On my current placement on a cardiothoracic surgery ward, I had a patient who underwent a right middle lobectomy. I saw her from Day 1 to 4 post-op, and saw remarkable results that I believe are largely due to the physiotherapy treatment she received.
Her chest x-ray from Day 1 showed consolidation of pleurae below the area of lung tissue that had been removed. The right hemidiaphragm was superiorly displaced 3 ribs higher than the left. Subjectively she reported pain with coughing and no production or clearance of sputum. Upon observation she had an upper chest breathing pattern. Auscultation showed inspiratory crackles throughout bilateral lower zones, reduced breath sounds in her right lower zones, and absent breath sounds in the area here her right posterior and lateral lower lobe should be. Chest expansion was reduced in bilateral lower zones. Cough was weak, painful (7/10), moist, ineffective, non productive. She was unable to mobilise in and out of bed due to discomfort.
For the following 3 days her treatment program consisted of; education on PCA use and importance of mobilising, deep breathing exercises (breathing control, Sustained maximal inspirations, huffs and supported cough), mobilising out of bed and ambulating on ward and IPPB (Bird).
Chest x-ray on Day 3 showed great results. Her lungs appeared to be re-expanding. The right hemidiaphragm was 1.5 ribs higher than the left. Subjectively she reported little pain with a supported cough and she was not producing or clearing any sputum. Her breathing pattern was almost normal and she consciously corrected herself when she began upper chest breathing. Auscultation showed no inspiratory crackles, and breath sounds in the right lower zone was improving. Cough was moderate, no pain and dry. She could mobilise with stand by assist. Medical staff anticipated discharge over the weekend. She had booked Therapy In The Home (TITH) to assist with her mobility for the initial week or so, and will come to Cardiothoracic rehabilitation classes for the next 4-6 weeks.
I think this is a good example of how a simple physiotherapy regime can be effective. It is nice to have an uncomplicated and rewarding case!
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