1rst clinical case

Mr Smith has developed right lower lobe
atelectasis four days after his cardio-oesophagectomy.

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Cardio-oesophagectomy
is the surgery patients with oesophageal
cancer undergo, in which the part of oesophagus affected by cancer is removed. Part of the stomach is also
removed in order to be joined up to the remaining oesophagus and is thereafter
located in the thorax. Patients undergoing this
surgery are usually at high risk of developing
postoperative complications due to the extent of the surgery (anesthesia), the late presentation of  the 
disease  and  the 
associated  common  symptoms, 
which  include  dysphagia 
and  weight loss (El-Ansary
et al, 2016). The complications
include: wound infections, leaking anastomosis, haemorrhage,
delayed gastric emptying,
anastomotic stricture and most commonly pulmonary
complications (Flanagan
et al, 2016).

Pulmonary complications occur in approximately 30% of
cases and include pleural effusions, atelectasis, chylothorax, pneumonia, pulmonary
embolism, and respiratory failure (Ong et
al, 1978). Risk factors of
pulmonary  complications include  surgery procedure, advanced  age, 
history  of   smoking, 
cirrhosis  and diabetes,  abnormal 
chest radiograph or lung disease, blood loss and low serum albumin, preoperative chemoradiotherapy, 
general  performance and nutritional status, obesity, inadequate postoperative
analgesia and stage of disease (Avendano et
al, 2002). Understanding of how these risk factors can cause pulmonary complications,
first needs understanding of the normal structure and function of the
respiratory system.

The respiratory system is divided
into 2 parts, the upper and the lower respiratory tract. The upper
respiratory tract, where air comes in and out, consists of the nasal cavity,
the pharynx and the larynx. The lower respiratory tract is responsible for the
act of breathing and includes the trachea, the
bronchi, broncheoli and the lungs (located in the chest cavity). The trachea is
a tube that connects the pharynx and larynx to the lungs,
allowing the passage of air. The
trachea extends from the larynx and branches into the two primary
bronchi, one leading to the left lung, the other to the right lung. Inside the
lungs each of the bronchi divides into smaller bronchi, the broncheoli which
end in the pulmonary alveolus. The pulmonary alveoli are tiny
air sacs delineated by a single-layer membrane with blood capillaries at the
other end. The main functions of the respiratory system are to obtain oxygen from
the external environment and supply it to the cells and to remove from the body
the carbon dioxide produced by cellular metabolism. The exchange of gases takes place in the pulmonary alveoli.
Fresh air, containing oxygen, is inspired into the lungs through
the conducting airways (inhalation), gets
absorbed into the alveoli blood
capillaries (ventilation) and the action of the heart circulates it through all
the tissues in the body. The forces causing the air to flow are
generated by the respiratory muscles. Contraction of the diaphragm
and rib muscles causes the expansion of the chest cavity, thus
reducing air pressure and causing air to be passively drawn into the lungs.  At the same time, venous blood (high carbon
dioxide and low oxygen content) returning from the various body tissues is
pumped into the lungs (perfusion). In the pulmonary capillaries, carbon dioxide
is exchanged for oxygen from the alveoli and the blood recirculates to the
tissues of the body. The carbon dioxide is then expelled during exhalation, when respiratory muscles relax and the chest cavity contracts, thus increasing air pressure and causing the air in
the lungs to be expelled through the upper respiratory tract (Levitzky, 2013).

The aforementioned
risk factors have been associated with the development of postoperative
pulmonary complications in many studies and some of them can be explained. The surgery procedure related factors are the most
important. Upper abdominal and thoracic surgery with general anesthesia often
result to an impairment in the functions
of respiratory muscles (diaphragmatic dysfunction), which leads to a reduction of functional residual capacity- FRC
(the volume of air left in the lungs at the end of a quiet exhalation). The reduced FRC, along with a decreased postoperative
vital capacity (maximum
amount of air expelled from the lungs after a maximum inhalation) leads to ventilation perfusion (V/Q) mismatch, hypoxemia and possibly respiratory failure (Miskovic & Lumb, 2017). Elderly patients have higher risk for developing pulmonary
complications possibly due to higher prevalence of pre-existing cardiopulmonary
diseases or generally organ dysfunction (Shirinzadeh & Talebi, 2011). Obesity can increase the risk of pulmonary complications due to the associated physiological changes described before. Pain control with analgesics improves deep
breathing, resulting in decreased atelectasis and pneumonia.  The risk from smoking is primarily
related to the resulting chronic lung disease. Patients with chronic lung disease have an increased
risk of developing pulmonary complications due to chronically fatigued respiratory muscles and
poor nutritional status contributes to respiratory muscle weakness (Rudra &
Sudipta, 2006).

Mr Smith has developed right lower lobe atelectasis, one of the
most common pulmonary complication after a
surgery.
Atelectasis is found
in 90% of all patients who are anaesthetised and it’s the complete
or partial collapse of a lung or lobe of a lung, resulting in reduced or absent gas exchange. It is a
condition where the alveoli are deflated down to little or no volume (Wedding et al, 2005). Physiological factors contributing to formation of atelectasis
include direct compression of lung tissue, for example by the displaced
diaphragm, airway closure when FRC is reduced and rapid absorption of gases
from alveoli in lung regions where the airways are narrowed or closed. Supplementation of high oxygen concentration has also
been associated with atelectasis formation (Miskovic & Lumb, 2017). Chest pain due to surgery can cause patients avoid taking deep breaths which can result in
compression of the lungs and atelectasis. Another possible cause
of atelectasis is the accumulation
of mucus in the airways due to anesthesia drugs given during
surgery, which disrupt the body’s normal breathing patterns and cause secretions
to collect in the airways. Other pulmonary complications such as pneumonia,
pneumothorax and pleural effusion, can also cause atelectasis in some
occasions. Atelectasis itself is asymptomatic unless hypoxemia or pneumonia
develops. Hypoxemia (low blood oxygen) caused by atelectasis results to difficulties in
breathing, increased heart rate and the skin turning blue (cyanosis). Pneumonia may cause cough,
dyspnea, and pleuritic pain, which is also caused by the surgery (Woodring & Reed, 1996).

 

2nd clinical case

Mr Aston has been admitted to hospital for a
left trans-tibial amputation in two days’ time.

Transtibial amputations, also known
as below-knee amputations (BKA), are among the most frequently performed major
limb amputations. It is a surgical procedure performed to remove a limb that
has been damaged due to trauma or disease (vascular disease, ischaemia, diabetes, foot ulcer, tumor) (Smith, 2003). One of the most important
pre-operative problems a patient (Mr Aston) scheduled for an amputation faces,
is the presence of one or more diseases (eg cardiac/pulmonary/vascular
diseases, diabetes mellitus etc) that can influence the surgery (anesthesia in
some conditions is not suitable), the rehabilation process and possibly induce
postoperative complications (eg pulmonary). Another common pre-operative
problem is the pain felt by the patient due to limp trauma or the disease
responsible for the amputation. Patients who will undergo an amputation have
usually physical function impairments such as limited mobility, muscle
weakness, difficulties in daily activities etc due to the trauma or disease.
They also face psychological/emotional issues such as depression and anxiety
for the imminent limp loss and their possible social closure after the surgery
(Melsom & Danjoux, 2011). Their
potential post-operative problems include: pain (from amputation but also from
existing diseases), wounds and infection (poor tissue perfusion, tight dressing
etc), oedema (mishandling
of tissues during surgery), muscle
weakness, muscle contractures and joint instability (muscles and soft tissues become stiff
from lack of movement), phantom limp/pain (sensation
that the lost limp still exists and hurts) and skin breakdown (prosthesis presses on and rubs the
skin) and psychological issues (grief, social closure) (Bowker et al,
2002).

Rehabilitation of
amputees refers to the process of receiving professional aid and support, in
order to optimize health status,
function, independence, and quality of life. The rehabilitation encompasses not only the
pre-operative, postoperative, pre-prosthetic and prosthetic (use of prosthetic
aiding device) stages, but also the subsequent long-term monitoring and
follow-up. The implementation of the rehabilitation process requires a multidisciplinary and an interdisciplinary approach for an effective and efficient service
of the amputee with teamwork (Kova? et al, 2015). In table 1 (appendix), we
can see a typical initial treatment plan for two postoperative problems amputees
face, the muscle weakness and possible contractures if let without physical
therapy and the phantom limb pain, a very common type of pain among amputees
referring to pain from the non-existing limb possibly due to neuron hyper
activation at the stump and the still existing neurosignature of the limb (Flor, 2002). Another major problem
amputees face in both pre-operative and post-operative stages and can be
controlled from the rehabilitation process is pain. Specifically, in the
pre-operative stage analgesia using medications, should
be ensured in all patients to reduce the sympathetic stress response, improve
perioperative cardiovascular stability and ensure a stable postoperative
progress without pain limitations.  Pain control in
this stage should include a variety of simple analgesic medications in addition
to oral opioids and agents for neuropathic pain (gabapentin and amitriptyline)
where appropriate.  Opioid-based
analgesia may be required in the immediate preoperative period to control
severe ischaemic pain.  The use of
epidural infusions may, also, provide significant preoperative pain control. Anti-inflammatory drugs can reduce mild swelling
or soreness, and are useful for mild to moderate pain. Narcotics mimic the pain killing chemicals released by the brain
and can therefore be used in pain control (Melsom & Danjoux, 2011). A very reliable and accurate monitoring tool
for the evaluation of the pain treatment is the
McGill Pain Questionnaire. The McGill Pain Questionnaire can be used to
evaluate a person experiencing significant pain and specifically allows
patients describe how their pain feels, how does it change over pain and how
strong it is. + Based on the nature of the
questions and the wide range of pain aspects this questionnaire covers, we can
infer that it provides
quantitative information that can be treated statistically, and is sufficiently
sensitive to detect differences among different methods to relieve pain (Waldman, 2009).

 

 

3nd clinical
case

Mr Bury’s condition has improved and he is now
seven days post-admission following his acute exacerbation of Chronic
Obstructive Pulmonary Disease. The medical team plan to discharge him home in
two days’ time with a referral for pulmonary rehabilitation.

Pulmonary rehabilitation is defined by the American Thoracic Society and
the European Respiratory Society as an evidence-based, multidisciplinary, and
comprehensive intervention for patients with chronic respiratory diseases who
are symptomatic and often have decreased daily life activities (Nici, 2006). In general, it’s a program of exercise, education, and support to improve
the well-being and quality of life of patients with respiratory diseases, such
as COPD (chronic obstructive pulmonary disease). At pulmonary rehabilitation,
patients cooperate with a team of specialists who will help them improve
physical condition and manage of COPD, so that they will stay healthy and
active long after the completion of the course. The team may
include doctors, nurses, and specialists. Examples of specialists include
respiratory therapists, physical and occupational therapists, dietitians or
nutritionists, and psychologists or social workers. The
rehabilitation team will first take a complete health history of patients,
perform medical examinations (heart rate, blood pressure, oxygen level etc),
discuss with patients about their current level of activity and help them set
goals.  Although it is focused on the
patient care, there is also the family
involvement. Pulmonary
rehabilitation is effective in all settings including hospital inpatient,
hospital outpatient, the community, and the home (AARC Clinical Practice
Guideline, 2002).

Outpatient
programs should contain a minimum of 6 weeks of physical exercise, disease
education, psychological and social intervention with two supervised sessions and
additional instructions to train at home on a daily basis. Exercise is the core of pulmonary rehabilitation programs. Although, exercise training does not directly improve lung function, it
causes several physiological adaptations which can improve physical condition.
There are three basic types of exercises to be considered.  Aerobic exercise tends to improve
the body’s ability to use oxygen by decreasing the heart rate and blood
pressure. Strengthening or resistance exercises can help build strength in the
respiratory muscles. Stretching and flexibility exercises can enhance
breathing coordination. Training should involve three
sessions (20–30 minutes) per week and the intensity should usually be 60–70% of
maximal oxygen consumption. Since
exercise usually causes shortness of breath, it is suggested for patients to
start in slow pace and gradually increase the level of exercise, under the
supervision of health care professionals. During exercise, there is monitoring
of oxygen level, heart rate and blood pressure for safety purposes and supplementary oxygen can be provided when necessary. Additionally pursed
lip breathing can be used to increase oxygen level in patient’s body (Morgan, 2001). People with COPD who are underweight can improve their respiratory muscle
strength by increasing their calorie intake and regular exercise (Ferreira
et al, 2012). Patient education is, also, a central
feature of pulmonary rehabilitation. Areas commonly covered by the education
component are: anatomy, physiology, pathology and pharmacology, nutritional
advice, managing travel, anxiety management, goal setting and
rewards, relaxation, exacerbation management and the benefits of physical
exercise. Psychological
intervention is very important in rehabilitation programs, in order to overcome
feelings of depression and anxiety that may halt the patient’s progress. These
interventions are carried out by professional psychologists and consist of
proper education, small group discussions, and relaxation therapy (Morgan, 2001). 

The clinical improvement in
outcomes due to pulmonary rehabilitation is measurable with various tools
monitoring all aspects of a patient’s improvement eg physical function, dyspnea and handicap. The central aim
of rehabilitation is to increase function and there are an increasing number of
questionnaires of functional status, such as the Pulmonary Functional Status
Scale (PFSS) and Pulmonary Functional Status and Dyspnoea Questionnaire (PFSDQ).
The physical function assessment is also measured with field based exercise
tests such as the timed 6 minute walk test (6MWT) or the shuttle walking test
(SWT). A measure of dyspnoea or fatigue (VAS
or Borg scales) alongside exercise testing should be, also, considered to
increase the sensitivity of exercise measurements. Handicap or the social
impact of disease, can be assessed using health status measures, such as the
Short Form-36 (SF-36), Quality of Well Being Scale (QWB) and the Psychosocial
Adjustment to Illness Scale-Self Report (PAIS-SR). Finally, as domestic
independence is an important goal of rehabilitation, this can be reflected by
standardised activity of daily living (ADL) scales (Morgan, 2001).