A 40-years-old female underwent lobectomy for bronchiectasis and lung

A 40-years-old female underwent lobectomy for bronchiectasis and lung carcinoma. She's in the immediate postoperative period with chest drain in suite. Describe the postoperative physiotherapy management and assessment.

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Postoperative Physiotherapy Management and Assessment Following Lobectomy (Chest Drain In Situ)

This 40-year-old female has undergone lobectomy for both bronchiectasis and lung carcinoma - two conditions with significant implications for her respiratory reserve and secretion burden. She presents with a chest drain in situ, which is standard following any lung resection to drain fluid/air and allow re-expansion of the remaining lung. The goals of physiotherapy are to prevent pulmonary complications, promote lung re-expansion, manage secretions, restore function, and facilitate safe early mobilization.

I. POSTOPERATIVE PHYSIOTHERAPY ASSESSMENT

Before initiating any treatment, a structured assessment must be completed. This is done at the bedside with the chest drain in situ.

A. Chart Review (Pre-assessment)

Type and extent of lobectomy (which lobe resected - affects side-lying positions)
Intraoperative findings and any complications
Anaesthetic technique, duration of ventilation
Preoperative lung function (FEV1, DLCO - important given dual pathology)
Pre-existing bronchiectasis location and sputum burden
Pain score and current analgesia regime (epidural, PCA, intercostal block)
Fluid balance and haemodynamic stability
Drain type: pleural drain (water seal or digital drain), output volume, and character (serous, haemosanguinous, presence of bubbling/swinging)
Current oxygen requirements and SpO2 targets

B. Subjective Assessment

Pain: site, severity (NRS/VAS 0-10), nature (incisional, pleuritic, referred shoulder tip)
Breathlessness: severity at rest and on movement (Borg scale or MRC)
Sputum: ability to cough effectively, sputum colour/consistency/quantity
Ability to comply with treatment

C. Objective Assessment

1. Respiratory Assessment

Respiratory rate and pattern: tachypnoea (>20 bpm), shallow breathing, use of accessory muscles, paradoxical breathing
SpO2 on current FiO2: target typically SpO2 ≥94% (lower if known CO2 retainer)
Auscultation:
- Reduced air entry - expected on operated side (removed lobe, residual fluid, pain splinting)
- Crackles: secretion retention vs. pulmonary oedema
- Wheeze: bronchospasm (especially relevant given pre-existing bronchiectasis)
- Absent breath sounds: check for pneumothorax or significant collapse
Cough assessment: voluntary cough strength - effective (generates flow to clear secretions), weak, or absent
Sputum: colour (clear/white = normal; yellow/green = infection; pink/frothy = oedema; blood-stained = post-surgical), amount, viscosity

2. Cardiovascular/Haemodynamic Assessment

Heart rate, blood pressure, rhythm (atrial fibrillation is a common post-lobectomy complication)
Temperature: rising temperature at 24-48 hrs may indicate atelectasis or early infection

3. Chest Drain Assessment

Swinging (fluctuation with breathing) - indicates patent drain
Bubbling: continuous = air leak; intermittent = expected after lung resection, should reduce over time; cessation = drain blocked or lung re-expanded
Volume and character of drainage
Position of drain (apical for air, basal for fluid)
Ensure drain is not clamped during physiotherapy (unless directed by surgical team for specific reason)
Suction vs. water-seal status

4. Musculoskeletal/Functional Assessment

Chest wall mobility and expansion: measure with tape or observe symmetry
Shoulder girdle mobility on operated side (thoracotomy or VATS wound restriction)
Ability to perform active limb movements
Posture: tendency to lean toward operated side
Current level of mobility: bed-bound, sitting out, standing
IV lines, arterial lines, catheter - note and plan safe mobilization

5. Pain Assessment

Thoracotomy pain significantly inhibits deep breathing, coughing, and mobilization - this is the most important barrier to effective physiotherapy
Assess whether analgesia is adequate before physiotherapy
Note if splinting the wound with a pillow during coughing has been taught

II. POSTOPERATIVE PHYSIOTHERAPY MANAGEMENT

A. Pain Management (Prerequisite to All Physiotherapy)

Adequate analgesia must be confirmed before physiotherapy begins. As noted in Fishman's Pulmonary Diseases and Disorders, "Adequate analgesia should be provided, particularly for patients undergoing major, open surgery... alternative approaches, including use of epidural analgesia, peripheral nerve blockade, paravertebral block, and wound catheter infiltration may be employed as alternatives to systemic opioids." - Fishman's Pulmonary Diseases, p. 1826

Liaise with the anaesthetic/surgical team if pain is inadequately controlled
Time physiotherapy sessions 30-60 minutes after analgesia administration
Teach wound splinting: patient presses a pillow/rolled towel firmly over the incision site during coughing and moving

B. Airway Clearance and Secretion Management

Particularly important in this patient given her pre-existing bronchiectasis, which causes chronic excessive secretion production even before the surgical insult.

1. Active Cycle of Breathing Technique (ACBT)

The primary tool for secretion clearance in the postoperative thoracic patient:

Breathing Control (BC): gentle, relaxed, lower chest breathing at tidal volume - used to rest between active phases
Thoracic Expansion Exercises (TEE): 3-4 deep, relaxed breaths with passive expiration - mobilises secretions, helps re-expand dependent lung areas
Forced Expiratory Technique (FET / Huffing): a forced expiration from mid- to low-lung volume through an open glottis - more effective and less distressing than formal coughing; generates sufficient flow to clear secretions without the extreme pressure swings of a cough

2. Supported / Assisted Coughing

Teach the patient to hug a pillow firmly against the wound before coughing (wound splinting)
For ineffective cough: provide manual thoracic support/compression by the physiotherapist
For very weak cough: consider assisted cough techniques (manual rib springing)

3. Postural Drainage (Modified)

Position adjustments to use gravity to facilitate secretion drainage from specific lobes
Important caveat with chest drain in situ: avoid positions that put the drain entry site dependent or that risk drain dislodgement. Inform the nursing team of positions used.
Avoid steep head-down positions in the immediate postoperative period
Side-lying toward the non-operated side can facilitate drainage from the remaining lung segments on the operated side

4. Manual Techniques

Percussion/clapping (if tolerated): rhythmic clapping over the chest wall to loosen retained secretions - avoid directly over the wound site or chest drain
Vibrations: applied during expiration - transmits energy to small airways to mobilise secretions

5. Humidification

If secretions are thick and tenacious (common in bronchiectasis), nebulized saline (0.9% or hypertonic 3-7%) can be used before airway clearance to reduce viscosity and facilitate expectoration

C. Lung Expansion Strategies

The primary goal is to prevent or treat atelectasis, which is the most common postoperative respiratory complication following thoracic surgery.

As summarized in Murray & Nadel's Textbook of Respiratory Medicine: postoperative interventions include "Early and frequent ambulation/mobilization; Lung expansion maneuvers (cough/deep breathing exercises, IS, IPPB, CPAP); Adequate pain control." - Murray & Nadel's, p. 2770

1. Deep Breathing Exercises (DBE)

Instruct patient to take slow, maximal inspiratory breaths, hold briefly at full inspiration (inspiratory hold, 2-3 seconds), then allow passive expiration
Frequency: 5-10 breaths, 4-6 times/day minimum
Goal: recruit collapsed alveoli, increase functional residual capacity (FRC), and improve V/Q matching

2. Incentive Spirometry (IS)

Provides visual feedback on inspiratory effort
Patient breathes in slowly and deeply through the device, aiming to sustain flow/volume at a target level
Fishman's notes that "deep breathing exercises and incentive spirometry" are "two equally effective measures" for prophylactic lung expansion - Fishman's p. 1826
Useful particularly when the patient is performing exercises independently

3. CPAP / NIV

Reserved for patients who cannot cooperate with inspiratory maneuvers, or those developing respiratory failure
Can be applied by face mask intermittently
As per Fishman's: "CPAP may be useful in the patient who cannot cooperate with inspiratory maneuvers"

D. Early Mobilization

This is a cornerstone of postoperative care.

"Early patient mobilization and ambulation should be encouraged... these measures are important postoperatively in reducing the incidence of atelectasis, in promoting the clearance of secretions, and in decreasing the risk of thromboembolic disease." - Fishman's Pulmonary Diseases, p. 1826

Progression of mobilization (with drain in situ - use a portable drain bag/bottle):

Timeframe	Mobility Goal
Day 0-1 (immediate postop)	Sitting upright in bed, active limb exercises (ankle pumps, knee/hip flexion), bed-to-chair transfer with assistance
Day 1-2	Sitting out of bed in a chair, stand at bedside, short supervised walks
Day 2-3	Increasing walk distances along the ward corridor
Day 3+	Independent mobility, stair practice before discharge

Key points for mobilization with chest drain in situ:

Ensure drain bottle is kept below the level of the patient's chest at all times (to prevent fluid back-flow)
Never lift the drain bottle above chest level
Ensure tubing is not kinked or pulling
Use a long enough tube/portable stand to allow comfortable walking
Monitor SpO2, HR, RR, and pain during all mobilization

E. Shoulder and Thoracic Mobility

Following thoracotomy (or even VATS), wound pain and chest drain discomfort lead to ipsilateral shoulder guarding and restricted thoracic expansion.

Active shoulder exercises: shoulder shrugs, arm raises, shoulder circles from day 1-2 postoperatively
Thoracic expansion exercises: bilateral deep lateral costal breathing with hands on lower ribs to facilitate full chest wall movement
Posture correction: encourage upright posture; patients tend to hunch toward the operated side
Aim for full shoulder elevation on the operated side before discharge

F. DVT Prophylaxis

Active and passive leg exercises from day 0
Early ambulation
TED stockings and pharmacological prophylaxis per surgical team protocol
This is especially relevant in a patient with lung carcinoma, who is at higher thrombotic risk

G. Patient Education

Key educational points to reinforce throughout the admission:

Importance of deep breathing and coughing regularly (every 1-2 hours while awake)
Wound splinting technique for coughing
Recognizing and reporting increasing breathlessness, fever, purulent sputum, or wound changes
Home exercise programme prior to discharge
Avoiding lifting or strenuous activities until wound healed (6-8 weeks post-thoracotomy)

III. MONITORING AND RED FLAGS

During and after each physiotherapy session, monitor:

SpO2 (stop if falls below safe threshold)
HR and RR (stop if tachycardia >120 or RR >30)
Pain score (treatment should not worsen pain significantly)
Drain bubbling: increased bubbling during deep breathing is expected; massive continuous bubbling may indicate large air leak
Haemoptysis or blood-stained sputum in large amounts - stop and report

Precautions specific to this patient:

Bronchiectasis: higher baseline secretion load, increased infective risk - aggressive secretion clearance is warranted
Lung carcinoma: heightened VTE risk; fragility of remaining lung tissue post-resection
Chest drain in situ: all mobilization and position changes must account for safe drain management

Summary Framework

Phase	Priority
Immediate (0-24 hrs)	Pain assessment, positioning, DBE, wound splinting, limb exercises
24-48 hrs	Add ACBT + huffing, sit to stand, short walks with drain
48-72 hrs	Progress mobilization distance, shoulder exercises, IS
72 hrs+	Functional independence, stair practice, discharge planning

Supporting Evidence: A 2021 systematic review and meta-analysis (Mao et al., Front Surg, PMID 34646857) confirmed that pulmonary rehabilitation reduces postoperative complications and mortality following lung cancer resection. A 2021 meta-analysis (Bibo et al., Interact Cardiovasc Thorac Surg, PMID 33907813) found preoperative physiotherapy and rehabilitation programmes improve patient outcomes following lung resection.

Sources: Fishman's Pulmonary Diseases and Disorders, p. 1825-1826; Murray & Nadel's Textbook of Respiratory Medicine, p. 2768-2778

"A 45 years old sedentary male, three weeks after myocardial infarction, is referred to physiotherapy for rehabilitation. Outline the principle of exercise, prescription and home exercise program."

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Exercise Rehabilitation After Myocardial Infarction - Phase II (3 Weeks Post-MI)

This 45-year-old sedentary male presenting 3 weeks post-MI is at the classic entry point for Phase II (outpatient) cardiac rehabilitation. Being sedentary at baseline is both a cardiovascular risk factor and a consideration for lower initial exercise tolerance - the program must begin conservatively and progress systematically.

I. BACKGROUND: WHAT IS CARDIAC REHABILITATION?

Cardiac rehabilitation (CR) is a clinically proven, multidisciplinary exercise training and secondary prevention program. As stated in Fuster & Hurst's The Heart: "Cardiac rehabilitation is a clinically proven, multidisciplinary exercise training and risk factor modification program that enhances survival, reduces the risk of recurrent cardiac events, and improves physical and psychological well-being."

It comprises five core competencies:

Aerobic and resistance exercise training
Risk factor modification (hypertension, dyslipidaemia, diabetes, obesity, smoking)
Patient education
Dietary counselling
Psychosocial intervention

Standard program structure: 36 supervised sessions, delivered 2-3 sessions per week over 12-18 weeks. - Fuster & Hurst's The Heart, 15th ed., p. 714

II. PHASES OF CARDIAC REHABILITATION

Phase	Setting	Timing	Focus
Phase I (Inpatient)	Hospital ward	Acute admission (Days 1-5)	Mobilization, education, discharge planning
Phase II (Outpatient - Supervised)	Rehab centre	2-12 weeks post-MI	Structured monitored exercise; this patient's current phase
Phase III (Supervised community)	Community gym/clinic	3-6 months	Independent exercise, risk factor control
Phase IV (Maintenance)	Independent	Long-term	Lifelong active lifestyle

III. PRE-EXERCISE ASSESSMENT (Phase II Entry)

Before prescribing exercise, a thorough assessment is mandatory.

A. Risk Stratification

Using AHA/AACVPR criteria to classify the patient as low, moderate, or high risk - this determines how closely he must be supervised:

Risk Category	Features
Low risk	Uncomplicated MI, EF >50%, no significant arrhythmias, no symptoms at moderate exercise
Moderate risk	Mildly impaired EF (40-49%), mild angina on moderate exertion
High risk	EF <40%, complex arrhythmias, recurrent ischaemia, cardiac arrest survivor

As a sedentary 45-year-old, his baseline fitness is low - he requires particular caution with initial exercise intensity even if objectively low-risk.

B. Pre-Exercise Testing

Resting ECG and blood pressure
Symptom-limited exercise test (ETT/stress test): ideally performed before starting Phase II. This establishes:
- Maximum heart rate (HRmax) achieved
- Ischaemic threshold (HR at which ST changes or angina begin)
- Blood pressure response to exercise
- Exercise capacity in METs
- Any arrhythmia provoked by exercise

As per Murray & Nadel's: "A joint position statement...stressed the importance of functional evaluation through exercise testing before starting an aerobic training program." - Murray & Nadel's Respiratory Medicine, p. 802

Echocardiography: left ventricular ejection fraction (LVEF), wall motion abnormalities
Current medications: beta-blockers (alter HR response), ACE inhibitors, antiplatelet agents
Fasting glucose, lipid profile, BMI

IV. PRINCIPLES OF EXERCISE IN CARDIAC REHABILITATION

These are guided by the classical FITT principle (Frequency, Intensity, Time, Type), adapted for the post-MI patient.

1. Safety Principle

Exercise must remain below the ischaemic threshold - defined as the heart rate at which ECG changes, angina, or haemodynamic instability appear on stress testing. Target training HR is set at 10 beats per minute below the ischaemic threshold.

2. Overload Principle

The exercise stimulus must progressively exceed the current capacity to produce physiological adaptation (improved cardiac output, VO2max, peripheral muscle efficiency). Load is increased gradually as the patient adapts.

3. Specificity Principle

Training adaptations are specific to the type of exercise performed. Aerobic (endurance) training improves cardiac output and VO2max; resistance training improves muscle strength and reduces the metabolic demand of daily tasks.

4. Reversibility Principle

Gains achieved through training are lost if exercise ceases. The home exercise programme ensures continuity between supervised sessions.

5. Individuality

Exercise prescription must be individualized based on the patient's functional capacity, co-morbidities, medications, baseline fitness (sedentary in this case), and psychosocial factors.

V. EXERCISE PRESCRIPTION - FITT FRAMEWORK

A. Intensity

This is the most critical and carefully managed parameter in post-MI exercise.

Methods of prescribing intensity:

1. Heart Rate Reserve (Karvonen Method) - Preferred

Target HR = Resting HR + (HRR × prescribed %) Where HRR = HRmax (from stress test) - Resting HR

Initial phase (weeks 1-4): 40-60% HRR (moderate intensity)
Progression phase (weeks 5-12): 60-75% HRR
Advanced phase (if tolerated): 70-85% HRR

Fuster & Hurst's notes: "Patients exercised over 36 sessions, with exercise intensity adjusted to maintain the training heart rate within 70% to 85% of the peak heart rate observed on the exercise test." - Fuster & Hurst's, p. 692

Important note for this patient: He is on a beta-blocker (standard post-MI therapy), which blunts the HR response. The maximum achievable HR will be lower than predicted by age. Always use the measured HRmax from stress testing, not the age-predicted formula (220 - age).

When baseline exercise test is unavailable: As per Fuster & Hurst's: "When a baseline exercise test is not performed, patients' initial target heart rate may be initiated at approximately 20 beats above the standing heart rate."

2. Rating of Perceived Exertion (RPE) - Borg Scale

Target: RPE 11-14 (range: "fairly light" to "somewhat hard") on the 6-20 scale
RPE 13 corresponds approximately to moderate intensity
Useful when HR response is blunted by beta-blockers

3. MET-based (Metabolic Equivalents)

Initial: 2-4 METs (walking at comfortable pace)
Progression to: 5-7 METs

4. Talk Test

A simple practical guide: the patient should be able to hold a conversation comfortably. If too breathless to speak, intensity is too high.

B. Frequency

Phase	Frequency
Week 1-2	3 sessions/week supervised + daily gentle walking at home
Week 3-8	3-5 sessions/week
Week 8+	5 sessions/week (3 supervised + 2 independent home)

C. Duration (Time)

The session must include three components:

Component	Duration	Purpose
Warm-up	5-10 min	Gradual HR increase, prevent arrhythmia, improve muscle blood flow
Aerobic training phase	Start: 15-20 min; Progress to 30-45 min	Main cardiovascular conditioning
Cool-down	5-10 min	Gradual HR recovery, prevent post-exercise hypotension and arrhythmia

The warm-up and cool-down are non-negotiable in cardiac patients. Abrupt onset or cessation of exercise dramatically increases arrhythmia risk.

Initial sessions for this sedentary patient may begin with only 10-15 minutes of aerobic work, building progressively by 1-5 minutes per session as tolerated.

D. Type of Exercise

1. Aerobic (Endurance) Training - Primary Mode

Low-impact, rhythmic, large muscle group activities:

Walking (first choice for home programme - accessible, controllable)
Stationary cycling (preferred if joint problems)
Swimming/pool walking (excellent - unloads joints, reduces cardiac afterload)
Treadmill
Rowing ergometer

Continuous steady-state exercise is the standard. High-intensity interval training (HIIT) - alternating short bursts of intense effort with recovery periods - has shown greater improvements in VO2max than continuous moderate exercise in selected stable patients. A 2022 systematic review and meta-analysis (Campos et al., Rev Cardiovasc Med, PMID 35229565) confirmed exercise-based cardiac rehabilitation after revascularization significantly improves functional capacity and reduces readmissions. However, HIIT is not appropriate in the early phase for this sedentary patient.

2. Resistance (Strength) Training - Adjunct (from ~4 weeks post-MI)

Light-to-moderate weight training with high repetitions (12-15 reps, 2-3 sets)
Reduces the metabolic demand of activities of daily life
Target major muscle groups: upper limbs, lower limbs, core
Avoid Valsalva manoeuvre (breath-holding during exertion - causes dangerous HR/BP spikes)
Avoid isometric exercises early on
Begin with resistance bands before free weights

3. Flexibility

Gentle stretching during warm-up and cool-down
Maintains joint range of motion, reduces injury risk

VI. MONITORING DURING EXERCISE

At every supervised session:

Continuous ECG monitoring in early Phase II (telemetry during exercise) - watch for ST changes, arrhythmias
Heart rate - ensure within target zone
Blood pressure - take at rest, mid-exercise, and post-cool-down
SpO2 if indicated
RPE (ask the patient at intervals)
Symptoms: chest pain, dyspnoea, dizziness, palpitations, claudication

Stop exercise immediately and rest/refer if:

Angina or chest tightness
HR >target zone or HR fails to rise appropriately
SBP >220 mmHg or falls >10 mmHg with increasing workload
New ST changes or significant arrhythmia on ECG
Severe breathlessness, dizziness, pallor, or syncope
RPE >15 ("hard")

VII. HOME EXERCISE PROGRAMME (HEP)

The home programme ensures that exercise continues between supervised sessions and forms the foundation for long-term, independent physical activity. For this sedentary patient, the home programme must be simple, achievable, and gradually progressive.

Phase II Home Programme (Weeks 1-6 Post-Referral)

Primary activity: Walking

Week	Duration	Frequency	Pace/Intensity
1-2	10-15 min	Daily	Slow, comfortable (RPE 10-11, "light")
3-4	15-20 min	Daily	Brisk walk, can hold conversation (RPE 11-12)
5-6	20-25 min	Daily	Moderate brisk pace (RPE 12-13)
7-8	25-30 min	5-6 days/week	Moderate (RPE 13)
9-12	30-45 min	5 days/week	Moderate-brisk (RPE 13-14)

Session structure at home (each walk):

5 minutes slow warm-up walking
Target aerobic walk (as per table above)
5 minutes slow cool-down walking
Gentle stretches (calves, hamstrings, quadriceps, shoulders) - hold 20-30 seconds each

Key instructions for the patient:

Always carry GTN spray in case of angina during exercise
Do not exercise if feeling unwell, feverish, or if resting HR is >100 or <50 bpm
Do not exercise in extreme heat/cold without acclimatization
Avoid strenuous activity immediately after a large meal (wait 1-2 hours)
If you miss 2 or more days, drop back one week's level before progressing
Walk on flat, even surfaces initially
Never exercise alone in the early weeks - walk with a partner or in a public area
Record your walks in a diary (time, distance, how you felt, resting HR)

Phase III Home Programme (Weeks 12+ / Maintenance)

Goal: 150-300 minutes of moderate-intensity aerobic exercise per week (WHO/AHA guidelines for CVD secondary prevention)

Continue walking (30-45 min, 5 days/week)
May progress to: jogging intervals, cycling, swimming
Add light resistance training 2 days/week (resistance bands, bodyweight exercises)
Warm-up and cool-down maintained lifelong

VIII. SECONDARY PREVENTION - ACCOMPANYING MEASURES

Exercise prescription is only one component. The physiotherapist reinforces and coordinates with the team on:

Component	Goal
Smoking cessation	Complete and permanent cessation
Diet	Mediterranean-style diet, reduced saturated fat, increased omega-3, calorie restriction if overweight
Weight management	Target BMI <25 kg/m²
Blood pressure control	Target <130/80 mmHg
Lipid management	LDL <1.8 mmol/L; medication compliance (statins)
Medication adherence	Beta-blocker, ACE inhibitor, antiplatelet, statin - reinforce rationale
Psychosocial support	Screen for depression/anxiety (common post-MI, affects adherence); refer to psychologist/counsellor if needed
Return to work	Typically 4-8 weeks post-MI for desk work; 8-12 weeks for physical work

IX. CLINICAL BENEFITS OF CARDIAC REHABILITATION

This evidence base justifies the program and helps motivate adherence:

From Fuster & Hurst's (evidence-based summary):

Reduced cardiac death and MI recurrence
Reduced all-cause mortality
Reduced hospitalisations and healthcare costs
Improved quality of life, reduced depression and anxiety
"Older adults with CHD who participated in supervised CR experienced 21% to 34% lower mortality than non-users over the subsequent 5 years." - Braunwald's Heart Disease, p. 3013

A 2025 network meta-analysis (Yu et al., Front Cardiovasc Med, PMID 41246009) compared exercise modalities post-MI, finding combined aerobic and resistance training offers the greatest improvement in cardiac function. A 2025 systematic review (Zhang & Lin, Curr Probl Cardiol, PMID 39571837) confirmed CR reduces major adverse cardiac events following acute MI.

X. BARRIERS AND SPECIAL CONSIDERATIONS FOR THIS PATIENT

This patient is sedentary - this is both a risk and an opportunity:

Start lower, progress slower than a previously active patient
Initial exercise tolerance may be very limited (METs 2-3)
Strong motivation through early education on the benefits is essential
Gradual success at achievable targets builds self-efficacy and long-term adherence

Fuster & Hurst's notes that "Cardiac rehabilitation can be particularly helpful in catalysing physical activity and wellness in adults who are sedentary amidst illness, deconditioning, and entrenched behaviour patterns."

Sources: Fuster & Hurst's The Heart, 15th ed., pp. 689-695 (Chapter 22); Braunwald's Heart Disease, 2-vol set, p. 3012-3013; Murray & Nadel's Textbook of Respiratory Medicine, pp. 802-803

Physiotherapy management for coronary artery disease and inpatient rehabilitation, seven step MI program. Physiotherapy management for coronary artery disease and inpatient rehabilitation, seven-step MI program.

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