Case Report: A comprehensive rehabilitation protocol in a post-operative case of ASD closure along with PAPVC

Introduction

The atypical drainage of pulmonary veins into the right atrium leads to a variety of congenital cardiac conditions known as partial anomalous pulmonary venous connections (PAPVC). This can occur by draining directly into the right atrium or through systemic veins.¹ PAPVCs, which frequently coexist with atrial septal defect (ASD) and manifest as a left-to-right shunt, have negative consequences on cardio-pulmonary physiology.²

In 0.4-0.7% of autopsies, PAPVC are discovered. Most frequently, the right pulmonary veins that drain into the right atrium or superior vena cava (SVC) are involved in the aberrant venous connection. Less commonly, abnormal pulmonary veins flow into the coronary sinus, innominate vein, or inferior vena cava.^2,3

Various transcathater or surgical approaches have been proven to improve the competency of the patient’s having anomalous venous connections, which includes balloon angioplasty and surgical repair of associated anomalies.⁴ To facilitate flow of blood from pulmonary veins to left atrium, the wall between the coronary sinus and left atrium is excised. The coronary sinus opening is then sealed off. ASD is also closed, if it is present.² An anastomosis between the left atrium and the pulmonary venous confluence is made in infracardiac and supracardiac PAPVC. Unless there is severe pulmonary hypertension, the vertical vein is mostly ligated in the same surgical setting. In complicated and mixed type PAPVC, a number of other procedures, such as intra-atrial rerouting, have also been employed.^2,5

Following heart surgery, there are a number of issues that call for specialised treatment, particularly in the respiratory system. These issues can extend a patient’s stay in the hospital, raising hospital expenses and playing a significant role in morbidity and death. Recent research has demonstrated that early mobilisation, such as getting out of bed and walking, improves the patient’s functional state and shortens the period of hospitalisation. Patients should receive physical treatment regularly to ensure their rehabilitation of their motor skills.⁶

These studies show that inspiratory muscle re-training (IMRT) is possibly beneficial in improving breathing mechanics and decreasing exercise-induced dyspnea. It is also likely useful in enhancing respiratory muscle strength and lowering airway closure (i.e., greater FVC). These mechanistic alterations reflect our developing understanding of the function of IMRT in paediatric patients and can be used to explain improvements in symptomology and clinical outcomes.⁷

Case report

Clinical presentation

Prior to the examination, the patient’s caretaker provided informed permission, and the patient was then placed in a supine posture. The patient was conscious and following instructions. The patient’s BMI was 16.1 kg/m², making her ectomorphic. Prior to surgery, the patient had gradual, insidious dyspnea that worsened as she walked uphill and subsided with rest. The patient is currently having discomfort at the suture site (Figure 1), which she rates 5/10 on a VAS (visual analogue scale). The pain was abrupt in start and dull aching in character. The pain aggravates on coughing and while inhaling deeply and she rated it 7/10 on VAS. Foley’s catheter, central line and drain were present in situ.

Figure 1. Illustrating the suture line.

An examination of the cardiovascular and respiratory systems revealed a normal pericardium that was bilaterally symmetrical, had an apex beat at the level of the fifth intercostal space, and had sutures on the midsternal area. The heartbeat was regular and rhythmic at 89 beats per minute, and all of the peripheral pulsations were present. The middle and lower zones of the chest expanded less than usual, and the respiratory rate was 18 beats per minute.

Timeline: Table 1 included a timeline of the occurrences. It depicts series of incidence from the patient’s hospital admission until the commencement of the physiotherapy treatment.

Table 1. Timeline of the events.

Sr. No	Dates	Events
1.	30 August 23	Patient came to rural hospital with the complaints of breathlessness while walking uphill
2.	1 September 23	2D ECHO was done reviling ASD along with PAPVC
3.	4 September 23	Patient underwent ASD closure surgery
4.	5 September 23	Physiotherapy session was started

Diagnostic assessment: 2D ECHO revealing 14×16 mm of Atrial septal defect along with PAPVC along with grade 1 pulmonary arterial hypertension with interstitial edema.

Therapeutic intervention: Table 2 represents a comprehensive rehabilitation protocol post cardiac surgeries in paediatric population. The protocol includes education of the patient’s care taker and family members about the condition and post-operative care. Pain control: using chest binder to support suture line and decrease pain. Promote bronchial hygiene: nebulization and initiating with active cycle of breathing technique for effective expectoration. Improving inspiratory hold and vital capacity by giving incentive spirometer (Figure 2) and diaphragmatic breathing exercises. Facilitation of normal chest movements by asking the patient to perform thoracic expansion exercises. Improving inspiratory muscle strength: making use of Powerbreathe medic plus device (Figure 3) which is exclusively used for re-training of inspiratory muscles. Hallway ambulation to improve functional capacity (Figure 4). Incorporating home exercise programme to promote functional independence and improving level of activities of daily living.

Table 2. A table representing a well-planned rehabilitation protocol for patients undergoing cardiac surgery.

Sr. No.	Goals	Intervention	Rationale
1.	To inform the patient and her family of the procedure for physical treatment and its advantages	Education and counselling for the patient's family	To promote the patient's active involvement, hence boosting the treatment's effectiveness
2.	To keep the bronchial system clean	Nebulization with Budecort and huffing technique with chest binding for five repetitions, twice daily	Helps in preserving patency of airways thereby enhancing essential capacity
3.	To increase vital capacity and respiratory function	• Thoracic expansion exercises and diaphragmatic breathing (2 sets of 10 repetitions twice a day) • Incentive Spirometer with 3-5 second holds that are increased to 10 second holds twice day in sets of 10.	Keeping lungs expanding properly, and refrain from using your auxiliary muscles
4.	To increase the respiratory muscles' strength	Exercising the muscles of inspiration using the PowerBreathe medic plus device (Twice a day, two sets of ten repetitions)	To avoid cardiac and pulmonary problems after surgery
5.	To improve strength of bilateral upper and lower limb	• Strengthening of upper and lower extremities with half kilogram weight cuff progressing to 1 kilogram weight cuff (2 sets of 10 reps twice a day) • Bed mobility training	Reduce fatigue and improve exercise outcome
6.	To improve Quality of Life	Home exercise programme	To maintain the gained progress and promote further improvement

Figure 2. The use of incentive spirometry to improve inspiratory holds.

Figure 3. Inspiratory muscle training by using powerbreathe medic plus device.

Figure 4. Hallway Ambulation training to improve functional capacity.

Follow-up and outcome measures: Preoperatively and on the first day of physical therapy rehabilitation, the outcome measures were evaluated. A follow-up was done after one week and two weeks of the physiotherapy intervention. The outcomes were listed in Table 3.

Table 3. Outcome measures.

Outcome measure	Pre operatively	POD - 1	After 1 week	After 2 weeks
PIMax	37.5 cmH2O	19.1 cmH2O	29.1 cmH2O	35 cmH2O
RPE (Borg scale)	9	9	9	7
6 MWD	530 m	210 m	470 m	500 m
Fatigue severity scale	5.4	5.10	4.2	3.9

Discussion

André Luiz Lisboa Cordeiro et al. in their studies have stated that Surgery for a coronary artery bypass graft (CABG) is linked to longer hospital stays, pulmonary problems, and reduced functional ability. Patients who are at a high risk for post-operative (PO) pulmonary problems prior to CABG experience these adverse effects to a greater degree. The healing phase for CABG patients has been demonstrated to be aided by inspiratory muscle training (IMT). However, there is insufficient evidence to support the use of IMT post-operatively to promote speedier recovery in high-risk patients.⁶ According to Tamires Daros Dos Santos et al. Patients undergoing CABG experienced additional advantages from short-term moderate-to-high intensity IMT combined with aerobic and resistance training in terms of exercise capacity, inspiratory muscle strength, QoL, and antioxidant profile.⁸ Studies conducted by Balbino Rivail Ventura Nepomuceno Jr et al. suggest that early implementation of inspiratory muscle training on hospitalised patients without established respiratory deficits may prevent adverse outcomes that are either directly or indirectly related to the loss of respiratory muscle mass inherent to a prolonged hospital stay. Training the respiratory muscles can prevent endotracheal intubation, muscular wasting, and death.⁹ According to Rhoia Neidenbach et al. Respiratory training is known to improve exercise capacity and cardiopulmonary function showing significant improvement in oxygen saturation and maximum workload capacity.¹⁰ In this current case we have found significant improvement in PIMax and functional capacity.

Consent

An informed written consent was taken from patients parents before assessment and implementing rehabilitation protocol. Written informed consent was taken from the patient and her parents for sharing clinical details and images for the publication.