leading to decrease of oxygen and nutrients delivery to this area leading to tissue damage. 2- Friction: Means rubbing of the skin against bed sheets or clothing leading to fragile skin and increase the risk of skin injury and damage. 3- Shearing: occurs when two surfaces moves against each other Risk factors of pressure ulcers: 1- Immobilization (for example) as a result of coma, spinal cord injury and paralysis. 2- Incontinence makes the skin moist and more prone to get infected. 3- Decrease of sensation (for example) patients with diabetic neuropathy , spinal cord injury. 4- Dehydration will make the skin more dry and easily to break down and get infected. 5- Diseases that affect blood flow like diabetes mellitus and vascular disease. Presence of 3 factors + Risk factors = Increase risk of pressure ulcers Stages of pressure ulcer 27  Prevention 1) Skin care 2) Relieve pressure over bony prominence areas 3) prevent sharing and friction forces 28  4) Reduce risk factors as much as possible Skin care during phase 1 1) The skin of the patient should be examined daily for any change of skin color , texture , swelling, tenderness , cold or warm areas of the skin that feels abnormal should also be examined. ( All theses signs called warning signs of pressure ulcers). 2) The skin of the patient should always be dry not moist and clean by applying creams and sprayers to isolate the skin from getting moist and infected by urine or faces like in case of incontinence. 3) The sheets of the bed and patient clothes or gown should not be wrinkled to prevent skin irritation. Wrinkled sheets 4) Relieve pressure over bony prominence areas: To minimize the effect of prolonged pressure turning the patient every 2 hours in different positions. And every 1 hour in obese patient Use pressure relief air matters. 5) prevent sharing and friction forces: by keeping the sheets and the patient clothes un wrinkled. 6) Reduce risk factors as much as possible Treatment last from 1 day to 3day Skin care during phase 2 1) The same steps as phase 1 2) Wash wound by normal saline 3) Use mebo cream and Fucidin cream 29  Treatment last from 3 days to3 weeks Skin care during phase 3 1) The same steps as phase 2+ 2) Using antibiotics(bivatracin) 3) Air matress 4) +glycrein manesia+ Vaseline gauze 30  Treatment last from 1 month to 3 months Skin care during phase 4 1) The same steps as phase 3+ Bepanthen plus last from 4 month to 1 year ( Stage 4) C. Deep Venous Thrombosis (DVT) Def:It is a blood clot formed in the deep veins commonly in the legs. As a result of venous stasis,hypercoagulability and damage to blood vessels. Patient complains Redness , pain , swelling DVT diagnosis : 31  Ultrasound (leg veins) conventional or duplex coagulation profile Venogram Impedance plethysmography CT scan D dimer test Magnetic resonance imaging (MRI) other tests : Homan’s sign the patient’s knee is in an extended position and the examiner forcefully dorsiflexes the patient’s ankle (1). A positive sign is indicated when pain in the popliteal region and the calf is elicited as the foot is dorsiflexed Prevention 1)Medications 2) early mobility and transfer activities (according to the patient condition) 3) ankle pump exercise 32  Respiratory System In the supine position the body weight restricts the movement of the rib cage, reducing the tidal volume. This restriction of the movement of the chest cavity leads a reduction in total lung capacity and residual volume. This decrease in residual volume may lead to a lower concentration of oxygen in the blood Immobility also leads to reduced secretion, and decrease tendency for the mucus to accumulate, under the influence of gravity and the diminution of the tidal volume; this effect can be aggravated when the person is dehydrated, as the mucus becomes thicker and expectoration more difficult. which predisposes the patient to pneumonias. Prevention Diaphragmatic and segmental breathing Modified postural drainage position with head elevated 45 degree. Teach patient effective cough if not effective use suction and hyper oxygenating the patient to avoid complications. If no other serious complications two therapists will turn the patient to each side and hyper oxygenate using ambubag Then use pulmonary hygiene techniques to mobilize secretions like percussion, shaking and vibration then remove secretion by suction lying prone can improve ventilation and oxygenation Coordinate upper extremities mobility with inspiration and expiration to improve lung expansion. Musculoskeletal System Muscles: 33  short periods of bed rest are sufficient to cause the loss of muscle loss and strength, at a magnitude of 10 to 15% per week of disuse, and up to 5.5% per day of bed rest. Antigravity muscles suffer greater strength loss than other muscles during inactivity, because they lose tone when there is no movement of weight. Besides the loss of strength, shortening of muscle fibres also occurs. The number of sarcomeres (muscle filaments) decreases when the muscle is held in a shortened position, and the extent of atrophy is significantly increased when the muscle is maintained in such a position. Connective tissues: When movement is restricted, the metabolic activity of the joints is altered, and these tissues suffer a marked increase of collagen, becoming denser; and the fiber that involve the muscles, ligaments and tendons are shortened, resulting in an overall decrease in joint flexibility. Although all joints may be affected by immobilization, the hip, knee and ankle are the most susceptible due to the effects of gravity, and by the difficulty of full extension of the joints when sitting or lying down, and the contracture of these joints makes it difficult to perform movements of transference. Bone During immobility, the process of bone formation ceases, but the activity of osteoclasts continues, resulting in loss of bone density, causing the bone to have a soft, weak structure. With a few days of rest the circulating calcium increases, and with three days there is an increase of calcium loss through the urine. Vertebral bone loss is accelerated by 50 times when a healthy person is bedridden. If the patient is comatosed muscle length and strength can be assessed by observing the shortened position of the joint and contour of the muscle Prevention: Muscle shortening is prevented or corrected by stretching exercises in opposite direction. Muscle strength is maintained by active exercises (esp. resistive), if the patient is comatosed or disoriented use passive ROM exercises. Osteoporosis can be prevented or decreases by weight bearing and resistive exercises 34  Joint stiffness is prevented by passive ROM exercises (osteokinematics). And joint mobilization (arthrokinematics or joint play) → gliding , traction. Gastrointestinal System Stomach transit time is 66% slower in the supine position in comparison with standing, which contributes to reduced appetite and decreased peristalsis, which leads many patients to exhibit symptoms of gastroesophageal reflux. Constipation may be the main problem of immobilization in the elderly due to decreased bowel mobility, inadequate Fiber and fluid intake associated with anorexia, the development of weakness of the evacuation muscles, the inability to respond to the urgency of evacuation, and inability to assume a seated position, making evacuation a difficult process for this population. Bed rest is commonly associated with reduced taste, smell and loss of appetite, leading to the disuse of the intestinal tract, which in turn leads to mucosal atrophy and shrinkage of glandular structures. There is also a reduced sensation of thirst, which can easily evolve into dehydration. Decreased caloric demand, endocrine changes, anxiety and depression contribute to the loss of appetite. Prevention : ( early mobility) especially post operative Good nutrition (meals rich in fibers Urinary System Urinary complications caused by immobilization include the development of renal calculi and urinary tract infection, which first appear due to changes in renal drainage and alterations in urinary calcium levels and pH. In addition, the potential for the development of urinary tract infections increases during immobilization due to the predisposition to urinary stasis in both kidneys and the bladder, which allows the growth of bacteria. 35  In the supine position, the effects of gravity are negative and the urge to urinate is reduced. This can lead to an overfull bladder, which leads to stretching of the muscles. After prolonged periods of time the stretch receptors lose the ability to be stimulated, leading to the loss of sensation of urinary urgency. Prevention: ( early mobility) Good hydration 36  Chapter IV: Assessment of cardiothoracic surgery patient - Subjective assessment - Objective assessment Cardiothoracic rehabilitation exercises, which include walking, cycling, rowing, and jogging, can also strengthen the heart. Yoga is sometimes included in these exercises, as studies have shown that it is beneficial to heart health. Cardiac rehabilitation is advised by the American College of Cardiology and the American Heart Association, as according to research, cardiac rehabilitation can lower the chance of developing new cardiac problems and passing away from heart disease. One component of cardiac rehabilitation is assessment. Patients are examined by his medical team. His physical abilities and medical restrictions are examined. Also, the risk of cardiac problems is assessed by the team, especially when patients exercise. This aids in designing a cardiac rehabilitation program that is both safe and beneficial. Regular examinations make it easier for the medical team to monitor patient progress and overall health. Assessing the cardiovascular/ respiratory system includes performing several subjective and objective assessments: 37  Figure (18): Patient assessment 1- Subjective assessment Medical History: (personal, past, present, and family history) Some questions could be asked:  Have you ever been diagnosed with any heart or circulation conditions, such as high blood pressure, coronary artery disease, peripheral vascular disease, and high cholesterol, heart failure, or valve problems?  Have you had any procedures done to improve your heart function, such as ablation or stent placement?  Have you ever had a heart attack or stroke?  Have your parents or siblings been diagnosed with any heart or chest conditions?  ………….etc. Cardiac Risk Factors è if your patient:  Currently smoke, or smoked in the past  Physically active during the week  Eats fruits and vegetables in a day  Monitor the amount of saturated fats you eat  Eats a meal prepared by a restaurant?  Add salt to your foods before tasting it?  Have caffeine during the day, and how much, or drinks alcoholic drinks?  Rates the amount of stress in your life from 0-10 and how does he cope with the stress.  Can sleep normally or has sleep disorders. Chief complain  Symptom of chest pain, shortness of breath (Dyspnea)  Edema, palpitations dizziness (Syncope)  Poor peripheral circulation, calf pain 38  Figure (19): History taking 2-Objective Assessment The physical examination of the cardiovascular/respiratory system involves the interpretation of vital signs, inspection, palpation, and auscultation of heart and breathing sounds to evaluate sufficient perfusion and cardiac output. Inspection 1-level of consciousness:  Alert  Lethargic  Obtundation  Stupor  Coma Figure (20): Patient inspection 39 2- Body type:  Normal  Obese  Cachectic  Chest area over and lungs the heart Precordium for abnormalities. Inspect the area for deformities, scars, or any abnormal pulsations. Figure (21): some body types 40 Figure (22): Cachectic patient 41  Figure (23): Cachectic patient in association with chronic conditions 3-Accessory muscles of ventilation hypertrophy, pattern of breathing, or uses of pursed lip breathing. 4-Skin color to assess perfusion. Inspect the face, lips, and fingertips for cyanosis, malar flush, jaundice or pallor.  Cyanosis is a bluish discoloration of the skin, lips, and nail beds and indicates decreased perfusion and oxygenation.  Malar flush: Reddish color of nose & checks; indicates tight mitral stenosis.  Jaundice: Yellowish discoloration of skin and mucus membrane due to increase amount of bilirubin >3 mg. (site: Sclera of eye).  Pallor is the loss of color, or paleness of the skin or mucous membranes, as a result of reduced blood flow, oxygenation, or decreased number of red blood cells. Patients with light skin tones should be pink in color. For those with darker skin tones, assess for pallor on the palms, conjunctiva, or inner aspect of the lower lip. Figure (24): skin color assessment 5-Jugular Vein Distension (JVD). Inspect the neck for JVD that occurs when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible 42  on the right side of a person’s neck. JVD should not be present in the upright position or when the head of bed is at 30-45 degrees. Figure (25): Anatomy of jugular vein Figure (26): Jugular Vein Distension 6-Extremities: 43   Upper Extremities: Inspect the fingers, arms, and hands bilaterally noting color, warmth, movement, and sensation (CWMS). Assess capillary refill by compressing the nail bed until it blanches and record the time taken for the color to return to the nail bed. Normal capillary refill is less than 3 seconds.  Lower Extremities: Inspect the toes, feet, and legs bilaterally, noting CWMS, capillary refill, and the presence of peripheral edema, superficial distended veins, and hair distribution. Document the location and size of any skin ulcers.  Edema: Note any presence of edema. Peripheral edema is swelling that can be caused by infection, thrombosis, or venous insufficiency due to an accumulation of fluid in the tissues.  Clubbing fingers: which may occur alone or with other symptoms such as coughing or shortness of breath  Deep Vein Thrombosis (DVT): A deep vein thrombosis (DVT) is a blood clot that forms in a vein deep in the body. DVT requires emergency notification of the health care provider and immediate follow-up because of the risk of developing a life-threatening pulmonary embolism. Inspect the lower extremities bilaterally. 2- Palpation:  Chest expansion  Chest tenderness  Tactile vocal fremitus  Tracheal shift. 44 Figure (27): Chest expansion 45  Figure (28): Tactile vocal fremitus Figure (29): Tracheal shift. 3-Percussion and occultation for heart and chest sounds: 4-Radiological assessment: (X-ray, ultrasonography …etc.) 46 6-Laboratory assessment: (CBC, blood gases…………...etc.) 7- Electrophysiology: (ECG, EMG) 8- Exercise testing: 9- Functional status assessment: The New York Heart Association (NYHA) Functional classification in a Patient with Heart Disease Limitation on Symptoms with physical activity ordinary physical Status at rest Class activity None None Comfortable I Slight Symptomatic with Comfortable II ordinary activities Marked Symptomatic at Comfortable III less than ordinary activities Unable to perform Discomfort with Symptomatic at IV any activity any activities rest 47  PREOPERATIVE REHABILITATION Preopera ve rehabilita on: includes the range of interven ons delivered to pa ents awai ng cardiothoracic surgery with the aim of improving postopera ve outcomes, reducing the incidence or severity of post-opera ve complica ons, and prepare the pa ents for surgery. Aims of preopera ve rehabilita on: 1) To evaluate and screen the func onal capacity of the pa ent to tolerate the surgery. 2) To prepare the pa ent for surgery. 3) It is cri cal to ensure safe performance of the surgical procedures. 4) Minimizing periopera ve and long-term morbidity and mortality. Effect over me of Preopera ve rehabilita on on hospital and longer-term outcomes: A. Early extuba on B. Reduced ICU length of stay C. Early discharge D. Improved quality of life / good func onal status PRE-OPERATIVE MANAGEMENT (Assessment & Treatment) ASSESSMENT The aim is to iden fy pa ents who are at risk for intra-opera ve and/or post-opera ve complica ons. Steps for pre-opera ve evalua on: A. History and Physical examina on 1) History: Personnel history, Pa ent's smoking history, History of alcohol & drug use, Present history, Drug history, Past medical & surgical history, Family history, and social history. 2) Physical examina on: chest, cardiac examina ons, and examina on of other systems (e.g. neurological, or musculoskeletal) may be needed. B. Preopera ve screening tests 1) Pulmonary func on tests: Spirometry - Arterial blood gas analysis (ABG) 2) Sub-maximal exercise tes ng 3) Electrocardiograms (ECG) 4) X-ray 5) CT scan 48  6) Bronchoscopy I- Pulmonary func on tes ng: It is very important part in the preopera ve evalua on especially for pa ents: 1) Older than 60 years of age. 2) Known to have pulmonary disease. 3) Obese. 4) Have a history of smoking, cough or wheezing. 5) Under anesthesia for a long period of me. A. Spirometry parameters The forced expiratory volume in 1 second (FEV1): is the volume of air (in liters) exhaled in the first second during forced exhala on a er maximal inspira on. Normally, at least 80% of the forced vital capacity (FVC) is exhaled in the first second. FEV1 is the most commonly used parameter for assessment of postopera ve outcomes (complica ons & mortality). Pa ents with preopera ve FEV1 > 1.5 L can undergo lobectomy > 2 L can undergo pneumonectomy with minimal postopera ve complica ons and mortality. FEV1 > 80% predicted is associated with a low risk of complica ons following major lung resec on and these Pa ents predicted usually require no further pulmonary tes ng. B. ABG (Arterial blood gas analysis) Hypercapnia (Pa Co2 > 45 mm Hg). Hypoxemia & room air O2 satura on of < 90% all have been associated with increased risk of complica ons. II- Sub-maximal exercise tes ng The 6-minute walk test 49  The purpose of this tes ng is to iden fy those pa ents with a marginal cardiopulmonary reserve who can s ll tolerate lung resec on This is a self-paced test that measures the distance that the pa ent can walk on a hard straight flat surface for 6 minutes. Achieved distances greater than 1000 feet (305 meters) indicate → - good func onal capacity - improved survival following lung resec on. Stair climbing ability: Can be used as an indirect indicator for the cardiopulmonary reserve of preopera ve pa ents. This is a simple test used to assess the number of flights that can be climbed without stopping. Historically, pa ents were considered suitable for lobectomy if they are able to climb three flights of stairs, and for pneumonectomy if they are able to climb five flights. This test was found to correlate with FEV1 and VO2 max. Three flights indicate an FEV1 > 1.7 liters, and five flights indicate an FEV1 > 2 liters. Pa ents who can climb five flights of stairs have VO2 max > 20 ml/ Kg /min and those who are unable to climb one flight have VO2 max < 10 ml / kg / min. VO2 max, or maximal oxygen consump on, refers to the maximum amount of oxygen that an individual can u lize during intense or maximal exercise. This measurement is generally considered the best indicator of cardiovascular fitness and aerobic endurance. III- ECG: is required to exclude any cardiac pathology in pulmonary surgery and to assist in making the diagnosis in cardiac condi ons. 1. Ischemia of the myocardium is represented on ECG as ST-segment inversion. 2. Acute myocardial infarc on is represented on ECG as ST-segment eleva on. 50  3. Old myocardial infarc on is represented on ECG as inverted Q-wave.  Pa ent's factors increasing the risk of postopera ve pulmonary complica ons: 1-Age 2-Smoking 3-Pre-exis ng lung disease 4- Pre-exis ng cardiac disease 5-Intercurrent illness 6-Obesity 7-Poor nutri onal status 8-Reduced pa ent mo va on 9-Func onal dependency & exercise limita on 10-Alcohol and drug dependency TREATMENT The next step a er the iden fica on of high- risk pa ents is to determine how to correct periopera ve risk factors, and to prevent intra-opera ve and/ or postopera ve complica ons. 1. Pre-opera ve Interven on: 1) Smoking cessa on. 2) Management of the underlying lung disease; i. Medical treatment ii. Physiotherapy treatment a. →Airway clearance techniques b. →Lung expansion maneuvers 3) Proper management of pre-exis ng cardiovascular diseases such as heart failure, hypertension, or coronary heart disease is recommended. 4) Proper management of inter-current illness such as diabetes, anemia, hemophilia. 5) For pa ents with morbid obesity, it is recommended to postpone elec ve surgeries un l morbidly obese pa ents lose some weight. 51  6) For obese who are at high risk for obstruc ve sleep apnea (OSA), it is recommended to ini ate con nuous posi ve airway pressure (CPAP) in the preopera ve period. 7) For pa ents with poor nutri onal status and anemia, nutri onal reple on for 7-10 days before surgery is recommended. If diet alone cannot correct the problem or if the pa ent is unable to eat adequately, nutri onal support may be indicated. 2. Pre-opera ve pa ent educa on & informa on: Informa on should be given about: The role of physiotherapy in the pre & postopera ve periods. The postopera ve rou ne use of intravenous lines, intercostal drains, catheters, oxygen therapy, and/or suc on. The expected postopera ve pain. Possible postopera ve complica ons (e.g. Atelectasis, pneumonia, DVT) & the appropriate measures to be taken to prevent these complica ons. The adjuncts to postopera ve physiotherapy, such as the use of incen ve spirometer, con nuous posi ve airway pressure (CPAP), and/or heated humidifica on. The importance of post-opera ve breathing exercises. The importance of diet control. Shoulder and leg exercises. 3. Preopera ve psychological support Reassurance about post-opera ve wound. Educa on about the program of early mobiliza on. Adequate medica on improves confidence. Introduc on to the ICU. Morale effect of watching others progress 52  POSTOPERATIVE REHABILITATION Defini on of Cardiothoracic Rehabilita on: is a comprehensive program aimed at op mizing physical, psychological, and social well-being a er cardiothoracic surgery or acute cardiac events. It combines exercise training, educa on, counseling, and psychosocial support to improve cardiovascular and respiratory func on, enhance quality of life, and restore func onal independence.  Goals of Cardiothoracic Rehabilita on: 1. Maintaining a Clear Chest: Learn techniques to promote effec ve coughing, airway clearance, and removal of respiratory secre ons to prevent complica ons and ensure op mal lung func on. 2. Maintaining Good Air Entry: Discover breathing exercises that promote deep breathing, lung infla on, and efficient oxygena on, aiding in the preven on of respiratory difficul es. 3. Improving Cardiovascular Fitness: Engage in tailored exercise programs to strengthen the heart, decrease cardiovascular risk factors, and improve endurance and overall fitness level. 4. Enhancing Respiratory Func on: Prac ce progressive respiratory exercises to restore lung capacity and efficiency, op mizing oxygena on and respiratory mechanics. 5. Restoring Func onal Independence: Acquire strategies and techniques to regain independence in daily ac vi es, improving mobility, strength, and overall quality of life. 6. Prevent posture devia on secondary to incisions or tubes.  Components of Cardiothoracic Rehabilita on 1. Exercise Training: Engage in supervised physical ac vi es, including aerobic condi oning, resistance training, and flexibility exercises, tailored to individual needs and goals. 2. Educa on and Counseling: Receive valuable informa on on cardiac health, medica on management, risk factor modifica on, and stress reduc on techniques to empower self-care. 3. Psychosocial Support: Access professional support and guidance to address emo onal and psychological challenges, fostering resilience and promo ng mental well-being.  Benefits of Cardiothoracic Rehabilita on 1. Improved Cardiovascular and Respiratory Func on: Enhance heart and lung efficiency, increase oxygen delivery, and improve overall cardiovascular health through tailored exercise and respiratory training. 53  2. Increased Physical Ac vity and Endurance: Build stamina, enhance func onal capacity, and op mize physical performance, enabling individuals to engage in daily ac vi es with greater ease. 3. Enhanced Quality of Life: Promote psychological well-being, social interac on, and self-confidence, leading to an improved overall quality of life post-cardiothoracic surgery or cardiac event.  Challenges in Cardiothoracic Rehabilita on 1. Adherence to Exercise Program: Overcome barriers and maintain a consistent exercise rou ne, ensuring the long-term benefits of cardiothoracic rehabilita on. 2. Managing Comorbidi es: Address and manage addi onal health condi ons, ensuring safe and effec ve par cipa on in the rehabilita on program. 3. Addressing Psychological Barriers: Support individuals in coping with emo onal challenges, anxiety, and depression, enabling holis c recovery. POST-OPERATIVE MANAGEMENT (Assessment & Treatment) ASSESSMENT Assessment of postopera ve complica ons: Clinically, pa ents with Postopera ve pulmonary complica ons have the following: 1- Arterial desatura on: SpO2˂90% on two consecu ve days. 2- Hyperthermia: defined as body temperature > 38ºC, persis ng for more than one day a er surgery, as a raised temperature on the 1st day a er surgery is a common finding resul ng from surgical insult. 3- Produc on of yellow or green sputum 4- Abnormal lung sounds on ausculta on: ↓breath sounds + fine crepita ons → atelectasis. Bronchial sound+ crepita ons → pneumonia. Note: ↓ breath sounds are a common finding in the first 2 days a er surgery a) Assessment of hemodynamic and/or cardiopulmonary stability of postopera ve pa ents: 1) Assessment of vital signs: Criteria for cardiorespiratory instability: i. Tachypnea ii. Tachycardia iii. Mean arterial pressure (MAP) ˂65 mmHg. (beter indicator of perfusion to vital organs than systolic blood pressure). iv. SpO2 ˂ 85 % v. Temperature: Extremes of core temperature are highly sugges ve of clinical instability 54  2) Assessment of organ perfusion: i. Urine Output: Is a useful tool to check organ perfusion. Oliguria (is a sign of organ-specific hypo perfusion due to inadequate renal perfusion and reduced cardiac output). ii. Capillary refill me (CRT): > 4.5 seconds was correlated with poor peripheral perfusion. TREATMENT Post-opera ve problems list: 1. Pain. 2. Decreased ven la on. 3. Retained secre ons. 4. Reduce arm and leg movement. 5. Decreased mobility. 6. Postural devia on. A. Postopera ve physiotherapy treatments: Physiotherapy treatment must be started postopera vely between 4 and 12 hours a er recovery from general anesthesia. The es mated session me is 30 minutes, with 2–3 daily sessions 1. Physiotherapy pain management: a) Transcutaneous electrical nerve s mula on: The dura on of TENS applica on can be for 20–30 minutes at 3-hour me intervals on the day following surgery. b) Cold therapy: applica on of simple ice packs over the incision dressing during the first 24 hours following surgery and a erwards c) Wound support: Different methods for wound support can be used during coughing, huffing, sneezing, and/or deep breathing exercises. The pa ent may be taught to hold a pillow firmly against the incision while coughing, or to wear an external thoracic support. 2. Posi oning: the easiest method to increase func onal residual capacity and to prevent lung atelectasis is early appropriate posi oning. Early upright posi oning, and modified postural drainage posi ons. 55  Modified postural drainage posi ons. Upright posi oning 3. Early mobiliza on and ambula on: as soon as the first postopera ve day for clinically stable pa ents; implemented on a scien fic basis and with strict guidelines: ℹ Safety guidelines for early mobiliza on and/or ambula on; 1. An appropriate assessment of the clinical stability of postopera ve pa ents 2. Pa ents should receive con nuous and close monitoring by the physiotherapist during and immediately a er mobiliza on 3. An appropriate assessment of organ perfusion is also important prior to ambula on. Urine output and capillary refill me (CRT) 4. All pa ent's connec ons should be checked before mobiliza on and/or ambula on 5. Adequate analgesia must be given before mobiliza on 6. Before upright mobiliza on, in addi on to the previously men oned guidelines, the pa ent’s ability to follow commands should be assessed, si ng balance should be checked, and the sensory and motor func ons of the lower limbs should be tested, especially in pa ents who have received spinal block 7. Upon standing, it is important to check for orthosta c hypotension 8. A graduated walking program should be adopted for mobilizing postopera ve pa ents 9. Stair climbing is ini ated once the pa ent can walk for a considerable distance on a flat surface with op mum cardiovascular and cardiopulmonary stability 10.During all mobiliza on ac vi es, careful aten on should be paid to subjec ve symptoms of exercise intolerance, such as shortness of breath, chest pain, dizziness, cold swea ng, leg fa gue, and pain, and these symptoms should be monitored carefully during mobiliza on. 11.When walking a pa ent who is receiving supplemental oxygen, the physiotherapist should monitor oxygen satura on the en re me 4. Lung expansion maneuvers: a) Deep breathing exercises (deep diaphragma c breathing, thoracic expansion exercises, deep breathing coupled with arm and trunk movement, sustained maximal inspira on) 56  b) Incen ve spirometry (flow-incen ve spirometry, and volume-incen ve spirometry) c) Inspiratory muscle training 5. Airway clearance techniques: a) Supported coughing b) Huffing c) Forced expira on technique d) Ac ve cycle of breathing technique e) Posi ve expiratory pressure technique f) Modified postural drainage posi ons g) Manual chest physiotherapy techniques 57 6. Postural correc on: Pa ents should also be educated to keep both shoulders at the same level and the trunk straight while si ng, standing, or walking. 7. Shoulder range of mo on exercises and gentle scapula mobiliza on exercises: These exercises need to be performed 3–4 mes daily, However, shoulder abduc on and external rota on are ini ally avoided to prevent increased stress on the incision. 8. Leg, trunk, and thoracic mobiliza on exercises: Non-resistance leg exercises (i.e., quadriceps and ankle exercises) can be started on the first postopera ve day to minimize circulatory stasis and to prevent circulatory problems such as deep vein thrombosis and pulmonary embolism, The pa ent can also start non-resistance arm exercises and thoracic mobiliza on exercises on the first postopera ve day. 9. Home program:  They are advised to con nue regular breathing exercises, to gradually increase their mobility and daily ac vi es 58  Prac ce an airway clearance technique whenever necessary.  A graduated walking program can be ini ated following hospital discharge, as follows. → Immediately a er discharge, the postopera ve pa ent should start walking at a moderate level of effort for about 3 mes a day for 5 minutes each me for a total of 15 minutes/day. → Then, the pa ent should gradually increase the total walking me each week by 5 minutes, so that he or she becomes able to walk for a total of 30 minutes either intermitently or con nuously by the first month postopera vely. The pa ent can be educated to self-monitor effort intensity during walking. This can be achieved by observing his or her ability to talk during walking without feeling short of breath. 59  That is, if the pa ent is able to keep talking while walking without interrup on in speech or feeling difficulty in breathing, this means that he or she is walking at a moderate intensity. However, if during walking, the pa ent feels unable to keep talking con nuously (i.e., his or her speech is interrupted), and/or feels shortness of breath while talking, this means that his or her walking intensity has risen above the moderate level. At that point, the pa ent can slow down and pace walking with breathing to return to the targeted moderate intensity level of exercise. CHEST DRAINS → Types of Chest drains: 1- Intercostal pleural drains: Intercostal drains are used as a rou ne postopera ve prac ce a er thoracic surgery to assist in removal of air, fluid, or blood from pleural space. Two intercostal drains are commonly used following thoracic surgery; one is directed apically to drain air and the other one is directed basally to drain fluid. 2-Retrosternal drains: Are two types a) Medias nal chest drains are inserted as standard postopera ve prac ce following cardiac surgery to assist removal of blood from the pericardial sac and/or medias nal space. b) Pericardial drain is used in case of cardiac tamponade, which may occur a er cardiac surgery compressing the heart and reducing cardiac output. c) Types of intercostal chest drains: 1) Tradi onal underwater seal systems 3) Mobile chest drains 2) Disposable (all- in- one) plas c 4) Digital drainage system devices 1. Tradi onal underwater seal systems a- One-botle system: It consists of a botle which is used for air and/ or fluid collec on, and at the same me for securing the pleural cavity from entrance of air from the outside. A rigid straw, connected to the drainage tube, is immersed into the botle, so that its p is located 2 Cm below the surface of a saline solu on. When the pleural pressure is greater than + 2 Cm H2O, then air will enter in the botle. The one-botle system is suitable for use with simple pneumothorax or following pneumonectomy. Disadvantage of this system: Prac cally, this system works if only air is leaving the chest, because if fluid is also being drained, the fluid level will rise in the underwater seal botle. Thus, the pressure gradient necessary for drainage, between pleural space and the underwater sealed botle will be reduced. As a result, air will stay undrained in pleural space. 60 b- Two-botles system: For the aforemen oned disadvantage of the one-botle system, the two- compartment system has been introduced. This system is preferred over one-botle system when both air and fluid are being drained, or when there is large amount of pleural effusion is to be drained. With this system, The first botle collects the fluid and the second botle is the water sealed botle, in which the rigid straw will be constantly remaining at 2 Cm below the level of water. Therefore, it does not mater how much fluid is accumula ng in the drainage botle, as the pressure in the underwater seal botle will remain unchanged. It is to be noted If the pa ent has excessive pleural effusion or large air leak into the pleural space, gravity drainage and/or pressure gradient may not be sufficient to evacuate the pleural space, and thus suc on may be required. c- Three botle system: If suc on is required, a third botle is added. The first botle is the collec on or the drainage one, which is directly connected to the pa ent's chest tube. The middle chamber is the water seal botle which allows air to exit from the pleural space on exhala on and prevent air from entering the pleural cavity on inhala on. The third botle is the suc on botle, used when addi onal nega ve pressure is required to accelerate removal of a large amount of air or an excess pleural fluid from pleural space Disadvantage of tradi onal underwater seal systems 1. It is important to keep the drainage unit upright and below the level of pa ent's chest at all mes, which may compromise freedom of pa ents' ambula on. 2. Unless the water level is constantly monitor, water evapora on can occur which in turn reduces the depth of water into which the rigid straw is immersed. Note: Three-botle system is rarely used nowadays 2. Disposable (all- in-one) plas c devices: These refer to a combina on of the three-botle system into one device with waterless (dry) suc on system. The level of suc on is regulated by a dial which is usually set at 20 Cm H2O. These devices are easier to be moved around by the postopera ve pa ents during ambula on. Besides, it is easier to be managed. 61 3-Mobile chest drains: Mobile chest drains have the following advantages: 1- Each device has a mechanical one-way valve that lets air leaves the chest on exhala on and prevents it from re-entering on inhala on, thus they can func on in any posi on and doesn’t need clamping. 2- Small sized and portable devices, which allow for early and easy ambula on. a) Types of mobile chest drains: i. Heimlich valve: The Heimlich valve is a small (5 inches) one-way valve, that lets air A Heimlich valve is designed for air drainage, but it may also be used for fluid drainage by ataching it to a vented bag, similar to a urine collec on bag. However, when an air leak is accompanied by blood and/or large or thick effusion, a Heimlich valve is not used. In such cases, replacement of the valve is done and underwater seal drainage may be used. ii. The Pneumostat chest drain valve: Unlike the Heimlich valve, the Pneumostat has a built- in collec on chamber that can hold up to 30 ml of fluid. 62 iii. The Atrium Express 1500 chest drain bag: Beter suited than other devices, the Atrium Express bag is designed for drainage of postopera ve haemorrhagic or serous fluid in pa ents with or without an air leak, as it can hold up to 1,500 ml of fluid. It is a disposable and vented bag, and has a valve that prevents air and/ or fluid from re-entering the chest. The bag has a strap so that the pa ent can hang it from his shoulder or wear it around his waist. 4-Digital thoracic drainage Advanced chest drainage digital systems allow early mobiliza on of the pa ents with accurate char ng of air leak. They have scien fic digital flow recordings with an in built alarm system regarding blocks, high volumes and batery status. The device also cleanses the collec on tubing connected to the inter-costal drain, and prevents blockage of drains. Managing postopera ve pa ents with chest drainage: I-Assess the respiratory status of the pa ent 1-Frequent assessment of vital signs and respiratory status is recommended. Tachypnea, dyspnea, increased use of accessory muscles, orthopnea, restless, increased heart rate, or cyanosis may indicate malfunc oning of the drain system. 2-Intercostal drains are painful, so assess the pa ent for pain at regular intervals. Pain should be adequately controlled so that it's not interfering with the pa ent's ability to walk around, to take in deep breaths, or to cough. Epidural or pa ent-controlled analgesia can be used. II-Check the inser on site of the intercostal drain: 63 1- The loca on of inser on site informs you about the type of expected drainage. i.e. when air is being drained, chest tube is inserted at the mid-clavicular line in the 2nd intercostal space, or inserted at the midaxillary line in the 3rd intercostal space and directed upwards towards the apex of thorax. But, when fluid is being drained, chest tube is inserted in the midaxillary line in the 5th or 6th intercostal space. 2- There should be no fluid leaking from around the inser on site or sounds of air leaks. 3- Dressing should be dry and intact. 4- There should be no subcutaneous emphysema. III-Check the drainage tube: 1. Ensure that the chest tube is func oning well, and doesn't interfere with mobility. 2. The drainage tube should be tapped and secured to the chest wall to prevent accidental dislodgement. 3. If accidental dislodgement of chest tube occurs, immediately ask the pa ent to exhale and apply a firm pressure over the inser on site, by a gloved hand or by sterile dressing, to prevent entrance of air from outside. And pressure is maintained ll medical help arrives. 4. Ensure patency of drainage chest tube. To do so; don’t let it kink or loop, and milk it very gently if a visible clot is present in the tube. This is done by holding the tube (near the pa ent end) firmly with the le hand and pinching it off between the thumb and the fingers (Be careful not to pull it away from the chest). Then, the tube distal to the le hand is squeezed gently; this will dislodge any clot and drain it into the draining botle. Note: if you aren’t able to do that perfectly, don’t try it and seek help. 5. Each pa ent with a chest drain should have a pair of forceps available at all mes to clamp the tube if any disconnec on with the underwater sealed system occurs. 6. Don’t clamp a chest tube, except momentarily when replacing the chest drainage unit, or when necessarily li ing the drainage botle above the level of pa ent's chest. IV-Assessment of underwater sealed system: 1. Keep it in the upright posi on and at least 0.5 meter below chest level at all mes 64 2. Assess for swing: During inspira on when a more nega ve pressure is generated, the fluid moves up the tube immersed underwater and during expira on the fluid moves downwards. If no swing is seen, this may be due to: a) Kinking of chest tube b) A loop in the chest tube filled with fluid c) Clo ng in the tubing d) If the pa ent lies on the tube 65 Postopera ve Rehabilita on Program a er CARDIAC surgeries: divided into 4 phases: ❶ Hospital inpa ent period: (10-20) days. ❷ Convalescent stage a er hospital discharge: 12 weeks. ❸ Supervised ongoing rehabilita on: 6 months. ❹Unsupervised ongoing rehabilita on: long life process. 1. Program of phase I (Hospital inpa ent period: (10-20) days) The aims of phase I are: 1. Improve cardiovascular system. 2. Minimize the psychological effects of less ac vity. 3. Determine the effects of prescribed medica ons during ac vity. 4. Establish clinical data that contributes to the medical management of the pa ent. Program of phase I Stage 1: Passive ROM- Breathing exercises- Ankle exercises Stage 2: Ac ve ROM for upper limb in supine. Ac ve 3: ROM in si ng- Calisthenics exercise walking 50-70 feet. Stage 4: Calisthenics exercise- walking 2-3 minutes. Stage 5: Calisthenics exercise- walking 3-5 minutes - Walking up 3-5 steps. Stage 6: Calisthenics exercise- Walking 5-7 minutes- Walking down one flight of stairs. Stage 7-9: Calisthenics exercise- walking up one flight of stairs. Calisthenics Exercises CEs are gymnas c exercises designed to develop muscular tone and promote physical well-being. CEs are a form of dynamic exercise consis ng of a variety of simple rhythmical movements generally using minimal equipment or apparatus. CEs are intended to increase body strength and flexibility with movements such as bending, twis ng using only one's body weight for resistance. 66  CEs benefit both muscular and cardiovascular fitness, in addi on to improving psychomotor skills such as balance and coordina on. Calisthenics Exercises Side bending of the trunk 2. Program of phase II (Convalescent stage a er hospital discharge: 12 weeks) It is the supervised and monitored exercise program with a structured basic educa on service: The aims of phase II are: 1. Increase pa ent’s exercise capacity in safe and progressive manner so that adap ve changes in cardiovascular and muscular systems occurred. 2. Enhance cardiac func ons and reduce the cost of work. 3. Progress the pa ent to an independent exercise program. 4. Return to work as soon as possible. 5. Decrease exercise induced hypotension. 6. Increase the distance, the speed and the intensity of walking. 7. Increase upper limb strength and endurance. 8. Reduce the risk factors. 9. Educate the pa ent about cardiac disorders, diet, exercise and risk factors. 10. Increase self-confidence. Training program of phase II Dura on of training: 10-15 minutes that could be increased to 30-40 minutes of con nuous exercise in low intensity. Frequency of training: 2-4 mes per week. Mode of training: It is essen al to train both upper and lower limbs. Star ng the exercise with lower limb exercise. For lower limb: treadmill or cycle ergometer can be used. For upper limb: arm ergometer or rowing machines can be used. 67  Weight li ing can be started in this phase. Exercise on treadmill Exercise on bicycle Arm ergometry exercise 3. Phase III (Home program) It is the maintenance phase which provides the pa ent an opportunity to achieve a higher level of: a) Physical func on. b) Mental func on. c) Social func ons. d) Psychological func ons. Aims of Phase III (Home program) 1. Improve level of fitness at high exercise intensity. 2. Increase myocardial work capacity. 3. Increase myocardial blood supply. 4. Improve psychological orienta on. Training program of phase III 1. Walk for 3 miles. 2. Walk for 3 miles in 40 minutes. 3. Run or jog for 3 miles. 4. Run or jog for 3 miles in 30 minutes. 5. Cycling for 5 miles in 45 minutes. 68 4. Program of phase IV Pa ent should con nue to follow the guidance on exercise, nutri on, and lifestyle, as set out by the rehabilita on team. Pa ent proceed independently, or decide to further training with a physical therapist to help support the pa ent’s progress. Pa ent receive regular check-ups with the healthcare provider to make sure that effec vely managing the heart condi on. Goals of phase IV 1. Pa ents con nue and maintain the changes of the lifestyle that they acquired in Phase III. 2. Pa ents keep up with the exercise regime. 3. Pa ents con nue to avoid tobacco, eat well, and manage the stress Sternal Precau ons and Sternal Instability Management Sternal instability, infec on, and wound dehiscence are the primary complica ons of median sternotomy. While the incidence of complica ons is involved, the rates of subsequent morbidity and mortality are high. The proper healing of the sternum is a priority for ensuring good pa ent outcomes Tradi onal Sternal Precau ons There is no universal defini on of sternal precau ons. As a result, the type and dura on of ac vity restric ons vary widely across facili es. Common precau ons include: 1. No li ing more than 5-10 pound (lbs.). 2. No reaching behind the back. 3. No pushing or pulling through the arms. 4. Addi onal instruc ons may prohibit reaching overhead with one or both arms, or driving. Recommended adherence can last anywhere between 4 to 12 weeks. Recommenda ons a er sternotomy 1. Bilateral movements of the arms in the horizontal level, backwards or over the shoulder level, should only be performed within pain-free limits during the ini al 10 days following sternotomy or un l the wound is healed. 2. Loaded movements of the arms should only be done at a pain-free level. 69 3. In general, pa ents should keep the upper arms close to the body for 6-8 weeks. 4. Pa ents with BMI≥35 should wear a suppor ve vest to protect the sternum for 6-8 weeks. 5. Pa ents should be taught to hug a pillow over the surgical incision when coughing and sneezing for 6–8 weeks. 6. Pa ents who cough frequently should wear a sternal vest suppor ng the en re circumference of the thorax. 7. Pa ents with large breasts should use a suppor ve brassiere that fastens in the front Management of Sternal Instability Sternal instability can be described acutely as sternal dehiscence/disrup on or chronically (>6 months postopera vely) as sternal nonunion. Sternal separa on can occur along the en re sternum or a limited por on (usually the caudal end) and is closely interlinked with sternal infec on, which can result in sternal clicking, excessive sternal movement, pain, and difficulty performing func onal tasks. Thoracic support during coughing, applying counter pressure to the median sternotomy incision (i.e., “splinted coughing”), is thought to prevent dehiscence, reduce pain, and facilitate cough effec veness. Once serious condi ons have been ruled out and the sternal instability has been confirmed as minor and non-displaced, treatment of instability can be started. Overhead li ing, pushing, pulling, and li ing objects that weigh more than 5- 10 pound (lbs.) and ac vi es which place large amounts of stress through the sternum, par cularly lying face down and applying direct pressure or impact to the chest, should be avoided un l the instability has healed. Local applica on of heat or cold may provide temporary relief of discomfort, in conjunc on with pain relieving medica on. The therapist will instruct pa ents in deep-breathing exercises to promote full lung expansion, relieve muscle spasm, and mobilize lung secre ons. when the condi on is stable, shoulder and trunk stretching exercises may be used, to relieve discomfort, promote chest expansion & func onal shoulder mobility, and improve posture. Once the instability has healed, there can be a gradual return to normal ac vi es, provided there is no increase in pain and other symptoms. This should take place over a period of weeks to months. 70  When returning to contact sports or ball sports, the use of protec ve padding or chest guards may be required to prevent further injury. Pa ents with more severe sternal instability, par cularly those which require surgical correc on, or when other structures have been involved, will usually require a prolonged period of management over many months before recovery can take place. INTRODUCING KEEP YOUR MOVE IN THE TUBE: 71 We moved away from load and time restrictions and instead used standard kinesiological principles to develop this new approach. Because Keep Your Move in the Tube is based on the ergonomics that shorten the length of the outstretched arm (lever arm reduction), it enables patients to perform previously contraindicated movements. The first step in applying this approach is to explain to patients in layman’s terms what happened to their sternum during surgery, using an illustration of the attachments of the pectoralis major on the sternum, the humerus, and the clavicle. 72 By keeping their upper arms close to their body, as if they were inside an imaginary truncal tube, patients can modify load-bearing movements and thus avoid excessive stress to the sternum. More specifically, limiting the movement of the humerus minimizes the lateral pull on the sternum and decreases the leverage of the hand and forearm during load bearing actions such as rolling a wheelchair, opening a heavy door, or lifting a toolbox. Th e graphic’s simple drawings show movements that are “in the tube” (green) versus “out of the tube” (red). Th ese color-coded diff erences are easy to comprehend, and the overall format overcomes barriers related to language preference and reading ability. 73  Intensive care unit (ICU) Definition: is a special department of a hospital that provides intensive treatment medicine. also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU) It cater to patients with severe or life-threatening illnesses and injuries, which require constant care, close supervision from life support equipment and medication in order to ensure normal bodily functions. highly trained physicians, nurses and respiratory therapists are the main staff who are specialize in caring for critically ill patients Patients may be referred directly from an emergency department if required, or from a ward if they rapidly deteriorate, or immediately after surgery if the surgery is very invasive and the patient is at high risk of complication 74  General guidelines for dealing with ICU patient 1. Monitor physiological responses such as heart rate, blood pressure, respiratory rate and oxygen saturation at all times. 2. The physical therapist should be aware of effects of positioning and mobility of the patient on the various monitoring devices and their readings. 3. The physical therapist should always deal with the patient as if he/she were conscious and awake even if the patient appears not to be (talk to him and explain all procedures he is going through, and do not talk about his condition within his hearing). This may help to relax the patient and decrease patient anxiety and possible subsequent increase in muscle tone. 4. Frequency and intensity of treatment sessions will be determined by patient condition, but should generally be at least twice a day. 5. Treatment should be carried out at least 1 or 1/2 hours after feeding time. 6.. The physical therapist must be aware of patient's medication, laboratory test result patient's management by other health care team, and patient's / family concerns. 7. The physical therapist should be familiar with all ICU equipment. Physical therapy goals for patients in the ICU 1) Improve / Maintain normal ventilation and oxygenation Clearance of Airways Improve Chest Expansion Improve Breath Sound &pattern Improve Cough Effectiveness 2)Maintain musculoskeletal system within functional limit Improve ROM 75  Improve Muscle Strength and Endurance Prevent Joint Deformities and Contractures 3) Improve circulatory system function Prevent DVT Prevent Swelling Prevent Pressure sore 4) Improve / maintain neurological system and cognitive status within functional limits. 5) Ensure proper and safe transfer of the patient from the bed to the chair and vice versa. ICU patient categories Intensive Care Unit Equipment 1)Patient monitoring equipment's 1.Cardiac or heart monitors: 76 Definition: a computer screen with lines moving across the screen. The monitor has electrodes that are attached to the patient’s chest with sticky pads which are used to monitor the electrical activity of the heart. Recorded parameter: 1. Heart rate (and rhythm) 2. Blood pressure 3. Respiratory rate 4. Oxygen saturation and Co2. Apparatus ECG Blood pressure Pulse oximeter cuff Parameter  Heart rate  arterial blood  saturation of oxygen in  heart ,rhythm pressure the arterial blood  respiratory rate Consist of Six coloured coded Consist of: A probe with an electro electrodes placed Inflatable cuff optical sensor placed on on chest hardwired usually placed 2.5 finger ,toe ,ear lobe or nose. to a monitor in cm proximal to the patient’s room antecubital space attached to a pressure monitoring device Normal  heart rate: 50-  Systolic ≈ 100 –  SPO2 : ≥ 93 -94 Value 80 beats/min 140 mmhg  respiratory  Diastolic ≈ 60 – rate≈16-20 90 mmhg breath/ min 2.Swan Ganz catheter (pulmonary artery catheter): 77  Swan-Ganz catheter permits measurement of right atrium, right ventricle, pulmonary artery, and pulmonary artery wedge pressure (also called pulmonary artery occlusion pressure). measure the pressure. a balloon is inflated in the tip of this flow-directed catheter. The balloon is inflated to occlude a small distal branch of the pulmonary artery, and then the pressure is measured during occlusion and captures the reflected pressure coming from the left atrium. 3. Arterial lines (a-lines): Arterial line is a thin catheter inserted into an artery. It is most commonly used to monitor blood pressure directly and in real-time and to obtain samples for arterial blood gas analysis. An arterial line is usually inserted into the radial artery in the wrist, but can also be inserted into the brachial artery at the elbow, into the femoral artery in the groin, into the dorsalis pedis artery in the foot, or into the ulnar artery in the wrist. Insertion is often painful; an anesthetic such as lidocaine can be used to make the insertion more tolerable and to help prevent vasospasm, thereby making insertion of the arterial line somewhat easier. 78  Arterial lines B) Life support and resuscitative equipment 1. Mechanical Ventilation (MV)ventilator/ vent Definition: a machine that helps people breathe when they are not able to breathe enough on their own or breathing insufficiently. It also called a ventilator, respirator, or breathing machine. 79  Difference between normal respiration and respiration through mechanical ventilation Normal Respiration 1. Mechanism: In normal respiration, the diaphragm and intercostal muscles contract, creating a negative pressure in the chest cavity. This pressure difference allows air to flow into the lungs. 2. Control: Breathing is controlled by the respiratory center in the brain, which responds to the levels of carbon dioxide and oxygen in the blood. 3. Gas Exchange: Oxygen is inhaled into the alveoli, where it diffuses into the blood, and carbon dioxide diffuses out to be exhaled. Mechanical ventilation 1. Mechanism: Mechanical ventilation uses a machine to push air into the lungs, creating a positive pressure that forces air in. This can be done invasively (with a tube in the airway) or non-invasively (using a mask). 2. Control: The ventilator settings control the rate, volume, and pressure of breaths. This can be adjusted based on the patient’s needs. 3. Gas Exchange: Similar to normal respiration, but the process is assisted or fully controlled by the ventilator, ensuring adequate oxygenation and removal of carbon dioxide Physiological review Physiology of gas exchange (respiration  Ventilation :process of moving of the gas into and out of the lung 80  Diffusion of o2 from the alveoli to the pulmonary capillaries and diffusion of CO2 from pulmonary capillaries to the alveoli  Perfusion : is the flow of the blood through the pulmonary bed  Transport : o2 is carried in the blood in two form :dissolved and attached to hemoglobin Uses (physiological objectives) of mechanical ventilation To get oxygen into the lungs and body. To help the body get rid of carbon dioxide through the lungs. Increase lung volume To ease the work of breathing and uncomfortable To breathe for a person who is not breathing because of injury to the nervous system, like the brain or spinal cord, or who has very. weak muscles Indications of mechanical ventilation 1) Respiratory failure 81  a) SPO2 less than 60%  normal (95-100%) b) Pao2 less than 50  normal (80-100%) mild hypoxemia moderate hypoxemia severe hypoxemia Pao2 less than 80 Pao2 less than 70 Pao2 less than 60 C) Paco2 less than 50 mmhg  normal (35-45 mmhg) c) PH less than 7.25  Normal (7.35-7.45) d) Tachypnea (more than 30 beat/min)  Normal (12-20) f)Bradypnea (less than 12)  Normal (12-20) 2) Exagertated symptoms( COPD -ARDS)-Pulmonary edema 3) Other cases 82  Coma GCS Neurological 8 disorders Respiratory General arrest anathesia Types of ventilators Negative pressure Positive pressure ventilation ventilation (iron lung) can’t be used nowadays Link between patient and MV through Endotracheal tube Tracheostomy 83 HOW to conduct mechanical ventilaton The main three output button 84  inspiration expiration humidifier moist air adjust air (37) Check water every half an hour Connections between the three out puts 85   From inspiration out put to humidifier  From humidifier out put to y shape connector  From expiration output to y shape  water trap collect water before entering to patient How does a ventilator work? The ventilator is connected to the person through a tube (endotracheal or naso tracheal tube) that is placed into the mouth or nose and down into the windpipe. When the health care provider places the ET tube into the person’s windpipe, it is called an intubation. Some people go through surgery to have a hole place in their neck and a tube (tracheostomy or “trach” tube) is connected through that hole. The ventilator can deliver higher levels of oxygen than delivered by a mask or other devices. The ventilator can also provide what is called positive end expiratory pressure (PEEP).This helps to hold the lungs open so that the air sacs do not collapse.  The tube in the windpipe also makes it easier to remove mucus if someone has a weak cough. (suction)  Types of y shape connec on Invasive (endotracheal tube) Non invasive (face mask) (Trachystomy) 86  How does a patient feel while on a ventilator? The ventilator itself does not cause pain. Some people don’t like the feeling of having the tube in their mouth or nose. They cannot talk because the tube passes between the vocal cords into the windpipe. They also cannot eat by mouth when this tube is in place. A person may feel uncomfortable as air is pushed into their lungs. Sometimes a person will try to breathe out when the ventilator is trying to push air in. This is working (or fighting) against the ventilator and makes it harder for the ventilator to help.  People on ventilators may be given medicines (sedatives or pain controllers) make them feel more comfortable. These medicines may also make them sleepy. Sometimes, medications that temporarily prevent muscle movement (neuromuscular blocking agents) are used to allow a person to breathe with the ventilator. Modes of ventilation Volume cycled Pressure cycled fixed amount of tidal volume (TV) Constant Peak inspiratory pressure (PIP) Variable Peak inspiratory pressure variable amount of tidal volume (PIP) (TV) 87  PCV PSV ACV SIMV CPAP BIPAP HFOV APRV Volume cycled parameter 1. ACV (Assist- control ventilation) Patient spontaneous breath is assisted as it allows the patient to initiate or trigger each mechanical breath (assisted ventilation) but can also deliver a preset level of minute ventilation if the patient is unable to trigger the ventilator (controlled ventilation) Assist :patient start breath but cannot complete it due to weakness of respiratory muscle (patient triggered breath ) Control :mechanical ventilator only the controller in breath ( inspiration or expiration) patient cannot start breath The combination is called assisted -control ventilation 88 Disadvantage: Patient may enter in hyperventilation if his breath is rapid (continuous patient -triggered ACV) sedation or change mode to (SIMV) 2. SIMV:synchronized intermittent mandatory ventilation 89  Spontaneous breath Ven lator breath Ven lator provides a mandatory breath at the end of the me period only in case of the pa ent fail to ini ate ven la on breathing stoppage Disadvantage: SIMV usually associated with increase work of breathing and muscle fa gue associated with pa ent effort as this mode can’t complete weak pa ent breath Pressure cycled parameter PCV PSV CPAP BIPAP HFOV APRV PCV:Pressure control ventilation 90  The target pressure is set and never exceeded by the machine Constant pressure during respiration allows high initial flow Tidal volume and minute volume may vary depending on lung compliance and resistance Advantage: simple ,avoid high inspiratory pressures improved oxygenation allow long inspiration time more than expiration time allow enough time to reach the best flow rate Control alveoli pressure (. decrease lung injury ) Disadvantage : Increase air way resistance Decrease alveoli volume PSV(pressure support ventilation ) ventilation (PSV) is a mode of partial ventilator support. This mode requires apatients with a consistent spontaneous respiratory pattern.Such modes are widely used in intensive care units (ICUs) because most ventilated patients (unless deeply sedated) have preserved respiratory drive. 91 Advantage: patient is the controller of tidal volume and respiratory rate and potentially prevents disuse atrophy of the respiratory muscles that can result from controlled ventilation The use of these modes helps to reduce need for sedation, an important issue in the ICU partial support may facilitate both the screening process for detecting patients able to breathe spontaneously as well as the weaning of patients with prolonged or difficult weaning. Disadvantage: patient should be able to take breath byhis own (cant be used with patient can’t start breath) Cpap :continous positive airway pressure Continuous positive airway pressure (CPAP) is a type of positive airway pressure that is used to deliver a set pressure to the airways that is maintained throughout the respiratory cycle, during both inspiration and expiration. Advantages: The application of CPAP maintains PEEP, can decrease atelectasis, increases the surface area of the alveolus, improves V/Q matching, and hence, improves oxygenation. Used in COPD and obstructive sleep apnea Disadvantage : Reduced consciousness and inability to protect their airway 92  Trauma or burns involving the face Air leak syndrome (pneumothorax with bronchopleural fistula) Copious respiratory secretions Bi PAP( Bi phasic-Bi level positive air way pressure) Called NIV (non invasive ventilation ) Bilevel positive airway pressure (BPAP) is the second of two cardinal modes of noninvasive ventilation (continuous positive airway pressure, or CPAP, is the other). Can control inspiratory positive air ay pressure (IPAP)8-20 CM H2O (high pressure Can control expiratory positive air way pressure (EPAP) 5-8 CM H2O (low pressure ) Advantages : best tolerated than CPAP. Allow more pressure than cpap Allow more oxygenation More tidal volume Disadvantage: the same as cpap Low blood pressure Aspiration pneumonia APRV:air way pressure release ventilation 93 Bi level form of ventilation with sudden short release in pressure to rapidly reduce FRC and allow for ventilation (Patient take his breath in presence of high end expiratory pressure … pressure reach too zero (pressure release) Advantage : high pressure improves oxygenation and open collapsed alveoli (ARDS) Pressure release facilitate CO2 removal from lung Disadvantage: cannot be used in case of severe asthma,copd High frequency oscillator y ventilation High frequency oscillatory ventilation (HFOV) utilizes rapid ventilation rates with small tidal volumes and active inspiratory AND expiratory phases. A constant distending airway pressure is applied to the alveoli which aims to maximize functional residual capacity and ventilation/perfusion matching, over which small tidal volumes are superimposed at a high rate. 94 Advantage : reduce ventilator associated lung injury when high airway pressures and volumes in conventional ventilation modes are required to maintain adequate gas exchange. When initiated early, high frequency oscillatory ventilation may improve oxygenation and reduce risk of lung injury in neonates and infants.allow high pressure treat collapsed alveoli improve gas exchange.Decrease tidal volume decrease volutrauma Disadvantage : need specific ventilator Cause hypotension (high intrathoracic pressure) Barotrauma Ventilation alarms causes Solution Ventilator inoperative Ambubag + oxygen 100% High pressure due to Suction Increase secretions Un kink connector Kinked connector Oral air way Patient bite tube Hear chest and reposition it Change position of endotracheal tube (enter to right side ) Low pressure Check all connector and correct defect Due to Spores in vent connectors 95  Disconnection of vent connectors Leakage in humidifier or cuff endotracheal tube High respiratory rate Sedation and treat cause Due to Anxiety Pain Hypoxeia Fever Apnea Ambobag one breath Change ventilatory mode Low oxygen inlet