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    1. 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

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    3. 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. Pre-operative factors Wynne and Botti, 2004 COPD Obesity Advanced age Diabetes Smoking Chronic heart failure Emergency surgery Previous cardiac surgery Immobility

    5. 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. Post-operative factors Wynne and Botti, 2004 Respiratory depression Phrenic nerve and/or diaphragmatic dysfunction Pain Immobility/bed-rest Chest drains Pleural effusion

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    11. 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. 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. 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. 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. Pre-operative interventions Post-operative (inpatient) interventions

    16. 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. 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. 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. 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. 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

    23. 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

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