Lobectomy

Lobectomy

1. Lobectomy Submitted by- Tasneem Zafar Submitted to- Dr. Jamal Moiz Submission date- 29 th, December 2020 Subject- Physiotherapy in cardiopulmonary condition(BPT 402)

2. Introduction Lobectomy is the surgical operation where the lobe of the lung is removed. Lobectomy remains the treatment of choice for patients with early-stage lung cancer. The surgery can be performed via thoracotomy or VATS(video assisted thoracoscopic surgery) or RATS(robotic assisted thoracoscopic surgery). Indications Bronchiectasis Tuberculosis Lung abscess Carcinoma

3. Procedures Patient is given anesthesia before the procedure and will be placed on mechanical ventilator with a breathing tube inserted into the throat. Thoracotomy - incision will be made on the side of the body at the front of the chest around the nipple and wrap around the back to the area under the shoulder blade. VATS or RATS - three or four small cut will be made around the area of the lobe. A thoracoscope , a small tube with a light and tiny camera is inserted in to the chest cavity Following dissection of the fissure and hilar structures, the branches of the pulmonary artery and veins to the lobe are isolated and ligated. The bronchus is usually stapled but can be sewn. At completion of the operation, the remaining lung is reinflated. Some air leak is common and usually settles within a few days. One or two intercostal drains are inserted. The patient does not routinely need intensive care and postoperative ventilation is best avoided. The 30-day mortality rate is 2–3%, with morbidity such as chest infection or cardiac arrhythmia at around 10%. The average length of stay is around 5–7 days.

4. Complications Respiratory Infection of lung tissues Consolidation/collapse of remaining lung tissues Pneumothorax Broncho-pleural fistula Circulatory- DVT, cardiac arrhythmias Wound Joint stiffness Muscle weakness Postural deformity

5. Pre operative physiotherapy Gain the patient confidence Clear the lungs field Teach respiratory control and inspiratory holding Teach postural awareness Teach arm, trunk and leg exercises Teach mobility around the bed

6. Post operative physiotherapy 1.pain management Pain impairs the patient’s ability to take deep breath leading to reduced lung volume and sputum retention. Pain induces sympathetic stimulation, restrict shoulder and scapula ROM TENS- it is effective as an adjunct to analgesic medication. It relieve ipsilateral shoulder pain, minimize dose of analgesics, and incision pain. It can be applied for 20-30 minutes at 3 hour interval on the day following surgery. Frequency can be either high-frequency or low-frequency, but alternate frequency of 2-100 Hz is more effective due to its synergistic effect with analgesic. Cryotherapy- application of simple ice packs over the incision dressing during the first 24 hours following surgery and afterwards reduces remarkable decrease in incision pain. It can be used before or during coughing to reduce aggravation of incision pain.

7. 2.Wound support Support the patient’s incision and intercostal drain sites with firm but gentle pressure, but do not pressure directly on the incision or drain site. this reduces pain and allow the patient to breathe in deeply and cough with little discomfort. Physiotherapists standing on the contralateral side, with one hand placed on the anterior chest wall to stabilize the incision from the front, and another hand placed on posterior chest wall to stabilize the incision from behind, while at the same time the physiotherapists forearms stabilize the entire chest and create a bear hug hold. Another method for wound support can be done by patient by placing the hand of the unoperated side across the front of the thorax as far as possible resting firmly over the incision and drain sites, while the other hand reinforces the hugging hold by clasping the opposite elbow and pulling it against the thoracic wall. Alternatively patient may be taught to hold a pillow firmly against the incisions while coughing or to wear an external thoracic support.

8. 3 . Positioning Positioning patients after thoracic surgery utilizes gravity to provide 2 major benefits- Gravity assisted position to improve ventilation Early upright position- upright position in and out of the bed as soon as possible after patient is woken up, with endotracheal tube still in place. This position increase diaphragmatic excursion, improve ventilation and increased lung volume and capacity. If patient can not sit upright, they should be positioned to high side lying position with operated lung on the top. This insure adequate V/Q mismatch and adequate expansion of the operated lung. Gravity-assisted position to assist the clearance of bronchial secretions - modified(horizontal) postural drainage position is recommended first, instead of classical (head down) position, in post operative patients, as latter can lead to decreased arterial oxygenation.

9. 4.Early mobilization and ambulation Early mobilization , with sitting in bed at 3.5 hours after surgery, maintaining a sitting position for 30 minutes, and then ambulation in the fourth hour led to better recovery. Patient is considered Unstable if vital sign exceed following threshold: HR <40/min or >140/min, RR<8/min or >36/min, po2 <85% and BP <80/200 mm hg or >110 diastolic. CRT>4.5sec suggest poor peripheral perfusion. Once a patient is able to sit on the edge of the bed for 5 min and can perform full bilateral knee extension along with clinically vital signs, they can bee progressed to standing and ambulation. Session with short(3-5 min), more frequent(2-3/day) and non intense (60% HRmax) is suggested. Stair climbing is initiated 4 th or 5 th day if patient walk considerable distance on flat surface. In case of shortness of breath, chest pain, dizziness, cold sweating, leg fatigue and pain, mobilization should be stopped until hemodynamic stability returns. After mobilization patient’s re-assess vital sign for any abnormal responses.

10. 5.Lung expansion manoeuvres Deep breathing exercise can be practiced in erect position, in a high side lying position or in a modified postural drainage position. As periodic deep breathing is important , recommended protocol is 5 deep breath with a 3 sec hold per every waking hour. Thoracic expansion exercise (lateral costal breathing exercise)- unilateral TTEs is performed in high side lying position with operated side on the top and arm brought to abduction at the level of the head. PT placed hand on incision site and patient is instructed to breathe in slowly and deeply to push PT hands up, to hold his breath for 2-3 sec and finally exhale from mouth. Deep diaphragmatic breathing patient is sitting upright, with back supported and pelvis in posterior tilting position. Patient is asked to relax the upper chest and breath in from nose by expanding lower chest and abdominal region and then to gently exhale. Deep breathing exercise coupled with arm or trunk movement - patient is asked to coordinate deep breathing with arm flexion, arm abduction, trunk extension away from operated side, while coordinating exhalation upon returning to starting position.

11. Lung expansion manoeuvres Sustained maximal inspiration - holding one’s breath for 3 second after reaching deep inspiration. Incentive spirometry the patient is asked to breathe in slowly and deeply for as long as possible through the mouth piece of the device to maximally distribute the ventilation, and then hold the deep breath for period of 5 second, which is then followed by normal expiration. Inspiratory muscle training- Brocki et al. has shown that addition of IMT to standard postoperative physiotherapy improved hypoxemic status in high-risks patient after lung cancer surgery, but no additional benefits for preserving respiratory muscle strength.

12. 6.Airway clearance technique It include coughing, huffing, the forced expiratory technique(FET), active cycle of breathing technique(ACBT), modified postural drainage position and positive expiratory pressure(PEP). It should be started as soon as patient wakes on the day of surgery. It should be repeated every 30 min. Supported coughing - patients sits upright, tilt the chin up, support the wound with pillow, take a deep breath combined with extension, and momentarily hold the breath, then carries out series of sharp expiration while leaning forward. Huffing- take medium size breath and then with mouth and glottis open breath out forcefully and slowly. FET- combination of 1-2 forced expiration (huff) and a period of breathing control. G

13. ACBT- patient should start with breathing control for 20-30 second, then practice TEEs 3-4 times then re-start breathing control again(20-30 sec or 6 breaths) and finally practice FET. The whole cycle should be repeated 2-3 times every waking hours. PEP- for PEP application patient sits upright or leans slightly forward with elbow supported on the table and hold the mouthpiece firmly. Then the patient is asked to larger than normal breath with a short breath hold(3-5 sec) and to exhale through the PEP device w ith active but not forced expiration against an expiratory resistor. Resistance range from 6-25 cm h2O, 10-20 breath/cycle and 4-8 cycle/sessions for maximum of 20 minutes.

14. 7. Postural correction patient tend to side-flex their trunk towards the thoracotomy side, i.e. to drop the shoulder and raise the hip on the operated side. Patient is encouraged to keep both shoulders at the same level and the trunk straight while sitting, standing, or walking. 8. Shoulder ROM exercises and gentle scapula mobilization exercises auto-assisted or active ROM exercise for shoulder (arm elevation) within pain limits can started as possible on the first postoperative day. Scapula on the operated side can be mobilized gently through its full range of protraction, retraction, elevation, and depression while the patient is in side-lying position. It can be practiced 3-4 times daily. Shoulder abduction and external rotation are initially avoided to prevent increased stress on the incision.

15. 9. Leg, trunk, and thoracic mobilization exercises Non-resistance exercise(quadriceps and ankle exercises) and Non-resistance arm exercises and thoracic mobilization(thoracic extension exercise, chest wall rotation exercise and thoracic lateral flexion exercise )on first post op day can be started. 10. Discharge and home programme After discharge patient is advised to continue regular breathing exercises, to gradually increases their mobilization and daily activities and practice an airway clearance technique. After discharge walking should be 3 times a day for a total of 15min/day. Then increase walking time each week by 5 minutes, so patient will be able to walk 30 minutes either intermittently or continuously by first month postoperatively.

16. Summary Lobectomy is the surgical operation where the lobe of the lung is removed. Lobectomy remains the treatment of choice for patients with early-stage lung cancer . The surgery can be performed via thoracotomy or VATS(video assisted thoracoscopic surgery) or RATS(robotic assisted thoracoscopic surgery ). Indication are Bronchiectasis, Tuberculosis, Lung abscess and Carcinoma. Rehabilitations protocol include pain management, wound support, airway clearance technique, lung expansion maneuver, mobilization, and arm, leg and trunk exercise.

17. References Essential of physiotherapy after thoracic surgery: what physiotherapists need to know, narrative review- Ahmad Mahdi Ahmad Bailey & Love’s Short Practice of Surgery, 27 th edition. Donna Frownfelter , E lezebeth dean