00:01
So the next step to approaching our
surgical patient is B for breathing.
00:06
So it's vitally important for
patients to be able to breathe,
it helps to decrease
post-op complications.
00:14
So some potential post op complications
include: Wound infection,
Respiratory complications, Bleeding,
Thrombo-embolism, Urinary complications and Ileus.
00:25
So, the mnemonic to remember for patients that
present with post-op fever are the 5 W's.
00:32
So if someone has a
fever post-operatively,
you have to think of potential
problems with their lungs.
00:40
Perhaps they have developed atelactasis
or pneumonia.
00:44
This is common because the
post-op patient was intubated.
00:48
Also, after surgery, especially
if there's abdominal incision,
patients tend to splint and not
want to take a deep breath in.
00:56
So atelectasis is when the alveola collapse
or potential complication with pneumonia.
01:03
You have to consider possible UTI's.
01:06
So water stands for a possible infection
of the urinary tract infection,
especially with patients that had a foley
catheter introduced for the surgery.
01:16
The 3rd W stands for Walking.
01:19
It reminds you that patients may develop deep
vein thrombosis, especially post-operatively.
01:24
Patients are pretty immobile.
01:26
Usually they are stuck in bed and
immobility increases their risk for a DVT.
01:33
The 4th W is Wound.
01:35
Surgical wound infection potentially
could cause a post-op fever.
01:40
And the last W is Wonder drug.
01:43
So anesthetic medication sometimes
could induce a drug fever.
01:48
So patients that present with a post-op
fever, you have to think of these 5 things.
01:55
Out of these 5 things, OMT
potentially could help patients with
preventing some and also help
treating some of these issues.
02:06
So, there's a major importance of
optimizing breathing mechanics.
02:10
If we are able to optimize
breathing mechanics,
we are gonna be able to improve the amount
of oxygen being delivered to our tissues,
release and give off more CO2.
02:20
It discourages atelectasis and
prevents pulmonary infections.
02:24
This alternating intrathoracic pressurewill help return
of venous return and also promote lymphatic flow.
02:32
The sympathetic chain ganglion actually will
be massaged or pumped with our breathing.
02:38
And important structures that enter or
pass through or reside within the thorax
also will have proper motion and function.
02:46
So, postsurgical complications are major
cause of morbidity and mortality.
02:54
Pulmonary complications include
atelectasis, bronchospasm, pneumonia
and exacerbation of
chronic lung disease.
03:01
Post-op atelectasis is usually caused by
decreased compliance of a lung tissue,
impaired regional ventilation, retained
airway secretions, and/or postoperative pain
that interferes with spontaneous
deep breathing and coughing.
03:14
In fact, most post operative patients
are given incentive spirometer.
03:17
This is a device where they have a little
ball inside the tube and they use the tube
and they have to inhale really
deeply to keep the ball elevated.
03:27
And so, this device helps patients to expand
their airway and to take deep breaths in.
03:37
So in postsurgical patients, we want
to optimize the patient's recovery
by addressing musculoskeletal structural findings
to help them with thoracic cage mobility.
03:47
We wan to improve lymphatic drainage to
decrease inflammation and to promote healing.
03:51
And we want to decrease post-op pain
and to improve the body's structure
to help restore normal
function and promote healing.
03:58
So in order to prevent
pulmonary complications,
there are some key areas we
need to diagnose and treat.
04:03
So it's really important to
look at the thoracic rib cage.
04:06
When we breathe, we need proper
mobility and motion of the rib cage.
04:09
The rib cage will articulate with the thoracic spine
and all the muscles of respiration that attach to it.
04:17
So if there's restriction in the rib cage, the
muscles that attach to it or the spine itself
that could prevent proper
expansion and movement.
04:25
We also have to look at
the abdominal diaphragm.
04:27
The abdominal diaphragm is a major muscle that
attaches to the lower rib cage and posteriorly
to the 12th rib and it attaches also
to the thoracolumbar junction.
04:36
So we wanna look at the abdominal
diaphragm and it's excursion.
04:39
If the diaphragm is restricted, it's also gonna
restrict the lungs, prevent proper inhalation
and will not allow for proper changes
in interthoracic pressure.
04:52
So again, our rib cage is a structure
that surrounds the lungs and the heart.
04:58
Breathing is required to change the
shape of the thoracic container.
05:01
The container changes shape.
05:04
And then when it changes shape,
it also changes pressures.
05:07
These changing pressures
ventilate the lung and also,
help to bring fluids and lymphatics
back into the thoracic cavity.
05:15
So in order to assess rib dysfunctions, what
we're going to do is we're going to screen
for rib restrictions based on the ability of the
patient to breathe and also with motion testing.
05:26
So what we're going to do is we're gonna place our
hand on the rib cage and three different areas:
the lower rib cage, the middle
rib cage and the upper rib cage.
05:34
You could use translation to see if you
could detect restrictions in rib motion.
05:39
Or you could also place your hands there passively,
have the patient take deep breaths and out
and see if there's regions
where the ribs do not move
or expand as much comparing
right and left sides.
05:53
So remember, the change and shape of the thorax
helps to augment venous and lymphatic return.
05:59
In order to try to augment that shape
change, we want to treat the diaphragm.
06:04
And also, we could perform
oscillation throughout the thorax
to allow for improved
motion of the fluids.
06:12
So doming done on the diaphragm,
here what we want to do,
is with the patient supine, get your thumbs
underneath the costal margin on both sides,
you're gonna have the patient take a
breath in and when the patient exhales,
you're gonna follow the
diaphragm into exhalation.
06:29
So most of the time when the
diaphragm is restricted,
it's gonna be restricted in inhalation
because that's when the diaphragm contracts.
06:36
The diaphragm will descend, so you're
trying to treat the diaphragm by doming it,
bringing your thumbs underneath it, trying
to restore it's natural shape on exhalation.
06:46
So you do this for several cycles, you resist on
inhalation and gently follow with exhalation.
06:52
You don't wanna push really hard,
this is a very sensitive area.
06:56
Patients would complain if you put too much
pressure and it could cause pain.
07:01
So again, when the patient exhales, you
keep following inhalation and exhalation
and you continue this until you feel like the
diaphragm domes easily at the end of exhalation.
07:11
So there are techniques that
we could utilize to help treat
the thoracic cage and improve it's compliance
and also, it balances sympathetic tone.
07:19
So we could use soft tissue techniques to try to
treat the different muscles that might be spasmed.
07:25
And try to relax those muscles to allow
the rib cage to move and expand better.
07:29
You could utilize rib raising which helps to
articulate the ribs and also helps to treat
any viscerosomatics and remove any restrictions
that might be blocking proper sympathetic tone.
07:42
And you can also use Myofascial release to help
with reducing tension throughout the thoracic cage.
07:49
So, movement of the diaphragm is vital
to a patient's ability to heal.
07:55
If the diaphragm is restricted, you
then cut off the pump for lymphatics.
08:00
And so, we need to ensure that there
is proper motion and movement
of the diaphragm to allow for
venous and lymphatic flow.
08:08
The abdomen and pelvis is a container which
holds all of the abdominal pelvic viscera.
08:14
Any sort of diaphragmatic dysfunction
will limit it's excursion
and thus the ability to move
fluids and allow for healing.
08:22
Here's a closer look at
tha abdominal diaphragm.
08:26
The diaphragm is of upmost importance to treat
and make sure that it is functioning well.
08:32
the aorta and the cisterna chyli pass through
the medial arcuate ligament between the crura.
08:39
The right crus also forms the major portion
of the gastroesophaegeal junction.
08:45
The sympathetic chain passes through
the medial arcuate ligament.
08:49
And so there's a lot of important
structures that pass through the diaphragm,
and if there's restriction of the diaphragm,
that could potentially cause issues
in functioning of the structures
that pass through there.