Physical therapy management to reduce post operative

CABG
Published: 23rd March, 2015
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Coronary Artery Bypass Graft surgery (CABG) is a medical
procedure used in the treatment of coronary artery disease
(CAD). CAD is a disease that causes narrowing of the
coronary arteries (the blood vessels that supply oxygen and
nutrients to the heart muscle) due to the accumulation of
fatty deposits called plaques within the walls of the arteries.
Investigations such as electrocardiogram, stress tests,
cardiac catheterization, imaging tests such as chest x- rays,
echocardiography, or computed tomography (CT), and
blood tests to measure blood cholesterol, triglycerides, and
other substances are used to diagnose CAD. The accretion of
plaques over the years causes symptoms such as chest pain,
fatigue, palpitations, and shortness of breath. Some patients
with CAD may be symptom free in the early stages; the
disease will progress until sufficient artery blockage exists to
cause symptoms and discomfort. Blockage of the coronary
arteries will cause the heart muscle to weaken due to
inadequate blood supply, leading to a condition called
ischemia. If the blood flow is not restored to the particular
area of the heart muscle, the tissue dies, leading to
myocardial infarction or heart attack. In order to restore
blood supply and treat the narrowing of the arteries, the
blocked portion of the artery is bypassed or rerouted with
another piece of vessel, this is called CABG surgery1.
Despite the many advances and development in anesthesia,
surgical techniques, and postoperative care for CABG
surgery, postoperative pulmonary complications (PPCs)
retain a high postoperative morbidity and mortality rate 1.
The risk of PPC has increased in CABG procedure due to
two factors: intra-operative and external. The intra-
operative factors are factors that are associated with the
surgical procedure such as general anesthesia, surgical
incision, type of graft, topical cooling for myocardial
protection, and cardiopulmonary bypass2. General
anesthesia increases the risk of PPC when the anesthetic
component is administered to the patient while lying in
supine position; it results in respiratory depression leading
to a Ventilation-Perfusion (VQ) mismatch. In the surgical
approach, the incision site in the upper thoracic area, which
is a standard 20cm incision, decreases the preservation of
pulmonary function. The type of graft used such as "IMA"
increases the risk of attaining PPC. Topical cooling also used
in CABG increases the incidence of phrenic nerve injury.
Cardiopulmonary bypass which is unique to this surgery
causes additional lung injury and longer pulmonary
recovery, which occurs due to the acute systemic and
pulmonary inflammatory response which is known as
“pump lung" or “post pump syndrome 2.
External factors that could increase the risk of acquiring
PPC are aging, the prevalence of surgical delay, increased
sickness and complex health problems. The diagnosis of
PPC, requires symptomatic pulmonary dysfunction
symptoms such as increased work of breathing, shallow
respiration, ineffective cough, and hypoxemia 2; in addition
to clinical findings such as atelectasis, pleural effusion,
pneumonia etc. The most frequent types of PPC associated
with CABG are atelectasis which ranges from16.6% to 88%,
phrenic nerve paralysis (30 % to 75%), and pleural effusion
(27%-95%) 2.
Acquiring PPC leads to the increased use of medical supplies
and other health care expenses. Numerous interventions
have been used to treat PPC but, due to variance in opinions,
no resolution has been reached to which is the most effective
and efficient intervention in treating PPC. To prevent
postoperative complications such as PPC, less invasive
techniques are applied by physical therapists. Physical
therapists are responsible for the management and
rehabilitation of the patient, which includes treating and
educating the patient and helping them to attain the
maximum function, and satisfying level of independence;
this is achieved by decreasing the level of limitation and
impairment. Physical therapy treatments include
mobilization and airway clearance techniques, positioning,
breathing exercises, coughing maneuvers, mobility and
functional exercises. Physical therapy has been known to
intervene in surgical procedures such as CABG, but most of
the intervention used in patient's rehabilitation is performed
postoperatively. Recent studies have confirmed that post-
operative patients, "especially in CABG" can improve as
much as 50% 3 by introducing pre-operative physical
therapy management. The preoperative management targets
patients pre-surgically and directs its rehabilitating
techniques towards the reduction of a possible PPC pre-
operatively. Preoperative physical therapy management
includes appropriate patient selection, preoperative PT
assessment, patient education, and pre-operative physical
therapy treatment (PPTT). These management protocols
further enhance post-operative results by training patients
on post-operative techniques. Thus pre- and post- operative
physical therapy management is performed to reduce post-
operative CABG pulmonary complications.
Literature review
Pre-operative Physical Therapy Treatment
Preoperative management is an early involvement of
physical therapy prior to surgery. It is a method used in
prevention of patient deterioration by directing its efforts
towards the patient's respiratory and physical condition.
Preoperative physical therapy management ensures that the
patient is in the best respiratory and physical condition prior
to surgery, to be able to have a rapid recovery. Preoperative
management mainly focuses on appropriate patient
selection, patient education, pre-operative assessment, and
preoperative treatment.
Appropriate patient selection
Patients undergoing surgery have certain characteristics
which can increase or alter the risk of any surgical
complications especially in CABG. These characteristics
affect the outcome of surgery, therefore leading to post
operative complications. Suitable patient selection in
preoperative rehab is important. This allows the physical
therapists to categorize patients. Patients can either be
classified as low risk or high risk patients. Classifying
patients in such order ensures that each patient will obtain a
tailored preoperative management program according to
their condition and will receive maximum benefits from the
program 4.
The characteristics that alter the patients risks are pre-
existing respiratory problems, obesity, age, smoking, patient
motivation, and nutritional status 4.
Pre-existing respiratory problems is of three factors
infection, restrictive defects, and obstructive defects.
Infection may affect both upper and lower respiratory
tracts. If the upper respiratory tract is infected, it will cause
increased mucus production. And if it infects the lower
respiratory tract it may initiate impaired gas exchange
leading to hypoxia secondary to pneumonia, resulting in
exacerbation of infection. Restrictive defects include lung
fibrosis, pulmonary oedema, and pleural effusion. The
restrictive may reduce lung volume, resulting in an increase
of airway resistance and closing of airways following
anesthesia. Obstructive defects are also known as Chronic
Obstructive Pulmonary Diseases (COPD). The occurrence of
COPD in patients undergoing surgery will lead to an
increase in the anesthesia dose due to bronchial
hyperactivity.
Obesity is another characteristic that can upgrade a patient
into the higher risk group. Obesity is usually detected by
using the Body Mass Index (BMI). According to Selsby and
Jones 1993, increase in body mass may lead to reduced lung
compliance by approximately one third; this is due to the
additional weight on the chest wall.
As a person ages the lung loses its elasticity in recoiling and
the lung volume is reduced. During aging, respiration is
reduced by weakening of the respiratory muscles and
stiffening of the rib cage.
Smoking is the major cause of greater ventilation/perfusion
(V/Q) shunt, and impaired oxygenation during anesthesia.
This is because smoking results in narrowing of the airways,
excessive mucus secretion and decreased mucus clearance,
and irritable airways.
Patient motivation is the current mental or cognitive, and
emotional state of the patient. Any disturbance in such states
may result in decrease patient compliance and increases the
duration of the patient's recovery.
Preoperative PT assessment
Pre-operative assessment is a technique used to establish an
outline of the patient's current status, and form a baseline to
assess the patient's progress. The pre-operative assessment
includes subjective and objective assessments.
Subjective assessment is an interrogation procedure used by
the physical therapist to obtain information to help with the
preoperative treatment program. During the subjective
assessment, open-ended questions 4 are used, which allows
the patient to discuss their current problems. There are five
main points that need to be clarified during this type of
assessment; dyspnea, cough, secretion (sputum and
haemoptysis), wheeze, and chest pain.
During the objective assessment, the physical therapists use
their own skill in examining the patient. The physical
therapists examines by observation, palpation, percussion,
and auscultation. Further details may be obtained by the use
of tests such as spirometry arterial blood gases (ABG's), and
chest radiographs 4.
When assessment is completed, the physical therapist
analyzes the information obtained and integrates it with
their knowledge, resulting in a problem list.
According to the problem list the physical therapists
addresses these problems by setting specific, measurable,
achievable, realistic, and time specific goals according to the
problems obtained from examination. A well designed
treatment plan is set to help resolve these problems.
Patient Education
Patient education plays an important role in rehabilitation.
The patient is educated by the staff, which includes the
surgeon, physical therapists and nurses. The patient is
educated on preoperative and postoperative programs or
protocols. During patient education, verbal and written
information is given to patients. The role of the
physiotherapist in patient education is to highlight and
clarify the main points of the CABG procedure, allowing the
patient to become familiar with the surgery. The physical
therapist also explains the main effects of surgery on the
respiratory function, location of the wound, and wires and
monitors attached. The instructions given before the surgery
puts the patient at ease and postoperatively accelerates the
functional recovery of the patient. To reinforce the verbal
information, leaflets and brochures are given to help the
patient.
Pre-operative Physical Therapy Treatment (PPTT)
PPTT is directed towards maximizing pulmonary function 4
by the reduction of PPC and the use of non-invasive PT
interventions. Since PPTT is a newly emerged, few studies
are found that discuss the preoperative treatment of patients
undergoing CABG procedures. Therefore no precise
treatment techniques or protocols are followed during
PPTT. Studies have suggested that the most common types
of PPC that occur following CABG surgery are atelectasis,
and pneumonia.
Atelectasis "which is an abnormal respiratory condition
"causes lung collapse, therefore leading to deprivation of gas
exchange. It is caused by an obstruction of major airways
and bronchioles. It is a complication that is frequently seen
in post-operative period and is found in the basilar region in
post CABG. To treat and prevent such condition deep
breathing techniques and incentive Spirometry is used 5.
Pneumonia is an infection or inflammation of the lungs. It
can be caused by microorganisms such as bacteria, viruses,
or fungi or by a potential complication such as pleural
effusion. Pneumonia is treated by pharmaceutical agents,
coughing techniques, and breathing exercises 5.
It was found that both PPC's are caused by the patients
inability to expectorate sputum and due to insufficient
diaphragmatic breathing. Therefore the most appropriate
way to treat such conditions is to rehabilitate patients
preoperatively.
PPTT treatments are of a large variety and no precise
treatment has been advised solely for treatment. During my
investigation I have came upon many techniques used. The
most common treatment used within the PPTT is breathing
exercises (BE), respiratory muscle devices, and sputum
expectoration techniques.
BE are several techniques used to help increase the muscle
strength and increase air entry. It is performed by inflating
and deflating the lungs. There are many types of BE some
are pursed lip breathing (PLB), paced breathing,
diaphragmatic breathing, segmental breathing, sustained
maximal inspiration (SMI), and global lung expansion.
Respiratory muscle devices are instruments used to help
strengthen the surrounding breathing muscle by the use of
resistance as shown with the inspiratory muscle trainers
(IMT) and aids the patient in air entry by visual aid, as
shown with the incentive spirometer (IS).
The sputum expectoration techniques are tactics used to
expel secretions from the lung. One of the most common
techniques used nowadays is the secretion removal
technique, this is a method used to remove mucus from the
lung and helps in expectorating the sputum, it is known as
postural drainage. This method can be applied according to
area of secretion and can be modified according to the
patient's condition. Other supporting or assisting techniques
is coughing and the Forced Expiratory technique. Coughing
is used to help the patient to expectorate sputum. The PT
can teach the patient the correct method and may support
the patient incision or wound when coughing if needed, or
assists the patient by applying force on the abdomen,
increasing the abdominal pressure therefore giving extra
force. FET is less forceful technique, it is similar to
coughing, and the patient huffs instead of coughing. This
method brings the mucus to the upper airways and is usually
followed by coughing to expel sputum.
An observational follow up study was performed by Isabel
Yanez-Barage. The purpose of the study was to examine the
use of preoperative respiratory physiotherapy, on the
incidence of pulmonary complications in CABG surgery.
Two groups of patients were involved in the study. The first
group was the intervention group, whom received PPTT and
the second group was the control group, who had no PPTT.
The apparatuses used within the study included Incentive IS
and, BE. Prior to their use, uses and importance of the
apparatus was explained to the patients. The techniques that
was used during the study, were ten deep BE, diaphragmatic
breathing, thirty long expansion maneuvers, tactile
stimulation, three stages of Sustained Maximum Inspiration
(SMI), ten global lung expansion, secretion removal
techniques, supported or assisted coughing. The above
techniques were put in a program, and all exercises were
performed in two sessions per day, while the SMI was
performed six times per day, five sets with 30-60 seconds rest
between each set. The results of the study showed that the
presence of atelectasis occurred 48hours after surgery. The
PPTT group had a 17.3% of atelectasis, while the non PPT
group had 36.3%. The study also showed that a relationship
existed between atelectasis and patient gender, and that
21.8% was found in females while 37.5% in males 3.
Another study performed by Erik H. J. Hulzebos, focused on
two primary outcomes. One was post operative
complications, which is pneumonia. The second outcome
measure is the post-operative pulmonary complications
(PPC), which include the influences of morbidity and
mortality rate, the length or duration of stay at hospital, and
the overall resource utilization. The interventions used in
this study included such as IMT and IS, while the techniques
included are patient education in active cycle of breathing
techniques and Forced Expiratory Techniques (FET). The
program followed within the study was the use of FET and
performing it on daily basis seven times per week for
duration of two weeks before surgery, and the IMT was
done for twenty minutes, six times per week without
supervision and once per week with PT supervision. The
result of the primary outcome measure is that18% (25 of
139) of the patients from the IMT group developed PPC,
while patient 35% (48 of 137) of usual care group developed
PPC. The incidence of pneumonia was less in the IMT group
whom had 6.5% (9 of 139). While on the other hand the
usual care group had a higher incidence which was 16.1%
(22 of 137).The usual care group had also another
complication, where 3 of the 22 patients developed
respiratory failure and died after surgery as a result of
cardiac failure, while none of the IMT patients died. The
study concluded that preoperative physical therapy reduced
PPC by 50%. The study suggests that no a single PT
techniques or intervention is better than the other in
preventing PPC. Pre-operative PT has increased inspiratory
force, decreased the incidence of PPC and hospitalization,
and reduced morbidity 1.
.
Post-operative Physical Therapy Management
Post operative complications are common in patients
undergoing cardiothoracic surgeries. According to
Agnieszka Piwoda et al, the fundamentals to a properly
designed and conducted cardiac surgery, is physical therapy
management 6. To minimize postoperative complications,
physical therapy management is introduced. Postoperative
physical therapy (POPPT) starts the instant the patient is
transferred from the operating room to the intensive care
unit (ICU), which lasts 1 to 2 days and is continued in the
ward from 2nd day till the date of discharge which is the 7th
day 6.
During the patients stay at the ICU postoperative, physical
therapy rehab is aimed towards the reduction of airway
obstruction, increasing and enhancing ventilation-perfusion
matching, which is also known as gas exchange (VQ
matching), restoring normal gasometrical values which
when by doing so, the patient is prevented from re-
intubation 6, decreasing ventilatory failure where the patient
becomes dependent to the mechanical ventilator 3, and
preventing thrombo-embolitic changes altogether leading to
a decrease in ICU stay. The ward rehab starts when the
patient gains early extubation; this allows the patient to
regain contact with reality. During this period the physical
therapist is able to eradicate secretion accumulation, and
rapidly mobilize or ambulate the patient 6. Maintenance of
permanent and intensive mobilization will improve
cardiopulmonary tolerance, leading to an increase in
physical endurance and patient independence, therefore
reducing hospital stay 7.
Most of the studies involving a majority of patients
undergoing CABG are focused on reducing basilar
atelectasis and pneumonia and hypoxemia 7 by applying
specific post operative physical therapy objectives such as
recruiting lung tissue from shunt to zone of low ventilation
in relation to perfusion 8, increasing lung capacities
especially FVC and FEV8, decreasing respiratory muscle
dysfunction 3, increasing respiratory muscle function
"diaphragm" 6, restoring thoracic breathing manoeuvres by
strengthening postural and respiratory muscles, and
endorsing effective breathing patterns by reducing the work
of breathing 7.
To achieve optimum results and regain the inclusive
functional independency, POPPT management should
include airway clearance techniques, early mobilization, bed
mobility and positioning, breathing exercises (BE), and
patient education. Specific post operative physical therapy
techniques such as the use of intensive deep breathing
exercises and devices such as IS, and IMT should be
emphasized when rehabilitating post CABG patients. Prior
to POPPT, an extensive patient evaluation similar to the
preoperative assessment should be performed. When
assessing the patient problems, goals should be set and are
treated accordingly.
Airway clearance techniques
A manual or mechanical procedure that assists in clearance
of secretion from the airways is known as Airway Clearance
Techniques (ACT) 9. ACT is indicated for impaired
mucociliary transport or an ineffective and unproductive
cough. When choosing an ACT the patient's
pathophysiology, symptoms and medical status should be
taken in consideration. The techniques included in ACT are
Postural Drainage (PD), manual chest clearance, and
coughing.
PD is a technique that drains secretion by gravity assistance,
and the use of more than one body position. There are 12
positions used during PD 9, in each position the segmental
bronchus is drained perpendicular to the floor. These
positions can be modified according to the patient's medical
status. The most affected segment should be prioritized. The
patient is positioned using an adjustable bed, pillows or
blanket rolls, and enough personnel to assist in moving the
patient safely. PD is used for approximately 5-10 minutes
solely and longer if tolerated 9.
Manual chest clearance technique is the application of
manual supplementary techniques such as vibration,
percussion, and shaking to postural drainage positions 10.
Coughing technique is a forceful airstream method used to
remove secretions out through the trachea and to the mouth.
Coughing technique is performed in four stages, and may be
applied before, during and after PD and manual chest
clearance techniques. In CABG patients, the coughing
technique is supported using splinting. This is done is
applying pressure to the incision site either by using a pillow
or a belt. This techniques helps with decreasing the pain
associated with the surgery.
Early mobilization
Early mobilization or ambulation is the method used to set
patients in motion postoperatively by using the assistance of
PT. The patient mobilization process is performed gradually
and according to the patient's tolerance. Mobilization starts
by sitting the patient from supine to a long sitting position.
Then when further stability is regained the patient is
positioned on the edge of the bed. The patient is then
progressed to standing, and later when the patient regains
more stability, walking is initiated.
Positioning
Positioning is a therapeutic and ventilatory movement that is
used to assist the patient in regular changing of position
while in bed. It is essential in the patient early stages of
recovery. Positioning allows the patient to progress from
dependence to independence. The technique involves the
selection of certain positions to assist the patient with
efficient and diaphragmatic breathing patterns. The
technique is indicated for patients with diaphragmatic
weakness, patients unable to correctly use the diaphragm for
efficient inspiration, or who have inhibition of diaphragm
muscle due to pain 9. The training usually commences in the
ICU. An example used by Sadowsky et al on positioning is
the performance of ROM exercise with breathing. The
exercise is performed by the patient inspiring air and
accompanying it with shoulder flexion, abduction, external
rotation, and eyes in an upward gaze. Then the patient
exhales with shoulder extension, adduction, internal rotation
and downward gaze. In addition to the exercise the patient is
asked to tilt the pelvis posteriorly. This allows
diaphragmatic breathing pattern and optimizes the length-
tension relationship of the diaphragm 9. This technique
progression should be applied to transfer, ambulation, and
stair climbing. This technique is highly recommended for
patient patients that underwent CABG since they are likely
to have 90.7% of diaphragmatic elevation 11.
Breathing exercises
Breathing exercises are maneuvers used for patients with
signs and symptoms of decreased strength or endurance of
the diaphragm and intercostal muscles 9. There are many
breathing exercises one of them is known as the Active Cycle
of Breathing Technique (ACBT) 10. ACBT includes a group
of breathing techniques such as breathing control, thoracic
expansion exercises, and forced expiration technique. Other
methods that assist BE are respiratory devices such as
Inspiratory Muscle Trainers (IMT) and Incentive
Spirometry (IS). Respiratory devices are mechanical
equipments used in attempt to reduce postoperative
pulmonary complications particularly atelectasis and
pneumonia. BE and respiratory devices are suggested for
patients at high risk of having atelectasis such as CABG
patients, whom are for 24.7% of postoperative atelectasis 9,
11.
A study performed by Elizabeth Westerdahl investigated the
effect if deep breathing exercise on pulmonary function,
atelectasis, and Arterial Blood Gases (ABG's) after CABG.
The study was performed on two groups, the first group was
the deep breathing group and the second was the control
group. Both groups were approached similarly in
assessment, positioning, and mobility once or twice daily
during the first 4 postoperative days. Chest PT was done
twice in the first 4 post-op days, the therapy includes early
mobilization, instructions in coughing techniques, and daily
active exercises of the shoulder girdle, upper back, and
assistance to turn form side to side and get out of bed. The
deep BE group received an extra program, performing
breathing exercises every hour during the day for four
postoperative days. The exercise used is, 30 slow deep
breaths with PEP blow bottle device, a 50cm plastic tube in a
bottle containing 10 cm of water. The exercise was
performed sitting; it is 3 sets of 10 deep breathing exercises
with 30-60 seconds pause between each set. If needed,
patient coughs during the pause to mobilize secretion. The
result of the study illustrate that atelectasis was found in
large areas at basal level close to the diaphragm and minor
at the upper level near the apex. There was a significant
decrease in atelectasis in deep breathing group by one half
compared to the control group, and the correlation between
PaO2 and atelectasis was weak. Recruited lung tissue is most
likely converted from shunt regions to zones with low
ventilation in relation to perfusion. In conclusion, Patients
who performed deep-breathing exercises had a significant
smaller atelectasis, and less reduction in FVC and FEV on
the 4th post-op day. 8
Patient education
Patient education which is an integral part of the post-
operative physical therapy management is applied similarly
to the preoperative patient education program. When
educating a patient in the post-operative period, the
instructions given should highlight the thought of improving
quality of life by emphasizing on points such as having
healthy eating habits, ceasing smoking, achieving
independence, and accentuating the benefits of rehab, and
returning back to ADL. Patients should also improve their
physical education by participating in other therapies that
have been introduced such as tai chi, PNF, NDT Bobath and
music therapy 6.
Conclusion
As PPC has been of great concern to health professionals,
the reduction of complications that accompany major
surgeries such as CABG is of an important development.
The main objective in physical therapy with regard to
CABG is to reduce PPC by intervening with less invasive
protocols. The combination of both pre-operative and post-
operative physical therapy management has had effective
results in managing CABG patients.
The reduction of PPC by the use of preoperative physical
therapy management has led to many advantages. Some of
them are significant reduction in mechanical ventilators
duration therefore reducing the duration of ICU stay,
reduced hospitalization, decreased morbidity and mortality
rate, enhanced early functional recovery, improved lung
function and gas exchange. Such accomplishments are
significant, but more studies have to be performed to
develop PPTT programs and provide a certain protocol
The reduction of PPC by the use of postoperative physical
therapy has lead to the best outcome of treatment. It has
decreased complications associated with surgery and reduces
PPC, allowing the patient to regain maximum physical
condition, reducing ICU and hospital stay by achieving
physical and functional independence therefore assisting the
patient in regaining better-quality of life 5. The patient can
further continue physical therapy at the cardiac facility to
promote additional cardiopulmonary conditioning.
In Kuwait, post-operative PT management is more widely-
used than preoperative. During my investigation I found out
that the chest hospital is aware of the preoperative
management and is applying it, but in an informal way. I
would like to call attention to the use of post-operative PT
management in association with pre-operative physical
therapy management to help the patient have a better
surgical outcome, regain maximal independence and
improve the quality of their life.