Randomized Clinical Trial of Physiotherapy after Open Abdominal Surgery in High Risk Patients

1. Randomized Clinical Trial of Physiotherapy after Open Abdominal Surgery in High Risk Patients Background: Postoperativephysiotherapy has been shown to reduce the incidence of postoperative pulmonary complications after open abdominal surgery. Purpose: This study aimed to determine if the addition of deep breathing exercises and secretion clearing techniques to a standardized physiotherapist-directed program of early mobilization improved clinical outcomes in patients undergoing open abdominal surgery. Methods: Fifty-six patients undergoing open abdominal surgery, at high risk of developing postoperative pulmonary complications, were randomized before operation to an early mobilization-only group or an early mobilization-plus-deep breathing and coughing group. Mobility duration, frequency and intensity of breathing interventions were quantified for both groups. All outcomes were assessed by a blinded outcomes researcher using a standardized outcomes measurement tool developed specifically for this population. Outcomes included incidence of clinically significant postoperative pulmonary complications, fever, length of stay, and restoration of mobility. Results: There were no significant differences between groups in mean age, anesthetic time, perioperative morbidity, or postoperative mobility. Outcome data were available for 89% of enrolled subjects. Overall incidence of postoperative pulmonary complications was 16%. The incidence of postoperative pulmonary complications in the non-deep breathing and coughing group was 14%, and the incidence of postoperative pulmonary complications in the deep breathing and coughing group was 17%, (absolute risk reduction -3%, 95% C1 -22 to 19%). Conclusion: There was no significant difference between groups in the incidence of fever, physiotherapist time, or the number of treatments. This study suggests that, in this clinical setting, the addition of deep breathing and coughing exercises to a physiotherapist-directed program of early mobilization does not significantly reduce the incidence of clinically significant postoperative pulmonary complications in high risk open abdominal surgery subjects. Abstract Mackay, M, Elizabeth E, Johnston C. Randomized clinical trial of physiotherapy after open abdominal surger in high risk patients. Australian Journal of Physiotherapy. 2005; Vol. 51. Background/Introduction To be eligible for inclusion subjects had to have surgery planned which involved manipulation of the viscera via a single upper, or combined upper and lower, midline open abdominal incision, and be classified as at high risk of developing postoperative pulmonary complications High risk patients were those under 59 years with a history of cigarette smoking, pulmonary disease, heart disease, cancer, renal and/or liver disease, an American Society of Anesthesiologists (ASA) score > 2, or obese (body mass index > 27 kg/m2), plus any patient having the same surgery aged 59 years and over 56 subjects started, 50 subjects completed the experiment, 21 subjects in the control group (early mobilization only) and 29 subjects in the experimental group (early mobilization with deep breathing and clearing exercises) Control group: goals were attempted in order during each treatment session: 1. Sit out of bed 
 2. Walk 5 m with assistance
 3. Walk 15 m with assistance Experimental Group subjects received the same program of early mobilization as the Control Group with the addition of coached lateral basal expansion exercises and sputum clearance techniques(DB&C). The DB&C exercises consisted of at least three coached lateral basal expansion maneuvers (deep breaths) followed by a cough, huff, or forced expiratory maneuver A postoperative pulmonary complication is deemed to have occurred if three or more of the following objective respiratory signs occur within the same day, in the first 14 days after surgery: Auscultation changes (decreased breath sounds, crackles, wheezes, bronchial breathing) that were additional to those found prior to surgery, temperature over 38 degrees Celsius. chest X-ray changes consistent with collapse, consolidation, or atelectasis, increase in amount and/or changed color of sputum produced, compared to what the patient reports is usual for them. Methods and Materials The overall incidence of postoperative pulmonary complications in this study was 16%. Three subjects in the non-DB&C Group (14%) and five subjects in DB&C Group (17%) developed clinically significant postoperative pulmonary complications The incidence of postoperative pulmonary complications and fever in the DB&C Group was higher than in the non-DB&C Group, however these differences were not statistically significant Results Conclusion The addition of DB&C exercises to a physiotherapist-directed program of early mobilization does not significantly reduce the incidence of clinically significant postoperative pulmonary complications in high risk open abdominal surgery subjects. Further research is required to determine if similar results can be obtained with less PT input or if clinical outcomes can be improved by increasing distance, time, or exertion of early mobility interventions. Article 1 Evidence Pasquina P, Tramer M, Granier J, Walder B. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery. Chest. 2006; 130: 1887-1899. This article also supports my original article. Its purpose was to examine the efficacy of respiratory physiotherapy for prevention of pulmonary complications after abdominal surgery. This was a systematic review that concluded that only a few trials supported the usefulness of prophylactic respiratory physiotherapy, and that use of respiratory therapy physiotherapy after abdominal surgery was not justified. This article was found to be similar in both purpose and results in comparison to my original article. PT for patients after open abdominal surgery consists of a variety of interventions intended to improve cardiopulmonary/physical function to reduce the incidence of postoperative pulmonary complications (PPC) The incidence of clinically significant postoperative pulmonary complications after open abdominal surgery has been shown to be as high as 53% PPC has been shown to be lower in patients who receive PT to those who receive none It is unknown whether it is the lung expansion and coughing exercises, or the patient’s change in position and assisted early mobilization that accompanies these interventions, or a combination of both, which is responsible for the decrease in incidence of postoperative pulmonary complications The purpose of this study was to investigate whether the addition of deep breathing and coughing exercises (DB&C) to a standardized program of early mobilization for all patients conferred any significant benefit in reducing the incidence of clinically significant postoperative pulmonary complications after open abdominal surgery in high risk patients Discussion This study found that in a clinical setting, the addition of coached lateral basal expansion and secretion clearance techniques to a targeted program of PT early mobilization resulted in no additional benefit in reducing the incidence of postoperative pulmonary complications after open abdominal surgery in high risk subjects, thus each group obtained equally good results This investigation is the first to control for the possible treatment effect of early mobilization and the effect of physiotherapist attention on subject outcome by having both study groups receive the early mobilization intervention, rather than having a no-intervention ‘control’ group such as in previous studies Further studies are needed investigating the efficacy of various PT interventions (including coached lateral basal expansion, CPAP, and mobilization) in improving the rate of resolution of clinically significant postoperative pulmonary complications after they have developed Summary Clinical Significance This article is relevant to Physical Therapy because it advises that the use of deep breathing exercises and clearing techniques have yet to be proven beneficial in preventing postoperative pulmonary complications. Presents a well known procedure to follow postoperatively for this kind of patient which is early mobilization. This is designed to maximize the rate of restoration of mobility and improve pulmonary ventilation. Article concludes that the use of DB and clearing techniques when coupled with early mobilization do not significantly reduce the incidence of clinically significant postoperative pulmonary complications in high risk open abdominal surgery patients. The use of respiratory therapy (DB&C, IS, prophylactic respiratory physiotherapy) have yet to justify there ability to reduce the incidence of clinically significant postoperative pulmonary complication in high risk abdominal surgery patients in a clinical setting. Therapists must first agree on a definition of postoperative pulmonary complications and determine a “gold standard” of therapy for these patients. Once that is accomplished, further testing can be done to truly assess the effectiveness of this intervention on future patients. Poster Presented by: Paul Clark Student PT Article 2 Evidence Guimaraes M, Dib R, Smith A, Matos D. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews.2009; issue 3. My second article supports my original article in regards to the lack of effectiveness of the use of deep breathing exercises for prevention of postoperative pulmonary complications in abdominal surgery This article used an incentive spirometer to evaluate the effectiveness of deep breathing exercises. An incentive spirometer is a device that measures the amount of air that is inhaled during each breath. It is a visual cue to patients to try and increase how air they are bringing in to expand the lungs. It encourages patients to take deep, long, slow breaths in order to increase the amount of air they can inhale. This kind of technique is very similar to the use of deep breathing exercises. In both studies, these are thought to prevent accumulation of fluid in the lungs and prevent obstruction The purpose of this study was to assess the effectiveness of incentive spirometry, compared to no such therapy or other therapy, on postoperative pulmonary complications and mortality in adults undergoing upper abdominal surgery This was a meta-analysis study that combined many different interventions and compared them to one another It was documented that there was no statistically nor significant difference between the participants receiving IS compared to those with no respiratory treatment There was no statistically significant difference between the participants receiving IS compared tot hose receiving DBE. Thus it was concluded that there is no benefit/good evidence regarding the effectiveness of incentive spirometry for prevention of postoperative pulmonary complications Margaret R Mackay, Elizabeth Ellis, Catherine Johnston 4. Walk 30 m with assistance 5. Walk 30 m without assistance