Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial
Introduction
Postoperative pulmonary complications (PPCs) are a leading cause of morbidity and mortality following upper abdominal surgery [1], contributing to prolonged hospital stay and additional health costs [2]. Physiotherapeutic techniques to increase mean lung volume are of benefit in preventing PPCs [3], but the effects of mobility alone have not been evaluated. Mobilisation improves lung volume in patients after abdominal surgery [4]. However, it is unclear whether the decrease in PPCs is due to mobilisation alone or in combination with breathing exercises.
Mackey et al. found that the addition of deep breathing to physiotherapy-directed early mobilisation did not reduce PPCs significantly in high-risk patients undergoing open upper abdominal surgery [5]. However, the frequency of postoperative physiotherapy sessions used by Mackey et al. may be considered impractical: three times daily on Days 1 and 2, twice daily on Days 3 and 4, and daily thereafter until the patient was independently mobile with a clear chest assessment on three consecutive days. The frequency of treatment has implications for resource allocation and cost. The key concern is whether frequent physiotherapy sessions in the first four postoperative days ensured that these patients were upright and mobilised more than normal, and if this influenced the outcomes.
Prophylactic physiotherapy following upper abdominal surgery is performed once daily at the authors’ hospital. Therefore, the primary aim was to investigate whether the addition of deep breathing exercises to physiotherapy-directed early mobilisation (once daily) conferred any benefit in reducing PPCs compared with mobility alone among high-risk patients following elective open upper abdominal surgery. The secondary aim of this study was to examine whether physiotherapy-directed early mobilisation (commencing on the first postoperative day) had a beneficial effect on postoperative outcomes [PPCs, number of days until discharge from physiotherapy, physiotherapy input and length of stay (LOS)] compared with delayed mobilisation (commencing on the third postoperative day).
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Participants
Following approval by the Human Research Ethics Committee of Concord Repatriation General Hospital, Sydney, Australia, patients were recruited from the pre-admission clinic between March 2006 and March 2008.
The study population consisted of patients undergoing elective open upper abdominal surgery involving upper or upper and lower midline abdominal incision. Criteria for classification as high risk for the development of PPCs [6] were: age >59 years, or age <59 years with a history of one or
Data analysis
The primary outcome measure was PPCs. Based on a clinically significant reduction in PPCs of 36% in high-risk patients after open abdominal surgery [10], a sample size of 16 patients per group was required for 80% confidence to detect differences with two-tailed tests at an alpha level of 0.05 [14]. Twenty-five subjects per group was considered to be sufficient to allow for dropouts.
The data were analysed using Statistical Package for the Social Sciences Version 7 (SPSS, IBM Corporation, NY,
Results
Ninety patients were invited to participate in the trial. Four patients declined to participate, and there were no dropouts (see Appendix A, supplementary online material).
Cluster randomisation yielded three groups that were comparable in most areas, except for a significant difference in the number of smokers (0.052) (Table 3). There was no significant difference in the number of smokers or patients with COPD between Groups A and B. However, there were significantly more smokers (P = 0.037) and
Discussion
The primary aim of this research was to determine whether the addition of deep breathing exercises to physiotherapy-directed early mobilisation of high-risk patients undergoing elective open upper abdominal surgery would further reduce PPCs compared with mobility alone. Treatment was given once daily post surgery until discharge from physiotherapy. A group of Australian cardiopulmonary physiotherapists previously indicated that, for a therapy to be clinically worthwhile, one PPC should be
Conclusions
Mobility alone can reduce PPCs in high risk patients following elective open upper abdominal surgery without the addition of deep breathing exercises. Reduction in PPCs can be achieved when patients are treated once daily if mobilised to a moderate level of exertion. This is cost beneficial and allows allocation of physiotherapy to patients with PPCs to be commenced on breathing and other physiotherapy techniques. Early mobilisation may improve postoperative outcomes compared with delayed
Acknowledgements
The authors wish to thank the Physiotherapy Department of Concord Repatriation General Hospital, NSW, Australia for their assistance in conducting this investigation.
Ethical approval: Human Research Ethics Committee of Concord Repatriation General Hospital, Sydney, Australia (CH62/6/2005-023-Y Silva).
Conflict of interest: None declared.
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