Value of Physiotherapy Prior to and Following Abdominal and Chest Surgery - Essay Example

Value of physiotherapy prior to and following abdominal and chest surgery Cardiovascular system consists of heart and blood vessels. It helps the transport of respiratory gases, nutrient substances and excretory products through blood to various parts of the body (Reghunandan 1997). The gastrointestinal system is essentially a long tube with muscular walls and a glandular epithelial lining. The parts of the tubular digestive systems are, in order, the mouth, pharynx, esophagus, stomach, small intestine (with three subdivisions, the duodenum, jejunum, and ileum) and large intestine (including cecum and vermiform appendix, colon, rectum, and anal canal). The respiratory system consists of the nose and nasal passages, part of the pharynx, the larynx, the trachea with its subdivisions, the bronchi and the lungs (Hollinshead 1985). Many advances have been made in surgical procedures but surgery still carries considerable risk to the patient, both adult and child (Webber 1993). No matter how simple and straightforward an operation, or how physically fit the patient is before he undergoes it, there are always certain risks, which cannot be avoided, though preventive measures can lessen their incidence. Some of the complications that may follow surgery are respiratory problems, thrombosis, wound infections, pressure sores, hemorrhage, muscle wasting and impairment of function and cardiac arrest. Respiratory complications are liable to follow any operation in which general anesthesia is used. They are most common in thoracic surgery since, in many cases, the lung function may be impaired already. After thoracic surgery the highest incidence is probably in abdominal operations, particularly those that requires a supraumblical incision. Postoperative respiratory complications are due to retained secretions and/or decreased thoracic expansion due to pain. Sometimes these secretions are stringy and viscid and therefore difficult to expectorate. Following operation the patient is drowsy, making deep breathing and coughing difficult, and if the incision is thoracic or abdominal, coughing is voluntarily inhibited through fear of pain. Provided the patient is reassured that his stitches will not break through coughing, and his pain relieved by adequate analgesia, a good effective cough will clear these secretions. Postoperative analgesic make the patient lethargic and the presence of drains, intravenous lines or other tubes may make him relatively immobile and less likely to be able to clear his chest of secretions. Retained secretions may lead to the problems such as atelectasis or postoperative pulmonary collapse, postoperative pneumonia or aspiration pneumonia. The aim of pre and post operation physiotherapy is to prevent complications ( Downie 1985). It has been well established that pulmonary function decreases following open-heart surgery (Taggart et al 1993, Van Belle et al 1992, Vargas et al 1992). General anesthesia has been shown to reduce functional residual capacity (FRC) by approximately 20%, cardiopulmonary bypass impairs gas exchange, and cardiac surgery patients with mammary arteries harvested have been shown to have a higher risk of pleural effusion and subsequent pulmonary problems (Matthay et al 1989). The incidence of alelectasis increases with each of general anesthesia; cardiopulmonary bypass and cardiac surgery (Matthay 1989) and atelectasis itself can result in decrease in FRC, vital capacity and lung compliance (Weiman et al 1993). As a result, patients undergoing cardiac surgery are at risk of developing postoperative pulmonary complications. There is three major clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, co morbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (Pereira 1999). The physiotherapist must consider the general condition of the patient and must remember the possible feelings and fears that he may have in his unnatural surroundings. Physiotherapy should be timed to coincide with the administration of analgesia and sedation, and turning of the patient. Patients at risk from postoperative complications should be identified and when possible seen preoperatively by the physiotherapist. Pre-operative assessment will identify pre-existing problems and potential problems. Instruction in breathing techniques, including breathing control, thoracic expansion exercises with a hold at full inspiration, and the forced expiration technique, and instruction in wound support should be given. Positioning can be used to counter the postoperative reduction in functional residual capacity, and as soon as possible patients should be encouraged to sit upright and out of bed in a chair, rather than in a slumped position. Early ambulation will minimize postoperative complications. Physiotherapy key points in a cardiac surgery patient include the following. 1.If breath sounds are reduced or bronchial, positioning to improve ventilation and perfusion matching may be indicated, for example positioning in right side lying for a left lower lobe collapse. 2. Periodic continuous positive airway pressure may be effective if lung collapse persists in a spontaneously breathing cooperative patient, and intermittent positive pressure breathing in a patient unable to cooperate with the active cycle of breathing techniques. 3. Support of the wound by the physiotherapist or the patient himself, or the use of a pillow held over the wound, or a 'cough-lock' or towel, may assist huffing and coughing (Webber 1993). In the intubated patient, the endotracheal tube and mechanical ventilation can cause mucosal inflammation and increased secretions, but intubations and ventilation are not in themselves a prescription for physiotherapy. The rationale for treatment should be based on excessive secretions, atelectasis, or abnormal gas exchange. However, airway obstruction and lung collapse caused by retained bronchial secretions after complicate the clinical course and prolong the recovery phase and, therefore can impact on long term outcome. In such situations, chest physiotherapy may facilitate reinflation of collapsed areas by the removal of obstructive secretions (Herbert 2001). Historically, chest physiotherapy has been performed prophylactically with patients undergoing open-heart surgery to reduce the risk of postoperative pulmonary complications. Physiotherapy for open-heart surgery may include a variety of techniques. Those most commonly used in Australia in the initial post operative period include deep breathing exercises, early ambulation, positioning, huffing and coughing (Tucker et al 1996). O' Donohue (1992) suggested that refractory postoperative atelectasis may best be prevented or treated by spontaneous deep breathing exercises to improve inspiratory capacity and lung compliance, with an hourly routine of at least five sequential deep breaths, each held for five to six seconds. Blaney et al (1997) found a significant increase in diaphragmatic displacement when deep breathing exercises were performed with tactile stimulation over the subject's lower costal margin in addition to verbal instruction, compared with instruction alone. In addition, deep breathing exercises are advocated to improve tidal volume (Webber and Pryor 1998). Acute lobar atelectasis as a result of mucous plugging is more commonly encountered in the intensive care setting and physiotherapy is often requested to assist in reinflation. (Herbert 2001). Studies examining the use of physiotherapy as a prophylactic measure in the prevention of postoperative pulmonary complications are contradictory. There is considerable variability in patient groups, treatment modalities, and outcome measures. The effectiveness of prophylactic deep breathing exercises in patients undergoing cardiac surgery has been questioned (Stiller et al 1994). Brasher P A in the year 2003 carried out a randomized controlled trial to establish whether removal of breathing exercise from a regimen including early mobilization changes the incidence of post-operative pulmonary complications for patients after cardiac surgery. Two hundred and thirty patients undergoing open-heart surgery were enrolled in the randomized controlled trial. All patients received physiotherapy treatment pre-operatively and postoperatively for three days. Patients were mobilized as soon as possible after surgery. Breathing group (control) patients performed a set routine of deep breathing exercise at each physiotherapy visit while those in the intervention group did not perform this routine. Other than breathing exercises, patient management was similar between groups in terms of assessment, positioning and mobility. The incidence of postoperative pulmonary complications, postoperative length of stay, oxyhaemoglobin saturation and pulmonary function were measured pre-operatively and post-operatively. There were no significant differences between the groups in the primary dependent variables. It was concluded that removal of breathing exercises from the routine physiotherapy management of open-heart surgery patients does not significantly alter patient outcome. A limitation of the study was that the physiotherapists treating the subjects could not be blinded to allocation and nor could subjects be blinded to the aims of the research if they were to give true informed consent. (Brasher P A 2003). One hundred and twenty patients undergoing coronary artery surgery completed a randomized controlled study designed to investigate whether prophylactic chest physiotherapy affected the incidence of postoperative pulmonary complications. Group 1 patients received no preoperative or postoperative chest physiotherapy. Group 2 patients received preoperative education and instruction in breathing and coughing exercises and postoperative supervision and assistance in performing the same. These exercises were supervised by a physiotherapist twice per day on the first 2 postoperative days and once per day on the 3rd and 4th postoperative days. Physiotherapy for group 3 patients was the same as for group 2 patients except that patients were seen by a physiotherapist 4 times per day on the first 2 postoperative days and twice per day on the 3rd and 4th postoperative days. Group 2 and 3 patients were instructed to practice breathing and coughing exercises every hour. Overall, an incidence of clinically significant postoperative pulmonary complication of 7.5 percent was demonstrated. In general, these patients demonstrated lower levels of preoperative pulmonary function and very low early postoperative oxygenation compared with those who did not develop pulmonary complication. These were no indication that the incidence or severity of fever, hypoxemia, chest roentgenologic abnormalities or clinically significant postoperative pulmonary complications was different between groups. These results suggested that the necessity for prophylactic chest physiotherapy after routine coronary artery surgery should be reviewed (Stiller 1994). A prospective, randomized, controlled study analyzing the treatment for atelectasis after cardiac surgery showed that noninvasive pressure support ventilation was superior to continuous positive airway pressure for improving atelectasis based on radiological score. The study has some limitations. The first regards the large number of patients who met exclusion criteria. Although this created a more homogeneous study group, some excluded patients, particularly those with refractory hypoxemia, could have benefited more from NIPSV. The second limitation was the short duration of the treatment of both groups because of the transfer of patients to the wards (Pasquina 2004). A systematic review performed by Pasquina (2003) concluded that large randomized trials are needed with no intervention controls, clinically relevant end points, and reasonable follow up periods in order to assess whether respiratory physiotherapy prevents pulmonary complications after cardiac surgery. Of the 107 papers screened, 27 randomized controlled trials were eligible for inclusion. 18 trials were analyzed. The average group size was 32 patients (range 12-95). Four trials described an adequate randomization method, two reported on concealment of treatment allocation, and 14 reported on blinding of observers. Here trials used an intention to treat analysis. Co interventions were used in most trials but adequately described in only four. Eighteen trials tested eight regimens of prophylactic respiratory physiotherapy. This variety, which is not dissimilar to other settings, may be due to the lack of a gold standard method for respiratory physiotherapy. If ethically acceptable, the best comparator is then a placebo, or, as in the physiotherapy setting, a no intervention control. Four trials only had a no intervention control group, and each tested a different method of physiotherapy. Based on these trials it was therefore difficult to determine the efficacy of different methods of respiratory physiotherapy. On average the quality of the trials was low. Only a minority reported on an appropriate method of randomization or on concealment of allocation although bad reporting may not mean bad practice. In only few trials was the follow up of patients adequately reported and data analyzed according to intention to treat. One inherent problem of trials in this setting is that at best the observer can be blinded. Over two thirds of the trials attempted to blind the observers (Pasquina 2003) All patients have some impairment of respiratory function after abdominal surgery. Areas of microatelectasis develop during anesthesia and grow in the presence of the shallow monotonous ventilation and reduced mucociliary clearance that accompanies postoperative somnolence (Strandberg 1987, Jones 1987). These changes occur even in the presence of good analgesia. By way of explanation, Ford et al have emphasized that anesthesia induces "a shift in respiratory pump activity from the diaphram to other muscles". This temporary dysfunction of the diaphram after abdominal surgery helps to explain the affinity of atelectasis for the bases of the lungs (Dureuil 1987). Physiotherapy treatment for patients after open abdominal surgery consists of a variety of interventions intended to improve cardiopulmonary and/or physical function and reduce the incidence of postoperative pulmonary complications. These interventions may include lung expansion exercises, secretion clearance techniques, limb exercises, progressive mobilization programs, and other techniques. (Mackay 2005) the incidence of clinically significant postoperative pulmonary complication after open abdominal surgery has been shown to be as high as 53 percent in NSW hospitals (Mackay and Ellis 2002). A nested case-control study by Lawrence in the year 1996 concluded that the evidence of lung disease on physical examination and chest radiography plus cardiac disease and composite comorbidity indicated increased pulmonary risk in the study of veterans undergoing elective abdominal operations (Lawrence 1996). There are concerns that some forms of physiotherapy are inappropriate prophylaxis. It is now believed that prophylaxis against postoperative respiratory are optimal when it is based on techniques that promote a maximal inspiratory effort (Hall C 1996). Chuter et al have presented suggestive evidence that deep breathing maneuvers, rather than incentive spirometry, best increases diaphragmatic movement after surgery (Cuter 1990). The need for prophylactic chest therapy for patients at low risk of postoperative respiratory complication is contentious. Celli et al compared a no treatment control group with intermittent positive pressure breathing, deep breathing exercises and incentive spirometry in 172 patients undergoing elective surgery. There were similar benefits for each of the control groups (Celli 1984). Another study reported that deep breathing exercises were better than no treatment in patients undergoing elective upper abdominal surgery (Roukema 1988). On the other hand, a small study by Schweiger et al suggested that healthy patients did not benefit from incentive spirometry after elective open cholecystectomy (Schweiger 1986). Hence, the balance of evidence suggests that any form of maximal inspiratory therapy is better than nothing, yet no particular regimen has clear superiority. The study by Hall C J (1996) confirms that deep breathing exercises provide reasonable prophylaxis for low risk patients and that incentive spirometry alone is adequate prophylaxis for high-risk patients. This information provides a platform for postoperative respiratory complication. A randomized controlled study by Olsen (1997) evaluated the clinical benefit and physiological effects of prophylactic chest physiotherapy in open major abdominal surgery. It was concluded from the study that preoperative chest physiotherapy reduced the incidence of postoperative pulmonary complications and improved mobilization and oxygen saturation after major abdominal surgery. The incidence of postoperative pulmonary complication has been shown to be lower in open abdominal surgery patients who receive physiotherapy compared to those who receive none (Chumillas et al 1998, Olsen et al 1997). This effect has been attributed to the application of various forms of lung expansion and secretion clearance techniques. However, it is not known 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 indeed, a combination of both, which is responsible for the decrease in incidence of postoperative pulmonary complications. The study conducted by Mackay (2005) was aimed to determine if the addition of deep breathing exercises and secretion clearance techniques to a standardized physio-therapist directed program of early mobilization improved clinical outcomes in patients undergoing open abdominal surgery. 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. A blinded outcomes researcher assessed all outcomes. A standardized validated outcome measurement tool, the Abdominal surgery Physiotherapy Outcomes Data Sheet (APODS) was used to collect data for all subjects in the study. Outcomes included incidence of clinically significant postoperative pulmonary complications, fever, length of stay and restoration of mobility. There was no significant difference between groups in the incidence of fever, physiotherapist time, or the number of treatments. The study concluded that 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. This study was significant in that, unlike previous randomized trials of physiotherapy after open abdominal surgery, it documented the actual type and dosage of physiotherapy interventions and used a sample of subjectsfrom the population of abdominal surgery patients who are most likely to benefit from physiotherapy, that is, those identified as high risk of developing postoperative pulmonary complications. Previous studies have involved a mix of low, medium and high risk subjects ( Hall et al 1996, Olsen et al 1997). The study also used blinded assessment of postoperative pulmonary complications outcome rather than the more subjective 'physician assessment' for postoperative pulmonary complications in earlier studies (brooks-Brunn 1996, Hall et al 1996). Postoperative physiotherapy should never be "routine" but should be used judiciously. Specific physiotherapy techniques might have different effects on oxygen saturation and homodynamic stability in different age groups and careful assessment should ensure that the intervention is beneficial and effective rather than hazardous (Hussey 1996). References Blaney, F., & Sawyer, T. (1997). Sonographic measurement of diaphragmatic motion after upper abdominal surgery: A comparison of three breathing maneuvers. Physiotherapy Theory and Practice, 13, 209-215. Brasher, P.A., Kristin, H.M., Linda, D., & Ian S. (2003). Does removal of deep breathing exercises from a physiotherapy program including pre-operative education and early mobilization after cardiac surgery alter patient outcomes Aust J Physiother, 49, 165-173. Brooks-Brunn, J.A. (1995). Postoperative atelectasis and pneumonia. Heart and Lung, 24, 94-115. Celli, B.R., Rodriguez, K.S., & Snider, G.L. (1984). A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercisein preventing respiratory complications after abdominal surgery. Am Rev Resp Dis, 130, 12-15. Chumillus, S., Ponce, J.L., Delgado, F., Viciano, V., & Mateu, M. (1998). Prevention of post operative pulmonary complications through respiratory rehabilation: A controlled clinical study. Archives of Physical Medicine and Rehabilitation, 79, 5-9. Chuter, TAM., Weissman, C., Mathews, D.M., & Starker, P.M. (1990). Diaphragmatic breathing maneuvers and movement of the diaphram after cholecystectomy. Chest, 97, 1110-4. Dureuil, B., Cantineau, P., & Desmonta, J.M. (1987). Effects of upper or lower abdominal surgery on diaphragmatic function. Br J Anesth, 59, 1230-559,120-5 Ford,G.T., Rosenal, T.W., Clergue, F.C., & Whitelaw, W.A. (1993). Respiratory physiology in upper abdominal surgery. Clin Chest Med, 14, 237-52. Hall, J.C., Tarala, R.A., Tapper, J., & Hall,J.L. (1996). Prevention of respiratory complications after abdominal surgery: a randomized clinical trial. BMJ, 312, 148-52. Herbert, R.D., Chris, G.M., Anee, M.M., & Catherine, S. Effective Physiotherapy. BMJ, 2001, 323, 788-790. Hussey,J., Hayward,L., Andrews, M., Macrae, D., & Elliot,M. (1996).Chest physiotherapy following pediatric cardiac surgery: the influence of mode of treatment on oxygen saturation and hemodynamic stability. Physiotherapy Theory and Practice, 12, 77-85. Jones,J.G. (1987). Anesthesia and atelectasis: The role of V (sub TAB) and the chest wall. Br.J Anaesth, 59, 949-53. Lawrence, V.A., Dhanda, R., Hilsenbeck, S.G., & Page, C.P. (1996). Risk of pulmonary complications after elective abdominal surgery. Chest, 110, 744-750. Menkes, H.A., & Britt, J. (1980). Rationale for physical therapy. Am Rev of Resp Dis. 122, 127-131. Mackay,M.R., Elizabeth, E., & Catherine Johnston. (2005). Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother, 51, 151-159. Matthay, M.A., & Weiner, K. (1989). Respiratory management after cardiac surgery. Chest, 95, 424-434. Olsen, M.F., Hahn, I., Nordgren, S., Lonroth, H. (1997). Randomised controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery, 84, 1535-1538. Pasquna.P. (2003). Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. BMJ, 327,1379.Lawrence, V.A., Hilsenbeg, S.G., Mulrow, C.D., Dhanda, R., Sapp,J., & Page, C.P. (1995). Incidence of hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intra Med, 10, 671-8. Pasquina, P., Paolo, M., Jean, M.G., & Bara, R. (2004). Continuous positive airway pressure versus noninvasive pressure support ventilation to treat atelectasis after cardiac surgery. Anesth Analg, 99, 1001-1008. Pereira , E.D., Fernandes, A.L., Da, S.A., De, A.P., Atallah, A.N., & Faresin, S.M. (1999). Sao Paulo Med J, 117, 151-60. Regunandan, V., Gopinath, K., & Regunandan, R. (1997). Elementary human anatomy and physiology. New Delhi: Vallabh Prakashan, 138. Roukema, J.A., Carol, E.J., & Prins, J.G. (1988). The prevention of respiratory complications after upper abdominal surgery in patients with noncompromised respiratory status. Arch surgery, 123, 30-4. Schweiger, I., Gamulin., Forster, A., Meyer, P., Gemperle, M., Suter, P.M. (1986). Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy: a controlled randomized study. Chest, 89, 652-6. Stiller. K., Montarello, J., Wallace, M., Daff, M., Jenkins>S et al (1994). Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery. Chest, 105, 741-7. Strandberg, A., Tokics, L., Lundquist, H., & Hedenstiena G. (1987). Constitutional factors promoting development of atelectasis during anesthesia. Acta Anaesthesiol Scand, 31, 21-4 Taggart, D.P., El-Filky, M., Carter, R., Bowman, A., & Wheatly D.J. (1993). Respiratory dysfunction after uncomplicated cardiopulmonary bypass. Annals of Thoraccic surgery, 56, 1123-1128. Tucker, B., Jenkins, S., Davies, K., McGann, R., Waddel, J., King, R., Kirby, V., & Lloyd, C. (1996). The physiotherapy management of patients undergoing coronary artery surgery: A questionnaire survey. Aust J Physio, 42, 129-137. VanBelle, A.F., Wessling, G.J., Penn, OCKM., & Wouters, EFM., (1992). Postoperative pulmonary function abnormalities after coronary artery bypass surgery. Respiratory Medicine, 86, 195-198.Vargas, F.S., Cukier, A., Terra, F.M., Hueb, W., Teixeira, L.R & Light,R.W. (1992). Relasionship between pleural changes after myocardial revascularization and pulmonary mechanics. Chest, 102, 1333-1336. Wallis,C., & Ammani,P. (1999). Who needs chest physiotherapy Moving from anecdote to evidence. Arch Dis Child, 80, 393-397. Webber, B.A., & Pryor J.A. (1993). (1993). Physiotherapy for respiratory and Cardiac Problems. Edinburgh: Churchill Livingstone, 113-171, 237, 238, 243, 258,261-262. Read More