Physiotherapy Management After Exploratory Laparotomy

(CVTS - Cardio-Vascular & Thoracic Surgery Context | 10 Marks)

Introduction

Goals of Physiotherapy

1. Prevention and management of post-operative pulmonary complications (PPCs) - atelectasis, pneumonia, pleural effusion
2. Airway clearance and secretion removal
3. Pain management to enable therapeutic breathing
4. Prevention of DVT and pulmonary embolism
5. Early mobilization and restoration of functional independence
6. Prevent post-operative respiratory failure

Phase-wise Physiotherapy Management

Phase 1 - Preoperative (Before Surgery)

(Fishman's Pulmonary Diseases & Disorders, Table 102-8)

Phase 2 - Immediate Post-operative (ICU / Day 0-2)

A. Breathing Exercises

• Diaphragmatic / abdominal breathing
• Instruct patient to take slow, maximal inspiratory breath, hold 2-3 seconds, then exhale
• 10 repetitions every 1-2 hours while awake
• Reduces atelectasis and promotes alveolar recruitment

• Flow-oriented or volume-oriented device
• Patient inhales slowly and deeply, sustaining the inspiratory effort
• Equally effective as DBE; used every 1-2 hours
• Incorporated in the I COUGH protocol (see below)

• Applied via face mask when patient cannot cooperate with inspiratory maneuvers
• Application immediately post-extubation, continued for ≥1 hour, significantly reduces PPCs after major abdominal surgery (OR 0.37; 95% CI 0.24-0.56)
• Most useful in high-risk, non-cooperative patients

• Reserved for patients unable to perform IS or DBE
• Associated with side effects (abdominal distension); generally not first-line

B. Coughing Techniques

• Assisted / Supported coughing: Patient holds pillow or therapist's hands firmly against wound before coughing ("huffing" technique)
• Huff coughing (Forced Expiration Technique - FET): Two or three huffs from mid-lung volume to clear peripheral secretions, preventing wound pain compared to explosive cough
• Performed after bronchodilator nebulization if secretions are present

C. Airway Clearance Techniques

• Postural drainage: Positioning to drain specific lung segments using gravity
• Manual chest percussion and vibration: Applied over thorax during expiratory phase to loosen retained secretions
• Active Cycle of Breathing Technique (ACBT): Combines relaxed breathing, thoracic expansion exercises, and FET
• Nasopharyngeal suctioning: If patient unable to cough effectively (early post-op)

D. Pain Management

• Coordinate chest physiotherapy after analgesic dosing (peak effect)
• Epidural analgesia, peripheral nerve blocks, or paravertebral blocks preferred over systemic opioids (reduce respiratory depression)
• Minimization of systemic opioids; maximize non-opioid analgesia (paracetamol, NSAIDs, ice application)

E. Positioning

• Semi-recumbent positioning (head of bed elevated 30-45°): Reduces aspiration risk, improves diaphragmatic excursion
• Side-lying/lateral positioning: Assists in dependent lung drainage
• Avoid prolonged supine position

Phase 3 - Early Mobilization (Day 1-5)

• Day 1: Sitting up in bed, dangling legs, active limb exercises (ankle pumps, knee bends)
• Day 2: Sit out of bed in chair, standing with support
• Day 3 onwards: Supervised ambulation, increasing distance daily

• Increases FRC and tidal volume by reversing diaphragmatic splinting
• Promotes secretion clearance
• Reduces risk of DVT and pulmonary embolism (thromboprophylaxis)
• Reduces hospital length of stay

The I COUGH protocol (Murray & Nadel's Respiratory Medicine, Table 34.6) summarizes best practices:

Phase 4 - Circulatory / Peripheral Vascular Exercises

• Ankle-toe pumps (calf muscle pump): 10-15 repetitions per hour, prevents venous stasis
• Active limb exercises: Hip and knee flexion/extension while in bed
• Compression stockings / TED stockings: Applied from Day 0
• Intermittent pneumatic compression (IPC) devices: Used in high DVT-risk patients

Phase 5 - Progressive Rehabilitation (Day 5 onwards / Discharge Phase)

• Progressive ambulation: corridor walking, stair climbing
• Core muscle and diaphragm strengthening exercises
• Abdominal breathing re-education (avoid breath-holding)
• Patient education on: wound care, activity restrictions, return to normal function
• Scar tissue mobilization (abdominal scar massage after wound healing)
• Fitness/walking programs as home exercise

Complications the Physiotherapist Monitors For

Contraindications / Precautions

• Unstable hemodynamics (avoid mobilization if HR >120 or SBP <90)
• Unsecured drains / surgical sites in fragile state
• Active internal bleeding
• Severe pain not yet controlled
• Respiratory failure requiring ventilator dependence

Summary Table

Key Points for Exam

1. Upper abdominal surgery (laparotomy) carries the highest risk of PPCs among abdominal surgeries (9-40% incidence).
2. Deep breathing exercises and incentive spirometry are equally effective for lung expansion - both are first-line.
3. CPAP post-extubation significantly reduces PPCs (OR 0.37) in abdominal surgery patients.
4. Early mobilization (getting out of bed) is the single most impactful intervention.
5. Pain management must be addressed FIRST - undertreated pain defeats all respiratory physiotherapy efforts.
6. The I COUGH protocol is a validated pulmonary risk reduction bundle that physiotherapists implement.
7. Chest physiotherapy WITHOUT excessive secretions has NOT been shown to reduce PPCs - it is secretion-driven, not routine.