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Physiotherapy and surgery


Chest physiotherapy has been and sometimes is used to prevent and treat postoperative pulmonary complications, especially in high risk patients with a history of obesity, smoking, or old age, where lung function may be relatively impaired. Is it effective? A randomised trial of prophylactic chest physiotherapy from Sweden [ 1 ] comes to a very positive conclusion.

Trial


The study was conducted on all patients undergoing elective, open, upper abdominal surgery in one University hospital in Göteborg over a 14 month period. Randomisation was to physiotherapy being used or not used in alternate months. High risk patients were defined as those with age over 50 years who smoked, had a body mass index (BMI) of over 30 or who had a medical condition causing reduced lung function.

The intervention was a visit on the day before operation by a physiotherapist who trained the patient in breathing exercises with pursed lips, huffing and coughing hourly, information on changing position in bed, and the value of early mobilisation. High risk patients were additionally given a positive respiratory pressure mask for respiratory resistance training. Patients in the treatment group were told to take 30 deep breaths with huffing and coughing between every tenth breath every hour in daytime after the operation. After surgery physiotherapy continued, adjusted to pulmonary status.

In the control group, patients were given no preoperative training, and treatment by a physiotherapist occurred if a pulmonary complication developed.

Outcomes included surrogate measures like oxygen saturation, postoperative pulmonary complications, mobilisation and hospital stay. A pulmonary complication was defined as oxygen saturation less than 92%, or two of:

Results


There were 174 patients given the prophylactic physiotherapy and 192 in the control group. Groups were well matched for demographic variables and type of surgical procedure.

There were many fewer cases of pulmonary complications with prophylactic chest physiotherapy, for all patients where the number needed to treat (NNT) was 4.7, and for high and low risk patients, and obese patients, where the NNT was 2.1 (Table). There was a reduction in the number of patients with radiological and clinical pneumonia with treatment, where the NNT was 16.
Effect of prophylactic chest physiotherapy on postoperative complications
Outcome Patients Treated Control NNT (95%CI)
         
Pulmonary complications All 10/172 52/192 4.7 (3.5 to 7.1)
Pulmonary complications Low risk 4/132 32/153 5.6 (4.0 to 9.3)
Pulmonary complications High risk 6/40 20/39 2.8 (1.8 to 5.9)
Pulmonary complications BMI >30 3/36 27/48 2.1 (1.6 to 3.2)
Pneumonia All 1/172 13/192 16 (10 to 41)



There were significant increases in postoperative oxygen saturation with treatment, and for time to walking in the room and full mobilisation, but no difference in the length of hospital stay.

Comment


The good things about this study design were that it was comprehensive in its scope, including all patients over 14 months, and the pre-hoc identification of sub-groups for analysis. The alternate month randomisation was less than ideal because it raises the possibility of unconcealed allocation which is a known source of bias. The study was not blinded, but outcomes were objective and pre-defined.

This is good evidence that prophylactic physiotherapy reduces postoperative lung complications in people undergoing abdominal surgery. The effect may be greater in those at high risk, but not markedly so compared with those at low risk. Apart from people with BMI >30, there was overlap in the confidence intervals for the NNTs for pulmonary complications. Total hospital stay was not reduced, a fact not commented upon in the paper. But this is a blunt outcome, much affected by many other factors, and getting patients home earlier was not the focus of the study.

It would be interesting to have a health economist look at this. Would the costs of additional physiotherapy be outweighed by the costs of the complications prevented?


Reference:

  1. M Fagevik Olsén, I Hahn, S Nordgren, H Lönroth, K Lundholm. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997 84: 1535-38.

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