Secretion retention and desaturation on day 2 after emergency laparotomy
Mr Lee, 68, an ex-smoker with a 40 pack-year history, was admitted with perforated diverticulitis and underwent emergency laparotomy and sigmoid colectomy. He is now day 2 in intensive care and was extubated 6 hours ago. He is on 4 L/min nasal cannula with SpO2 91–93%, respiratory rate 28/min, heart rate 112/min, BP 132/78 mmHg, and temperature 38.0°C. There are coarse crackles at the right base, his cough is weak, secretions are audible, and he has pain 7/10 at the midline incision. He is drowsy but rousable and follows commands. His abdomen is firm with a drain in situ. He is prescribed morphine via patient-controlled analgesia and antibiotics. Physiotherapy has been called for 'chest clearance'. He has not been out of bed since surgery.
1. Prioritise your assessment and immediate management, including risks and contraindications.
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First assess airway, breathing, and circulation: conscious level, respiratory rate, SpO2, oxygen delivery, chest expansion, breath sounds, cough strength, and secretion character. Check whether he can clear secretions and whether suction is needed. Review the notes for haemoglobin, white cell count, lactate, chest X-ray, analgesia, and surgical restrictions. Identify risks: recent abdominal surgery with a drain, pain limiting cough, possible atelectasis or pneumonia, drowsiness from opioids, and risk of desaturation. Contraindications to aggressive manual techniques include an unstable abdomen, active bleeding, uncontrolled pain, and cardiovascular instability; none are absolute here, but the incision and drain require protection.
Immediately sit him upright as tolerated, give pre-treatment analgesia within prescribed limits, check SpO2 and haemodynamics, and use supported coughing or huffing with a folded towel over the wound. If secretions are audible and he cannot clear them, use assisted cough or suction according to competency and policy. Do not commence vigorous mobilisation until oxygenation and pain are optimised. Escalate to the medical team if SpO2 falls below 90% on supplemental oxygen, respiratory rate rises further, or he becomes less responsive.
2. Design a treatment session, including positioning, breathing exercises, manual techniques, and the decision about mobilisation. Give parameters and stopping criteria.
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Position him upright in bed or in a chair at 45–60 degrees, with the right side uppermost if tolerated to improve ventilation-perfusion matching. Give pre-treatment analgesia, then teach relaxed diaphragmatic breathing and a supported huff. Use a positive expiratory pressure device or incentive spirometer if available, with 10–15 breaths, pauses, and a huff, repeated for 2–3 cycles. Add slow expiratory vibrations or rib-springing over the right base, avoiding the incision and drain, for 3–5 breaths per cycle. Suction only if he cannot clear audible secretions.
Mobilisation can be considered after the first clearance cycle if SpO2 is at least 92% on 4 L/min or less, heart rate is below 120/min, pain is controlled, and he is alert enough to sit on the edge of the bed with assistance. Start with sitting on the edge for 2–3 minutes, then stand with a frame if tolerated. Stop for SpO2 below 90%, heart rate above 130/min or new arrhythmia, systolic BP fall greater than 20 mmHg, chest pain, severe distress, or a fall in conscious level. Reassess breath sounds and SpO2 after the session.
3. How would you evaluate effectiveness and when would you escalate?
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Evaluate effectiveness by comparing pre- and post-treatment respiratory rate, SpO2 at the same oxygen flow, work of breathing, auscultation, sputum volume and colour, cough strength, pain score, and distance mobilised. A successful session produces easier breathing, reduced audible secretions, improved air entry, and no fall in SpO2. Document the techniques used, duration, oxygen requirement, and patient response. Reassess after 30–60 minutes because secretion clearance can improve oxygenation gradually.
Escalate to the intensive care team if SpO2 remains below 90–92% despite 4 L/min, respiratory rate stays above 30/min, he becomes drowsy or confused, secretions are copious or purulent with worsening fever, or he cannot clear secretions without suction. Escalate urgently for chest pain, new arrhythmia, hypotension, or a rising oxygen requirement. If he deteriorates during mobilisation, stop, sit him down, give oxygen, and call for medical review. Physiotherapy should be documented as part of the medical plan, not as a standalone order.