MedicalResearch.com Interview with:
Titled Cardiorespiratory APAM, PhD Candidate, MSc, BAppSc
Manager Abdominal Surgery Research Group
Clinical Lead – Cardiorespiratory Physiotherapy, Physiotherapy Department
Allied Health Services
Tasmanian Health Services – North |
Launceston General Hospital
MedicalResearch.com: What is the background for this study?
Response: Major upper abdominal surgery involves opening up the abdomen – mainly to remove cancer or damaged bowel, liver, stomach, pancreas, or kidney. It is, by far, the most common major surgical procedure performed in developed countries with millions of procedures performed per annum. Unfortunately a respiratory complication following these operations occurs relatively frequently with between 1 in 10 to almost a half of all patients getting some type of respiratory complication after surgery. Respiratory complications included problems such as pneumonia, lung collapse, respiratory failure, and an acute asthma attack. These complications, especially pneumonia and respiratory failure, are strongly associated with significant morbidity, mortality, increased antibiotic usage and longer hospital stay.
These breathing problems occur quite quickly after surgery, becoming evident usually within the first two to three days after surgery. In an effort to ameliorate these complications in developed countries it is common for physiotherapists/respiratory therapists to see a patient for the first time on the day after surgery and start patients doing breathing exercises. However as respiratory dysfunction starts occurring immediately following surgery it is debated that these breathing exercises are being provided too late. Initiating prophylactic treatment more than 24 hours after the end of surgery may not be as effective as starting prophylaxis immediately. Unfortunately, immediately after surgery patients are either very sleepy, in pain, feeling sick, or delirious. It may not be possible to effectively teach patients at this point on the importance of breathing exercises and get good performance.
One method to overcome this would be to meet patients before the operation to educate them about their risk of a postoperative chest infection and to motivate and train them to perform breathing exercises to do immediately on waking from surgery. Previous trials have indicated that this may help prevent postoperative respiratory complications, although evidence is inconclusive and weak.
We set out to robustly and conclusively see if respiratory complications could be prevented after major upper abdominal surgery if patients were taught breathing exercises to do as soon as they woke up after the operation. We ran this trial in two countries (Australia and New Zealand) and three different types of hospitals. All patients were met by a physiotherapist at our hospitals’ scheduled pre-admission clinic appointment and either provided with an information booklet (control) or provided with an additional 30 minute education and training session with the physiotherapist. At this preoperative session the patient was educated about respiratory complications, their risk, and how to prevent them with breathing exercises. These exercises were then taught and practiced for just three repetitions. Patients were instructed to do these breathing exercises for 20 repetitions as soon as they woke from surgery and then 20 times every hour after surgery until they were up and out of bed frequently.
Following surgery each patient had a standardised rehabilitation program and no respiratory therapy of any type was provided to the patients after surgery.
For the first two weeks after surgery patients were assessed daily for a respiratory complication by research assistants unaware of what treatment the patient had received before surgery.
MedicalResearch.com: What are the main findings?
Response: We found strong evidence that a single, once-off, no-harm, physiotherapy session prior to surgery reduces the incidence of a respiratory complication, and especially pneumonia, by half. Detailed analysis of the data further demonstrated that experience of physiotherapist matters – those seen by the most experienced physiotherapist also had less days in hospital and most importantly the patients’ 12month all-cause mortality was also reduced by half.
MedicalResearch.com: What should readers take away from your report?
Response: Deep breathing exercises performed after major abdominal surgery prevents pneumonia. However, for these exercises to be effective, patients need to see a physiotherapist just once prior to surgery to be trained on these exercises. Importantly experience matters. The more experienced the physiotherapist conducting the training the better the result. Considering the strong practitioner response, it can’t be extrapolated that any other type of professional group or medium of delivery (DVD, Skype, on-line) would work as effectively.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Further work is required to determine why the experienced physiotherapist was so much more effective than less experienced therapists in educating and training patients. Is it possible to train others to be just as effective, or is it simply practice makes perfect?
More also needs to be done to investigate how to reduce respiratory complications further, especially in patients at highest risk. The risk of dying any time in the first 12 months after surgery was 4 times worse in the patients who got a respiratory problem in the first 2 weeks after surgery compared to those that didn’t. Pre-operative education and training from a physiotherapist is a great starting point, yet more needs to be done to reduce the risk further. Other therapies such as non-invasive ventilation, positive expiratory pressure devices, incentive spirometry, and early ambulation, all need to be investigated further to consider their usefulness and cost effectiveness in reducing respiratory complications after major surgery.
Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.j5916 (Published 24 January 2018)Cite this as: BMJ 2018;360:j5916
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