1 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
67
Embed
Post operative physiotherapy management for flail chest or Multiple ribs fracture or Cardio-pulmonary rehabilitation or physiotherapy or physical therapy or flail chest or BPT or MPT
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
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
2
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.
3
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
4
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.
5
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.
6
ANATOMY OF THORACIC CAGE
7
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.
8
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.
9
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.
10
MECHANICS OF RESPIRATION
11
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
12
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
13
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.
14
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
15
FLAIL CHEST
16
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]
17
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]
18
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]
19
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.
20
[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
21
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.
22
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.
23
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.
24
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
25
SURGICAL MANAGEMENT
TRACTION FOR A FLAIL CHEST
26
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:
27
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]
28
[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.
29
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
30
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.
31
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.
32
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.
33
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.
34
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
35
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
36
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
37
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
38
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