Case scenario
Oesophageal cancer is the sixth most common cause of cancer-related death worldwide and is associated with a poor long-term prognosis (Atkins & D'Amico, 2006). There are 2 main types of oesophageal cancer: squamous cell and adenocarcinoma. Squamous cell is usually found in the upper and middle sections of the oesophagus, whilst adenocarcinoma is at the gastroesophageal junction and the distal oesophagus. Cigarette smoking and irritation of the oesophageal mucosa due to gastroesophageal acid reflux, both of which pertain in Mrs Noble’s case, are known risk factors for the development of oesophageal cancer. As with other cancers, there is a genetic factor linked with oesophageal cancer, caused by a mutation in the gene which produces the tumour suppressor protein (Mackenzie et al., 2004).
An Ivor Lewis Oesophagectomy involves the removal of a tumour through an abdominal incision and an incision in the chest wall. The stomach and remaining oesophagus are then reattached in the upper chest. This reattachment is called an oesophagogastric anastomosis (Stanford Health Care, 2017). Post-operative pulmonary complications (PPCs) are frequent and increase the risk of patient mortality and the length of inpatient stay, implying increased healthcare costs. Respiratory changes begin at the start of surgery, on induction of general anaesthetic and can last for 6 weeks (Miskovic, 2017). In a study by Avendano et al (2002) 86.9% of patients developed pleural effusion or atelectasis following surgery, with pneumonia occurring post-operatively in 32.8% of patients. Post-operative mortality rates range from 5-13% and are most commonly caused by cardiopulmonary complications (Mackenzie et al., 2004). An oesophagectomy is associated with the highest rate of PPCs of all upper abdominal surgery (Lunardi et al., 2011).
Initial Assessment
After reading Mrs Noble’s notes and reviewing her chest x-ray (CXR), it would be important for physiotherapists to carry out a thorough objective assessment which should include heart rate, blood pressure, respiratory rate, body temperature and auscultation. Although this information should be available from the medical notes, these observations might have changed since the last examination. The data also provide the physiotherapist with baseline measures, allowing monitoring of the patient’s progress throughout treatment (Middleton & Middleton, 2008).
Management
As soon as the patient is under the effect of general anaesthetic, respiratory muscle function reduces. Airway obstruction, cephalad diaphragm displacement and a reduction in the cross-sectional area of the chest wall, which all occur during surgery, lead to a reduction in functional residual capacity (FRC). This decreased FRC, alongside a reduced cardiac output due to loss of consciousness and intermittent positive pressure ventilation provided during surgery, cause an abnormal distribution of ventilation which leads to a mismatch between ventilation and perfusion (V:Q). This altered V:Q leads to more alveolar deadspace and therefore impaired oxygenation (Miskovic, 2017). This change is clearly evident in Mrs Noble, whose oxygen saturation (SaO2) is 92% despite being on 2 litres of oxygen. She also has an elevated respiratory rate (R/R), indicating an increased work of breathing (WOB). The combination of hypoxemia and elevated R/R are associated with acute respiratory distress syndrome (ARDS). Non-invasive positive pressure ventilation (NPPV) can improve gas exchange in patients with this presentation. In a study by Yu et al. (2013), patients were defined as having ARDS if they exhibited an acute onset of symptoms, hypoxaemia despite additional oxygen, a chest x-ray showing consolidation bilaterally and the presence of pulmonary oedema (not due to cor pulmonale) received NPPV. From the case notes, Mrs Noble fits some of these criteria with her low SaO2 and chest x-ray showing bilateral opacity. However, it is unclear whether this opacity is due to sputum retention or atelectasis. The patients who received NPPV in this study spent less time in ICU, had a lower mortality rate and improved oxygenation compared to those receiving intermittent positive-pressure ventilation. The number of PPCs was also significantly reduced in the NPPV patient group. Positive airway pressure as used in NPPV is commonly used to correct hypoxaemia. It improves ventilation to collapsed areas of the lung and unloads the muscles used in inspiration, which reduces the patient’s WOB (BTS guidelines, 2002). This should subsequently help to reduce Mrs Noble’s R/R. As ventilation to collapsed lung areas is improve by NPPV, Mrs Noble will benefit from this even if her CXR opacity is atelectasis rather than consolidation. It is more likely that the opacity is caused by atelectasis, as in an Ivor Lewis Oesophagectomy the right lung is deflated as part of the surgical procedure (Reed, 2009). It is also reported that atelectasis occurs in dependent parts of the lung in 90% of anesthetised patients due to alveolar collapse (Duggan and Kavanagh, 2005).
Mrs Noble is reported as being slumped in bed. According to Behrakis et al. (1983), resistance of the airways and lungs to airflow increases whilst expiratory reserve volume (ERV) decreases when in supine compared to sitting. This reduction in ERC leads to a reduced FRC. Vital capacity also reduces when patients are repositioned from sitting to lying. These changes in lung volumes are due to gravity and an increase in abdominal pressure which occurs when a person is positioned horizontally. This causes the diaphragm to displace upwards giving less room for lung expansion. Obesity can also cause a significant decrease in FRC (Ruppel, 2012). Mrs Noble, who is obese and poorly positioned at present, will therefore significantly benefit from repositioning. According to Rowat (2001), SaO2 is most improved when sitting out of bed in a chair compared to being in any position in bed. Patients who are left propped-up in bed become slumped and this can reduce the space available for lung expansion which leads to reduced oxygenation. It is likely that this is what has happened with Mrs Noble. Hardie et al. (2002) confirm this, observing that gas exchange improves in a sitting position compared to supine. However, the study conducted by Rowat (2001) used stroke patients and Hardie et al. (2002) used healthy elderly individuals. Whilst the same physiology can be applied to Mrs Noble, the effects may not correspond exactly for this patient. Haines et al. (2013) report that the risk of developing a PPC increases for every day that patients do not ‘mobilise away from the bed’. In this patient group, over half of patients had some difficulties mobilising due to hypotension. This is something to be considered when mobilising Mrs Noble.
Obesity, as seen in Mrs Noble, can have a detrimental effect on pulmonary function. A restrictive pattern of reduced lung volumes, particularly ERV, has been linked to obesity. This is thought to be due to added weight on the chest wall, which reduces its compliance. Airflow limitation has also been identified as a respiratory side-effect of obesity. These adverse effects on pulmonary function due to obesity are thought to be occur through restricted diaphragm function (caused by an increase in the mass of abdominal contents), reduced chest wall compliance (due to extra chest wall fat) and impaired strength of the respiratory muscles (due to fatty deposits in the muscles). Obesity also increases the risk of developing pulmonary diseases such as asthma and chronic obstructive pulmonary disease. Significant weight loss has been shown to reverse these effects (West and Burton, 2009). Physiotherapists should be active in the management of obesity through facilitating physical activity and providing lifestyle advice which is tailored to each patient. This includes prescribing physical activity, managing associated conditions and helping bariatric patients to overcome psychosocial factors which may be inhibiting their ability to participate in exercise (CSP, 2015). This is supported by the NICE Guidelines (2015), who state that physiotherapists should be active in the management of obesity by increasing physical activity in a way that is suited to the individual and offering advice about achieving a healthy and balanced diet. Following discharge, Mrs Noble should therefore be educated about the importance of a healthy lifestyle, which includes physical activity five times a week (CSP, 2015). Mrs Noble should be referred to exercise schemes where possible. This will enable Mrs Noble to lose weight, which will facilitate her management of adverse post-operative pulmonary changes following discharge.
The active cycle of breathing techniques (ACBT) are a series of breathing exercises commonly used in post-operative physiotherapy (Reeve et al., 2007). ACBT and associated breathing techniques (such as deep breathing exercises and breath-holding at end inspiration) are often used for patients with secretions and hypoxaemia to aid sputum clearance and improve SaO2 (Osadnik et al., 2013). Mrs Noble presents with low SaO2 and opacity on her CXR, suggesting some sputum retention. The data drawn from the above study suggests that Mrs Noble would benefit from the prescription of breathing exercises post-operatively.
Breathing exercises are thought to improve the strength of respiratory muscles, as well as improving forced vital capacity (FVC) (Grams et al., 2012), but small-scale controlled trials have failed to provide conclusive information (Chumillas et al., 1998 and Lundari et al., 2011). There is a deficit of evidence and good quality studies on the effects of post-operative breathing exercises, making it hard to draw a conclusion as to whether Mrs Noble should receive breathing exercises as part of her post-operative physiotherapy (Grams et al., 2012). – not very specific, use ACBT ref?
? above paragraph vague and may need to choose a specific breathing technique (e.g. incentive spirometry).
The Multidisciplinary Team (MDT)
Mrs Noble is receiving analgesia through a PCA (patient-controlled analgesia) machine. This allows Mrs Noble to decide when and how much pain relief she gets. This type of pain relief is most commonly used in post-operative patients (Macintyre, 2001). PCA is normally provided by a pain team, made up of specialist nurses and anesthetists. It is these professionals who should advise patients to use PCA before physiotherapy to help reduce pain and therefore make physiotherapy more effective (UHS, 2016).
Mrs Noble may also benefit from a referral to occupational therapy (OT) before being discharged home. OT could help Mrs Noble to manage the stairs in her house and to ensure that her mother is cared for, as these tasks may initially be difficult to manage following her surgery. OTs may also be able to help Mrs Noble to get back to work as quickly as possible. The aim of OT is to provide patients with the means of being able to carry out activities of daily living including domestic work, employment and voluntary activities. This may include the installation of adaptive equipment such as grab rails by the stairs to make certain activities safer and more manageable (NHS, 2014).
Conclusion
Respiratory complications following surgery, particularly oesophagectomy, are frequent and have a number of subsequent negative effects, both on the patient and on the NHS. However, post-operative physiotherapy can help to minimise these adverse risks of surgery. Cooperation of the MDT allows pain relief to ensure effective physiotherapy as well as important parts of post-operative care such as early mobilisation and positioning which are advocated by physiotherapists. In conclusion, physiotherapists can play a crucial role in helping the MDT to tackle the post-operative challenges patients face and enable them to lead a normal life. This essay however highlights the lack of evidence for post-operative physiotherapy. The absence of NICE guidelines and gold standards for this area of physiotherapy needs to be addressed to ensure physiotherapists provide adequate care for patients in the post-operative period.
1415 words (max. 1650)
Nakamura et al 2008, Westwood et al 2007 (incentive spirometry)
References
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Need to do critical analysis!!!