Lung surgery, thoracotomy, chest drain and chest trauma

1Definition

Thoracic surgery is surgery on the lungs, pleura, chest wall, oesophagus or mediastinum. Physiotherapy matters because every chest operation reduces lung volumes and cough strength and stiffens the shoulder and trunk on the operated side.

An intercostal chest drain (ICD) is a tube passed between the ribs into the pleural space to remove air, blood, fluid or pus, connected to an underwater seal that lets air and fluid out but not back in.

2Classification: incisions and operations

Thoracic incisions (7 marks in S22; 3 marks in W19 and S23)

Lung operations

• Pneumonectomy: whole lung removed.
• Lobectomy: one lobe removed (commonest for lung cancer); bilobectomy on the right.
• Segmentectomy: one or more segments removed (S22: stage 1 lung cancer).
• Wedge resection: a small wedge of lung.
• Sleeve resection: a lobe with a section of main bronchus, rejoined.
• Decortication: removal of a thick fibrous peel from the lung (chronic empyema).
• Pleurectomy and pleurodesis: to stop recurrent pneumothorax or effusion.
• Bullectomy, lung volume reduction, thoracoplasty (see the TB page), lung transplant.

3Indications

• Lung cancer (commonest), carcinoid and other tumours; risk factors are smoking, occupational exposure (asbestos), air pollution and family history.
• Localised bronchiectasis, lung abscess, aspergilloma, complications of TB.
• Hydatid cyst (W16 case): a parasitic cyst from dog tapeworm, common in farming communities.
• Empyema needing decortication; recurrent pneumothorax.
• Chest trauma: rib fractures, flail chest, haemothorax, pneumothorax, lung contusion, penetrating wounds.

4Pathophysiology to impairments after thoracic surgery

1. Anaesthesia and lying flat reduce functional residual capacity; small airways close at the lung bases.
2. Pain from the incision, rib spreading and drains makes breathing shallow and stops deep breaths and effective coughing.
3. Lung tissue is removed, so total lung capacity and exercise reserve fall; the remaining lung must expand to fill the space.
4. Sputum is increased (surgery, smoking history) but cannot be cleared: sputum retention, then atelectasis and pneumonia.
5. Cut shoulder-girdle muscles and guarding cause shoulder stiffness and a posture bent towards the operated side.
6. Bed rest and drains reduce mobility and fitness and raise DVT risk.

5Clinical features after surgery

• Incision and drain-site pain, worse on deep breathing and coughing.
• Shallow, fast breathing; reduced chest expansion and breath sounds on the operated side; crackles if secretions are retained.
• Weak, painful cough with sputum (W16: "cough with expectoration").
• Drains in place; oxygen; drips; possibly an epidural or nerve-block catheter.
• Stiff shoulder on the operated side, posture leaning towards the incision.
• Fatigue and breathlessness on exertion.

6Investigations

7Medical and surgical management

Intercostal drain and underwater seal (7 marks in W20; part of W22)

• Indications (3 marks in S25): large or breathless pneumothorax; tension pneumothorax after needle decompression; any pneumothorax in a ventilated patient; haemothorax; empyema or infected effusion; large or malignant pleural effusion (and before pleurodesis); chylothorax; after thoracic or cardiac surgery.
• Site: usually the "safe triangle": bordered by the front edge of latissimus dorsi, the side edge of pectoralis major, and a line at the level of the nipple (about the 5th intercostal space), with its apex below the axilla.
• Underwater seal: the tube from the chest ends about 2 cm under water in the drainage bottle. Air and fluid can bubble out, but water blocks air from being sucked back. The bottle must stay below the level of the chest at all times.
• Swinging of the water in the tube with breathing shows the drain is open and in the pleural space. Bubbling shows an air leak from the lung. No swing may mean the tube is kinked or blocked, or the lung has fully expanded.
• Suction (low negative pressure) may be added to help re-expand the lung.

Other medical care

• Pain control: epidural, paravertebral or intercostal nerve block, patient-controlled analgesia, regular oral analgesia.
• Oxygen, nebulisers, antibiotics as needed.
• Enhanced recovery programmes: early eating, early drain removal, walking on day 1.
• For cancer: chemotherapy or radiotherapy after surgery where needed.

8Complications and prevention (7 marks in S17 and S18)

9PT assessment

• Pre-op: lung function, exercise tolerance, smoking, sputum, shoulder range, occupation and hand dominance; teach the post-op plan.
• Post-op chart: operation, incision, drains (number, site, swing, bubbling, amount and type of drainage), analgesia, oxygen, X-ray.
• Respiratory: breathing pattern and rate, SpO₂, chest expansion, auscultation, cough and sputum.
• Pain at rest and on coughing (VAS).
• Musculoskeletal: shoulder range on the operated side, posture.
• Function: bed mobility, sitting, standing, walking distance with SpO₂.
• Outcome measures: 6MWT, shoulder ROM, pain scale, quality of life (for example EORTC questionnaire for cancer).

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (W16, 5 + 5 + 5 marks)

"A 40 year old male labourer, diagnosed case of hydatid cyst of right lower lobe, underwent right lower lobe lobectomy two days back via a posterolateral thoracotomy. He is right hand dominant, is currently having cough with expectoration with an intercostal drain in situ. Discuss functional diagnosis, short term and long term physiotherapy management."

11Problem list and goals

12PT management

Before surgery

• Explain the operation, drains and the post-op routine; teach breathing exercises, ACBT, supported cough, bed mobility and shoulder exercises.
• Stop smoking as early as possible.
• Prehabilitation: aerobic and strength training for a few weeks before lung cancer surgery reduces post-op lung complications and hospital stay (Cochrane review).

After surgery (lobectomy or segmentectomy)

Pneumonectomy (7 marks in S23; long cases W21 and S26)

Surgical approach and soft tissues cut (S26): usually a posterolateral thoracotomy through the 4th or 5th intercostal space; a rib may be removed or divided for access. In order: skin and subcutaneous tissue → latissimus dorsi → serratus anterior (divided or retracted) → lower trapezius and rhomboids if the cut extends up → intercostal muscles (external, internal, innermost) → parietal pleura. The pulmonary artery, pulmonary veins and main bronchus are then divided and the bronchial stump is closed.

• The empty space: it slowly fills with fluid over weeks, and the mediastinum shifts towards it. A drain, if used, is usually clamped or balanced and removed early.
• Positioning: lie on the back, sit up, or turn a quarter towards the operated side. Avoid lying fully on the remaining lung side, because fluid in the space could spill through a leaking bronchial stump into the only lung. Avoid head-down tilt.
• Breathing: all gas exchange depends on one lung, so deep breathing, thoracic expansion of the remaining lung, supported huff and cough, and early walking matter even more.
• Shoulder and posture: active shoulder exercises on the operated side from day 1 (the cut muscles move the shoulder); patients lean and drop the shoulder towards the operated side, and a scoliosis can develop, so correct posture in a mirror and add trunk mobility.
• Watch and report: irregular pulse (atrial fibrillation is common), breathlessness with crackles in the remaining lung (fluid overload), fever, and coughing up thin, watery or blood-stained fluid, especially when lying on the good side. That last sign, or air still bubbling from a drain days later (as in W21), suggests a bronchopleural fistula: a leak at the bronchial stump.
• Long term: exercise capacity is lower but improves with a graded walking and exercise programme.

Physiotherapy with an intercostal drain

• Check before every session: swing, bubbling, type and amount of drainage, tubing not kinked.
• Keep the bottle upright and below chest level; carry it low when walking (or use a portable drain).
• Never clamp a drain that is bubbling.
• If the tube disconnects: put the chest end under sterile water or clamp briefly as per ward protocol, and call the nurse. If the drain falls out: cover the hole with a sealed dressing and call for help.
• Support the drain site during coughing; do shoulder exercises gently near the drain.

Chest trauma (W17 electrician with 3 rib fractures, on ventilator)

• Good pain control (nerve blocks, epidural) is the key to breathing and coughing.
• On the ventilator: positioning, suction, airway clearance, careful manual techniques away from fractures, limb exercises.
• After extubation: deep breathing, supported cough, early walking, shoulder exercises.
• No percussion or vibration over fractured ribs; flail chest is covered on the chest-wall page.

By impairment

13Precautions, contraindications and stop criteria

14Education, lifestyle and home programme

• Keep doing deep breathing and huffing for a few weeks after going home.
• Walk every day, increasing the distance gradually.
• Do shoulder and trunk exercises until the range is full.
• No heavy lifting for the first weeks; return to heavy work gradually as advised.
• Stop smoking for good.
• Report fever, more breathlessness, wound redness or discharge.

15Prognosis and discharge criteria

Prognosis: most patients recover well after lobectomy or segmentectomy, especially after VATS. Lung function settles at a lower level depending on how much lung was removed. Cancer prognosis depends on stage.

Discharge: drains out; chest clear; walking independently and managing stairs; shoulder range near full; knows home exercises and warning signs.

16Exam corner

Past questions (MUHS, 2016–2026)

• W16 Q4(b), 5 + 5 + 5 marksThe worked example in section 10.
• S22 Q3(a), 15 marks40-year-old male chemical engineer, segmentectomy for stage 1 lung carcinoma 5 days ago. Functional diagnosis, goals and physiotherapy management in detail.
• W21 Q3(a), 15 marks30-year-old man, left pneumonectomy for bronchiectasis 7 days ago; pain at the suture site; his ICD drains air and serous fluid. Functional diagnosis and management.
• S25 Q3(b), 4 + 4 + 7 marks35-year-old painter, right lower lobectomy 2 days ago; suture-site pain, cough and difficulty bringing up sputum; treated for TB 7 years ago. Pre-op PFT: FVC 60%, FEV1 82%, FEV1/FVC 94% predicted (a restrictive pattern). ICF; short- and long-term goals; physiotherapy.
• S26 Q3(a), 3 + 5 + 7 marks35-year-old housewife with left bronchiectasis and a destroyed lung; pneumonectomy 3 days ago; incision pain, restricted left shoulder movement, pain at the ICD site. (i) Surgical approach and soft tissues cut; (ii) ICF with short- and long-term goals; (iii) physiotherapy.
• 7-mark questionsComplications of pulmonary surgeries (S17). Complications and post-op management after right lower lobectomy (S18). Intercostal drainage and underwater seal (W20). Types of thoracic incisions and complications of thoracotomy (S22). Pneumothorax, and precautions and physiotherapy with an intercostal drain (W22). Physiotherapy after right middle lobectomy (W19). Physiotherapy after pneumonectomy (S23).
• 3-mark questionsMuscles incised in posterolateral thoracotomy (W20). Three incisions in pulmonary surgery (W19). Three thoracic incisions with the soft tissues dissected (S23). Indications of intercostal drainage (S25).

Technique cards for this topic: ACBT and autogenic drainage, breathing exercises, positioning, suctioning, chest X-ray.

Keywords to underline

posterolateral thoracotomy latissimus dorsi, serratus anterior lobectomy underwater seal swing and bubbling bottle below chest supported cough early mobilisation shoulder exercises from day 1 prehabilitation

Answer skeleton: post-thoracotomy long answer

1. Restate: age, job, hand dominance, operation, incision, day, drains, sputum.
2. [Functional diagnosis or ICF, 5] ICF diagram from the case; reasons.
3. [Short-term, 5] Day-by-day: breathing, ACBT, supported cough, positioning, drain care, walking, shoulder ROM.
4. [Long-term, 5] Exercise training, shoulder and posture, return to work, smoking cessation.

Draw these

• The posterolateral thoracotomy incision with muscles (section 2)
• The underwater seal drain (section 7)

Viva questions

1. What does it mean if the water in the drain tube stops swinging?
2. Why must the bottle be kept below the chest?
3. Which side should a patient lie on after pneumonectomy?
4. Which muscles are cut in a posterolateral thoracotomy?
5. What is the safe triangle?
6. Why does VATS cause less pain than thoracotomy?

Linked practical spots

• Device: underwater seal drainage bottle, portable drain bag.
• X-ray: drain in the pleural space; surgical emphysema; post-pneumonectomy space.