Surgical Management of Cardio & Pulmonary Disorders

Question 1

What is a Thoracotomy?

Answer 1

Surgical procedure = incision made between the ribs to access the lungs or other structures of the thorax

Examples: Pneumonectomy, lobectomy, lung reduction surgery, single-lung transplant, some double-lung transplants

Approach = anterior, lateral, posterior

Question 2

Possible Complications of thoracotomy include:

Answer 2

phrenic nerve laceration

complete motor innervation to the diaphragm and sensation to the central tendon aspect of the diaphragm

Question 3

PT implications of thoracotomy include:

Answer 3

Chest tubes, Chest PT, Thoracotomy side shoulder ROM, Breathing Re-training, Incentive spirometry, Bed mobility, Transfers, Early progressive ambulation

Question 4

Pneumonectomy =

Answer 4

Surgical removal of one lung

Question 5

Most common reasons for Pneumonectomy:

Answer 5

Lung Cancer
Congenital abnormalities
Traumatic lung injury
Chronic lung infection = tuberculosis, fungal infections, abscesses

Question 6

Thoracocentesis =

Answer 6

A technique used to remove fluid or air from the pleural space

It can be used as both a diagnostic tool and a therapeutic intervention

Typically used with ultrasonography to pinpoint location, and effectiveness of treatment

Question 7

Most common reasons for Thoracocentesis:

Answer 7

Large pleural effusions
Heart failure
Liver cirrhosis
Nephrotic syndrome

Question 8

Pleural effusion =

Answer 8

excess amount of fluid around the lung in the pleural cavity

Question 9

Medical Surgical Management: Thoracic Surgical Procedures

Answer 9

Posterolateral Thoracotomy Muscles Impacted

Lung Volume Reduction Surgery (LVRS)

Video-assisted thoracoscopic surgery (VATS)

Question 10

Posterolateral Thoracotomy Muscles Impacted:

Answer 10

Latissimus Dorsi, Serratus, Rhomboid Major

Question 11

Lung Volume Reduction Surgery (LVRS):

Answer 11

used for the treatment of pulmonary malignancy, infection, and trauma

used to diagnose pulmonary disease

Question 12

Video-assisted thoracoscopic surgery (VATS):

Answer 12

a minimally invasive surgical technique used to diagnose and treat pulmonary conditions, thoracoscope used for image, small surgical instruments used via a small incision in the chest wall

VATS -> aortic procedures, aortic valve replacement (AVR)

Question 13

VATS Surgical Approach

Answer 13

• Less surgical time/less anesthesia time
• Less painful
• Smaller wound = decreased chance of wound infection
• Faster recovery/shorter hospitalization
• Less invasive internally

Question 14

Anterolateral Thoracotomy Muscles Impacted:

Answer 14

Pectoralis Major/Minor, Serratus Anterior

Commonly used for cardiac procedures, pulmonary resections, esophageal procedures

Question 15

Lateral Thoracotomy Muscles Impacted:

Answer 15

Latissimus Dorsi, Serratus Anterior, Obliques, Pec Major

Commonly used for pneumonectomy, lobectomy, wedge resection

Question 16

Chest Tubes =

Answer 16

Fluid or Air Removal:

Placed between ribs = Pleural space between parietal & visceral layers

Used post-surgical for air and fluid removal

Pneumothorax = creates a negative pressure for air removal

Question 17

Chest tube placement =

Answer 17

through the chest wall to drain intra-pleural fluid or blood in the chest post thoracic surgery or chest trauma

Question 18

Jackson-Pratt Drain (JD)

Answer 18

placed in wounds during surgery to prevent the collection of fluid underneath the incision site or used for persistent fluid leaks after surgery

closed, air-tight drainage system which operates by self-suction

drain(s) promote healing by keeping excess pressure off the incision and decreasing the risk of infection.

Question 19

Lung Bullectomy =

Answer 19

Bullectomy: surgical removal of a bullae, which is a dilated air space in the lung parenchyma measuring more than 1 cm

Most common cause of a lung bulla is chronic obstructive pulmonary disease

Question 20

Lung Volume Reduction Surgeries (LVRS) =

Answer 20

Surgical treatment for the symptoms of emphysema in which approximately 30% of the damaged lung tissue is removed in an attempt to improve the mechanics of respiration

Surgery is generally performed by either a median sternotomy or video-scope assisted thoracoscopy (VATS)

Question 21

Optimization of Diaphragm after LVRS =

Answer 21

Reduces lung volume, improves elastic recoil

Results in a less expanded thoracic cage, improved mechanical function of the muscles of respiration, particularly the diaphragm and the mobility of the rib cage

With removal of localized emphysematous areas, lung expansion & recoil of more normal lung tissue may occur = improving ventilation/ perfusion

Question 22

Lung Transplant Candidates =

Answer 22

FEV1 < 30%

Have a condition for which lung transplant is considered an effective treatment

Have severe/progressive lung disease that no longer responds to medical tx

Be physically capable of undergoing surgery and subsequent treatments

Stopped smoking or abusing alcohol, drugs—including pain meds

Have adequate financial resources

Have an acceptable support system

Motivated/compliant with therapy

Question 23

Lung Transplant =

Answer 23

‘Clamshell’ incision = Bilateral thoracotomies

Question 24

Lung transplant PT Implications:

Answer 24

Splinted cough, bilateral shoulder ROM, Chest PT, Breathing exercises  diaphragm & rib cage mobility, Incentive spirometry, Bed mobility, Transfers, Posture, day 1 ambulation

Question 25

The primary indication for heart or lung transplantation is =

Answer 25

terminal cardiopulmonary disease

Question 26

Heart and Lung Transplantation indication =

Answer 26

Combined heart-lung transplantation remains the only definitive therapy for patients who have both end-stage heart failure and end-stage lung failure Most common indication is congenital heart disease (CHD) followed by idiopathic pulmonary arterial hypertension (IPAH)

Question 27

Donor Organs =

Answer 27

The availability of donor organs dictates the pace of the transplant The list of candidates awaiting transplantation is maintained by the United Network for Organ Sharing (UNOS) Pharmacological agents are used to medically manage organ transplant candidates until a donor organ is available Donor organs are matched to the recipient using a specific organ allocation system

Question 28

Candidates for transplantation are evaluated by a transplantation team member and must meet certain eligibility criteria =

Answer 28

Cardiopulmonary Exercise Test is primary indicator used to guide transplant listing Patients eligible are classified as: Class I, IIa, IIb, III based primarily on CPET along with other factors such as ventilation status, obesity, age A Physical Therapist evaluates the patients cardiac and/or pulmonary system limitations as well as musculoskeletal condition, exercise capacity, ventilator function, and mucociliary clearance

Question 29

Preoperative rehabilitation program: (heart and lung transplantation)

Answer 29

Patient and family education Cardiovascular endurance training Musculoskeletal strength Flexibility training Breathing retraining

Question 30

The goal of the pre-operative rehabilitation, is to:

Answer 30

improve or prevent deterioration of the candidate’s physical condition and to assure the ability to increase post-operative physical function

Question 31

Factors considered when an organ becomes available:

Answer 31

Blood type Body size: within 10% Medical urgency Survival Location of donor and recipient UNOS

Question 32

UNOS computer system generates a “match run” =

Answer 32

a rank-order list of candidates to be offered each organ

Question 33

Organ preservation time:

Answer 33

kidney = 24-36 hours pancreas = 12-18 hours liver = 8-12 hours heart/lung = 4-6 hours

Question 34

Heart-Lung Transplant Procedure - donor

Answer 34

No significant valvar stenosis or insufficiency Chest X ray free of significant infiltrate Free of systemic infection No evidence of malignancy

Question 35

Heart-Lung Transplant Procedure - recipient

Answer 35

Sternotomy Cardiopulmonary bypass Heart excised followed by each lung leaving the main stem bronchus intact Donor heart-lung bloc placed Aortic, inferior vena cavam superior vena cava anastomosis Considerable time taken to weak patient form bypass and initiate ventilation to allow for homeostasis

Question 36

Heart-Lung Bypass Machine =

Answer 36

pump returns oxygenated blood to the aorta and delivers it to the rest of the body Functions as the heart and lungs during surgery Maintains circulation of blood and oxygen Maintains appropriate temperature Bloodless field for thoracic surgery

Question 37

Reasons for Lung Transplant =

Answer 37

COPD Pulmonary fibrosis Pulmonary hypertension Cystic fibrosis

Question 38

Lung transplant post-op care =

Answer 38

ventillatory support hemodynamic monitoring immunosuppressive therapy monitor for s/s of infection and rejection emotional support

Question 39

First 3 months post lung transplant =

Answer 39

ICU -> P Rehab -> Home Health -> OP Rehab Close daily to weekly monitoring by lung transplant team

Question 40

Domino effect Heart and Lung Transplantation =

Answer 40

donor = deceased patient 1 = has malformed but viable heart and bad lungs patient 2 = has a bad heart donor heart and lungs given to patient 1 old heart from patient 1 given to patient 2

Question 41

Common Immunosuppressants =

Answer 41

Azathioprine Basiliximab Belatacept Prednisone

Question 42

Immunosuppressive medications are used to:

Answer 42

prevent rejection and infection

Question 43

Acute rejection =

Answer 43

both cellular and/or antibody mediated occur when the immune system is not adequately suppressed, thus causing inflammation that can damage the new tissue over time

Question 44

For all thoracic transplant patients, vital signs should be monitored:

Answer 44

Hemodynamic Response = heart rate, BP, RR, RPE, SpO2 and/or SaO2 Heart rate of a heart transplant recipient will not increase linearly with activity progression secondary to denervation

Question 45

Cardiac Denervation =

Answer 45

Disappearance of neural input to the sinoatrial node Loss of efferent and afferent nerve signaling into and out of the heart = Heart Transplant recipients unable to experience the sensation of angina due to ischemia Loss of ventricular sensory input = hypotension and bradycardia Potential impact on inotropic responses = decreased strength of heartbeat

Question 46

Exercise capacity in denervated HTx recipients seems to be diminished =

Answer 46

denervated hearts must rely on circulating catecholamine to adjust to increased needs of exercise HR increases more slowly than normal to reach a lower maximal HR HR decrease during recovery from exercise at a slower than normal rate Abnormal cardiac output (CO) response to exercise

Question 47

Exercise prescription for a patient after heart transplantation =

Answer 47

critical to have a sufficient warm-up and cool-down period to allow the denervated heart to accommodate to the change in activity level and maintain cardiac output This accommodation occurs during the warm-up phase by an increase in stroke volume provided by the contracting muscles of the new heart and by increases in circulating catecholamines (a type of inotrope) Breathing and pacing exercises to allow for increased gas exchange in lung transplant pts

Question 48

Inpatient treatment and goals =

Answer 48

focus on improving impaired gas exchange, ineffective airway clearance, patient positioning, pain reduction, and reducing mobility restrictions

Question 49

Outpatient treatment and goals =

Answer 49

focus on strengthening large skeletal musculature, weight-bearing exercise, continues aerobic conditioning, resolution of any musculoskeletal problems, home exercise program, education and independence with self-monitoring

Question 50

The Physical Therapist should be alert for transplant complications, which can often manifest themselves initially in the exercise response:

Answer 50

decrease in SaO2/SpO2 reduced exercise tolerance = SOB, dizziness, fatigue abnormal increase/decrease in HR or RR

Question 51

Frequent complications of the transplant patient include:

Answer 51

rejection, infection, steroid myopathy, osteoporosis, and malignancy

Question 52

Surgical Management of CHF =

Answer 52

Cardiac Transplantation Left Ventricular Assist Device (LVAD) Cardiomyoplasty

Question 53

Left Ventricular Assist Device (LVAD) =

Answer 53

Successfully used as an alternative to cardiac transplantation Used for patients with end-stage heart failure who are not candidates for cardiac transplantation Mechanical pump that typically assists the LV, can be used to assist the RV Used to bridge a patient waiting for a heart transplant = not available, patient not strong enough

Question 54

Research to date has shown that exercise testing and training for patients with an LVAD =

Answer 54

are safe and effective in improving physiologic and functional status

Question 55

Cardiomyoplasty: Left or Right Ventricular Muscle Flaps

Answer 55

Latissimus dorsi or trapezius muscle > wrap around LV/RV > attached to a pacemaker > pacemaker stimulates flap to contract > contracts the LV/RV major problem = muscle fatigue

Question 56

General Post-Operative Issues =

Answer 56

General Anesthesia: anaphylaxis, aspiration, peripheral nerve damage, nausea and vomiting, respiratory distress, hypoxic tissue damage Blood & Fluid Loss Blood Transfusion Pain Infection Chest tubes Mobility

Question 57

Post-Surgical Observation

Answer 57

Incisional care = Watch for redness, drainage, edema, heat