NIHR Signal Breathing training before major surgery may reduce lung complications afterwards

Published on 15 January 2016

This review found that physiotherapist-led training in breathing before heart or major abdominal surgery was associated with a reduced risk of lung collapse or pneumonia after surgery. There was no evidence that it reduced the numbers of people ventilated for 48 hours or more, or the chance of death after the operation.

Post-operative lung complications – such as collapse and pneumonia – are expensive and difficult to manage, with the risk of illness and death. Inspiratory muscle training (IMT) is a type of rehabilitation exercise that can be performed before surgery to try and help strengthen the muscles around the lungs and reduce the risk of PPCs.

However, the findings were based on small, low quality studies that may overestimate the effectiveness of breathing training. Commissioners should be aware of this if considering this addition to standard practice. No costs were reported in these trials.

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Why was this study needed?

After major abdominal or heart surgery, people can experience a number of complications. These include lung infections (pneumonia), areas of collapsed lung from plugs of secretions in the airways, constricted airways or fluid in or around the lung. These may lead to respiratory failure (where the lungs cannot get enough oxygen into the blood stream). Such complications are associated with higher healthcare costs, longer stays in hospital, on-going illness and death. Prior to surgery people identified at risk can perform exercises supervised by a physiotherapist – called respiratory rehabilitation – designed to reduce the risk of complications. Inspiratory muscle training, which helps to strengthen the muscles around the lungs, is one example of a respiratory rehabilitation technique. This Cochrane review evaluated the effectiveness of inspiratory muscle training in people undergoing heart or major abdominal surgery, compared with usual care (such as advice on deep breathing exercises), a non-exercise intervention or no intervention. Trials of both low (i.e. healthy) and high risk participants were included. The risk factors that were reported in the trials included smoking, chronic obstructive pulmonary disease, diabetes, hypertension, and raised body mass index.

What did this study do?

This systematic review compared the results of 12 randomised controlled trials including 695 patients. Ten of the trials used a device that provides steady resistance against a breath in. Two trials used a threshold device in conjunction with exercise training, such as diaphragm strengthening. One trial compared a threshold device, deep-breathing exercises and incentive spirometry, which measures lung capacity and provides feedback.

This review followed the Cochrane Collaboration’s high methodological standards. Nine studies had a high risk of bias related to a lack of blinding - whether patients and staff were aware of the treatment received - but when researchers re-ran their analysis without these studies it did not affect the main findings. There was also a risk of selective reporting of outcomes in 11 studies. Overall across all studies the authors reported a risk of bias from the small number of patients included (small studies tend to overestimate the effects of an intervention).

What did it find?

  • The trials included adult patients with varying levels of risk and using differing definitions of risk. Outcomes also varied between studies, so the authors considered three complications that were consistently defined: atelectasis (volumes of collapsed lung), pneumonia and mechanical ventilation for over 48 hours.
  • Pooled results of seven trials showed that the breathing training significantly reduced the risk of collapsed lung (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.34 to 0.82) compared with usual care or no exercise. However, this evidence was judged low quality because the studies were small and may have had a risk of publication bias.
  • Eleven trials showed a reduction in postoperative pneumonia (RR 0.45, 95% CI 0.26 to 0.77); this evidence was judged to be moderate quality as although the studies were small their quality was upgraded to moderate as there was a large effect.
  • Eight trials reported adverse events, and found no adverse events directly resulting from either IMT or the comparator interventions.

What does current guidance say on this issue?

2003 NICE guidance on preoperative testing recommends that lung function tests are considered for people who have a chronic condition, like asthma or chronic obstructive pulmonary disease that may affect their recovery. There is no specific mention of preoperative respiratory rehabilitation. An update of NICE’s 2003 guideline is due in March 2016.

What are the implications?

Although this review indicated that IMT appears to have a beneficial effect on the risk of some post-operative pulmonary complications in people undergoing heart or major abdominal surgery, the underlying evidence was of insufficient quality to be certain about the magnitude of this effect.

The analysis only included three complications because there was either inconsistency or insufficient detail about how others were defined, which prevented comparisons across studies. Varying definitions also made it difficult to estimate the number of people affected. Larger, better designed trials that consistently and precisely define PPCs and patient risk. None of the included studies reported on costs of the interventions or the hospital or community costs saved so more data are needed to inform practice.

Citation

Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev. 2015;10:CD010356.

Bibliography

NICE. Preoperative tests for elective surgery. CG3. London: National Institute for Health and Care Excellence; 2003.

Why was this study needed?

After major abdominal or heart surgery, people can experience a number of complications. These include lung infections (pneumonia), areas of collapsed lung from plugs of secretions in the airways, constricted airways or fluid in or around the lung. These may lead to respiratory failure (where the lungs cannot get enough oxygen into the blood stream). Such complications are associated with higher healthcare costs, longer stays in hospital, on-going illness and death. Prior to surgery people identified at risk can perform exercises supervised by a physiotherapist – called respiratory rehabilitation – designed to reduce the risk of complications. Inspiratory muscle training, which helps to strengthen the muscles around the lungs, is one example of a respiratory rehabilitation technique. This Cochrane review evaluated the effectiveness of inspiratory muscle training in people undergoing heart or major abdominal surgery, compared with usual care (such as advice on deep breathing exercises), a non-exercise intervention or no intervention. Trials of both low (i.e. healthy) and high risk participants were included. The risk factors that were reported in the trials included smoking, chronic obstructive pulmonary disease, diabetes, hypertension, and raised body mass index.

What did this study do?

This systematic review compared the results of 12 randomised controlled trials including 695 patients. Ten of the trials used a device that provides steady resistance against a breath in. Two trials used a threshold device in conjunction with exercise training, such as diaphragm strengthening. One trial compared a threshold device, deep-breathing exercises and incentive spirometry, which measures lung capacity and provides feedback.

This review followed the Cochrane Collaboration’s high methodological standards. Nine studies had a high risk of bias related to a lack of blinding - whether patients and staff were aware of the treatment received - but when researchers re-ran their analysis without these studies it did not affect the main findings. There was also a risk of selective reporting of outcomes in 11 studies. Overall across all studies the authors reported a risk of bias from the small number of patients included (small studies tend to overestimate the effects of an intervention).

What did it find?

  • The trials included adult patients with varying levels of risk and using differing definitions of risk. Outcomes also varied between studies, so the authors considered three complications that were consistently defined: atelectasis (volumes of collapsed lung), pneumonia and mechanical ventilation for over 48 hours.
  • Pooled results of seven trials showed that the breathing training significantly reduced the risk of collapsed lung (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.34 to 0.82) compared with usual care or no exercise. However, this evidence was judged low quality because the studies were small and may have had a risk of publication bias.
  • Eleven trials showed a reduction in postoperative pneumonia (RR 0.45, 95% CI 0.26 to 0.77); this evidence was judged to be moderate quality as although the studies were small their quality was upgraded to moderate as there was a large effect.
  • Eight trials reported adverse events, and found no adverse events directly resulting from either IMT or the comparator interventions.

What does current guidance say on this issue?

2003 NICE guidance on preoperative testing recommends that lung function tests are considered for people who have a chronic condition, like asthma or chronic obstructive pulmonary disease that may affect their recovery. There is no specific mention of preoperative respiratory rehabilitation. An update of NICE’s 2003 guideline is due in March 2016.

What are the implications?

Although this review indicated that IMT appears to have a beneficial effect on the risk of some post-operative pulmonary complications in people undergoing heart or major abdominal surgery, the underlying evidence was of insufficient quality to be certain about the magnitude of this effect.

The analysis only included three complications because there was either inconsistency or insufficient detail about how others were defined, which prevented comparisons across studies. Varying definitions also made it difficult to estimate the number of people affected. Larger, better designed trials that consistently and precisely define PPCs and patient risk. None of the included studies reported on costs of the interventions or the hospital or community costs saved so more data are needed to inform practice.

Citation

Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev. 2015;10:CD010356.

Bibliography

NICE. Preoperative tests for elective surgery. CG3. London: National Institute for Health and Care Excellence; 2003.

Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery

Published on 6 October 2015

Katsura, M.,Kuriyama, A.,Takeshima, T.,Fukuhara, S.,Furukawa, T. A.

Cochrane Database Syst Rev Volume 10 , 2015

BACKGROUND: Postoperative pulmonary complications (PPCs) have an impact on the recovery of adults after surgery. It is therefore important to establish whether preoperative respiratory rehabilitation can decrease the risk of PPCs and to identify adults who might benefit from respiratory rehabilitation. OBJECTIVES: Our primary objective was to assess the effectiveness of preoperative inspiratory muscle training (IMT) on PPCs in adults undergoing cardiac or major abdominal surgery. We looked at all-cause mortality and adverse events. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (1966 to October 2014), EMBASE (1980 to October 2014), CINAHL (1982 to October 2014), LILACS (1982 to October 2014), and ISI Web of Science (1985 to October 2014). We did not impose any language restrictions. SELECTION CRITERIA: We included randomized controlled trials that compared preoperative IMT and usual preoperative care for adults undergoing cardiac or major abdominal surgery. DATA COLLECTION AND ANALYSIS: Two or more review authors independently identified studies, assessed trial quality, and extracted data. We extracted the following information: study characteristics, participant characteristics, intervention details, and outcome measures. We contacted study authors for additional information in order to identify any unpublished data. MAIN RESULTS: We included 12 trials with 695 participants; five trials included participants awaiting elective cardiac surgery and seven trials included participants awaiting elective major abdominal surgery. All trials contained at least one domain judged to be at high or unclear risk of bias. Of greatest concern was the risk of bias associated with inadequate blinding, as it was impossible to blind participants due to the nature of the study designs. We could pool postoperative atelectasis in seven trials (443 participants) and postoperative pneumonia in 11 trials (675 participants) in a meta-analysis. Preoperative IMT was associated with a reduction of postoperative atelectasis and pneumonia, compared with usual care or non-exercise intervention (respectively; risk ratio (RR) 0.53, 95% confidence interval (CI) 0.34 to 0.82 and RR 0.45, 95% CI 0.26 to 0.77). We could pool all-cause mortality within postoperative period in seven trials (431 participants) in a meta-analysis. However, the effect of IMT on all-cause postoperative mortality is uncertain (RR 0.40, 95% CI 0.04 to 4.23). Eight trials reported the incidence of adverse events caused by IMT. All of these trials reported that there were no adverse events in both groups. We could pool the mean duration of hospital stay in six trials (424 participants) in a meta-analysis. Preoperative IMT was associated with reduced length of hospital stay (MD -1.33, 95% CI -2.53 to -0.13). According to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group guidelines for evaluating the impact of healthcare interventions, the overall quality of studies for the incidence of pneumonia was moderate, whereas the overall quality of studies for the incidence of atelectasis, all-cause postoperative death, adverse events, and duration of hospital stay was low or very low. AUTHORS' CONCLUSIONS: We found evidence that preoperative IMT was associated with a reduction of postoperative atelectasis, pneumonia, and duration of hospital stay in adults undergoing cardiac and major abdominal surgery. The potential for overestimation of treatment effect due to lack of adequate blinding, small-study effects, and publication bias needs to be considered when interpreting the present findings.

Expert commentary

The effects of respiratory muscle training have been explored in a variety of clinical groups but it is not yet widely adopted as a routine therapeutic treatment modality. This review highlights what may be a valuable use of breathing training for patients at high risk of postoperative respiratory complications. Whilst there are limitations to the studies included in the review, the authors’ comprehensive analyses demonstrate the very real possibility that the training may have a positive impact on respiratory morbidity in these vulnerable groups.  Inspiratory muscle training devices are relatively inexpensive and offer physiotherapists a preoperative intervention worthy of further investigation.

Helen Humphreys, Lecturer in Physiotherapy (Cardiovascular and Respiratory specialism) and Rehabilitation Science, School of Health and Rehabilitation Keele University