For your convenience I'm describing the physiotherapy of lung transplantation as under;

Preoperative Physiotherapy

This should begin as soon as possible after the patient is admitted. The main aims are to:

1- Gain the patient confidence
2- Clear the lungs fields
3- Teach respiratory control and inspiratory holdings
4- Teach postural awareness
5- Teach arm, trunk and leg exercises
6- Teach mobility about the bed.


Patient’s confidence An explanation of the aim of physiotherapy helps the patient’s understanding. Teaching the exercises to be undertaked postoperatively and answering the patient’s questions helps to allay some of the fears of operations.

Clearing lung Fields

The patient must be discourged from smoking. Shaking, clapping and vibrations with postural drainage if necessary must be used to clear the secretions from the sound lung. Huffing is taught as this is used in preference to coughing postoperatively. The patient is instructed on how to support the wound during coughing and huffing. The arm of unaffected side is placed across the front of the thorax and around the affected side just below the incision side giving firm pressure with the forearm and hand. The upper arm of the affected side reinforces the pressure and the hand fixes the opposite elbow.

Teaching the respiratory control

Inspiratory exercises are taught for the sound lung together with the inspiratory holding. This means that the patient is asked to take a deep breath in, hold, then breathe in a little further, hold, then breathe out.

Breathing control has to be practiced after secretions have been cleared.

Postoperative physiotherapy

It is important to note whether the patient is on oxygen therapy, and whether there is drain in the thorax. This drain may be used to control the amount of fluid in the cavity left by the lung. If there is too much fluid, the mediastinum is shifted to the unaffected side but if there is too little fluid the shift will be to the affected side with over inflation of the lung. In both instances there will be loss of breath and a danger of heart being compromised.

Rate and depth of respiration are recorded. The patient must avoid straining with coughing as this can put at risk the sutures of the bronchial stump. Analgesia may be administered but must not depress the respiratory centre or cough reflex. Inhalations of, for example, benzoin tincture help to loosen the secretions. The aims of physiotherapy are:

1- Clear secretions from the remaining lung
2- Retain full expansion of the lung tissue
3- Prevent circulatory complications
4- Prevent wound complications
5- Regain arm and spinal movements
6- Maintain good posture
7- Restore exercise tolerance

A suitable programme may be as follows.

Day of operation (Surgery am, treat pm)

Patient in half lying with pillow arranged behind the neck and back and possibly both forearms on a pillow on the lap.
Expansion breathing exercises for all areas of the lung. Foot and ankle exercises.

Day1 Post-operation

Half lying-Segmental expansion exercises, shaking or vibrations as necessary, huffing and expectoration with wound support from the physiotherapist.

By the end of the day the patient should be huffing with self support. Foot and ankle exercises. Correct posture should be emphasized to prevent a Wikipedia reference-linkscoliosis on the scar side.

Short frequent sessions are better than few long ones. In the afternoon, the patient may sit out of the bed. This allows better excursion of the diaphragm. During two of the sessions the arm on the affected side must be moved.

1- Into full elevation
2- Hand behind head
3- Hand behind back
4- Hand touch opposite shoulder

A rope ladder should be provided so that patient can pull on it to move around in bed and sit up.

Day 2 Post-operation

Treatment is continued as above plus on two sessions:
1- Sitting on the edge of the bed
(a) Trunk turning
(b) Trunk bending side to side
(c) Trunk stretching backwards

2- Sitting in chair-Bilateral breathing exercises
3- Walk round bed with trunk erect and arms swinging

Day 3 Post operation

Breathing and huffing is continued as necessary. Other activities continue twice in a day. The patient may join in group therapy.

Day 4 post operation to discharge

The patient continues with group therapy, gets dressed, and walks further and, after the 7th day, practices going up and down stairs with breathing control. Bilateral breathing and trunk and arm exercises are essential.

Stitches come out usually 7-10 days after operation. Two weeks after the operation, the patient is generally discharged with strict instructions to continue the exercise regimen.

Modifications to this programme

Postural drainage may be necessary if the remaining lung does not clear satisfactorily. This involves positioning the patient on the operation side. Tipping must not be used because of the danger of broncho-pleural fistula due to the fluid bathing bronchial stump.

If the air entry to the remaining lung is not adequate, intermittent positive pressure breathing may be used to improve ventilation.

Oxygen therapy and humidification may be necessary. If the recurrent laryngeal nerve is injured, breathing exercises and huffing should clear the secretions. IPPB used with caution at low pressure and only after consultation with surgeon.

If phrenic nerve is damaged, coughing can be ineffective because there is paradoxicaql movement of the diaphragm. IPPB can be used to mobilize secretions and increase air entry.
Incentive spirometry may be helpful to improve the patient’s inspiratory capacity.

Incentive Spirometry

This a technique used to encourage the patient to take a deep breath in when there is hypoventilation after thoracic or high abdominal surgery due to pain or secretions retention. The breathes in through a tube which is attached to a device that illustrate the volume of the inspired air. For example, at low lung volume, a plastic ball rises to the top of the column, at mid lung volume a second ball rises and at high lung volume a third ball rises. So long as the patient holds a deep breath, the balls remain at the top of the columns. Some devices operate by a light coming on when the volume of breath reaches a pre set level. Some devices work on the expiratory phase rather than the inspiratory phase.

Long term management

The patient generally have three month check ups. On these visits to the surgeon it is helpful to have the physiotherapist check exercise tolerance, posture, trunk and shoulder mobility so that patient may have the home activity programme adjusted. The fluid in the cavity left by the removal of lung gradually fills up but must not reach the level of the stump before it has healed in 10-14 days. Slowly it will fill the whole cavity and become organized and fibrosed from the base to the apex over a 2 year period. It is important, therefore, that the patient continues thoracic mobility exercises on a regular daily basis for at least this period of time.