We recruited patients with an anticipated surgical procedure complying with the trial protocol. Setting Multidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zealand. Upper abdominal surgery (UAS) has the potential to cause post-operative pulmonary complications (PPCs). Cluster randomised controlled trial, Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. For all outcomes we estimated differences in effect size between groups on an intention-to-treat basis. Postoperatively, all participants received standardised early ambulation, and no additional respiratory physiotherapy was provided. Within the first six months of the trial we interviewed a convenience sample of participants in the week after their surgery.21 This was to explore further participants’ opinions on preoperative education and to assess the feasibility of delivering a memorable and impactful preoperative intervention that had the potential to change behaviour. Consequences of bacterial stagnation in the lungs were highlighted, utilising the booklet’s diagram of mucociliary clearance. Despite the large effect sizes, the generalisability and validity of these trials are reduced by the low risk populations, single centre designs, non-masked assessors, and interventions only by experienced practitioners. The participants were educated that self directed breathing exercises were vital to protect their lungs during this inactivity phase and to commence them immediately on regaining consciousness and to continue them hourly until fully ambulant. It cannot be extrapolated that preoperative education would be effective with the use of interpreters, in a different social-cultural context, through different modes such as visual recordings or group sessions, or with health professionals other than physiotherapists. In these participants we therefore did not assess days to discharge from assisted ambulation. Although specific management is provided in this article, your own hospital may differ slightly, and it is advised that you also refer to any local guidelines. Considering the strong association between PPCs and mortality and the consistent findings across three trials, four countries, and 1000 patients1718 that preoperative education significantly reduces PPCs; we recommend that future studies should investigate additional PPC prophylactic interventions to augment preoperative physiotherapy education, particularly targeting high risk patients. Physiotherapists are trained in facilitating the patient's physical recovery, reducing length of hospitalisation and maximising the patient's functional ability and degree of independence. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally. However, at present no PT treatment has been identified … Further research is required to investigate benefits to mortality and length of stay. 2019 Apr 25;365:l1862. IB and IKR did the statistical analysis. In particular, education provided by experienced physiotherapists was associated with shorter length of stay (fig 5) and lower all cause 12 month mortality (adjusted hazard ratio 0.29, 95% confidence interval 0.09 to 0.90, P=0.032; fig 3b). Considering the high mortality association with PPCs, more urgently needs to be done to prevent PPCs in high risk patients, over and above preoperative physiotherapy education and postoperative ambulation alone. Many practitioner dependent interventions have a learning curve, including surgery, where surgeon experience is associated with improved morbidity and mortality.40 A similar relationship might exist in preoperative education. This could just be a chance bias or a failure of true randomisation. Similarly, a single centre Swedish trial of 368 patients17 reported a 78% PPC risk reduction after open abdominal surgery where participants were met by experienced physiotherapists the day before surgery, taught postoperative breathing exercises, and educated about early ambulation. A meta-analysis and systematic review done in 2016 (Moran et al) concluded that more research was needed, but 'prehabilitation' consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease … The incidence of PPCs remained halved (hazard ratio 0.48, 95% confidence interval 0.30 to 0.75, P=0.001) in the intervention group when adjustments were made for baseline imbalances in three of the prespecified covariates—age, respiratory comorbidity, surgical procedure (table 3, fig 2), with a number needed to treat of 7 (95% confidence interval 5 to 14). Despite these limitations, exploratory subgroup analysis of our population revealed that in cohorts with stronger reductions in PPCs attributable to the intervention there was also a corresponding stronger signal to a reduction in length of stay. Secondly, preoperative education needs to be validated in other elective surgical populations such as cardiothoracic surgery and neurosurgery. Both groups were given a patient information leaflet, during a pre-operative outpatient clinic. Data are on an intention-to-treat basis and adjusted for age, previous respiratory disease, and surgical category. We chose to use sealed envelopes as our trial was minimally funded and clinician initiated, and reliable internet access at all sites was not always ensured. Main outcome measures: The primary outcome was a PPC within 14 postoperative hospital days assessed daily using the Melbourne group score. J Physiother. The incidence of hospital acquired pneumonia was halved in the physiotherapy group in the adjusted analyses (table 3), with a number needed to treat of 9 (95% confidence interval 6 to 21). We do not capture any email address. BMJ. To assess standardisation of postoperative ambulation we measured hours from surgery until participants were ambulant with a physiotherapist for longer than one minute, days until ambulant for longer than 10 minutes, and days until discharged from assisted ambulation. During this session, participants were educated about the possibility of PPCs after surgery and given an individualised risk assessment.7 The effect of anaesthesia and abdominal surgery on mucociliary clearance and lung volumes was explained. Our results were adjusted to control for prespecified confounders imbalanced at baseline; however, our trial could have been further improved by using stratified randomisation according to known confounders—for example, surgical category and respiratory comorbidity. Within this booklet, breathing exercises were prescribed and consisted of two sets of 10 slow deep breaths followed by three coughs, to be performed hourly and starting immediately after surgery. From the first postoperative day both control and intervention participants received a physiotherapy directed standardised assisted early ambulation programme20 (see appendix). To estimate primary outcome efficacy and binomial secondary outcomes we used multivariate robust random effects Poisson generalised linear regression. As a proxy measure of compliance, a convenience sample of 29 patients was interviewed on the fifth postoperative day, with 94% of intervention participants remembering the breathing exercises compared with just 15% in those who received the booklet alone.21 We extrapolate that a threshold proportion of intervention participants implemented the acquired knowledge provided by the preoperative physiotherapists and performed deep breathing exercises immediately on regaining consciousness from surgery and continued to perform them at a dose necessary to reverse the respiratory pathophysiological changes from surgery, thus preventing PPCs. Ethical approval: This study was approved by the Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia (H0011911) and the Health and Disability Ethics Committee, New Zealand (14/NTA/233) and informed written consent was given by all patients. Pre- operative education is given to the experimental group 1 only. We considered that measuring such performance could have resulted in a Hawthorne effect by artificially reminding patients to adhere to the prescribed breathing exercises, and results would not be reflective of the pragmatic nature of the intervention. The 12 month mortality effect size in our trial was an absolute risk reduction of 5% (12% v 7%). 10.1016/S0140-6736(08)60878-8 To determine a statistically significant difference in length of stay requires a larger sample size or meta-analysis to confirm effect. Tests of data quality, scaling assumptions, and reliability across diverse patient groups, A specific activity questionnaire to measure the functional capacity of cardiac patients, Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery, Knowledge retention from preoperative patient information, Individuals’ experience of living with osteoarthritis of the knee and perceptions of total knee arthroplasty, Surgeons underestimate their patients’ desire for preoperative information, Dose-dependent protective effect of inhalational anesthetics against postoperative respiratory complications: a prospective analysis of data on file from three hospitals in New England, Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data, An investigation of the value of routine provision of postoperative chest physiotherapy in non-smoking patients undergoing elective abdominal surgery, Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis, Chest physical therapy: comparative efficacy of preoperative and postoperative in the elderly, Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery, International Early SOMS-guided Mobilization Research Initiative, Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial, The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review, Participants in the VA National Surgical Quality Improvement Program, Determinants of long-term survival after major surgery and the adverse effect of postoperative complications, Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial tested the hypothesis that preoperative education and breathing exercise training delivered within six weeks of surgery by physiotherapists reduces the incidence of PPCs after upper abdominal surgery. Secondary outcomes included pneumonia,23 defined as the presence of new chest infiltrates on radiography with at least two of the following criteria: temperature >38°C, dyspnoea, cough and purulent sputum, altered respiratory auscultation, and leukocytosis >14 000/mL or leucopenia <3000/mL within the first 14 hospital days, length of hospital stay (acute and subacute inclusive), readiness for hospital discharge24 within the first 21 hospital days, number of days in an intensive care or high dependency unit, all cause unplanned admissions to an intensive care or high dependency unit, and hospital costs. Design Prospective, pragmatic, multicentre, patient and assessor blinded, parallel group, randomised placebo controlled superiority trial. IB, JR, CH, and LA recruited the patients and acquired the data, and were responsible for protocol adherence and managing the trial at each of the sites. -, Fernandez-Bustamante A, Frendl G, Sprung J, et al. The primary outcome was incidence of a PPC within 14 postoperative days, or hospital discharge, whichever came sooner. Any published peer reviewed manuscripts derived from post hoc analysis of these shared data must list the LIPPSMAck POP investigators as coauthors. Flow of patients through trial. A pre operative patient will be helped both physically and psychologically to overcome fear and pain after operation if he or she is Btriefed to an extent as required. The statistical analysis plan was prespecified20 and we used STATA (version 14.1) for all analyses. Data are per protocol and adjusted for age, previous respiratory disease, and surgical category. Our trial provides strong evidence that preoperative education and training delivered within six weeks of open upper abdominal surgery by a physiotherapist reduces the incidence of PPCs, including hospital acquired pneumonia, within the first 14 days after surgery. Neither CCF nor the University of Tasmania have managerial authority over IKR’s work. Non-reporting of PPC risk factors and non-standardisation of early ambulation and physiotherapy are additional confounders that limit conclusions. Considering the effect gradient according to experience level, further research is required to assess the repeatability of this intervention to ensure that it is provided with a similar degree of rigour across all treating therapists. 2020 Sep 22;4(6):1022-41. doi: 10.1002/bjs5.50347. There was a gradient in PPC reduction according to surgical category, with the greatest response to preoperative physiotherapy in colorectal surgery, then upper gastrointestinal surgery, with the least difference between groups for urology (fig 4). Ward physiotherapists assessed the participants daily using standardised criteria22 (see appendix) and discharged the participants from the assisted ambulation service once a threshold score was met. Transparency: The lead author (IB) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. Site investigators and preoperative physiotherapists aware of group allocation had no contact with patients postoperatively. Data are adjusted…, Sensitivity analysis of subgroup effects on 12 month all cause mortality. Data are adjusted for age, respiratory comorbidity, and upper gastrointestinal surgery, Sensitivity analysis of subgroup effects on hospital length of stay. If you are unable to import citations, please contact J Physiother. Epub 2018 Jun 9. Postoperative pulmonary complications (PPCs) are common in patients undergoing abdominal surgery and are responsible for the increased morbidity and mortality as well as length of hospital stay and health related cost of care. Patient reported health related quality of life, physical function, and post-discharge complications were measured at six weeks, and all cause mortality was measured to 12 months. Overall, 85 of the 432 participants (20%) were diagnosed as having a PPC. This suggests that our length of stay findings may be limited by sample size and heterogeneous response rates rather than by a lack of effect from the intervention. Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, Brown SR, Wyld L. BJS Open. -, Schultz MJ, Hemmes SN, Neto AS, et al. Assessors masked to group allocation assessed participants prospectively and daily until the seventh postoperative day. General anaesthetics are used for the safety and comfort of the patient. Timing may be a key factor in reversing postoperative atelectasis.15 The time point of initiation of breathing exercises could be improved if patients were educated and trained before surgery to perform their breathing exercises immediately after surgery, rather than waiting for the first physiotherapy session, which is commonly not provided until the day after surgery.16. Epub 2018 Jun 11. Competing interests All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare that IB received grants from the Clifford Craig Foundation (CCF), University of Tasmania, and Waitemata District Health Board to fund participating sites for physiotherapists to provide preoperative interventions outside of current standard care and for research assistants to acquire data. The reason that physiotherapy is vital after surgery is that scars can become very thickened, adhesed and stuck to the underlying tissues, causing problems of their own; joints can become very stiff and result in altered movement patterns, which can have an effect elsewhere in the body, and muscles can become short, weak and dysfunctional very quickly. Sensitivity analysis of subgroup effects on incidence of postoperative pulmonary complications (PPCs). Patient reported health related quality of life, physical function, and post-discharge complications were measured at six weeks, and all cause mortality was measured to 12 months. We assessed the success of patient masking in a convenience sample of 29 consecutive participants21 (see appendix). Site institutional review boards and ethics committees approved the study, and an independent data safety and monitoring board (see appendix) oversaw the trial’s safety and ethical conduct. Major surgery 2. -, Neto AS, Hemmes SN, Barbas CS, et al. A PPC was diagnosed when four or more of these eight criteria were present at any time from midnight to midnight each postoperative day. Interventions Preoperatively, participants received an information booklet (control) or an additional 30 minute physiotherapy education and breathing exercise training session (intervention). Site investigators screened preadmission clinics daily and invited eligible patients to participate in the trial. 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