If a patient's respiratory tract is to function normally, it must be kept clear of secretions. After some operations and in some patients this clearing mechanism fails, with the result that secretions accumulate, become infected and infect the lung, perhaps fatally. So you must get him to cough, and bring up the sputum that might otherwise block his smaller bronchi and cause atelectasis. Getting him to cough is most of the purpose of the physiotherapy in the next section.
Anything which will get him moving will help his chest. This may not be easy, but any activity is better than lying in bed. Antibiotics are less important, but he may need ampicillin, chloramphenicol, or tetracycline if his chest infection does not resolve with physiotherapy, or is very severe initially.
If he will not cough, there are various ways in which you can suck out his sputum for him. The last three in the list below[md]cricothyroid irrigation, tracheobronchial suction, and tracheostomy[md]are heroic measures of last resort.
POSTOPERATIVE RESPIRATORY COMPLICATIONS See also ''Primary Anasthesia' Section 4.6 and Section 9.11a.
RISK FACTORS. A patient is more likely to have respiratory difficulties if: (1) He has emphysema or chronic bronchitis. (2) He has a painful operation site, particularly an upper abdominal or thoracic one, which makes coughing painful, and so prevents him bringing up sputum. (3) He was given excessive opioids or barbiturates. (4) He only recovered slowly from the anaesthetic. (5) He had a high subarachnoid block. (6) He smokes. (7) He is dehydrated, which makes his sputum thick and more difficult to cough up. (8) He is immobile postoperatively as with a fractured femur or paraplegia. (9) He has any other reason for poor breathing postoperatively, such as multiple injuries or a head injury. (10) He is severely ill, debilitated, immobile, or had a prolonged general anaesthetic.
COMPLICATIONS. Here are some of the complications you may have to manage:
If his RESPIRATION IS DEPRESSED, and a tracheal tube is still in place, he should remain in the recovery room until he is breathing normally. Anaesthesia may have been very deep, or he may be very ill. Attach a self-inflating bag to the tube and inflate his lungs. Don't remove the tube until he is breathing adequately on his own. If the tube has been withdrawn, pull his tongue forward and insert an oropharyngeal airway. If this does not restore normal breathing, inflate him with a mask and a self- inflating bag. If necessary, reintubate him, and continue ventilation. If you treat postoperative respiratory depression vigorously, as in Section A 3.4, his lungs are less likely to collapse. If you have a ventilator (A 19.3), use it.
If he is CYANOTIC, WHEEZING, or has an EXPIRATORY STRIDOR; if he is breathing rapidly, with a fast pulse, or if he has vomit on his lips, suspect that he has INHALED HIS VOMIT. Put him in the head-down position. Immediately insert a laryngosope, and intubate him. Pass a sterile suction catheter into his trachea and bronchi. Fill a 10 ml syringe with 0.9% saline or 1% sodium bicarbonate and inject 5 ml down the tube. Turn him to one side, then the other, and then suck the fluid out again. Repeat this until he is breathing easily and quietly. Or, better, bronchoscope him, and suck him out through this (25.12). Give him oxygen. If his respiration is still poor, keep him in the recovery room or the ICU. See also A 16.2 and A 16.3.
If he has BRONCHOSPASM, give him aminophylline 250 mg by slow intravenous injection (A 3.3). This can also be due to the inhalation of vomit, see above.
If he has RESPIRATORY FAILURE with cyanosis, give him oxygen through a face mask with two side holes for his nostrils. If he has a tracheal tube down, give it to him through this.
CLEARING HIS RESPIRATORY TRACT In the following three situtations a patient needs an antibiotic and physiotherapy to clear the secretions from his chest. Tracheobronchial suction, cricothyroid irrigation, and tracheotomy or ''minitracheotomy' may also be useful.
(1) If he has a cough, confusion, restlessness, fever, tachycardia, cyanosis, rapid or irregular or grunting breathing, with flaring of his alae nasi he has a postoperative lung complication.
(2) If, in addition, he is dull to percussion over the bases of his lungs, usually on the right, with decreased breath sounds and bronchial breathing, low-pitched rhonchi, and X-rays show basal segmental areas of increased density, thick mucus has plugged his smaller bronchi, and caused his lung distal to them to collapse (atelectasis).
(3) If, in addition to the above signs of atelectasis, he has mucuopurulent sputum, rales, and toxaemia, he has bronchitis, bronchiolitis, or pneumonia.
TRACHEOBRONCHIAL SUCTION is useful if he has a ''bad chest' and you think that he is going to get chest complications after surgery. Consider leaving his tracheal tube in for 24[nd]48 hours, so that you can suck out his chest through it. He will not be able to cough forcefully, but you will be able to aspirate his chest frequently. Before you aspirate, turn him to one side and inject 5[nd]10 ml of saline. This will help to liquefy his sputum and will make suction easier. Turn him on to the other side and repeat it. Be sure there is a Y-connection on the suction tube. Release your thumb from the side arm intermittently to prevent you aspirating too much air, and making his bronchi collapse.
If you have already removed the tracheal tube that he had during the operation, and have done everything you can to make him cough, consider passing a nasotracheal tube (A 13.4), and sucking out his chest through that.
CRICOTHYROID IRRIGATION will usually make a patient cough when he is not inclined to do so. Under local anaesthesia, push a needle and cannula combination (''Intracath') on a syringe through his cricothyroid membrane in the midline. Aspirate to make sure that you withdraw air, and then remove the syringe and push the catheter in another 2 cm to be sure it is well inside his trachea. Suture it in place, and plug the opening to make sure that air does not go in or out. Instil 2[nd]3 ml of saline several times a day to make him cough.
TRACHEOTOMY. If other methods of aspiration, including bronchoscopy (25.13) fail; or you need to intubate him for more than 72 hours, consider doing a tracheostomy (52.2), and sucking out his chest through this. If you have bypassed his nose with anything but a minitracheotomy tube (see below), humidify the air he breathes (19.3), if necessary with a steam kettle. It will help him to cough. If you have a steam room put him in it for the first week.
A ''minitracheotomy' is the most practical way to suck out a patient's trachea. Use a small (4 mm) tube (preferably a disposable ''Portex' one). Using local anaesthesia with adrenalin in the solution, insert it through his cricothyroid membrane using a guarded scalpel and an introducer. Failing this use a 4 mm paediatric tracheotomy tube and pass a 10 Ch suction catheter down it. A tube of this size is not large enough to obstruct his respiratory tract, there is little bleeding, and the traditional complications of the cricothyroid approach using a large tube (particularly stenosis) are avoided. He can speak, cough, eat, and drink, and humidify his inspired air normally without the need for sedation or anaesthesia. His wound heals quickly with little scarring.
Fig. 9-22 CHEST PHYSIOTHERAPY. A, if secretions are sufficiently liquid you can pour them out of a patient's chest. B, if they are viscid, you may have to shake them out of his bronchi by percussing his chest in the same way that you can percuss tomato ketchup out of a bottle! C, you can lay him with his hips on pillows, so that his hips are higher than his shoulders. D, you can raise the foot of his bed. E, you can sit him up against a back-rest with pillows under his knees. F, you can raise the foot of his bed and put a pillow under his hips. G, if he is too weak to sit up you can rest him against a pillow and lay him on his side. H, you can lay him on his abdomen with a pillow under his hips and the foot of his bed raised. After Hardinge E, and Wilson PMP, ''A Manual of Basic Physiotherapy', published by TEAR Fund. 9. 11a Respiratory physiotherapy Some simple physiotherapy will often prevent the complications described in the previous section. If an at-risk patient (9.11) is to have an elective operation this physiotherapy should start before the operation. You will probably have no physiotherapist, so you will have to learn these skills yourself, and teach them to your nurses and to his relatives.
PHYSIOTHERAPY CAN BE LIFE-SAVING
RESPIRATORY PHYSIOTHERAPY INDICATIONS. These are the ''at-risk' patients in the previous section.
PREOPERATIVELY, take the patient through the motions of breathing in deeply through his nose and mouth. Either, sit him up at 70[de] well supported from behind by a back support, and with a bolster to prevent his knees slipping down. Or, lay him on his back with his knees bent.
Put your hands on his chest as he tries to breathe. Give him about 6 breaths only at a time, or he may become dizzy.
CAUTION ! Be sure to explain to him why these exercises are so necessary.
POSTOPERATIVELY, adequate analgesia is a big help. Try to get him to breathe properly, to move about in bed, and to get up as soon as he can.
His position is important; he must avoid the semirecumbent ''slumped' position, because this restricts the movement of his diaphragm, and promotes the collapse of his lower lobes. Encourage him to sit up with a back support, or lay him on his side sitting up and rolled well forward to ''free' his abdomen. Get him out of bed and walking on the second day, if you can[md]even if he has a catheter or a drip.
Ask him to do the exercises he has already learnt. An ''incentive spirometer' is very useful.
''Cough him' and ''huff him' as described below, and ask him to do the same every hour. Start on the day of the operation, visit him twice on the following day, and thereafter once daily.
''COUGH HIM'. Distinguish between an effective deep productive cough (which is what you want) and a noise in his throat, which is useless. Several short expiratory ''huffs' before coughing will help to loosen his secretions. Ask him to take a deep breath after each cough, and not to cough continually without pausing.
If he has an abdominal wound, ask him to bend his knees, to hold the wound, and then to take a deep breath and cough. Or, he can hold a pillow against the wound while he coughs. Reassure him that his stitches will not split. If you wish, you can vibrate him while he coughs.
''HUFF HIM'. A ''huff' is a rapid forced expiration without a cough. If he ''huffs' when his lungs are full, he will dislodge secretions from his larger airways. If he ''huffs' when they are half full, he will dislodge them from his smaller airways. So ''huff him' in both, with periods of relaxation and abdominal breathing between them.
CAUTION ! To be effective a ''huff' must be long and controlled and not spasmodic. He must use his abdominal wall. The noisiest ''huff' is not necessarily the best.
PERCUSSION AND VIBRATION. Percuss his thorax over a towel or blanket with your cupped hands for periods of about a minute. Then rapidly shake his chest during expiration. Relax while he inspires, and follow this with some deep breathing. Repeat this two or three times.
POSTURAL DRAINAGE will be useful if there is much fluid in his bronchi. Listen carefully to his chest, and if possible examine his chest X-ray. Decide where his secretions are worst, and arrange him so that this part of him is uppermost, using any of the positions in Fig. 9-23. Ask him to breathe deeply for 10 minutes, vibrate and slap his chest for 10 minutes, then repeat the breathing. If he has established collapse or infection repeat this two or three times a day.
If he is too ill for his hips to be raised, lay him on his side.
If his secretions are viscid, ideally he needs inhalation therapy to ''loosen' them prior to physiotherapy[md]steam with Friar's balsam, or saline with mucolytics from a nebulizer.
Fig 9-23 POSTURAL DRAINAGE. The positions which allow gravity to promote the drainage of secretions from particular parts of a patient's lung. Study his chest X-ray, and decide which position will be best. Kindly contributed by Lynne Wilson of Killingbeck Hospital, Leeds.