1rst clinical caseMr Smith has developed right lower lobeatelectasis four days after his cardio-oesophagectomy.Cardio-oesophagectomyis the surgery patients with oesophagealcancer undergo, in which the part of oesophagus affected by cancer is removed. Part of the stomach is alsoremoved in order to be joined up to the remaining oesophagus and is thereafterlocated in the thorax. Patients undergoing thissurgery are usually at high risk of developingpostoperative 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-Ansaryet al, 2016). The complicationsinclude: wound infections, leaking anastomosis, haemorrhage,delayed gastric emptying,anastomotic stricture and most commonly pulmonarycomplications (Flanaganet al, 2016). Pulmonary complications occur in approximately 30% ofcases and include pleural effusions, atelectasis, chylothorax, pneumonia, pulmonaryembolism, and respiratory failure (Ong etal, 1978). Risk factors ofpulmonary  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 postoperativeanalgesia and stage of disease (Avendano etal, 2002).

Understanding of how these risk factors can cause pulmonary complications,first needs understanding of the normal structure and function of therespiratory system. The respiratory system is dividedinto 2 parts, the upper and the lower respiratory tract. The upperrespiratory tract, where air comes in and out, consists of the nasal cavity,the pharynx and the larynx. The lower respiratory tract is responsible for theact of breathing and includes the trachea, thebronchi, broncheoli and the lungs (located in the chest cavity). The trachea isa tube that connects the pharynx and larynx to the lungs,allowing the passage of air.

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Thetrachea extends from the larynx and branches into the two primarybronchi, one leading to the left lung, the other to the right lung. Inside thelungs each of the bronchi divides into smaller bronchi, the broncheoli whichend in the pulmonary alveolus. The pulmonary alveoli are tinyair sacs delineated by a single-layer membrane with blood capillaries at theother end. The main functions of the respiratory system are to obtain oxygen fromthe external environment and supply it to the cells and to remove from the bodythe 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 throughthe conducting airways (inhalation), getsabsorbed into the alveoli bloodcapillaries (ventilation) and the action of the heart circulates it through allthe tissues in the body. The forces causing the air to flow aregenerated by the respiratory muscles.

Contraction of the diaphragmand rib muscles causes the expansion of the chest cavity, thusreducing air pressure and causing air to be passively drawn into the lungs.  At the same time, venous blood (high carbondioxide and low oxygen content) returning from the various body tissues ispumped into the lungs (perfusion). In the pulmonary capillaries, carbon dioxideis exchanged for oxygen from the alveoli and the blood recirculates to thetissues 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 inthe lungs to be expelled through the upper respiratory tract (Levitzky, 2013).The aforementionedrisk factors have been associated with the development of postoperativepulmonary complications in many studies and some of them can be explained.

The surgery procedure related factors are the mostimportant. Upper abdominal and thoracic surgery with general anesthesia oftenresult to an impairment in the functionsof 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 postoperativevital capacity (maximumamount 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 pulmonarycomplications possibly due to higher prevalence of pre-existing cardiopulmonarydiseases 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 deepbreathing, resulting in decreased atelectasis and pneumonia.  The risk from smoking is primarilyrelated to the resulting chronic lung disease. Patients with chronic lung disease have an increasedrisk of developing pulmonary complications due to chronically fatigued respiratory muscles andpoor nutritional status contributes to respiratory muscle weakness (Rudra &Sudipta, 2006).

Mr Smith has developed right lower lobe atelectasis, one of themost common pulmonary complication after asurgery.Atelectasis is foundin 90% of all patients who are anaesthetised and it’s the completeor partial collapse of a lung or lobe of a lung, resulting in reduced or absent gas exchange. It is acondition where the alveoli are deflated down to little or no volume (Wedding et al, 2005). Physiological factors contributing to formation of atelectasisinclude direct compression of lung tissue, for example by the displaceddiaphragm, airway closure when FRC is reduced and rapid absorption of gasesfrom alveoli in lung regions where the airways are narrowed or closed. Supplementation of high oxygen concentration has alsobeen associated with atelectasis formation (Miskovic & Lumb, 2017).

Chest pain due to surgery can cause patients avoid taking deep breaths which can result incompression of the lungs and atelectasis. Another possible causeof atelectasis is the accumulationof mucus in the airways due to anesthesia drugs given duringsurgery, which disrupt the body’s normal breathing patterns and cause secretionsto collect in the airways. Other pulmonary complications such as pneumonia,pneumothorax and pleural effusion, can also cause atelectasis in someoccasions. Atelectasis itself is asymptomatic unless hypoxemia or pneumoniadevelops. Hypoxemia (low blood oxygen) caused by atelectasis results to difficulties inbreathing, 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 caseMr Aston has been admitted to hospital for aleft trans-tibial amputation in two days’ time. Transtibial amputations, also knownas below-knee amputations (BKA), are among the most frequently performed majorlimb amputations.

It is a surgical procedure performed to remove a limb thathas been damaged due to trauma or disease (vascular disease, ischaemia, diabetes, foot ulcer, tumor) (Smith, 2003). One of the most importantpre-operative problems a patient (Mr Aston) scheduled for an amputation faces,is the presence of one or more diseases (eg cardiac/pulmonary/vasculardiseases, diabetes mellitus etc) that can influence the surgery (anesthesia insome conditions is not suitable), the rehabilation process and possibly inducepostoperative complications (eg pulmonary). Another common pre-operativeproblem is the pain felt by the patient due to limp trauma or the diseaseresponsible for the amputation. Patients who will undergo an amputation haveusually physical function impairments such as limited mobility, muscleweakness, difficulties in daily activities etc due to the trauma or disease.They also face psychological/emotional issues such as depression and anxietyfor the imminent limp loss and their possible social closure after the surgery(Melsom & Danjoux, 2011). Theirpotential post-operative problems include: pain (from amputation but also fromexisting diseases), wounds and infection (poor tissue perfusion, tight dressingetc), oedema (mishandlingof tissues during surgery), muscleweakness, muscle contractures and joint instability (muscles and soft tissues become stifffrom lack of movement), phantom limp/pain (sensationthat the lost limp still exists and hurts) and skin breakdown (prosthesis presses on and rubs theskin) and psychological issues (grief, social closure) (Bowker et al,2002). Rehabilitation ofamputees refers to the process of receiving professional aid and support, inorder to optimize health status,function, independence, and quality of life.

The rehabilitation encompasses not only thepre-operative, postoperative, pre-prosthetic and prosthetic (use of prostheticaiding device) stages, but also the subsequent long-term monitoring andfollow-up. The implementation of the rehabilitation process requires a multidisciplinary and an interdisciplinary approach for an effective and efficient serviceof the amputee with teamwork (Kova? et al, 2015). In table 1 (appendix), wecan see a typical initial treatment plan for two postoperative problems amputeesface, the muscle weakness and possible contractures if let without physicaltherapy and the phantom limb pain, a very common type of pain among amputeesreferring to pain from the non-existing limb possibly due to neuron hyperactivation at the stump and the still existing neurosignature of the limb (Flor, 2002). Another major problemamputees face in both pre-operative and post-operative stages and can becontrolled from the rehabilitation process is pain. Specifically, in thepre-operative stage analgesia using medications, shouldbe ensured in all patients to reduce the sympathetic stress response, improveperioperative cardiovascular stability and ensure a stable postoperativeprogress without pain limitations.

 Pain control inthis stage should include a variety of simple analgesic medications in additionto oral opioids and agents for neuropathic pain (gabapentin and amitriptyline)where appropriate.  Opioid-basedanalgesia may be required in the immediate preoperative period to controlsevere ischaemic pain.  The use ofepidural infusions may, also, provide significant preoperative pain control.

Anti-inflammatory drugs can reduce mild swellingor soreness, and are useful for mild to moderate pain. Narcotics mimic the pain killing chemicals released by the brainand can therefore be used in pain control (Melsom & Danjoux, 2011). A very reliable and accurate monitoring toolfor the evaluation of the pain treatment is theMcGill Pain Questionnaire.

The McGill Pain Questionnaire can be used toevaluate a person experiencing significant pain and specifically allowspatients describe how their pain feels, how does it change over pain and howstrong it is. + Based on the nature of thequestions and the wide range of pain aspects this questionnaire covers, we caninfer that it providesquantitative information that can be treated statistically, and is sufficientlysensitive to detect differences among different methods to relieve pain (Waldman, 2009).  3nd clinicalcaseMr Bury’s condition has improved and he is nowseven days post-admission following his acute exacerbation of ChronicObstructive Pulmonary Disease. The medical team plan to discharge him home intwo days’ time with a referral for pulmonary rehabilitation.Pulmonary rehabilitation is defined by the American Thoracic Society andthe European Respiratory Society as an evidence-based, multidisciplinary, andcomprehensive intervention for patients with chronic respiratory diseases whoare symptomatic and often have decreased daily life activities (Nici, 2006). In general, it’s a program of exercise, education, and support to improvethe well-being and quality of life of patients with respiratory diseases, suchas COPD (chronic obstructive pulmonary disease).

At pulmonary rehabilitation,patients cooperate with a team of specialists who will help them improvephysical condition and manage of COPD, so that they will stay healthy andactive long after the completion of the course. The team mayinclude doctors, nurses, and specialists. Examples of specialists includerespiratory therapists, physical and occupational therapists, dietitians ornutritionists, and psychologists or social workers. Therehabilitation 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 setgoals.  Although it is focused on thepatient care, there is also the familyinvolvement. Pulmonaryrehabilitation is effective in all settings including hospital inpatient,hospital outpatient, the community, and the home (AARC Clinical PracticeGuideline, 2002).Outpatientprograms should contain a minimum of 6 weeks of physical exercise, diseaseeducation, psychological and social intervention with two supervised sessions andadditional 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, itcauses several physiological adaptations which can improve physical condition.There are three basic types of exercises to be considered.  Aerobic exercise tends to improvethe body’s ability to use oxygen by decreasing the heart rate and bloodpressure.

Strengthening or resistance exercises can help build strength in therespiratory muscles. Stretching and flexibility exercises can enhancebreathing coordination. Training should involve threesessions (20–30 minutes) per week and the intensity should usually be 60–70% ofmaximal oxygen consumption. Sinceexercise usually causes shortness of breath, it is suggested for patients tostart in slow pace and gradually increase the level of exercise, under thesupervision of health care professionals. During exercise, there is monitoringof oxygen level, heart rate and blood pressure for safety purposes and supplementary oxygen can be provided when necessary. Additionally pursedlip breathing can be used to increase oxygen level in patient’s body (Morgan, 2001).

 People with COPD who are underweight can improve their respiratory musclestrength by increasing their calorie intake and regular exercise (Ferreiraet al, 2012). Patient education is, also, a centralfeature of pulmonary rehabilitation. Areas commonly covered by the educationcomponent are: anatomy, physiology, pathology and pharmacology, nutritionaladvice, managing travel, anxiety management, goal setting andrewards, relaxation, exacerbation management and the benefits of physicalexercise. Psychologicalintervention is very important in rehabilitation programs, in order to overcomefeelings of depression and anxiety that may halt the patient’s progress. Theseinterventions are carried out by professional psychologists and consist ofproper education, small group discussions, and relaxation therapy (Morgan, 2001). The clinical improvement inoutcomes due to pulmonary rehabilitation is measurable with various toolsmonitoring all aspects of a patient’s improvement eg physical function, dyspnea and handicap. The central aimof rehabilitation is to increase function and there are an increasing number ofquestionnaires of functional status, such as the Pulmonary Functional StatusScale (PFSS) and Pulmonary Functional Status and Dyspnoea Questionnaire (PFSDQ).

The physical function assessment is also measured with field based exercisetests such as the timed 6 minute walk test (6MWT) or the shuttle walking test(SWT). A measure of dyspnoea or fatigue (VASor Borg scales) alongside exercise testing should be, also, considered toincrease the sensitivity of exercise measurements. Handicap or the socialimpact of disease, can be assessed using health status measures, such as theShort Form-36 (SF-36), Quality of Well Being Scale (QWB) and the PsychosocialAdjustment to Illness Scale-Self Report (PAIS-SR). Finally, as domesticindependence is an important goal of rehabilitation, this can be reflected bystandardised activity of daily living (ADL) scales (Morgan, 2001).