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Surgery
Preoperative physiotherapy education prevented postoperative pulmonary complications following open upper abdominal surgery
  1. Shane Patman
  1. School of Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia, Australia
  1. Correspondence to Assoc Prof Shane Patman, School of Physiotherapy, University of Notre Dame Australia, Fremantle WA 6959, Australia; Shane.Patman{at}nd.edu.au

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Commentary on: Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.

Context

Upper abdominal surgery (UAS) triggers pathophysiological responses, potentially causing postoperative pulmonary complications (PPCs). Anaesthesia and surgery duration along with nociception depress mucociliary clearance and suppress the cough, contributing to reduced lung volumes and secretion retention, thereby contributing to atelectasis, impaired respiratory function and the development of infection.1 Additionally, patient-dependent parameters such as anxiety levels and willingness to participate, along with postoperative factors such as pain, create significant barriers to treatment and promote PPC development.1 The presence of PPCs following UAS negatively impacts morbidity and mortality, especially within the first week postoperatively.2 3 As a strategy to prevent PPCs, preoperative physiotherapy assessment and education for those subject to ‘at-risk’ surgery, such as cardiothoracic and UAS, was regular in the later part of the 20th century,4 with the role of prehabilitation currently topical.5 6

This trial evaluated whether preoperative education and breathing exercise training by physiotherapists within 6 weeks of UAS reduced PPC incidence.

Methods

This was a randomised controlled trial of a single 30 min education and breathing exercise coaching session with a physiotherapist to adults undergoing elective major open UAS. The intervention consisted of information on the risk of PPCs, individualised risk assessment, education about the impact of surgery, instructions on breathing exercises and memory prompts. The intervention was conducted as part of preadmission clinics at three tertiary public hospitals in Australia and New Zealand immediately after a ‘usual care’ preoperative physiotherapy session involving a standardised assessment and dissemination of an information booklet about PPCs, desired prevention via early breathing exercises and ambulation, and a specific prescription for deep breathing exercises starting immediately postoperatively (control group). Allocation was concealed, with both participants and assessors blinded.

Incidence of PPCs within 14 days postoperatively, as defined by the Melbourne Group Score,7 was the primary outcome, with secondary outcomes including hospital-acquired pneumonia, use of critical care services, length of hospital stay, discharge readiness, hospital costs, health-related quality of life (at 6 weeks), readmission rates, self-reported complications involving medical input and 12-month all-cause mortality.

Results are reported as absolute risk reduction and adjusted HR with CI.

Findings

Randomisation of 441 participants resulted in preoperative physiotherapy (n=222; intervention) and information booklet (n=219; control) groups, of which 432 completed the trial (98%). The PPC incidence was 20% (85/432), significantly fewer in the intervention group (27/218, 12%) compared with the control group (58/214, 27%), with an absolute risk reduction of 15% (95% CI 7 to 22; p<0.001). The PPC incidence was halved (adjusted HR 0.48, 95% CI 0.30 to 0.75; p=0.001) in the intervention group compared with the control group following adjustments made for baseline imbalances in three of the prespecified covariates—age, respiratory comorbidity and surgical procedure. A number needed to treat of 7 (95% CI 5 to 14) was determined. No significant differences were detected in other outcomes.

Commentary

Knowledge is power; education is key. Cliché, yes but this trial by Boden et al 8 challenges us to reconsider the value and significance of targeted preoperative education in affecting postoperative outcomes in high-risk candidates. In an era where in the major cohorts of thoracic, cardiac and abdominal surgery postoperative ‘early mobility’ is the mantra and the value of targeted breathing and expectoration strategies is questioned, these findings of the Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial reframes the conversation. A simple, low-risk preoperative coaching session seems an elegant non-complex solution to empowering patients to optimise postoperative outcomes. It sounds too good to be true; surely it cannot be that easy to have such an impact? A number needed to treat of 7 is hard to argue. So why then is this approach not evident universally in current practice? Such benefit needs to be tempered by the lack of difference in mortality, length of intensive care unit or hospital stay, discharge readiness, unplanned readmissions, or mobility status. Variances in outcomes based on site and therapist experience also impact generalisability. Modelling of specific costs and health economics supporting this clinical efficacy is anticipated8 and will no doubt fuel the conversation around implementation.

Implications for practice

A single, simple 30 min preoperative physiotherapy education session within 6 weeks of surgery reduced pulmonary complications after UAS. The provision of preadmission services to provide opportunity for physiotherapy-led coaching of postoperative breathing strategies warrants consideration and further investigation around cost and health economics implications.

References

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Footnotes

  • Contributors The author (SP) affirms responsibility for drafting this commentary, revising it critically for important intellectual content and providing final approval of the version published.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.