Ptp&M012 Ptm Of Rheumatologic Conditions Medical Journal

PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:0011 Revision: 01 Page: 1 of 21

PHYSICAL THERAPY MANAGEMENT OF POST SURGICAL CONDITIONS AT RISK OF DEVELOPING RESPIRATORY COMPLICATIONS:

NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of

Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.

Medicine: it’s a noble profession, it serves humanity.

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KAL MERA HAATH PAKADNA, JAB MAIN BOODHA HO JAAOON


SPEC. BY: Abdulrehman S. Mulla DATE: 04/09/2009 REVISION HISTORY REV.

DESCRIPTION

CN No.

BY

DATE

01 Initial Release PT00011 ASM 04/17/2009






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TABLE OF CONTENTS PAGE

1.0 PHYSIOTHERAPY IN SURGICAL CONDITIONS:..................................................................................................................................3

2.0 CHEST PHYSIOTHERAPY:.....................................................................................................................................................................7

2.1 DEFINITION: ............................................................................................................................................................................7

2.2 PURPOSE: ...............................................................................................................................................................................7

2.3 PRECAUTIONS: ......................................................................................................................................................................8

2.4 DESCRIPTION: ........................................................................................................................................................................9 2.4.1 TURNING: ................................................................................................................................................................9 2.4.2 COUGHING:.............................................................................................................................................................9 2.4.3 DEEP BREATHING:...............................................................................................................................................10

2.4.3.1 BREATHING EXERCISES:....................................................................................................................11 2.4.4 POSTURAL DRAINAGE: .......................................................................................................................................12

2.4.4.1 SUCTIONING:........................................................................................................................................12 2.4.5 PERCUSSION:.......................................................................................................................................................13

2.4.5.1 PERCUSSIO FOR UNDER FIVE YEAR OLDS: ....................................................................................13 A. CLEARING THE BACK OF THE RIGHT UPPER LOBE: ..............................................................13 B. CLEARING THE BACK OF THE LEFT UPPER LOBE:.................................................................14 C. CLEARING THE FRONT OF THE RIGHT UPPER LOBE:............................................................14 D. CLEARING THE FRONT OF THE LEFT UPPER LOBE: ..............................................................14 E. CLEARING THE SIDE OF THE RIGHT LOWER LOBES:.............................................................14 F. CLEARING THE SIDE OF THE LEFT LOWER LOBE: .................................................................14 G. CLEARING THE BACK OF THE LOWER LOBES: .......................................................................14 H. CLEARING THE FRONT OF THE LOWER LOBES:.....................................................................15 I. CLEARING IT ALL OUT:................................................................................................................15

2.4.6 VIBRATION: ...........................................................................................................................................................15 2.4.7 PREPARATION:.....................................................................................................................................................16 2.4.8 AFTERCARE:.........................................................................................................................................................16 2.4.9 RISKS:....................................................................................................................................................................16 2.4.10 NORMAL RESULTS: .............................................................................................................................................19

3.0. PULMONARY REHABILITATION: ........................................................................................................................................................21






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1.0 PHYSIOTHERAPY IN SURGICAL CONDITIONS: Pulmonary complications, including pneumonia and respiratory failure, are a common - and dangerous -

problem for patients following major surgery. To address this issue, a comprehensive systematic review and meta-analysis in the April 2006 issue of The Annals of Internal Medicine provides clinicians with new guidelines to use prior to surgery in assessing a patient's risk of developing pulmonary problems postoperatively.

"Independent of surgical complications, such as infections and bleeding, there are three major types of medical risks that accompany major surgery," explains the study's lead author Gerald W. The Doctor, MD, an internist in the division of general medicine and primary care at Beth Israel Deaconess Medical Center (BIDMC) and Associate Professor of Medicine at Harvard Medical School. "These include cardiac risks such as a heart attack, the risk of blood clot formation, and pulmonary risks."

Nearly 30 years ago risk indices and guidelines were developed to assess post-surgical cardiac risks, he adds, but until now, the issue of pulmonary risk factors had not been formally addressed.

"Many physicians will be surprised to learn that we found pulmonary complications to be as prevalent as cardiac complications," says the Doctor. The reason, he says, is that patients' lung volumes are lower following both surgery and the administration of general anesthesia. As a result, small areas of lung become vulnerable to collapse, thereby increasing patients' chances of developing pneumonia, suffering respiratory failure or experiencing a worsening of existing lung disease, such as emphysema.

The Doctor, together with coauthors Valerie Lawrence, MD, and John Cornell, PhD, of the South Texas Veterans Health Care System, performed a systematic review of nearly 1,000 medical studies published between 1980 and 2005 in order to develop the guidelines for the American College of Physicians. After calculating summary estimates of risk, the authors divided their findings into patient-related risk factors and surgery-related risk factors, according to the Doctors.

"Among the patient-related risk factors we made several clear observations," he adds. "Most notably, even among otherwise healthy patients, advanced age [over 70] increased a person's risk of developing pulmonary complications four-fold to six-fold. Given that age is not a risk factor for post-surgical cardiac complications, we






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were quite surprised by this finding." Other patient-related factors that increased the risk of complications included preexisting emphysema, functional dependence (patients' inability to care for themselves), congestive heart failure and smoking cigarettes.

Among pulmonary risk factors related to the surgical procedure, he adds, location of the surgical site was of greatest impact.

"The closer the surgery was to the diaphragm - any thoracic, upper abdominal, gallbladder or aortic surgery for example - the greater the risk of complications," notes The Doctors. In addition, emergency surgery or surgery lasting more than three hours also increased the likelihood that patients would develop postoperative pulmonary problems.

In an accompanying paper, the authors also evaluated the value of various interventions to reduce the risk of pulmonary complications, and found that two simple treatments that increase lung volume, deep breathing exercises and incentive spirometry, proved to be the most effective strategies.

"We hope that our findings will help doctors provide their patients with a good estimate of pulmonary risk prior to surgery," says The Doctors. "In fact, this review points out the importance of the doctor-patient relationship. Medical consultations are extremely important for patients as they prepare for surgery and this provides both doctors and patients with another tool to use in their decision-making processes."

Getting in physical shape prior to an operation may aid in healing. A recent study, at the University of Missouri, Columbia, found that regular exercise before a surgical procedure that produced prolonged bed rest, markedly enhanced recovery in laboratory animals.

Studies in humans have also found (that exercise before surgery is helpful in preventing surgical complications and enhancing recovery. One study involving 200 cardiac patients found that those individuals with the lowest level of physical fitness (aerobic capacity) prior to open-heart surgery had the highest risk of developing at least one serious surgical complication. Furthermore, the non-physically fit patients required a longer period of hospital stay following surgery.

A much earlier study found that cardiac patients undergoing elective abdominal surgery who participated in a preoperative physical training program experienced far fewer postoperative complications than did those patients with inadequate preoperative physical fitness. According to the study findings, cardiac episodes and mortality only occurred in those individuals who did not perform regular exercise before their surgery. The findings suggest that regular physical activity prior to surgery helps to facilitate (healing and reduce surgical risks, including death.

Is it possible that regular exercise performed prior to gastric bypass or other bariatric surgical procedures also helps to facilitate recovery and reduce surgical risks? A preliminary study, conducted by our Exercise Physiology Department under the direction of Justine Clark Strauss, found that exercise – even MILD exercise – before gastric bypass surgery significantly helps to reduce surgical complications and enhance postoperative recovery.

The study fo5nd that only 20% of our bariatric population exercised regularly before surgery, with 80% of patients performing no exercise at all. Furthermore, the 20% of patients who were exercising regularly were performing only mild exercise consisting of either walking or swimming for 20 minutes per day, 3 to 4 days per week. We found, however, that even ‘mild’ preoperative exercise was beneficial in reducing surgical complications and enhancing post-surgical recovery.

Gastric bypass patients who performed exercise before bariatric surgery, as compared to those who did not, had a significantly lower incidence of cardiac episodes (racing heart, sudden increase in blood pressure, heart attack, or other events requiring the care of a cardiologist). The incidence of respiratory complications with surgery, including atelectasis (collapsed lung), oxygen insufficiency, pneumonia, was far less for individuals who performed regular exercise before surgery as compared to those who did not. Pre-surgical exercise was






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also found 4o reduce the time required for patients to remain in the hospital following surgery, suggesting enhanced recovery.

Why would regular exercise before surgery help to prevent surgical complications and reduce the length of hospital stay? The morbidly obese have numerous health problems that increase the risk for surgical complications and hinder tissue repair and post-surgical recovery. Regular exercise – even ‘mild’ exercise - improves or resolves many of these obesity-associated health problems.

Obesity, i. general, may cause an enlargement of the left pumping chamber of the heart. Such change in the structure of the heart may cause, among other dysfunctions, abnormal heartbeats (arrthymias) which, in turn, may lead to sudden death. Studies have reported up to a 40-fold increased risk for sudden death with morbid obesity. Such risks may be even higher with the trauma of surgery. Regular exercise before surgery strengthens the entire heart muscle, improves cardiac function, and reduces the incidence of cardiac arrthymias and sudden death.

The majority of bariatric patients have one or more conditions that increase their risk for cardiovascular disease, including diabetes, hypertension, lipid abnormalities, high levels of oxidative stress, chronic inflammation, and psychological distress. Regular aerobic exercise (walking, swimming, cycling, jogging, etc.) before surgery reduces blood sugar, lowers blood pressure, improves lipids, and enhances overall mood. In addition, regular exercise reduces factors that cause inflammation and, by increasing antioxidant defenses, resolves or decreases oxidative stress. (Note: Even mild-to-moderate exercise is effective in reducing inflammation and preventing oxidative stress, whereas strenuous exercise may actually cause oxidative stress).

Regular exercise reduces the risk for vascular disease, reported to be 100-fold higher for individuals with morbid obesity. Vascular disease includes those conditions known as atherosclerosis, atherothrombosis (a blood clot in the artery), venous thrombosis (a blood clot in the vein), and a pulmonary embolus (blood clot in a vessel of the lungs).

Atherosclerosis is a progressive disease, involving injury to the arterial wall, lipid uptake into specific cells at the site of this injury, formation of fatty streaks along the vessel wall, and buildup of plaque that eventually occludes or partially occludes the artery. Occlusion of the vessel reduces or shuts off blood flow and, if the vessel is one that provides oxygen to the heart or brain, could 2esult in a heart attack or stroke. The morbidly obese have 3 times the atherosclerotic plaque buildup in major arteries than do individuals who are not obese.

Atherosclerotic plaque is susceptible to injury and such injury may, in turn, cause formation of a blood clot in the artery, a condition known as atherothrombosis. Such condition may completely occlude blood flow through the artery, shutting off the supply of oxygen and nutrients and destroying affected tissue. If the artery supplies oxygen and nutrients to the heart, a myocardial infarct or a heart attack may occur and if the artery supplies areas of the brain, a stroke may ensue. Atherothrombosis is believed to be responsible for 80% of heart attacks and over 50% of all strokes.

Obesity is associated with an increased risk for atherothrombosis not only because the obese have a higher incidence of atheroslcerosis but also because the obese have higher amounts of certain factors responsible for blood clotting (factor VIII, VII, IX, von Willebrand facto2s) and other factors (plasminogen activator inhibitor) that may prevent the blood clot from dissolving. The trauma of bariatric surgery worsens these conditions, further increasing the risk of developing an arterial blood clot.

Regular exercise, particularly mild or moderate exercise, helps to reduce the risk for atherothrombosis for several reasons. First, exercise reduces inflammatory factors and high levels of oxidative stress that can cause injury to the plaque on the vessel wall. Secondly, mild-to-mod%rate exercise is effective in helping to cause changes in those factors that help blood clots to dissolve. (Note: strenuous exercise may have adverse effects on blood clot factors and levels of oxidative stress).

Exercise is extremely important for prevention of blood clot formation in deep veins of the legs and hips. Deep veins require muscle activity to pump the blood back to the heart. Reduced physical activity from obesity






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co-morbidities or from the immobility of surgery may cause blood to pool in thes% veins with resultant blood clot formation. A blood clot in the deep veins is called deep vein thrombosis and occurs in approximately 2% to 3% of bariatric patients.

A deep vein blood clot that breaks loose and lodges in vessels in the lungs is called a pulmonary embolus. This is a very serious condition with a relatively high risk for death, i.e. 12% of individuals with this condition die within one month of diagnosis. The morbidly obese have a high risk for blood clot formation, as mentioned earlier, par4icularly with reduced mobility after surgery. Exercise keeps blood moving through the vessels and prevents blood clot formation.

The morbidly obese also have an increased risk for respiratory complications with surgery, including such conditions as atelectasis (collapsed lung), low oxygen in the blood requiring the use of a ventilator or the need for respiratory medications, and pneumonia. Respiratory complications with surgery are not all that uncommon for the bariatric patient because the morbidly obese (have a number of respiratory problems prior to surgery. Nearly half the morbidly obese population, for instance, suffers from sleep apnea or obstructive respiratory conditions such as asthma.

The morbidly obese also have an increased risk for respiratory complications with surgery due to weakened respiratory muscles, increased chest wall compliance and resistance, reduced lung volume, and a decreased exchange of oxygen from the lungs to the blood. Regular aerobic exercise strengthens respiratory muscles, increases lung volume, and helps to improve the exchange of oxygen from the lungs to the arteries. Furthermore, exercise improves blood flow, oxygen delivery to tissues and its utilization.

Exercise also help to promote healing and recovery and to prevent infections. Obesity is an inflammatory condition that can increase the risk for various surgical complications, including cardiac episodes. Exercise reduces the production of factors that cause inflammation. Obesity is also associated with defects in immune system function that reduce the body’s ability to fight against bacteria and viral invaders. Regular exercise improves the body’s line of defense against viruses and increases the efficiency of cells that fight bacterial invasion.

In addition to helping to prevent infections with surgery, exercise may also assist in repair. The morbidly obese have high levels of oxidative stress, a condition that is worsened by the trauma of surgery. Oxidative stress reduces energy production needed for cellular repair after surgery and can cause a loss of function or destruction of tissue. Regular mild-to-moderate exercise increases antioxidant defenses in all tissue, substantially lowering the risk for oxidative stress and enhancing tissue repair and post-surgical recovery.

Heat shock proteins are one of the body’s major repair mechanisms in response to stress, including the trauma of surgery. Heat shock proteins are small molecules that increase in number with stress and help to repair damaged protein or prevent damage to 4issue. Heat shock proteins also help to improve many cellular functions including the production of energy needed for the body to heal. Regular exercise helps to increase heat shock protein responses to stressful situations (such as surgery) in all tissues, including muscle, heart, and the immune system, and, in doing so, is extremely valuable in helping to facilitate recovery and tissue repair.

In all of the ways described above, regular exercise helps to prevent surgical complications and promote post-su2gical recovery. Furthermore, many of the benefits of exercise occur even with mild-to-moderate exertion. What then should be the exercise prescription for the preoperative bariatric patient? The main ingredient of the program should be to ‘Just Get Moving’.






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2.0 CHEST PHYSIOTHERAPY:

Several therapies that can be loosely classified as chest physiotherapy have been studied in relation to their ability to reduce postoperative pulmonary complications. These therapies have included deep breathing exercises in conjunction with chest percussion and postural drainage, perioperative intermittent positive pressure breathing, and incentive spirometry. As adjuncts to postoperative care, these therapies appear to be of some benefit in reducing pulmonary complications but are essentially of equivalent efficacy. Given the relatively low cost and simplicity of self-administered incentive spirometry, it is likely that incentive spirometry is the most reasonable intervention among these therapies for reducing the risk of pulmonary complications. It is important to note that preoperative instruction in the use of incentive spirometry is key to its effective use by the patient after surgery.

2.1 DEFINITION:

Chest physiotherapy is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.

2.2 PURPOSE:

The purpose of chest physiotherapy, also called chest physiotherapy, is to help patients breathe more freely and to get more oxygen into the body. Chest physiotherapy includes postural drainage, chest percussion, and chest vibration, turning, deep breathing exercises, and coughing. It is usually done in conjunction with other treatments to rid the airways of secretions. These other treatments include suctioning, nebulizer treatments, and the administration of expectorant drugs.

Chest physiotherapy can be used with newborns, infants, children, and adults. People who benefit from chest physiotherapy exhibit a wide range of problems that make it difficult to clear secretions from their lungs. Some people who may receive chest physiotherapy include people with cystic fibrosis or neuromuscular diseases like Guillain-Barré syndrome, progressive muscle weakness (myasthenia gravis), or tetanus. People with lung diseases such as bronchitis, pneumonia, or chronic obstructive pulmonary disease (COPD) also benefit from chest physiotherapy. People who are likely to aspirate their mucous secretions because of diseases such as cerebral palsy or muscular dystrophy also receive chest physiotherapy, as do some people who are bedridden, confined to a wheelchair, or who cannot breathe deeply because of postoperative pain.






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2.3 PRECAUTIONS: Chest physiotherapy should not be performed on people with Bleeding from the lungs Damaged chest walls Recent heart attack Neck or head injuries Tuberculosis Pulmonary embolism Fractured ribs Recent surgery, open wounds, or burns Lung abscess Collapsed lungs Acute asthma Active hemorrhage Some spine injuries

CHEST PHYSIOTHERAPY SHOULD NOT BE PERFORMED ON PEOPLE WITH






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2.4 DESCRIPTION:

Chest physiotherapy can be performed in a variety of settings including critical care units, hospitals, nursing homes, outpatient clinics, and at the patient's home. Depending on the circumstances, chest physiotherapy may be performed by anyone from a respiratory care therapist to a trained member of the patient's family. Different patient conditions warrant different levels of training.

Chest physiotherapy consists of a variety of procedures that are applied depending on the patient's health and condition. Hospitalized patients are revaluated frequently to establish which procedures are most effective and best tolerated. Patients receiving long term chest physiotherapy are revaluated about every three months.

2.4.1 TURNING:

Turning from side to side permits lung expansion. Patients may turn themselves or be turned by a caregiver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours around the clock.

2.4.2 COUGHING:

Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs. Coughing is repeated several times a day.






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2.4.3 DEEP BREATHING:

Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods.






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2.4.3.1 BREATHING EXERCISES: Breathing exercises may help strengthen the muscles that inflate and deflate

the lungs, but they do not directly improve lung function. Still, breathing exercises decrease the likelihood of lung complications after surgery in heavy smokers and others with lung disease. Such exercises are particularly helpful for sedentary people who have chronic obstructive pulmonary disease or those who have just been taken off of a ventilator.

Often, these exercises involve using an instrument called an incentive spirometer (see Symptoms and Diagnosis of Lung Disorders: Lung Volume and Flow Rate Measurements). A person breathes in as deeply as possible through a tube that is attached to a hand-held plastic chamber. The chamber houses a ball, and each breath lifts the ball. Ideally, this manoeuvre is done 5 to 10 consecutive times each hour while the person is awake. This device is used routinely in hospitals before and after surgery. However, deep-breathing exercises encouraged by nurses and respiratory therapists may be more effective than self-directed breathing exercises using an incentive spirometer.

Pursed-lip breathing is a type of breathing pattern that may be helpful when people who have chronic obstructive pulmonary disease over inflate their lungs during attacks of airway narrowing, panic, or exercise. It also can function as an additional breathing exercise for people undergoing pulmonary rehabilitation. People are taught—or often discover by themselves—to exhale against partially closed (pursed) lips, as if preparing to whistle. This measure increases pressure in the airways and helps prevent them from collapsing. The exercise causes no ill effects, and some people adopt the habit without instruction. People may also benefit from bending forward while performing pursed-lip breathing. In this position, the person stands with the arms and hands outstretched and supports the body on a table or similar structure. This position improves functioning of the diaphragm (the most important breathing muscle) and reduces shortness of breath.






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2.4.4 POSTURAL DRAINAGE:

Postural drainage uses the force of gravity to assist in effectively draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. The patient is placed in a head or chest down position and is kept in this position for up to 15 minutes. Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Percussion and vibration may be performed in conjunction with postural drainage.

There are 6 to 12 positions a person with pulmonary disease may take to drain mucus from a certain part of the lungs. Another person may tap in certain areas to help loosen the mucus and allow it to be coughed out. Other ways to relieve the lung congestion of cystic fibrosis or bronchiectasis include percussion vests and inhaled aerosols.

2.4.4.1 SUCTIONING:

Respiratory therapists, nurses, and family members who have been taught the procedure may use suctioning to help remove secretions from the airways. To perform suctioning, a small plastic tube is introduced through the nose and extended a few inches into the windpipe (trachea). A gentle vacuum sucks out the secretions that cannot be coughed up. Suctioning is also used to remove secretions in someone who has a tracheostomy (a surgical opening in the trachea to allow breathing) or who has a breathing tube inserted through the nose or mouth and into the trachea (endotracheal tube) while on a ventilator.






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2.4.5 PERCUSSION:

Percussion is rhythmically striking the chest wall with cupped hands. It is also called cupping, clapping, or Tapotement. The purpose of percussion is to break up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.

2.4.5.1 PERCUSSIO FOR UNDER FIVE YEAR OLDS:

Chest Physical Therapy (CPT) uses percussion to loosen mucus so the patient can get it out by coughing. To avoid injury, the technique is done with a cupped hand, never a flat hand. People often think that they must hit the chest hard to loosen mucus, but this is not true. The air that is trapped in the cupped hand is what hits the chest wall and shakes the mucus loose. Before you begin doing percussions, there are a few ground rules you should know: Never percuss over bare skin. Have the patient wear a t-shirt or place a thin

piece of cloth between his or her skin and your hand. Never percuss directly over the shoulder blade, collarbone, spine, breastbone,

or breasts. Place a towel under the child's face to protect your clothing from any mucus

coughed up during the treatment. Chest percussion should not hurt. If it does, you are not doing it correctly and

should stop and reposition to avoid injury.

When performing percussion, the following technique should be used: Place the cupped hand in the proper section of the patient's chest. Keep the wrist anchored on the chest. Bend at the wrist as you move the

hand quickly and firmly up and down in a tapping motion. This should make a loud hollow sound, not a slapping sound.

Continue for 3 to 5 minutes, then have the patient breathe deeply and cough for a minute or two before moving to the next section. The child should always be sitting upright during the coughing and deep breathing portion of CPT.

A. CLEARING THE BACK OF THE RIGHT UPPER LOBE:

The first thing you need to do is clear the mucus out of the upper lobes of the lungs to make room for mucus in the lower lobes to pass through. It doesn't really matter which side you do first, but for the purposes of these instructions we will start with the right upper lobe. Place the child facing you on your lap, resting his or her head on your

right shoulder as if giving you a hug. Place your cupped hand on the right side of the child's back, between the

shoulder blade and the top of the shoulder. Begin percussions as described in step one.

Sit the child upright and ask him or her to cough and deep breathe.






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B. CLEARING THE BACK OF THE LEFT UPPER LOBE: Now move the child to your left shoulder and repeat the percussions on the left side of his or her back. Sit the child upright and ask him or her to cough and deep breathe.

C. CLEARING THE FRONT OF THE RIGHT UPPER LOBE:

Next, turn the child around on your lap so he or she is facing away from you with arms above his or her head. Place cupped hand on the right side of the child's chest, between the

collarbone and nipple. Begin percussions, then sit the child upright and ask him or her to cough

and deep breathe.

D. CLEARING THE FRONT OF THE LEFT UPPER LOBE: Reposition your child as you did in the previous step and repeat the percussions on the left side of the chest between the collarbone and nipple. Again, sit the child up and ask him or her to deep breathe and cough.

E. CLEARING THE SIDE OF THE RIGHT LOWER LOBES:

Now that you have made some space in the upper lobes of the lungs, it is time to start clearing out the lower lobes. In this example, we will begin with the right side. Lay the child facing you across your lap on his or her left side. Place your cupped hand on the side of the child's ribcage below his or her

underarm Percuss, then sit the child upright and ask him or her to deep breathe and

cough.

F. CLEARING THE SIDE OF THE LEFT LOWER LOBE: Turn the child around on your lap so he or she is still facing you, but laying on his or her right side. Percuss on the left side of the ribcage just as you did on the right side. Remember to sit the child upright and ask him or her to deep breathe and

cough.

G. CLEARING THE BACK OF THE LOWER LOBES: Turn the child so he or she is laying face down horizontally across your lap. Place your cupped hand on one side of the child's back, toward the

bottom of the ribcage. Percuss and allow the child to cough if needed. Keeping the child in the same position, repeat percussions on the other

side of his or her back Once again, sit the child upright and ask him or her to cough and deep

breathe.






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H. CLEARING THE FRONT OF THE LOWER LOBES: The last section of the lungs to be cleared is the front of the lower lobes. Place the child on his or her back lengthwise on your lap, feet toward you

and head at your knees. His or her head should hang slightly over the edge but remain fully supported.

Place your cupped hand on one side of the child's chest just below the nipple area.

Percuss, sit the child up and allow him or her to cough and deep breathe. Resume the same position and repeat on the other side of his or her chest.

I. CLEARING IT ALL OUT:

Over the last 30 minutes or so, you have hopefully loosened up a lot of mucus with CPT. You've been having the child bring some of it up by coughing and deep breathing after each lung section percussed. Now, the final step is to try to get rid of the rest of the loosened mucus that may be lurking around. Sit the child up at a 90 angle on your lap. Put your arm around the child's chest and have him or her lean over it

slightly. Ask the child to deep breathe and cough until no more mucus comes

2.4.6 VIBRATION:

As with percussion, the purpose of vibration is to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.






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2.4.7 PREPARATION:

The only preparation needed for chest physiotherapy is an evaluation of the patient's condition and determination of which chest physiotherapy techniques would be most beneficial.

2.4.8 AFTERCARE:

Patients practice oral hygiene procedures to lessen the bad taste or odour of the secretions they spit out.

2.4.9 RISKS:

Risks and complications associated with chest physiotherapy depend on the health of the patient. Although chest physiotherapy usually poses few problems, in some patients it may cause Oxygen deficiency if the head is kept lowered for drainage






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Increased intracranial pressure

Increased intracranial pressure is almost always indicative of severe medical problems. The pressure itself can be responsible for further damage to the central nervous system by decreasing blood flow to the brain or by causing the brain to herniate (push through) the opening in the back of the skull where the spinal cord is attached. Causes of increased intracranial presure may include bleeding into the subdural space (subdural hematoma). Temporary low blood pressure

Bleeding in the lungs pain or injury to the ribs, muscles, or spine






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Vomiting

Inhaling secretions into the lungs heart irregularities






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2.4.10 NORMAL RESULTS:

The patient is considered to be responding positively to chest physiotherapy if some, but not necessarily all, of these changes occur: Increased volume of sputum secretions

Changes in breath sounds

Improved vital signs Improved chest x ray






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Increased oxygen in the blood as measured by arterial blood gas values

Patient reports of eased breathing






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3.0. PULMONARY REHABILITATION: Pulmonary rehabilitation is a program designed for people who have chronic lung disease. Its primary

goal is to enable people to achieve and maintain their maximum level of independence and functioning. Although most pulmonary rehabilitation programs focus on people who have chronic obstructive pulmonary disease, people with other types of lung disease may benefit as well. People in all age groups can benefit, including those older than 70.

Pulmonary rehabilitation programs may improve quality of life by reducing shortness of breath, increasing exercise tolerance, promoting a sense of well being, and, to a lesser extent, decreasing the number of hospitalizations. However, these programs do not significantly improve survival.

Pulmonary rehabilitation programs are usually conducted in an outpatient setting or in the person's home. Inpatient services often take place in special rehabilitation centers. Inpatient services are used mainly for people who are recovering from a hospitalization, often because of a severe lung problem. These people are often not stable enough to go home but no longer require care in an intensive care unit. The most successful rehabilitation programs are those in which a respiratory or physical therapist, a nurse, a doctor, a psychologist or social worker, and a dietitian working as the pulmonary rehabilitation team to coordinate complex medical services provide services. Most people are enrolled in these programs for 8 to 12 weeks. However, the techniques learned during the program have to be continued at home after the rehabilitation program ends or the gains made will be lost.

Supportive respiratory therapy, which includes oxygen therapy and chest physical therapy, can be used in conjunction with pulmonary rehabilitation. Supportive therapy can also be used for people not enrolled in these programs but who have chronic lung disorders (such as cystic fibrosis or bronchiectasis) or acute lung conditions (such as pneumonia).

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Title: PHYSICAL THERAPY MANAGEMENT OF POST SURGICAL CONDITIONS AT RISK OF DEVELOPING RESPIRATORY COMPLICATIONS

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