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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 PHYSIOTHERAPY MANAGEMENT FOR FLAIL CHEST

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.

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 TITLE PAGE NO.

1 INTRODUCTION 4

2 ANATOMY 5

3 PHYSIOLOGY 9

4 DEFINITION 14

5 AETIOLOGY 16

6 TYPES 17

7 CLINICAL FEATURES 19

8 INVESTIGATION 22

9 MANAGEMENT 24

10 PHYSIOTHERAPHY ASSESSTMENT 34

11 PHYSIOTHERAPHY MANAGEMENT 37

12 REHABILITATION 56

13 CASE STUDY 50

14 CONCLUSION 65

15 BIBLIOGRAPHY 66

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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 11th 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

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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.

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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.

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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 semi-

fowler 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.

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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

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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

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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)

46

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.

47

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.

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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 Improve ventilation

respiratory muscle fatigue

Prevent/deter the onset of Improve tissue oxygenation

respiratory insufficiency and *Cognition

fatigue *Perception

*Psycho-motor function

Improve clinical Improve sense of

signs and symptoms wellbeing

Improve activities of Improve quality of

daily living 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.

52

CHEST MOBILIZATION EXERCISES

53

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.

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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 Medical-

Dictionary.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.

56

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

PULSEOX, TO MEASURE BLOOD OXYGEN CONTENT AND

HEART RATE.

Cardio-Vascular Benefits And Respiratory Development.

58

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

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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:

60

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.

61

CASE STUDY

NAME : Mr. Ramakrishnan

AGE : 28

SEX : Male

OCCUPATION : Driver

ADDRESS : 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 : Hyper tension

Present medical history : Underwent surgery

Personal History : Smoking

Vital signs :

Heart rate : 76 beats/ min

Respiratory rate : 13 breaths/ min

Blood pressure : 150/90 mm/Hg

Body temperature : 101.4 F

Investigations :

X – Ray, C T scan, MRI

ON OBSERVATION

Level of awareness : Responsive

Body built : Obese

Chest Shape : -

Breathing pattern : Shallow rapid breathing

Cyanosis : Negative

Clubbing : Absent

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INCENTIVE RESPIRATORY SPIROMETERY

SELF ASSISSTED DIAPHRAGMATIC BREATHING EXERCISES

63

ON PALPAT0ION

Pain : Present

Tenderness : Grding 3

Peripheral pulse : Present / normal

ON AUSCULATION

Breath sound : Non vesicular

Investigation : 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)

65

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.

66

BIBLIOGRAPHY

Human Anatomy – Volume 1 -B.D. Chaurasia

Gray’s Anatomy –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

67

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