NIHR Signal Physiotherapy education before major abdominal surgery reduces lung complications

Published on 3 April 2018

A physiotherapy session before planned abdominal surgery, explaining the importance of breathing exercises and sitting out of bed as soon after surgery as possible, halves the risk of pneumonia.

This trial compared the physiotherapy session with usual care which was provided to all 432 participants. This consisted of a leaflet given in the pre-operative outpatient clinic outlining the exercises, and physiotherapy input in the days after surgery. Just seven people would need to receive the additional 30-minute pre-operative physiotherapy session to prevent one lung complication.

The study was carried out in Australia and New Zealand, where usual care may differ from that provided by the Enhanced Recovery Programme in the NHS. However, the results are impressive and show the importance of face-to-face sessions to prepare people to give themselves the best chance of a speedy recovery.

Patient and surgeon discussing abdominal surgery

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Why was this study needed?

Lung complications, such as pneumonia, are the most common serious adverse effects following upper abdominal surgery. The effects of anaesthesia increased pressure within the abdomen, immobility and difficulty taking deep breaths due to pain means that parts of the lung are not adequately expanded, providing a haven for bacteria. Lung complications are reported in 10 to 50%, depending on the type of surgery, individual risk factors and definition of lung complications.

People are usually advised to do breathing exercises, sit up out of bed and begin walking on the day after upper abdominal surgery to help prevent lung complications. This is supported by nursing and physiotherapy staff.

Previous observational research has shown mixed effects of breathing exercises on outcomes. This is the first prospective randomised controlled trial that aimed to see if a physiotherapy session before the operation reduced the risk of lung complications.

What did this study do?

This trial compared a pre-operative physiotherapy session with treatment as usual for 432 adults undergoing abdominal surgery. Both groups were given a patient information leaflet, during a pre-operative outpatient clinic. This provided recommendations on hourly breathing and coughing exercises after surgery. They were also seen by a physiotherapist on the day after surgery to help them start walking and to remind them to do the breathing exercises.

Those allocated to physiotherapy had an additional 30-minute session during the six weeks before surgery. It included education about stagnant lung secretions, and how to perform the breathing exercises.

Participants in the pre-operative physiotherapy group were younger (average age 63.4 versus 67.5 years) and slightly less likely to have diabetes, lung or heart disease.

What did it find?

  • Pre-operative physiotherapy halved the rate of lung complications up to 14 days after surgery. A post-operative lung complication occurred in 12% (27/218) of people who had received physiotherapy compared to 27% (58/214) who had not (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.30 to 0.75). The analysis was adjusted for age, type of surgery and prior lung disease.
  • Seven people would need to have pre-operative physiotherapy to prevent one post-operative lung complication (95% CI 5 to 14).
  • Physiotherapy also halved the rate of hospital-acquired pneumonia, which occurred in 8% (18/218) of the physiotherapy group versus 20% (42/214) of the control group (adjusted HR 0.45, 95% CI 0.26 to 0.78).
  • There was no difference in length of hospital stay, hospital readmissions; patient-reported complications at six weeks, or deaths up to one year.

What does current guidance say on this issue?

No national guidelines on pre-operative physiotherapy for abdominal surgery are available. However, physiotherapy and early mobilisation is a component of the Enhanced Recovery Programme for people having major surgery.

Local NHS trusts have patient information leaflets on physiotherapy after abdominal surgery. They recommend deep breathing exercises and coughing, preferably in a chair or as upright as possible in bed. They also advise walking on the day after surgery and keeping a diary of distances achieved each day.

What are the implications?

The combination of in-person coaching – and providing this before surgery – may be crucial to the improvements seen.

Both groups were reminded by a physiotherapist post-operatively to perform breathing exercises as directed in the leaflet, but they received no further instruction. If people have a greater awareness of the importance of breathing exercises and have been shown how to do them before surgery, then they can put them into practice straight after surgery.

This non-invasive intervention was clinically effective, and though a cost-analysis was not performed, pre-operative sessions could potentially be done in a group format to make the best use of resources.

Citation and Funding

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

This project was funded by the Clifford Craig Foundation and the University of Tasmania, both from Australia, and the Waitemata District Health Board and Three Harbours Health Foundation from New Zealand.   

Bibliography

AW, LM, HJ, Churchill Surgical Physiotherapy Team. Physiotherapy advice after abdominal surgery: Information for patients. Oxford University Hospitals NHS Trust. Oxford: 2015.

Northern Devon Healthcare NHS Trust. Physiotherapy advice after abdominal surgery. Northern Devon Healthcare NHS Trust. Devon.

The Royal College of Anaesthetists, Royal College of General Practitioners and Royal College of Surgeons. Guidelines for patients undergoing surgery as part of an Enhanced Recovery Programme (ERP): Helping you to get better sooner after surgery. The Royal College of Anaesthetists. London: 2012.

Why was this study needed?

Lung complications, such as pneumonia, are the most common serious adverse effects following upper abdominal surgery. The effects of anaesthesia increased pressure within the abdomen, immobility and difficulty taking deep breaths due to pain means that parts of the lung are not adequately expanded, providing a haven for bacteria. Lung complications are reported in 10 to 50%, depending on the type of surgery, individual risk factors and definition of lung complications.

People are usually advised to do breathing exercises, sit up out of bed and begin walking on the day after upper abdominal surgery to help prevent lung complications. This is supported by nursing and physiotherapy staff.

Previous observational research has shown mixed effects of breathing exercises on outcomes. This is the first prospective randomised controlled trial that aimed to see if a physiotherapy session before the operation reduced the risk of lung complications.

What did this study do?

This trial compared a pre-operative physiotherapy session with treatment as usual for 432 adults undergoing abdominal surgery. Both groups were given a patient information leaflet, during a pre-operative outpatient clinic. This provided recommendations on hourly breathing and coughing exercises after surgery. They were also seen by a physiotherapist on the day after surgery to help them start walking and to remind them to do the breathing exercises.

Those allocated to physiotherapy had an additional 30-minute session during the six weeks before surgery. It included education about stagnant lung secretions, and how to perform the breathing exercises.

Participants in the pre-operative physiotherapy group were younger (average age 63.4 versus 67.5 years) and slightly less likely to have diabetes, lung or heart disease.

What did it find?

  • Pre-operative physiotherapy halved the rate of lung complications up to 14 days after surgery. A post-operative lung complication occurred in 12% (27/218) of people who had received physiotherapy compared to 27% (58/214) who had not (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.30 to 0.75). The analysis was adjusted for age, type of surgery and prior lung disease.
  • Seven people would need to have pre-operative physiotherapy to prevent one post-operative lung complication (95% CI 5 to 14).
  • Physiotherapy also halved the rate of hospital-acquired pneumonia, which occurred in 8% (18/218) of the physiotherapy group versus 20% (42/214) of the control group (adjusted HR 0.45, 95% CI 0.26 to 0.78).
  • There was no difference in length of hospital stay, hospital readmissions; patient-reported complications at six weeks, or deaths up to one year.

What does current guidance say on this issue?

No national guidelines on pre-operative physiotherapy for abdominal surgery are available. However, physiotherapy and early mobilisation is a component of the Enhanced Recovery Programme for people having major surgery.

Local NHS trusts have patient information leaflets on physiotherapy after abdominal surgery. They recommend deep breathing exercises and coughing, preferably in a chair or as upright as possible in bed. They also advise walking on the day after surgery and keeping a diary of distances achieved each day.

What are the implications?

The combination of in-person coaching – and providing this before surgery – may be crucial to the improvements seen.

Both groups were reminded by a physiotherapist post-operatively to perform breathing exercises as directed in the leaflet, but they received no further instruction. If people have a greater awareness of the importance of breathing exercises and have been shown how to do them before surgery, then they can put them into practice straight after surgery.

This non-invasive intervention was clinically effective, and though a cost-analysis was not performed, pre-operative sessions could potentially be done in a group format to make the best use of resources.

Citation and Funding

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

This project was funded by the Clifford Craig Foundation and the University of Tasmania, both from Australia, and the Waitemata District Health Board and Three Harbours Health Foundation from New Zealand.   

Bibliography

AW, LM, HJ, Churchill Surgical Physiotherapy Team. Physiotherapy advice after abdominal surgery: Information for patients. Oxford University Hospitals NHS Trust. Oxford: 2015.

Northern Devon Healthcare NHS Trust. Physiotherapy advice after abdominal surgery. Northern Devon Healthcare NHS Trust. Devon.

The Royal College of Anaesthetists, Royal College of General Practitioners and Royal College of Surgeons. Guidelines for patients undergoing surgery as part of an Enhanced Recovery Programme (ERP): Helping you to get better sooner after surgery. The Royal College of Anaesthetists. London: 2012.

Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial

Published on 26 January 2018

Boden, I.,Skinner, E. H.,Browning, L.,Reeve, J.,Anderson, L.,Hill, C.,Robertson, I. K.,Story, D.,Denehy, L.

Bmj Volume 360 , 2018

OBJECTIVE: To assess the efficacy of a single preoperative physiotherapy session to reduce postoperative pulmonary complications (PPCs) after upper abdominal surgery. DESIGN: Prospective, pragmatic, multicentre, patient and assessor blinded, parallel group, randomised placebo controlled superiority trial. SETTING: Multidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zealand. PARTICIPANTS: 441 adults aged 18 years or older who were within six weeks of elective major open upper abdominal surgery were randomly assigned through concealed allocation to receive either an information booklet (n=219; control) or preoperative physiotherapy (n=222; intervention) and followed for 12 months. 432 completed the trial. INTERVENTIONS: Preoperatively, participants received an information booklet (control) or an additional 30 minute physiotherapy education and breathing exercise training session (intervention). Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery. Postoperatively, all participants received standardised early ambulation, and no additional respiratory physiotherapy was provided. MAIN OUTCOME MEASURES: The primary outcome was a PPC within 14 postoperative hospital days assessed daily using the Melbourne group score. Secondary outcomes were hospital acquired pneumonia, length of hospital stay, utilisation of intensive care unit services, and hospital costs. 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. RESULTS: The incidence of PPCs within 14 postoperative hospital days, including hospital acquired pneumonia, was halved (adjusted hazard ratio 0.48, 95% confidence interval 0.30 to 0.75, P=0.001) in the intervention group compared with the control group, with an absolute risk reduction of 15% (95% confidence interval 7% to 22%) and a number needed to treat of 7 (95% confidence interval 5 to 14). No significant differences in other secondary outcomes were detected. CONCLUSION: In a general population of patients listed for elective upper abdominal surgery, a 30 minute preoperative physiotherapy session provided within existing hospital multidisciplinary preadmission clinics halves the incidence of PPCs and specifically hospital acquired pneumonia. Further research is required to investigate benefits to mortality and length of stay. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTR 12613000664741.

Postoperative pulmonary complications were defined using the Melbourne group score diagnostic tool. Diagnosis was confirmed when four or more criteria were present in a post-operative day:

  • New abnormal breath sounds heard through the stethoscope that were not present in the pre-operative assessment.
  • Production of yellow or green sputum different from in the pre-operative assessment.
  • Pulse oximetry oxygen saturation (SpO2) less than 90% on room air on more than one consecutive post-operative day.
  • Maximum oral temperature greater than 38°C on more than one consecutive postoperative day.
  • Chest Xray report of collapse or consolidation.
  • An unexplained white cell count greater than 11×109/L.
  • Presence of infection on sputum culture report.
  • Physician’s diagnosis of pneumonia, lower or upper respiratory tract infection, an undefined chest infection, or prescription of an antibiotic for a respiratory infection.

Expert commentary

Lung related complications are common in patients undergoing major surgery, resulting in longer hospital stays or additional treatments. Pre-operative respiratory physiotherapy (in the form of education, breathing exercises, bed mobility exercises, and encouraging early ambulation) used to be routine, but these visits fell out of practice to focus on post-operative care.

This research found pre-operative physiotherapy was associated with fewer post-operative lung problems. Unfortunately, despite randomisation, there were more patients with higher baseline risk of complications in their control group, and cost-effectiveness of the intervention was not reported.

Nevertheless, pre-operative physiotherapy seems to be a beneficial addition to peri-operative care.

Anne Bruton, Professor of Respiratory Rehabilitation, NIHR Senior Research Fellow, Respiratory Research Programme Lead, University of Southampton

Expert commentary

When patients and carers prepare for upper abdominal surgery, the possibility of post-operative complications is a major concern. Respiratory complications in particular, such as hospital-acquired pneumonia, are more likely to increase the length of stay in the hospital, reduce general function and well-being and can often increase mortality.

Breathing exercises are vital to reducing respiratory complications post-surgery and teaching them is a core skill of all physiotherapists.

When a well-designed, multi-centre study shows that even a single pre-operative education session leads to better outcomes if appropriately timed and organised, what are we waiting for to implement this recommendation in clinical practice?

Dr Dimitra Nikoletou, Associate Professor, Director of Postgraduate Research, Kingston University and St George’s University of London Joint Faculty