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Physio for thoracotomy patients

Royal Devon and Exeter NHS Foundation Trust

Physiotherapy for Thoracotomy Patients

July 2008 (Review date: July 2011)

Smoke-free at the RD&E From September 2006 the RD&E hospitals became totally smoke-free sites. This means that no smoking is allowed in and around any of the RD&E buildings, in parked cars, in our courtyard gardens or anywhere on the hospital sites. This applies to patients, visitors and staff. We are very keen to help people in their efforts to stop smoking, so please see your GP before coming into hospital or talk to your nurse about this. For information on how to give up smoking, phone the Smoking Advice Service on 0845 1111142. The benefits begin the minute you stop smoking.

Physiotherapy Department.........................01392 402438 Mere Ward....................................................01392 402817

Introduction Physiotherapy is an essential part of your recovery from your operation. The physiotherapist will see you before your operation to explain the reason why physiotherapy is so important after your surgery and what you will need to do whilst you are recovering on the ward. This booklet aims to reinforce that information to allow you to absorb it in your own time. There are 3 main areas of physiotherapy involvement: 1. Chest care 2. General mobility 3. Advice for home

Chest Care Chest problems can occur after major surgery even if you have no history of chest problems or smoking. Reasons for chest problems after your operation include: ◆

Anaesthetic gases ●

Increase the amount of phlegm produced

Make the phlegm sticky and difficult to cough up

Make you sleep after your operation

Make you breathe shallowly

Make you cough less effectively -1-

Previous chest problems - smoking or recent coughs/colds can lead to increased amounts of phlegm being produced after your operation.

The operation - during the operation your lungs are not inflated fully and you need to re-expand them after your operation.

The wound - discomfort from wounds or drains may discourage you from taking deep breaths or coughing effectively.

Posture - if you sit or lie in a slumped position in your bed or chair you will be unable to take in a full deep breath. Always sit in an upright position - not slumped!!

Decreased activity - in the early stages after your operation when you are less active you will be breathing more shallowly than usual and so phlegm can then accumulate.

Smoking - stopping smoking as long as possible before your operation will decrease the risk of chest problems. Chemicals inhaled during smoking reduce the ability of the lungs to clear mucus.

Therefore to speed up your recovery and prevent chest infections it is important that you regularly practice the breathing exercises your physiotherapist teaches you. By practising before your operation you will find the exercises easier to do afterwards. Always sit in an upright position, not slumped!!

✗ -2-

Breathing Exercises There are 2 main types of breathing exercises to practice which both help to expand your lungs and remove secretions - Active Cycle of Breathing and Incentive Spirometry (using your Coach). For all breathing exercises make sure that you are in an upright position either in the bed or the chair.

Active Cycle of Breathing ◆

Sit upright.

Practice normal relaxed breathing with your hand placed gently over your upper abdomen - you should feel your abdomen gently rising and falling.

Take a slow deep breath in (through your nose if possible) and hold for 3-5 seconds, then gently breathe out - repeat 4 times, then return to relaxed breathing.

Follow your deep breaths with 1 or 2 supported ‘huffs’ and a supported cough.

Repeat the cycle if you feel that you have more phlegm to clear.

‘Huffing’ - is an effective way to help move phlegm higher in the airways in order to clear it more easily. A huff is like ‘steaming up a mirror’ - make an ‘O’ shape with your mouth and do a short sharp breath out from the back of your throat (not ‘blowing’ the air out). Supported coughing - to make coughing more comfortable you can use your hands or a folded towel to support your wound or drain site - your physiotherapist will show you how to do this.

Incentive Spirometry Using your incentive spirometer (or Coach) is another way to exercise and improve your lung to help prevent post-operative chest complications. Your physiotherapist will teach you how to use it -3-

effectively before your operation. It is important that you do not rush and that your technique is good. ◆

Sit upright.

Do a relaxed (normal) breath out.

Breathe (‘suck’) in with your lips firmly around the mouthpiece, aiming to get the small yellow counter in the box with the ‘smiley face’.

Keep breathing in for as long as you can, keeping the counter steady. (The longer you breathe in for, the greater the volume you will achieve.)

As you breathe in the larger yellow section will rise up; the top of it indicates the volume you have reached. (As soon as you stop breathing in it will drop back down.)

Slide the marker up to remind yourself how well you have done.

After your operation aim to practice up to 10 breaths per hour (take 3-4 breaths, have a rest, and then repeat).

Continue practising independently on the ward and after you go home - check with your doctors when you come to clinic if you should continue further.

Pre-operative volume:


Pain Control The nursing staff will monitor your pain very closely in order to make your pain control as effective as possible. They will regularly ask you for a ‘pain score’ from 0-10 (0 = no pain; 10 = the worst imaginable pain). It is important that your pain control is effective for physiotherapy as moving around, deep breathing and coughing are all generally more uncomfortable than lying still. -4-

You should expect some discomfort, but it is very important to let someone know if you feel pain is preventing you from taking deep breaths well or coughing effectively - DO NOT SUFFER IN SILENCE.

General Mobility It is important to become active as soon as possible to prevent postoperative complications, such as chest infection. The first day after your operation you should aim to sit out in your chair. This is important because it helps to improve your lungs by increasing the depth of each breath you take. After the operation you should aim to be walking as soon as possible, with assistance on the ward. Walking is an excellent way to take deep breaths and assist in clearing your chest. It will also help to increase your strength and stamina after your operation. Your exercise tolerance (amount of walking) will be gradually increased over the following days. You will need assistance until you can manage your drips and drains safely. WHEN YOU ARE ABLE TO WALK ON YOUR OWN, TRY TO HAVE A WALK EVERY HOUR. Before you go home, your physiotherapist will practice a flight of stairs with you to ensure that you can manage safely.

Shoulder Mobility Due to the wound and/or chest drains, you may be reluctant to move the arm on the operated side. It is important that you regularly -5-

practice the following exercises after your surgery to improve your range of movement and prevent joint stiffness. Your physiotherapist will instruct you when to start. ◆

Shrug your shoulders towards your ears, hold for 3 seconds and lower them back down.

Round your shoulders (taking them forwards), and then take them back (squeezing your shoulder blades together).

Place your hand on your shoulder; then gently lift your elbow out to the side, and lower back down.

Keeping your hand on your shoulder, lift your elbow forwards, and then lower back down.

Raise your hand up above your head (as if you are reaching up to the ceiling).

Repeat each exercise 4 times, 3 times daily. Aim for a gentle stretch or pulling sensation only - the exercises should not be painful.

Postural Advice Due to the wound and/or chest drains you may tend to lean towards the operated side, as this may feel more comfortable in the early stages; however it is important to maintain a good upright posture after your operation to help prevent neck/back pain or stiffness. The following exercises will maintain/improve your posture and ensure that your wounds to not become tight as they heal. ◆

Sitting upright, with your hands on your hips, slowly turn to the right as far as is comfortable; then repeat to the left. -6-


Stand up straight, with your arms by your sides. Slowly lean to the right, sliding your right hand down the outside of your leg. Return to an upright position, and repeat to the left.

Repeat each exercise 4 times, 3 times daily. Aim for a gentle stretch or pulling sensation only - the exercises should not be painful ALWAYS TRY TO STAND UP STRAIGHT WHEN WALKING.

Advice for Home After discharge, if you have any queries regarding the information in this booklet, contact the Physiotherapy Department on 01392 402436/402438 or Mere Ward on 01392 402817. Following your surgery, it is important to gradually increase the amount of exercise that you are doing. Your physiotherapist can advise you on what is appropriate for you, remembering that each person’s progress is different.

Breathing Exercises It is important to continue with your breathing exercises (ACBT and using your Coach) regularly in order to continue to improve your lung function. You can check at your follow-up appointment whether you need to continue further.

Shoulder and Postural Exercises Keep going with the shoulder and postural exercise for at least one month. This will ensure that you maintain the movement and prevent the wound from becoming tight and restrictive. Make sure that you continue to stand up straight and avoid poor posture after your discharge from hospital. -7-

Walking It is important to gradually increase the amount of exercise you are doing. Start by taking fairly gentle walks on the level and then progress to longer distance and walking up slopes. It is normal to experience some breathlessness when exercising; this is the body’s normal response to exercise. As a guide, aim for a comfortable breathlessness so that you can ‘walk and talk’ at the same time, and recover within a minute when you stop. If you are unable to do this, you are working too hard. Doing the stairs regularly is another good way to maintain or increase your strength and stamina - there is no need to avoid the stairs!!

Frequently Asked Questions What happens to my drips and drains when I’m walking? All of your drips and drains are portable and have in-built batteries if required; the staff assisting you will help you to carry your attachments to enable you to walk.

How long do I need to avoid heavier activities for eg lifting? We recommend that you wait until 6-8 weeks after surgery before you start doing heavier activities.

When can I drive again? Check with your consultant and insurance company that you are covered as policies vary; normally about 6 weeks, but you would need to be capable of dealing with an emergency situation and doing an emergency stop. -8-

When can I return to work? Normally 8-12 weeks after your surgery, depending on the nature of your job. Those working part-time or with light duties may return earlier than those going back to heavy/manual work.

When can I return to my sports and hobbies? Check with your consultant about specific activities if you are concerned; otherwise as soon as you feel ready within the guidance above.


For further information on other health topics, please contact the: Health Information Centre Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW Tel: 01392 402071

Helping us to help you ■

We offer a number of services for people with disabilities.

We can offer information in large print and Braille.

We can offer information on audio tape.

We can offer to interpret information into a language other than English.

For any of the above, please contact the Health Information Centre on

01392 402071 Website address: Reference No: PS 08 008 001

The Trust cannot accept any responsibility for the accuracy of the information given if the leaflet is not used by RD&E staff undertaking procedures at the RD&E hospitals. © Royal Devon and Exeter NHS Foundation Trust Design: Graphics Department, Royal Devon and Exeter NHS Foundation Trust

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