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POST OPERATIVE PHYSIOTHERAPY MANAGEMENT FOR FLAIL CHEST

SUBMITTED BY: D. SENTHIL KUMAR

A Project work submitted to

THE TAMILNADU DR. MGR MEDICAL UNIVERSITY, CHENNAI

in partial fulfillment of the requirements for the degree of

BACHELOR OF PHYSIOTHERAPY AUGUST 2010

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ACKNOWLEDGEMENT
First I would like to thank my Almighty God for his blessings to complete my project on POST-OPERATIVE successfully. I also like to thank Dr. P. M. NARGUNAM, M.D (O&G) Managing Director for providing good infrastructure and all facilities in our college. I am grateful to thank our principal Dr.S.MAHESH, M.P.T (O&G), M.I.A.P for his guidance and encouragement. PHYSIOTHERAPY MANAGEMENT FOR FLAIL CHEST

I also thank my guide Dr.V.KAMALASEKARAN B.P.T M.I.A.P for guiding me to complete my project successfully. My special thanks to my staff Dr. S.KALPANA B.P.T., M.I.A.P M.sc for his invaluable support. I thank our Librarian Mr. P. BOOPATHI, B.A, M.L.I.Sc, M.B.A who has helped me in getting the reference books and materials for my project.

I take immense pleasure in extending my sincere thanks to

my Parents

Mr. M.DHANAPAL and Mrs.D.MYTHILI who have helped and encouraged me to complete my project work in success. I also thank my Brothers Mr. C.GOPI KRISHANAN, Mr. S.JAI SELVAKUMAR, Mr. N.MAHARAJA, Mr. V. KARUPPAN V. ISSAC, M. RAJESHKUMAR, and sister D.GAYATHRI, for their support. I wish to express my hole hearted thanks to MY FRIENDS for their timely help & support.

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CONTENTS

SL.NO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 INTRODUCTION ANATOMY PHYSIOLOGY DEFINITION AETIOLOGY TYPES CLINICAL FEATURES INVESTIGATION MANAGEMENT

TITLE

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4 5 9 14 16 17 19 22 24 34 37 56 50 65 66

PHYSIOTHERAPHY ASSESSTMENT PHYSIOTHERAPHY MANAGEMENT REHABILITATION CASE STUDY CONCLUSION BIBLIOGRAPHY

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INTRODUCTION

Trauma or Injury to the human body has been a challenging situation even to the prehistoric man. The scope for getting injured has increased with the development of industry, agriculture and transportation to such an extent that epidemiologically, trauma is becoming one of the biggest killers and maimers of human beings all over the world.

A fracture is defined as break in the structural continuity of bone. In my studies I explained about FLAIL CHEST , it is refers to a section of the rib cage that has broken away from the surrounding ribs .it is more common in the elderly persons. It will occur due to chest trauma. It is a life threating medical condition. After the post – surgery, physiotherapy role is very important.

Physiotherapy in its various forms occupies an important place in the post – operative treatment of various cardio-thoracic conditions. In this study, I explained about the Anatomy and physiology of the flail chest. After that, I explained how to give a valuable therapy to the patient by using various techniques. After that, the complications are explained which will be produced by the flail chest. Finally, the rehabilitation and home programme will be admist by the therapist.

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ANATOMY
RIB CAGE
Thorax forms the upper part of the trunk of the body. It permits boarding and lodging of thoracic viscera thorax is supported by skeletal frame work and its called as RIB or THORACIC cage. The chest wall is inherently stable with twelve Ribs attached posteriorly to the spinal column and anteriorly to the sternum.

STERNUM
Is a flat bone forming the anterior median part of the thoracic skeleton? The upper part corresponding to the handle is called manubrium. The middle part resembling the blade is called the body. The lowest tappering part is xiphoid process or xiphi sternum.

THE MANUBRIUM
It is quadrilateral in shape. It is the thickest and strongest part of the sternum. It has two notches they are jugular notch or supra sternal notch and clavicular notch.

BODY OF STERNUM
The body is longer, narrower and thinner than the manubrium. It has two surfaces anterior and posterior. Two lateral borders and two ends upper and lower.

XIPHOID PROCESS
It is smallest part of the sternum. It varies greatly in shape and may be bifid or perforated. It lies in the floor of the epigastric fossa.

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ANATOMY OF THORACIC CAGE

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THE RIBS (COSTAE)
There are twelve ribs on each side forming the greater part of the thoracic skeleton. The ribs are bony arches arranged one below the other between each rib there is gap called inter costal space. The upper ribs are less oblique than lower ribs. The first seven ribs are connected with the vertebral column behind and with the sternum in front by means of the costal cartilages. The first seven ribs are called true to vertebro sternal ribs. The remaining five ribs are called false ribs. The cartilages of 8th & 9thand 10th ribs join to next higher cartilages they are known as vertebrochondral ribs. The 11 th and 12th ribs are free anteriorly and called as floating ribs or vertebral ribs. The first two and last three ribs have special features and typical ribs the third to 9th ribs are typical ribs.

TYPICAL RIBS

It includes head, neck, tubercle and costal cartilages. The shaft is flattened and curved. The shaft extends anteriorly towards these sternal ends for the costal cartilage. The costal groove runs along the inferior surface of the rib.

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ATYPICAL RIBS  FIRST RIB Anterior end is larger and thicker, posterior end is comprises the head, neck, tubercle and shaft.  SECOND RIB The length is twice of the first rib. Shaft is sharply curved. Non-articular part of the tubercle is small.

 TENTH RIB It closely resembles atypical rib, but it is shorter and is only a single facet on the head, for the body of the tenth thoracic vertebra.

 ELVENTH AND TWLEVETH RIBS They are short, have pointed ends, the neck and tubercle are absent. The angle and costal groove are poorly marked in the eleventh rib and are absent in the 12th rib.

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PHYSIOLOGY
RESPIRATORY MOVEMENTS:
The lungs expand passively during inspiration and retract during expiration. These movements are governed by the following two factors. 1. Increase in volume of the thoracic cavity creates a negative intra thoracic pressure which sucks air into the lungs. 2. Elastic recoil of the pulmonary alveoli and of the thoracic wall expels air from the lungs during expiration.

PRINCIPLE OF MOVEMENTS:
1. Each rib may be regarded as a lever, fulcrum lies lateral to the tubercle. Slight movements at the vertebral end are greatly magnified at the anterior end. 2. Anterior end moves forward during elevation. This occurs in vertebrosternal ribs. In this way anteroposterior diameter of the thorax is increased. 3. Along with the up and down movements of the 2nd to 6thribs, the body of the sternum also moves up and down called "Pump handle movements". 4. During elevation of the rib, the shaft moves outwards. This occurs in the transverse diameter of the thorax. Such movements occur in the vertebrochondralribs and are called "Bucket handle movements". 5. Each ribs are longer than the next higher ribs. On elevation the larger lower rib comes to occupy the position of the smaller upper rib. This also increases the transverse diameter of the thorax.

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MECHANICS OF RESPIRATION

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VENTILATION
During inspiration, chest wall expands, intrapulmonary pressure falls and becomes sub atmospheric and air from the atmosphere enters the lung. During expiration, chest wall and the lungs shrink, intrapulmonary pressure rises and air is forced to leave the lung. Therefore, thoracic cage expands and shrinks causing inspiration and expiration. Thus expansion and shrinking of the thoracic cage and lungs is called ventilation.

MECHANISM OF VENTILATION
Muscles of inspiration contract cause expansion of the thoracic cage. When the chest wall expands the parietal pleura also tries to move along with the expanding chest wall. In between visceral and parietal there is a thin layer of intrapleural fluid. Because of this both the layers cannot be separated. So when chest wall expands, visceral pleura also moves and tries to drag the lung. Lung expands due to its elastic properties but during inspiration intra pleural pressure become more negative. This expansion of the lung causes the dilation of the airway and alveoli system. Within the alveoli, pressure becomes sub atmospheric. Airway tube is in direct communications with the external atmosphere. Therefore when the intrapulmonary pressure falls, a pressure gradience develops, air enters from the external atmosphere into the lung. This flow continues until intrapulmonary pressure becomes equal to the external atmospheric pressure. This is inspiration. The muscles of inspiration stop contracting and the lung shrinks. Intrapulmonary pressure rises and the air leaves the 11

lung. The outward continues until the intrapulmonary pressure becomes equal to the external atmospheric pressure, this is expiration.

LUNG VOLUME AND LUNG CAPACITIES
LUNG VOLUME TIDAL VOLUME {VT}

Tidal volume is the volume of air inspired or expired by an individual Per respiratory exertion at rest. Tidal volume of the young healthy adult is about 500ml. From top end of a tidal volume inspiration phase, the subject makes a maximal inspiratory effort. The extra air that is drawn in is the inspiratory reserve volume. Normal value is about 2000 to 3000ml.
EXPIRATORY RESERVE VOLUME {ERV}

From the end expiratory position of the tidal volume breathing, the subject makes the hardest expiratory effort. The extra air that comes out is the expiratory reserve volume. Normal value is about 1000ml.

RESIDUAL VOLUME

After even the severest expiratory effort, the lungs still contain some air, called residual volume.Normal value is about 1500ml.
LUNG CAPACITIES

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Inspiratory capacity {IC} = IRV + VT. Functional residual capacity {FRC} = ERV + RV. Vital capacity {VC} = IC + ERV.
VITAL CAPACITY {VC} or FORCED VITAL CAPACITY {FVC}

It is the volume of air breathed out by a forcible expiratory effort after a maximal inspiration. VC = IC + ERV = [2500ml+3500ml] 1000ml =3.5 to 4.5litres approximately. The Forced expiratory volume for one second [FEV1] is the forced vital capacity that is recorded during the first second. TIMED VITAL CAPACITY The term timed vital capacity means the percentage of the total VC which is expelled in 1st, 2nd or 3rd second. TOTAL LUNG CAPACITY {TLC} The term total lung capacity means when all the capacities are added together. TLC =IC + FRC Normal value is 5.5 litres.

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FLAIL CHEST
DEFINITION:
The chest wall moves inward with inspiration, such as multiple rib fractures. - DONNA FROUNFELTEER

Multiple fractures of ribs can result from direct violence which may occur in a road accident or similar trauma. - AM THOMSON

Blunt injury to the chest can result in the fracture of one or more ribs. - BARBARA A. WEBBER

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FLAIL CHEST

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AETIOLOGY:
 Life-threatening chest injury  Pulmonary injury  Significant blunt trauma  Motor vehicle accident  Kinetic force to chest wall and rib cage  Osteoporosis, total sternectomy and multiple myeloma  Bone disease or deterioration in older patients (Very rare)

CHEST WALL INJURIES CASES FILED IN G.H

[233 cases: Closed injuries -210&open wounds -23]

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TYPES
LATERAL TYPE:
Multiple ribs are fractured anterior and posterior

ANTERIOR TYPE:
Anterior ends of ribs are fracture on both sides, so that the sternum along with anterior fragment of ribs becomes floating segment.

[ANTERIOR TYPE OF FLAIL CHEST]

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POSTERIOR TYPE:
Multiple ribs are fractured at their posterior angles, so that spinal column along with posterior fragments becomes floating segment.

[POSTERIOR TYPE OF FLAIL CHEST]

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CLINICAL FEATURES
 Paradoxical motion  Chest Pain  Sharp pain  Decrease in breathe sound  Shallow rapid respiration  Shortness of breathe  Difficulty drawing breathe  Dyspnoea  Uneven chest expansion  Tachycardia  Cyanosis  Brusises  Tachypnea  Discoloration of the chest area

PARADOXICAL MOTION:
The characteristics paradoxical motion of the flail segment occurs due to pressure changes associated with respiration that the rib cage normally resists. The ambient pressure is comparison to the pressure inside the lungs. It goes in while the rest of the chest is moving out and vice versa.

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[PARADOXICAL MOTION]

EFFECTS OF PARADOXICAL RESPIRATION:
 Imperfect ventilation leading to hypoxia  Mediastinal flutter – media sternum move towards the sound side during inspiration and towards affected side during expiration  Movement of media sternum severe shock  Stagnation of air  Accumulation of broncho pulmonary secretion  Post traumatic insufficiency or wet lung occurs

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INTERNAL CHANGES OF FLAIL CHEST

CHEST PAIN
May also be due to rib fractures, strain of the intercostal muscles or tumors of the ribs.

CYANOSIS
This is the name given to blue colour of the skin and mucous membranes. There are two types, peripheral and central.  Peripheral Cyanosis It is due to reduced blood flow through the peripheries and is associated with cold extremities.  Central Cyanosis It is due to reduced oxygen saturation of the arterial blood. It is noticed in the tongue, lips and ear lobes and it is associated with warm extremities.

DYSPNOEA
This is a state of disordered breathing, in which the patient has an unpleasant awareness of difficulty in breathing. 21

INVESTIGATION
PHYSICAL EXAMINATION
 Pain  Breathing problems  Paradoxical movement of chest wall  Unstable chest wall  Abnormal chest movement during respiration This shows the evidence of paradoxical movements of chest wall. Brushing, gazes or seat belt sign are visible. On inspection, and palpation may reveal the crepitus associated with broken ribs.

CT SCAN
Computerized Tomographic scanning has an occasional but important place, particularly in the investigation of fracture of thoracic cage. These have been found to provide very little additional useful information for initial evaluation of chest wall injuries

CHEST X-RAY
 The antero-posterior chest radiograph will identify most significant chest wall injuries, but will not identify all rib fractures.  Lateral or anterior rib fractures will often be missed on the initial plain film.

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 Underlying injuries ray (anteroposterior and lateral views) can assist with the diagnosis of rib fractures and such as pneumothorax (air in the pleural cavity), haemothorax (blood in the pleural cavity), atelectasis (collapse of lung tissue leads to absence of gas from part or all of the lungs), pneumonia or lung contusions.

 Negative X-rays do not necessarily exclude fractures that occur in the cartilaginous portion of the ribs, therefore physical symptoms must also be taken into consideration when making a diagnosis.

MRI:
Provides superior soft tissue contrast in multiple imaging planes and is used to examine the musculoskeletal, central nervous system and cardiovascular systems. Images are better at identifying soft tissue pathology but anatomical detail less clear. Fluid appears bright.

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MANAGEMENT
CONSERVATIVE MANAGEMENT

 DRUG THERAPY Treatment of the flail chest initially, follows the principles of
ADVANCED TRAUMA LIFE SUPPORT.

Adequate good analgesia avoiding narcotic analgesics is of paramount importance in patient recovery and may contribute to the return of normal respiratory mechanics. If analgesia is ineffective inter-costal Nerve blocks or morphine infusion may help control pain.

Mild analgesics- Paracetamol Pethidine -50-100mg Morphine sulphate- 10mg Diamorphaine- 5mg

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SURGICAL MANAGEMENT

TRACTION FOR A FLAIL CHEST

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SURGERY POSITION AND INCISION:
Antero –lateral flail chest injuries are approached with an antero-lateral thoractomy with the patient in a supine position with both arms abducted 90 degrees. Posterior –lateral flail chest are approached with an posterior – lateral thoracotomy with the patient in lateral decubitus position and the arms abducted 90 degree. A variety of surgical techniques have been reported in the past to stabilize the flail chest. 1. External towel clip traction (high risk of osscous and soft tissue infections) 2. Application of over lapping rib struts 3. Intra-medullar wiring 4. Mechanical relief of fracture ribs also done by a plate and screws, but this surgical approach may be difficult to perform in a case of osteoporosis or bone fragmentation that can be present over a trauma. SEAGULL WING PROSTHESIS: The stabilization of fragmented bones is obtained by a self -retaining sea gull wing prosthesis inserted under a sternum, with the wings allocated over the adjacent ribs. We use this technique in two cases of flail chest  Anterior flail chest  Lateral flail chest ADVANTAGE:

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This allows a fast recovery of the bone and an easier weaning from the mechanical ventilation. I. This does not require screws or other hardware to fix. II. Can be easily removed after the completion of bone fixation (4 to 6 months later) Osteosynthesis: Once both ends are fracture line re-expose, osteosynthesis is accomplished by with metal plates.

[OSTEOSYNTHESIS]
TYPES OF PLATE: Sanchez-Lloret is the rib segment stretching the lateral hooks as previous described for Judet plates (Are frequently used). On plate is placed, it is reinforced with a heavy “adsorbable polyfilament” suture at each ribs.

[JUDET PLATES]

[SANCHEZ PLATES]

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[SURGICAL STABILIZATION OF TRAUMATIC FLAIL CHEST]

Surgical stabilization was preferred by the patients rib fractures injuries. Ideal when chest wall continuity must be restored.

The length of the blades metal hooks must be carefully chosen to adapt to the rib size.

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TYPE OF INCISION : Posterolateral or anterolateral chest wall incision

[ANTEROLATERAL CHEST WALL INCISION]

MUSCLES INVOLVED  Trapezius  Rhomboid  Latissimus dorsi  Serratus anterior  Internal and external intercostal

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CHEST DRAINAGE
The purpose of drains in thoracic surgery is to remove fluid or air which expected to accumulate. Drainage may be closed or open.

CLOSED DRAINAGE
A tube with end and side holes isintroduced into the thorax via an intercostal space. It is connected to a closed bottle via a transparent tube which ends water. A second short tube left unconnected maintains atmospheric pressure in their bottle. This arrangement provides a simple one-way valve. If the short tube is connected to a suction apparatus the air pressure with the bottle will be reduced below atmospheric. If sufficient suction is applied the negative pressure which exists between the lung and the chest wall will be increased. The calibrated bottle allows for easy measurement of blood loss. The drainage bottle should be kept at a lower level than that of patient’s chest to prevent siphoning of fluid and back into pleural cavity. After other types of lung desection two drains, one placed at the apex of the pleural cavity and the other at the base are used.

OPEN DRAINAGE
A tube in the pleural cavity connects directly to the air. This arrangement is only safe when the pleural cavity has become rigid and immobile. This is used only to drain achronic empyma where infection is localized from the rest of the pleura by fibrosis. This is a rarely indicated following pulmonary surgery. 30

MECHANICAL VENTILATION
Mechanical ventilation can be effective immediately after trauma to assure a cardio respiratory stabilization and can be prolonged in patients with associated broncho pulmonary disease, but a fast weaning from the ventilation is preferable if a surgical fixation can be done.

HUMIDIFIER
Humidification is the moistening of the air or gases we breathe. Artificial humidification is essential for the maintenance of adequate ventilation. During normal respirations the inspired air is warmed and humidified by the mucus membranes so that it is fully saturated at body temperature when it reaches the trachea. If there not sufficient moisture available to replace that used up in humidifying the inspired air, cilial activity is decreased. Dehydration also makes the bronchial secretions thick and viscid. The combination of these tenacious secretions with depressed cilial activity makes expecotoration difficult. Humidity is the invisible moisture or water in the form of individual molecules in its vaporous or gaseous state.

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SUCTIONING
If a patient is unable to clear secretions by coughing, suctioning is Indicated. As it is an invasive procedure with significant risk, suctioning must be performed using very careful technique. 1. Preparation  Check that the suction apparatus is functioning properly and is connected, the suction is turned on, and the vacuum level is set between 80 and 120 Cm H2O.

SUCTIONING

 Make sure the oxygen flow is turned on and attached to the self-inflating breathing bag.  Position the patient properly and less contraindicated: Nasotracheal and pharyngeal suctioning are usually performed with a patient in the semifowler position with the patients neck hyperextended, whereas patients with a trechestomy or endotracheal tube are suctioned in the supine flat position.  Have water soluble lubricants available if the patient is to be suctioned nasotracheally. Put on protective eye wear. 32

 Layout of the sterile field containing gloves, catheter, and container for sterile.  Using sterile technique put on gloves, fill container with sterile water, and attach catheter to suction. 2. Pre-oxygenation  Using a self-inflating breathing and a mask or artificial air way connector, hyperventilate the patient with 100% oxygen. 3. Levage (Optional)  Instill 5 ml of sterile normal saline solution (Nacl) directly into the endotracheal or tracheostomy tube. 4. Suction Using sterile technique throughout:  Wet the catheter in the sterile solution or with the water soluble lubricant if nasotracheal suction is to be performed.,  Insert the catheter (with no suction applied) into the airway until resistance is met or until a reflex cough is triggered.  Pull the catheter back slightly and then withdraw the catheter in a twirling motion while applying suction (should not take longer than 5 to 10 seconds).  Re-oxygenate the patient with 100% oxygen.  Clean secretion from catheter by suctioning some of the sterile water.  Repeat process if necessary until there are no more secretions.

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PHIYSIOTHERAPY ASSESSMENT
SUBJECTIVE
Name Age Sex : : :

Occupation : Address :

CHIEF COMPLAINT: Pain Inability to move trunk Inability to breathe normally

HISTORY OF THE PATIENT
Past medical history: Hyper tension Ishaemic heart disease Diabetic melitius Asthma Present medical history: Medication for present complaint Social History: Work environment Home environment 34

Personal history: Smoking Alcoholism Vital Signs: Heart rate Respiratory rate Blood pressure Body temperature Pulse rate ON OBSERVATION Level of awareness: Alert? Responsive? Lethargic? Co-operative? Body Built: Obese Normal Cachetic Chest wall measurement: Axilla Nipple Xiphoid level Chest Shape: Barrel chest Pectus excavatum Pectus carniatum 35

Pattern of Breathing: Fish Mouth Breathing Shallow Breathing Cynosis: Peripheral Central Clubbing ON PALPATION Pain Tenderness Edema (pitting or non-pitting) Peripheral pulse ON AUSCULTATION Normal breath sound: Tracheal, Bronchial, vesicular, Broncho-vesicular Percussion (unaffected side): Chest wall mobility and expansion: Heart sound: ON EXAMINATION Range of motion: Shoulder and trunk Investigation: X-ray, CT scan, MRI

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PHYSIOTHERAPY MANAGEMENT
AIMS:  To improve breathing pattern  To improve ventilation  To decrease pain  To assist in the removal of excessive bronchial secretions  To ensure adequate ventilation of all areas of the lungs and to help preventing consolidation / atelectasis  To maintain full joint range and muscle length by passive movements – If the patient is unable to perform active exercise  To maintain mobility and blood circulation by free active exercise, when possible  To ensure the maintenance of a good posture by accurate positioning and advice  To help rehabilitate patient to as full and independent life

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Aggressive pain management techniques, such as epidural analgesia, need to be employed before patients have physiotherapy. The aim of physiotherapy for a patient with multiple fractured ribs is to minimize any compromise of the respiratory system. An initial assessment is carried out to obtain a set of baseline objective markers from which to develop a treatment programme; these include respiratory rate, oxygen saturation, breathing pattern, peak expiratory flow rate, arterial blood gases, and auscultation (listening to chest sounds).

Treatment is carried out at a minimum of twice a day for the first three days and then on an 'as required' basis. At each session the patient is reassessed and the initial objective markers re-tested.

Relaxed Position For Breathless Patient Accurate positioning to drain specific areas of lung may be limited, if possible at all, and may simply consist of tilting the bed or mattress from side to side (particularly if patient also has thoracic injuries), tilting the bed head up and head down may also be helpful provided the are no contra-indications.

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RELAXED POSITION FOR BREATHLESS PATIENT

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BREATHING EXERCISE
Patients generally use a pattern of breathing that is more efficient for them. There are several techniques of teaching breathing exercise. The term "Breathing exercise" is misleading as it implies that the patient is physically exerting himself. Patient should be taught a more relaxed and economical pattern of breathing.

GOALS OF BREATHING EXERCISE
 To decrease the work of breathing.  To improve alveolar ventilation.  To improve airway clearance by improving cough.  To increase strength, co-ordination and efficiency of respiratory muscles.  To assist in relaxation.  To maintain mobility of the thorax.  To enable patient to manage shortness of breath attacks.

DIAPHRAGMATIC BREATHING EXERCISE
It is the normal mode of respiration. One method of diaphragmatic breathing concentrates on forward movement of whole abdominal wall. Another technique combines forward movement of upper abdominal wall with some lateral movement of the lower ribs.

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DIAPHRAGMATIC BREATHING

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POSITION OF THE PATIENT
 Relaxed half lying or sitting.

TECHNIQUE
1. The physiotherapist places both hands over the abdomen. The patient gently

breaths in, concentrating on allowing the abdominal wall to swell, gently or forcibly under the slight pressure of the physiotherapists hands. On breathing out he feels his abdomen slowly sinking back to rest. The patient can practice by resting both hands over the abdomen. The upper chest and shoulder should remain relaxed throught. The expiratory phase is completely passive. Any prolonged or forced expiration may increase airway obstruction. Careful verbal command should be given. 2. The physiotherapist places the hand on the anterior costal margins and upper

abdomen to feel the movement occurring. He starts by gently breathing out, while relaxing the shoulders and upper chest and feeling the lower ribs sinks down and in towards the mid-line. When the patient has mastered the breathing pattern, then progress in sitting, standing, exercising positions.

ADVANTAGES
 Improves ventilation.  Improves oxygenation.  Increase tidal ventilation.  Eliminate accessory muscle activity.  Decrease respiratory rate.  Improve distribution of ventilation.  Reduce the work of breathing.

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PURSED- LIPS BREATHING EXERCISE
 Pursed- lips breathing improves ventilation and oxygenation and relieves respiratory symptoms.  One method recommends passive expiration.  Another method advocates abdominal muscle contraction to prolong expiration.

TECHNIQUE
 Position the patient comfortably.  The therapist should place the hand over the mid-rectus abdominis area to the detect the activity during expiration.  Instruct the patient to inhale slowly. Ask the patient to purse the lips before exhalation.  Instruct the patient to relax the air out through the pursed lips and refrain the abdominal muscle contraction.  When abdominal muscle activity is detected ask the patient to stop exhaling.  When the patient has learned the technique he is asked to perform the same while standing, sitting and exercising.

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[PURSED- LIPS BREATHING EXERCISE]

ADVANTAGES
 Increase tidal volume.  Increase alveolar ventilation.  Increase oxygenation.  Reduce the work of breathing.

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INTERMITTANT PRESSURE BREATHING (IPPB )
Serious impairment to ventilation results and the patient frequently requires intubation and intermittent positive pressure ventilation (IPPV).

The IPPV will also act as a form of internal splintage thus helping to prevent paradoxical breathing. Ventilation (full or assisted) may be continued for approximately ten days or until the rib stabilize. In the spontaneously breathing patient, intermittent positive pressure breathing is the maintenance of a positive air way pressure throughout inspiration, with air way pressure returning to atmospheric pressure during expiration. It has been suggested that IPPB may be of value in patient with chest wall deformities or pronounced inspiratory muscle weakness who cannot voluntarily generate transpulmonary pressures and inspiratory volumes great enough to produce sufficient expiratory flows to aid effective expulsion of secretions.

INTERMITTANT PRESSURE BREATHING (IPPB)

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PRACTICAL PROCEDURE:
The position of the patient depends on the condition for which the IPPB is being given. It may be effectively used in the sitting, high side lying or side lying positions. The patient should comfortable and able to relax the upper chest and shoulder girdle. The patient is told to close his lips firmly around the mouthpiece and breathe in through his mouth. The patient should relax during inspiration allowing air from the ventilator to inflate his lungs. Expiration should be quiet and relaxed. The patient relaxes his upper chest and shoulder girdle and the physiotherapist places his hands on the anterior costal margins to encourage gentle movement of the lower chest.

Treatment time and frequency with IPPB depend on the individual case, but it is likely to be between 10 to 20 minutes.

INCENTIVE RESPIRATORY SPIROMETRY
It is a form of low level resistance training that emphasizes sustained maximal inspiration. The patient inhales through a spirometer that provides visual or auditory feedback as the patient breathes in as deeply as possible. Incentive spirometry increases the volume of air inspired and has been used to prevent alveolar collapse in post operative conditions and to strengthen muscles in patients with neuro muscular disorders.

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PROCEDURE:  Place the patient in a comfortable position (Supine or semi upright)  Have the patient take three to four slow, easy breaths.  Have the patient maximally exhale with the fourth breath.  Then have the patient place the spirometer in his mouth and maximally inhale through the spirometer and hold the inspiration for several seconds.

[INCENTIVE RESPIRATORY SPIROMETRY]

INSPIRATORY MUSCLE TRAINING [IMT]
Inspiratory muscle training is currently used in pulmonary rehabilitation to increase the strength and endurance of the inspiratory muscles. To train a muscle to improve its functional ability, the muscle must be subjected to a stress greater than its usual load and the training must be directed at developing specific functional attributes of the muscle. 47

Endurance training of the inspiratory muscles is thought to promote an increase in the proportion of fatigue-resistant fibres in the diaphragm, an increase in the metabolic capability of the muscle, and a reduction in the susceptibility of muscle fibres to the deleterious effects of exercise. Improvement in the strength and endurance of the inspiratory muscles has enhanced the resistance to inspiratory muscle fatigue and improve ventilatory function.

[INSPIRATORY MUSCLE TRAINING [IMT]

The work of breathing is reduced and respiratory reserves are increased. This increases the muscle strength and endurance. Two techniques have been used. They are; 1) Isocapnic hyperventilation. 2) Inspiratory resistive or resistance breathing.

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1. ISOCAPNIC HYPERVENTILATION
Patient is asked to breath at the highest rate they can manage for 15 to 30 minutes. Rebreathing circuit is used in to prevent hypocapnia. It increase the endurance of inspiratory muscle.

2. INSPIRATORY RESISTIVE OR RESISTANCE BREATHING
There are two devices. They are a) A non-linear device. b) A threshold IMT device. With a controlled rate of breathing in a non-linear device, patient inspire through a narrow tube that offers a non-linear airway resistance for one or three daily periods of 15 to 30 minutes. Size of orifice is adjusted to provide level of resitance. With a threshold IMT device a reliable inspiratory pressure load is provided. The load is adjusted according to a desired % the patient's maximal inspiratory pressure [PI max].

RELAXED SITTING
The patient is made to sits with his back kept straight. The forearms are made to rest on thighs and the wrist is relaxed.

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CONCEPTUAL FRAMEWORK OF RESPRATORY MUSCLE TRAINING
Respiratory muscle training

Increased strength and endurance of respiratory muscle

Delay the onset of respiratory muscle fatigue

Improve ventilation

Prevent/deter the onset of

Improve tissue oxygenation *Cognition *Perception *Psycho-motor function

respiratory insufficiency and fatigue

Improve clinical signs and symptoms

Improve sense of wellbeing

Improve activities of daily living

Improve quality of life

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MOBILIZATION EXERCISES
It is essential to teach the patient to keep the shoulders in level, head erect and spine straight. The patient with tightness of the trunk muscles on one side of the body will not expand that part of the chest fully during inspiration. So, exercises which combine stretching of these muscles with deep breathing exercises will improve ventilation on the side of the chest.

TO MOBILIZE THE ONE SIDE OF THE CHEST

While sitting, have the patient bend away from the tight side to lengthen tight structures and expand that side of the chest during inspiration.

Then have the patient push the fisted hand into the lateral aspect of the chest, as he or she bends towards the tight side and breathes out. Progress by having the patient rise the arm on the tight side of the chest over the head and side bend away from the tight side.

This will place an additional stretch on the tight tissues.

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CHEST MOBILIZATION EXERCISES

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TO MOBILIZE THE UPPER CHEST AND STRETCH THE PECTORALIS MUSCLE
While the patient is sitting in a chair with hands clasped behind the head, have him or her horizontally abduct the arms (elongating the Pectoralis muscles) during a deep inspiration.

Then instruct the patient to bring the elbows together and bend forward during expiration.

TO MOBILIZE THE UPPER CHEST AND SHOULDER
With sitting in a chair, teach him to reach with both arms overhead [180 degree bilateral shoulder flexion and slight abduction] during inspiration. Bend forward at the hips and reach the floor during expiration.
To Increase Expiration During Deep Breathing While The Patient Is Supine

Have the patient “breath in” while in a crook lying position. Then have the patient pull both knees to his chest (one at a time at project the low back) during expiration.

SITTING
 Trunk turning with arms relaxed  Trunk bend sideways  Trunk bending forwards with breathing out and trunk raising with breathing in. 53

Range of Motion Exercises
Understand that passive range of motion exercises are merely a stopgap measure used while the patient recovers from his injury. During passive range of motion exercises, the patient's limbs will be manipulated by a third party to ensure that the muscles do not atrophy to an unreasonable degree. Passive range of motion training will typically be performed on the extremities (arms and legs) daily or twice daily for the duration of rehabilitation, according to information from MedicalDictionary.com.

Elbow Bends
Perform elbow bends to allow the patient's arms to remain mobile throughout the recovery period from a flail chest. To perform elbow bends, grip the patient's arm (keeping it by his side) and turning it so that the palm is facing toward the ceiling. Initiate the movement by bending the arm gently at the elbow until the fingertips lightly touch the shoulder. Repeat this drill 10 to 20 times per session on both sides of the body. After performing that variation, extend the arm out laterally to the side, keeping it at a 90-degree angle to the body and repeating the drill again to work the elbow through another range.

[RANGE OF MOTION EXERCISES]

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Knee Bend
Perform knee rotations to keep the lower body limber during the immobile portion of the recovery period. Manually grip the lower leg, bending it at the knee until the foot is fully rested on the bed with the leg at a 45-degree angle. Initiate the movement by gently pushing inward at the knee, creating rotation at the hip and bringing the knee across the body to brush against the other leg or the bed. Reverse the movement, pushing the knee to the outside to work the hip joint in both directions. Move slowly to avoid accidentally injuring the patient, repeat the drill for 10 to 20 times in both directions before switching and repating the exercise with the other leg.

[HIP FLEXION EXERCISES]
THORACIC EXPANSION EXERCISES
Thoracic expansion exercises are deep-breathing exercises emphasizing inspiration. The patient is instructed to take in deep breath to inspiratory reserve;

expiration is passive and relaxed.

At high lung volume the expanding forces between alveoli are greater than at tidal volume and assist in re-expansion of lung tissue. 55

Three or four expansion exercises are usually appropriate before pausing for a few seconds for a period of breathing control. Thoracic expansion exercise can be encouraged with proprioceptive stimulation by placing a hand either the patient's or the therapist's, over the part of the chest wall where movements of the chest is to be encouraged.

[THORACIC EXPANSION EXERCISES] ADVANTAGES
 Increase in chest wall movement.  Increase in lung volume.  Assist clearance of secretion along with rhythmic vibration

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FREE EXERCISES

THERABAND ARE USED TO DEVELOP ARM STRENGTH.

LEG STRENGTH AND STABILITY IS DEVELOPED THROUGH A VARIETY OF STANDING EXERCISE,.

PATIENTS ARE CLOSLEY MONITORED WITH A HANDHELD Cardio-Vascular Benefits And Respiratory Development. PULSEOX, TO MEASURE BLOOD OXYGEN CONTENT AND HEART RATE.

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REHABILITATION
The post operative rehabilitation may be longer and more complicated. Physical therapy is indicated in those individuals with fractured ribs who present with a compromised respiratory system, advanced age, or functional limitations associated with postural muscles.

THE GOALS OF REHABILITATION
 To decrease pain  Prevent respiratory complication and restore function

They should instruct patients in Deep-breathing exercises to promote full lung expansion relieve inter-coastal muscle spasm and mobilize lung secretions. Finally shoulder and trunk gentle stretching exercises may relieve discomfort and promote chest expansion. Functional shoulder mobility and improved posture. PHASE 1 DAY OF OPERATION  Breathing exercises – half lying position  Assisted cough DAY 1  Posture correction – push the head side ways against manual resistance towards the affected side and to push the shoulder down and back.  Active assisted arm movements - both sides DAY 2 58

 Breathing exercises and coughing  Posture – align the head, shoulder and thoracic spine with scapular retraction without the guidance of the therapist DAY 3  Manually resisted exercises for the shoulder girdle and arm on the affected side are added DAY 4  Trunk exercises in sitting are added DAY 5 – 7  Trunk exercises in standing  Posture correction in walking DAY 8 (To discharge from hospital)  Trunk mobility and thoracic mobility exercises  Good posture PHASE 2  This is an out patient programme  The patient visits the department two weeks following his discharge until tweleve weeks, thrice a week  Exercises are given for 30 to 45 min accompanied by checking the vital signs periodically.  A gradual warm up session for 05 to 10 min is given FOLLOW UP: Regular Check-up HOME ADVICE: 59

To avoid sternal discomfort, all patients will benefit from splinting the incisions with a hand or pillow when laughing, coughing and sneezing.

Patient should be instructed to avoid lifting, pushing and pulling objects until 4 to 6 weeks post surgery when the ribs is well healed.

Patients is encouraged to gradually increasing walking, with a goal of 30 minutes of ambulation 1 to 2 times per day at 4 to 6 days post surgery. Continue exercise for posture, upper extremity and trunk mobility and ribs protection are also important component of the home exercise program.

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CASE STUDY
NAME AGE SEX OCCUPATION ADDRESS : : : : : Mr. Ramakrishnan 28 Male Driver No: 4, South Mada Street, Mylopore, Chennai CHIEF COMPLIANTS : Pain over right side Inability to move trunk Inability to breathe normally HISTORY Past medical history Present medical history Personal History Vital signs  Heart rate  Respiratory rate  Blood pressure  Body temperature Investigations : : : : : : : : : X – Ray, C T scan, MRI 76 beats/ min 13 breaths/ min 150/90 mm/Hg 101.4 F Hyper tension Underwent surgery Smoking

ON OBSERVATION Level of awareness : Body built Chest Shape Breathing pattern Cyanosis Clubbing : : : : : Responsive Obese Shallow rapid breathing Negative Absent

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INCENTIVE RESPIRATORY SPIROMETERY

SELF ASSISSTED DIAPHRAGMATIC BREATHING EXERCISES

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ON PALPAT0ION

Pain Tenderness Peripheral pulse

: : :

Present Grding 3 Present / normal

ON AUSCULATION Breath sound Investigation : : Non vesicular X-ray – Anterior rib fractures (6, 7 and 8)

Surgical Management Right surgical stabilization Right Antero lateral thoractomy is done Problem List:

Pain Decreased movement – especially the shoulder on the operation side Decreased mobility Poor posture

TREATMENT PLAN Medical management: Adequate good analgesia (Morphine 10mg) Inter costal nerve blocks

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PHYSIOTHERAPY MANAGEMENT:
AIMS:  To relieve pain  To improve breathing pattern  To improve ventilation  To loosen secretion MEANS:  Breathing exercises  IPPB  Pursed lips breathing  Inspiratory muscle training  Mobilization exercise HOME ADVICE:  Practice exercises in home  Avoid carrying weight  Maintain good posture  Maintain dietary supplements  Avoid risk factors (alcohol, smoking) 64

CONULISION
Thus the thoracic surgeries, as explained above lead to wide variety of complications. These postoperative complications both local and general are known to occur frequently. However, the good news is that, they can be prevented. Proper pre-operative assessment with efficient medical and physiotherapy care will aid in preventing these complications. Post operative physiotherapy is therefore indispensable. It helps to bring back the patient to the optimum normal condition. It is therefore, the duty of the physiotherapist to reduce and prevent post operative morbidity as well as to make the patient to lead a normal life.

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BIBLIOGRAPHY
   Human Anatomy – Volume 1 Gray’s Anatomy -B.D. Chaurasia –Williams and Warwick

Rose and Wilson. Anatomy and Physiology in health illness –Anne Waugh, Allison Grant.

 

Concise medical physiology

–Sujit .K.Chaudhuiri

Davidson’s Principles and Practice of medicine -Christoper, Edwin, John, Nicholas

 

Tidy’s Physiotherapy

-Starurt B. Porter

Principles and Practice of Cardiopulmonary physical therapy -Donna Frownfelter, Elizabeth Dean

Cash;s textbook of Chest, Heart and Vascular disorders for Physiotherapist’s - Particia A. Downie

Physiotherapy for Respiratory and Cardiac Problems - Barbara A. Webber, - Jennifer A.Pryor

 

Textbook of physical rehabilitation –Susan O. Sullivan Therapeutic exercises, foundation and technique -Carolyn Kishner, Lylln allen Colby

General thoracic surgery

- S. Thomas W. Shields, Joseph Locicero, Ronald B. Ponn

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Project by, Dr. D. Senthil Kumar, B.P.T Chennai, Tamil Nadu, India

Project designing, Production and Marketing by, C. Gopi Krishnan, B.E Chennai, Tamil Nadu, India

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