Andrew Hirschhorn B.App.Sc. (Hons) Physiotherapy Senior Associate Physiotherapist

1. Physiotherapy in cardiac surgery The pre-operative period to hospital discharge Andrew Hirschhorn B.App.Sc. (Hons) Physiotherapy Senior Associate Physiotherapist Westmead Private Physiotherapy Services Sean Mungovan B.App.Sc. Physiotherapy, M.Phil Principal Physiotherapist Westmead Private Physiotherapy Services

2. Physiotherapy in cardiac surgery The pre-operative period to hospital discharge Take a deep breath…

3. Physiotherapy in cardiac surgery The pre-operative period to hospital discharge Effects of cardiac surgery on the respiratory system Respiratory ‘dysfunction’ versus respiratory ‘complication’ Traditional roles of physiotherapy in the care of the cardiac surgical patient ‘Chest’ physiotherapy: the techniques and the evidence base Interesting recent research Pre-operative interventions (respiratory and otherwise) Post-operative interventions (respiratory and otherwise) Westmead Private Physiotherapy Services Our current work: a change in outcome/focus

4. Physiotherapy in cardiac surgery The effects of cardiac surgery on the respiratory system Pre-operative factors Wynne and Botti, 2004 COPD Obesity Advanced age Diabetes Smoking Chronic heart failure Emergency surgery Previous cardiac surgery Immobility

5. Physiotherapy in cardiac surgery The effects of cardiac surgery on the respiratory system Intra-operative factors Wynne and Botti, 2004 Respiratory depression Neurological injury Lung deflation Cardiopulmonary bypass (and incrased duration thereof) Topical cooling IMA dissection Number of bypass grafts Lower core temperature Sternotomy

6. Physiotherapy in cardiac surgery The effects of cardiac surgery on the respiratory system Post-operative factors Wynne and Botti, 2004 Respiratory depression Phrenic nerve and/or diaphragmatic dysfunction Pain Immobility/bed-rest Chest drains Pleural effusion

7. Physiotherapy in cardiac surgery The effects of cardiac surgery on the respiratory system

8. Physiotherapy in cardiac surgery The effects of cardiac surgery on the respiratory system

9. Physiotherapy in cardiac surgery Respiratory dysfunction versus respiratory complication A digression of interest… What constitutes (normal) respiratory dysfunction following cardiac surgery? What, then, characterises a (significant) respiratory complication?

10. Physiotherapy in cardiac surgery Respiratory dysfunction versus respiratory complication What are the statistics? Brooks-Brunn, 1995: 20-95% Brasher et al, 2003: 3% Stiller et al, 1994: 7% Hulzebos et al, 2006: 26% Hirschhorn et al, 2008: Reduced VC: 100% CXR changes: 95% Temperature > 38 degrees: 54% NIVV: 8% FiO2>0.50 for >24 hours: 1% Positive sputum cultures: 1% Respiratory antibiotics: 1%

11. Physiotherapy in cardiac surgery The traditional role of physiotherapy Respiratory techniques ‘chest physiotherapy (+++)’ Positioning (SUIB, SOOB, SOEOB) Deep breathing exercises (DB) Thoracic expansion exercises (TEE) Sustained maximal inspiration (SMI) Incentive spirometry (IS) IPPB, CPAP, BiPAP, PEP Active cycle of breathing techniques (ACBT) Huffing, coughing, forced expiratory technique (FET) Manual chest techniques (‘percs’ and ‘vibes’)

12. Physiotherapy in cardiac surgery The traditional role of physiotherapy Respiratory techniques ‘chest physiotherapy (+++)’ Positioning (SUIB, SOOB, SOEOB) Deep breathing exercises (DB) Thoracic expansion exercises (TEE) Sustained maximal inspiration (SMI) Incentive spirometry (IS) IPPB, CPAP, BiPAP, PEP Active cycle of breathing techniques (ACBT) Huffing, coughing, forced expiratory technique (FET) Manual chest techniques (‘percs’ and ‘vibes’)

13. Physiotherapy in cardiac surgery ‘Chest’ physiotherapy – how does it go? Prophylactic respiratory physiotherapy after cardiac surgery: systematic review Pasquina et al, 2003 Does removal of deep breathing exercises from a physiotherapy program including pre-operative education and early mobilisation after cardiac surgery alter patient outcomes? Brasher et al, 2003 Deep breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery Westerdahl et al 2005 Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft (Cochrane database of systematic reviews) Freitas et al, 2007

14. Physiotherapy in cardiac surgery ‘Chest’ physiotherapy – how does it go? The upshot! There are many ‘chest’ physiotherapy techniques, with differing purported mechanisms of action. Evidence is lacking as to whether prophylactic, post-operative respiratory physiotherapy prevents pulmonary complications after cardiac surgery (although the component studies of systematic reviews are of low quality) There is some evidence that positive expiratory pressure techniques reduce the ‘normal’ respiratory dysfunction following cardiac surgery The available research does not discuss the efficacy of respiratory physiotherapy in patients who have developed a post-operative pulmonary complication.

15. Physiotherapy in cardiac surgery The current literature: what we know works! Pre-operative interventions Post-operative (inpatient) interventions

16. Physiotherapy in cardiac surgery The current literature Pre-operative interventions Inspiratory muscle training (IMT) Hulzebos et al, 2006 Design: Single-blind RCT Patients: Awaiting CABG, ‘high risk’ of PPCs Intervention group: Daily training for > 2/52 pre-operatively in IMT and incentive spirometry Outcomes: PPC, LOS

17. Physiotherapy in cardiac surgery The current literature Pre-operative interventions Inspiratory muscle training (IMT) Hulzebos et al, 2006 Findings: Preventative physiotherapy with IMT administered to patients at high risk of PPCs before CABG was associated with a decrease in the incidence of PPCs and length of hospitalisation.

18. Physiotherapy in cardiac surgery The current literature Pre-operative interventions Outpatient exercise training Arthur et al, 2000 Design: RCT Patients: Waiting list for elective CABG Intervention group: Twice weekly exercise training, education/re-inforcement/nursing support Outcomes: LOS, QoL Inpatient exercise training Herdy et al, 2008 Design: RCT Patients: Inpatients awaiting CABG Intervention group: Phase 1 CR, incentive spirometry, IPPB Outcomes: ICU stay, AF

19. Physiotherapy in cardiac surgery The current literature Post-operative interventions Inpatient exercise therapy van der Peijl et al, 2004 Design: Single-blind RCT Patients: Non-emergency CABG patients Intervention group: High frequency (twice daily, week-ends) exercise from POD 1 Outcomes: FIM scores, patient satisfaction

20. Physiotherapy in cardiac surgery The current literature: Hirschhorn et al, 2008 Post-operative interventions Twice-daily, moderate intensity, walking exercise program Design: RCT Patients: 1st time, isolated CABG patients (n=92) Treatment groups: Standard intervention, walking, walking/breathing Outcomes: 6MWA, vital capacity, HRQoL

21. Physiotherapy in cardiac surgery The current literature: Hirschhorn et al, 2008 6MWA distance(m)

22. Physiotherapy in cardiac surgery The current literature: Hirschhorn et al, 2008 Better than ‘standard’ care p = 0.005, p = 0.022

23. Physiotherapy in cardiac surgery The pre-operative period to hospital discharge The Cardiothoracic Surgical team: Surgeons A/Prof Richard Chard Dr Robert Costa Dr Ian Nicholson Dr Hugh Paterson Nursing Teams Operating theatres Intensive care unit Cardiovascular ward Clinical Research A/Prof David Richards Westmead Private Hospital Executive

24. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus Reduction in complication rates Focus on function and functional outcomes

25. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus Mortality and morbidity meetings Reporting outcomes: LOS, discharge destination, completed stairs How could we better measure the worth of what we are doing? 6 minute walk assessment Once an appropriate outcome measure had been established, how could we improve our performance?

26. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services

27. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus

28. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus

29. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus

30. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus For some patients, the exercise that they receive in hospital (phase 1 CR) may be the only supervised exercise they receive: Victoria: 53.1% attendance (Bunker et al, 1999) - CABG Queensland: 10% of patients discharged after acute coronary events and revascularisation procedures completed OCR programs. (Scott et al, 2003) Minnesota: 59% attendance (Evenson et al, 1998) - CABG

31. Physiotherapy in cardiac surgery Westmead Private Physiotherapy Services Our current work: a change in focus

32. Physiotherapy in cardiac surgery How do we get patients there faster? How do we get patients ‘as good as possible’? Drilling down Intensity of exercise Modality of exercise Duration of exercise Frequency of exercise Dose-response relationship to exercise

33. Rating of perceived exertion (RPE) Borg, 1982

34. Physiotherapy in cardiac surgery Stationary cycling versus walking: a comparison of exercise modalities following CABG

35. Physiotherapy in cardiac surgery Stationary cycling versus walking Some early results… n = 10 (9M:1F) (6W:4C) age: 64 ±10 years, range 44-81 years LOS: median 6.5 days, range 6-8 days post-operative atrial fibrillation: 1 patient* number of potential exercise sessions: 76 number of exercise sessions attended: 74

36. Physiotherapy in cardiac surgery Stationary cycling versus walking Some early results… walkers (n=6) mean distance walked daily (in 20 minutes): d3: 836m; d4:1135m; d5: 1274m mean distance walked overall: 3870 ± 1030m all patients %6MWA achieved at discharge: 87 ± 20%, distance: 430 ± 95m

37. Physiotherapy in cardiac surgery Stationary cycling versus walking Some early results… cyclists (n=4) mean cycling workload daily (in 20 minutes): d3: 32kJ; d4: 40kJ; d5: 49kJ; d6 55kJ mean cycling workload overall: 176 ± 85kJ all patients %6MCA achieved at discharge: 76 ± 47%, work: 17 ± 6kJ

38. Physiotherapy in cardiac surgery Future research directions and goals Intermittent versus continuous exercise… Measuring effects on Phase 2 cardiac rehabilitation uptake. With the ultimate goals of: i) maximising the skill of the surgeon, and their surgical technique ii) developing a structured, evidence-based approach to the post-operative management and training of the cardiac surgical patient caseload