Surgery of pleura

Surgery of pleura

1. SURGERY OF PLEURA SUBJECT:402-PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS SUBMITTED BY: FARAZ SHAMS ROLL NO. 9 BPT 4 TH YEAR SUBMITTED TO: DR. JAMAL ALI MOIZ CENTRE FOR PHYSIOTHERAPY AND REHABLITATION JAMIA MILLIA ISLAMIA

2. OPERATIONS OF PLEURA There are three types of pleural operations- 1- Pleurectomy 2- Pleurodesis 3-Decortication of the lung These all require a thoracotomy.

3. pleurectomy Pleurectomy is a type of surgery in which part of the pleura is removed. This procedure helps to prevent fluid from collecting in the affected area. It is the removal of the parietal layer of pleura from an area of the chest wall leaving a raw surface to which the visceral layer sticks and is performed for pneumothorax. Pleurectomy reduces the risk of symptomatic pleural effusions and recurrence of spontaneous pneumothorax. INDICATIONS- Pleurectomy is most commonly indicated for mesothelioma. However, other less common indications include the following: Primary pneumothorax Pneumothorax secondary to chronic obstructive pulmonary disease (COPD) Traumatic pneumothorax Malignant pleural effusions

4. PROCEDURE FOR PLEURECTOMY The patient is placed in a full lateral position after placement of a double-lumen endotracheal tube. A posterolateral thoracotomy incision is made, completely dividing the latissimus muscle, and the chest is entered through either the fourth or fifth intercostal space. Usually, the serratus muscle can be spared but occasionally must also be divided to allow adequate access. An additional eighth or ninth interspace thoracotomy within the same skin incision may be necessary for adequate exposure of the inferior thorax. Pleurectomy involves complete resection of both visceral and parietal pleura and can include both pericardial and diaphragmatic resection, as well as resection of additional lung nodules. The parietal pleura is first dissected off the chest wall and then the mediastinum. The pleura is then opened and removed.

5. Complications- Possible risks/complications of pleurectomy include the following: Difficulty in breathing Pneumonia Bleeding Chest infection Lungs and chest wall drainage Air Leak: makes the chest tube challenging to remove post surgery Post operative pain

6. pleurodesis Pleurodesis is the insertion of a powder into the pleural cavity. This acts as an irritant to the pleural surfaces, causing them to adhere to each other. obliteration of the pleural space by inducing adherence of the visceral and parietal layers by the use of sclerosing agents or surgicalabrasion INDICATIONS- Recurrent pneumothorax Malignant pleural effusions

7. Intrapleural injection of sclerosing agent- Performed by injecting sclerosant through a chest tube Size of chest tube — no effect Chest tube connected to a water- sealeddrainage system The effusion is allowed to drain Sclerosant injected as soon as lung has expanded If lung not expand with tube thoracostomy pleural fluid can be drained with: PleurX catheter, Pleuroperitoneal shunt Catheter then flushed with 50-100mI of saline Chest tube is clamped for at least 1 hr. Patient is rotated

8. Unclamp the chest tube and apply negative pressure Suction is maintained for 24hrs until pleural drainage <150ml/day. Chest tube removed after 96 hrs Sclerosing agents- Talc Tetracycline derivatives Antineoplastic agents Silver Nitrate

9. Decortication Decortication of the lung is the stripping off of layers of pleura that have become thickened due to chronic inflation from pleurisy which restricts movement of the chest wall and lung. Where empyema is not resolving, the whole pleura is removed to clear away the chronic pus-filled surrounding fibrous –tissue. This allows the lung to re-expand into the space previously occupied by the empyema.

10. PRE OPERATIVE PHYSIOTHERAPY Gain patient confidence Clear the lungs Teach respiratory control and inspiratory holding Teach postural awareness Teach arm, trunk and leg exercises Teach mobility around bed Lung expansion exercises should be taught

11. Post-operative physiotherapy Postoperative physiotherapy aims to minimize the risk of non-infectious and infectious pulmonary complications, the most common being atelectasis and pneumonia. Other common problems are loss of joint range in the shoulder on the incision side and reduced mobility. Therefore, the main aims of physiotherapy are: patient education maximisation of lung volume prevention of sputum retention sputum clearance maintenance of shoulder range of movement early mobilisation reduced lung volume retention of secretions increased work of breathing poor breathing control/pattern ineffective cough pain.

12. post-operative physiotherapy At the day of operation Patient in semi-fowler position with the head and back supported with the pillow and both the forearms over the lap on a pillow Cryotherapy over the incision dressing TENS ( 15-20 min. after every 3 hours) Wound support during manuevers Positioning Thoracic expansion exercises Breathing control with lateral costal expansion (max. insp – 3-5 sec hold , exp to end-tidal volume) Foot and ankle exercises

13. First and second day of operation- 4-5 sessions Side lying – chest expansion exercises on remaining side Postural drainage, if necessary huffing and coughing with passive wound support and active wound support on second day Nebulizer therapy and humidification therapy Foot and leg exercises Isometric quadriceps strengthening Posture correction should be emphasized to prevent scoliosis on scar side Neck exercise Assisted arm movement in functional pattern twice a day Provide a rope ladder to the patient so that patient can pull on it to move around the bed and sit on the edge of the bed till second day Trunk turning, bending side to side, stretching backward Sitting in chair on second day Deep diaphragmatic breathing exercises Walking round the bed with trunk erect and arm swinging

14. Third day onwards to discharge- Diaphragmatic b reathing exercises H uffing and coughing if secretions are present in the lungs. Continue trunk, shoulder girdle and arm exercises twice a day Foot and leg exercises are give when the patient is confined to bed. These can be discontinued when he is fully mobile. Aerobic exercises Practice stair climbing along with breathing control exercises after the 7th day Remove the stitches at 7th-10th day of operation usually The patient should be discharged after 2 weeks

15. After discharge- Inspiratory muscle training Home exercise programme Increasing exercise tolerance Deep breathing exercises Gradual walking programme Perform ADLs Practice ACBT wherever necessary Aerobic exercises using cycle ergometer

16. References Tidy’s Physiotherapy by Stuart Porter Cash's Textbook of General Medical and Surgical Conditions for Physiotherapists by Joan E. Cash Cardiovascular and Pulmonary Physical Therapy by Donna Frownfelter and Elizabeth Dean Physical Therapy for Cardiopulmonary Disorders by Dr Shehab M Abd El-Kader