Thoracoplasty.

Thoracoplasty.

1. JAMIA MILLIA ISLAMIA CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES PRESENTATION OF PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS(BPT-402) TOPIC- THORACOPLASTY SUBMITTED TO- DR. JAMAL ALI MOIZ SUBMITTED BY- SANIA TABIR BPT 4 th YEAR PRESENTATION DATE- 5.1.2021

2. INTRODUCTION Thoracoplasty means resection of body parts of the chest wall, usually more or less extended parts of the ribs. The aim of the procedure is to reduce the size of the chest wall to eliminate a hollow space, or to compress a pathologically altered lung by removing the ribs from the chest wall. This surgical method (also called collapse therapy of chest wall) historically applied to treat cavernous forms of lung tuberculosis and to eliminate empyematous cavities. Thoracoplasty was initiated in the late 19th century to treat destructive lung tuberculosis and was also a “last chance” treatment for chronic pleural empyema (in various intra/ extrapleural modifications with different degrees of mutilation ).The need for surgical intervention was considerably reduced as a result of the introduction of effective drug therapy of tuberculosis (starting with Streptomycin in 1944, then PAS, INH, and most recently Rifampicin , in 1966) as well as the development of multimodal and targeted treatment of pleural empyema .

3. Although surgery in the treatment of the pulmonary tuberculosis is currently of no great relevance, the importance of thoracoplasty has not decreased, especially in cases of infected intrathoracic cavities, which cannot be liquidated otherwise (e.g., after pulmonary resection). Thoracoplasties in particular represent a safe and life-saving treatment option in cases of permanent space infections after pneumonectomy .

4. INDICATIONS Cavitary  tuberculosis (of apical and posterior segments of upper lobe) Empyema Bronchopleural fistula Persistent spaces following pulmonary resections Thoracoplasty is never used to treat basal spaces because: Lower spaces are better managed by open window drainage or muscle flap transfer It is very difficult to obtain complete collapse of the chest wall at the base

5. COMPLICATIONS The two main complications of this operation are Deformity Paradoxical breathing DEFORMITY:- If the first rib is removed, the distal attachment of the scalene is removed and this results in the muscles of the opposite side pulling the head and neck over to the sound side. The shoulder is raised on the affected side and rotated medially because the rhomboids are cut. The trunk leans to the effected side to balance the head displacement , and the spine goes into a long C curve concave to the sound side. PARADOXICAL BREATHING:- The flaccid area of the chest wall is sucked in on inspiration and blown out on expiration. This can be prevented by strapping over a cotton-wool pad to support the chest wall until it become firmer.

6. Other postoperative complications include failure to heal failure to obliterate the space failure to control infection failure to close the bronchopleural fistula respiratory failure late complications of plombage thoracoplasty   leakage of plombage material fistulae formation late infection

7. GOALS Strategically , two therapeutic goals should be achieved: Infection cleansing respectively decontamination Cleansing of pleural cavity by flushing (e.g., drainage or repetitive thoracotomy / thoracoscopy ) Thoracostomy Vas treatment Fistula occlusion, if required (by surgery or with stents) 2. Elimination of the cavity Cave filling with muscular/ omental flaps Thoracoplasty as a final “ ultima ratio” intervention

8. PROCEDURE TYPES 1. Intrapleural thoracoplasty Involves multiple rib excisions as well as resection of the parietal pleura, periosteum , intercostal muscles, and intercostal neurovascular with preservation of intercostal muscles which is allowed to fall into the cavity  2. Extrapleural thoracoplasty The rib periosteum , intercostal muscle and parietal pleura are preserved and allowed to drop into cavity  3. Plombage thoracoplasty A space is created between the rib cage, periosteum and endothoracic fascia (with out resecting the ribs)  In this extrapleural space is inserted the plombe ( methymethacrylate spheres, lead bullets, tissue expanders, sponge, lucite balls and oil)  3,4 4. Tailoring (limited) thoracoplasty A limited operation 

9. PHYSIOTHERAPY KEY POINTS Postural re-education is extremely important due to the high risk of deformity following this procedure . Postural correction should be achieved in standing and maintained when walking. Early correction with the aid of a mirror will minimize the deformity but the postural exercises may need to be continued by the patient for about 2 months. A firm pad should be applied if there is paradoxical movement of the chest wall . Shoulder girdle and arm movements should include depression of the shoulder girdle on the side of the thoracoplasty , retraction of the scapulae, bilateral full range movements and neck lateral lean towards the side of the operation

10. PRE-OPERATIVE PHYSIOTHERAPY The patient has to be taught breathing control, expanding the remaining lung, forced expiration technique and coughing, posture correction, shoulder girdle and shoulder exercises. POST-OPERATIVE PHYSIOTHERAPY DAY OF OPERATION Treatment is given after analgesia. Half-lying breathing exercises to expand the lower areas of the lungs bilaterally. The physiotherapist applies firm pressure over the apical areas of the thorax, and the patient is encouraged to cough or huff. DAY 1 Posture correction must be started with the physiotherapist instructing the patient to push the head sideways against manual resistance, towards the affected side and to push the shoulder down and back. Active assisted arm movements are practiced on both sides.

11. DAY 2 Continue with breathing exercises and coughing techniques. Posture correction is progresses so that the patient has to align the head and shoulder and thoracic spine with scapular retraction without the guidance of the physiotherapist DAY 3 The patient will be up and about . Manually resisted exercises for the shoulder girdle and arm on the affected side should be included. DAY 4 Trunk exercises in sitting are added DAY 5-7 Trunk exercises in standing should be included. Posture correction in walking should be practiced.

12. DAY 8 TO DISCHARGE FROM HOSPITAL The patient must practice exercises to maintain trunk mobility, thoracic cage mobility and a good posture which have to be continued at home for at least 3 months after discharge. When a patient attends for check-up with the surgeon the physiotherapist should check the patient’s posture and thoracic expansion

13. REFERENCES Thoracoplasty - current view on indication and technique by oleg kuhtin , marina veith et al Physiotherapy for respiratory and cardiac problems, jennifer a pryor , 2 nd edition 1998 Reference article by Dr. Ian Bickle and Nikos Karapasias et al