Peri-operative physiotherapy

A postoperative pulmonary complication (PPC) is defined as any pulmonary abnormality occurring during the postoperative period and resulting in clinically significant disease or dysfunction, adversely affecting the clinical course[1]. The respiratory system is directly influenced by the type of surgery, the organ involved and the method used. Postoperative pulmonary complications are a major cause of morbidity, mortality, prolonged hospital stay, and increased cost of care[2]. They may be associated to respiratory muscle dysfunction which may start at induction of anesthesia and continue into the postoperative period. As a matter of fact, the surgical lesion, possible involvement of the phrenic nerve, drugs for sedation, all can lead to ventilation derangement. As a consequence a reduction in functional residual (FRC) and vital (VC) capacity can be observed resulting in higher likelihood of infection[2, 3].

Patients with chronic obstructive pulmonary disease (COPD) may be at particular risk of PPC, up to 30% of these patients possibly developing PPC after thoracic surgery[1, 4]. The postoperative course of patients with severe emphysema may take advantage from a multidisciplinary management including preoperative smoking cessation, drug therapy optimisation, physiotherapy (PT) programs, early mobilization and early extubation[5, 6].

Physiotherapy programs in post-surgical and critical area patients are aimed to reduce the risks of PPC due to long-term bed-rest, to improve the patient’s quality of life (QoL) and residual function, and to avoid new hospitalizations. At this purpose, PT programs apply advanced cost-effective therapeutic modalities to decrease complications and patient’s ventilator-dependency[7, 8].

Strategies to reduce PPC include monitoring and reduction of risk factors, improving preoperative status, patient education, smoking cessation, intra-operative and postoperative pulmonary care. Different PT techniques, as a part of the comprehensive management of patients undergoing cardiac, upper abdominal, and thoracic surgery, may prevent and treat PPC such as secretion retention, atelectasis, and pneumonia[9‐12]. Patients undergoing PT in the immediate postoperative period have likely reduced prevalence of “difficult weaning” and reduced mobility. In addition, QoL, Health status and general conditions may benefit[13, 14].

An important component of the weaning protocols should be PT availability. Weaning protocols and PT are related interventions to shorten patient’s recovery period. Both are used also in uncooperative and bedridden critically ill patients[15, 16]. Early PT in patients with surgery-associated critical illness may have significant impact on physical and functional outcomes in addition to decreasing length of ICU stay and its associated resource implications. The potential for early PT should therefore be assessed immediately upon surgical ICU admission in all patients and continue throughout the acute admission[17].

Fast-track rehabilitation programs include easy methods that have the potential to decline morbidity, hospital stay, and increase pain control when compared with conventional care. Patients with lung cancer who undergo lobectomy can be treated with fast-track rehabilitation. Fast-track rehabilitation is based on: minimally invasive surgical techniques using video-assisted and muscle sparring incisions, normovolemia, normothermia, good oxygenation, euglicaemia, no unnecessary antibiotics, epidural patient-controlled analgesia, systemic opiods-free analgesia, early ambulation and oral feeding[37].

Patients undergoing upper abdominal and thoracic surgery have a decreased postoperative VC, which leads to VA/Q mismatch and contributes to development of hypoxaemia. Thus, the incidence rate of PPC is substantially higher for thoracic and upper abdominal surgery than for lower abdominal surgery. This can be explained by diaphragmatic dysfunction.

Clinical outcomes and costs of 119 patients undergoing lobectomy, who underwent incentive spirometry as well as chest PT, and 520 historical control subjects who did not receive this care, were reviewed by Varela et al.[38]. The length of stay, the number of atelectasis, and the cost in the PT group were significantly less than in the control group. Furthermore, a review by Orman and Westerdahl demonstrated a little gain with positive expiratory pressure (PEP) treatment versus other physiotherapy breathing techniques in patients who underwent thoracic surgery[39].

A reduction in exercise tolerance and QoL is frequently observed, as a consequence of a lobectomy. In a randomized study of Arbane et al.[40] 53 patients with lung cancer were divided into two groups. Every patient underwent a thoracotomy, but one group of patients was treated with a PT program. No difference in QoL was reported between the two groups and no difference was detected in distance covered at 6 minute walking test even if the muscle strength of lower limb was higher in the group treated with physiotherapy. However, exercise capacity returned to pre-operative levels after 12 weeks independently of additional support offered.

Orman and Westerdahl in 2010 reviewed 6 randomized controlled trials that used PEP in adults who underwent abdominal surgery. They found out that just one trial showed a benefit for patients treated with PEP versus other PT breathing techniques[39].

The usefulness of IS in preventing PPC has not been confirmed by a recent meta-analysis on patients undergoing upper abdominal surgery[41]. Lunardi et al. found that PPC after oesophagectomy are reduced in patients who had undergone chest PT before surgery. Nevertheless the hospital length of stay did not differ in patients treated with PT compared to control patients[42]. Several reviews evaluated the potential effects of chest PT in the pre- and post-operative time. Manzano et al. found on a small sample of patients[43] that chest PT after abdominal surgery can improve oxygen haemoglobin saturation without worsening abdominal pain.

A recent systematic review[44] analyzed the effect of PT to prevent PPC in patients undergoing upper abdominal surgery. They excluded studies on patients with comorbidities and undergoing IS and mechanical ventilation more than 48 hours. Patients treated also with breathing exercises showed a greater respiratory muscles strength than control patients. No difference was observed in the PPC incidence between PT group versus control group. Nevertheless the mean quality of the studies included in the review was low.

Valknet et al.[45] in a systematic review demonstrated a benefit from PT before cardiac and abdominal surgery. In this review patients treated before surgery with PT had a reduced number of PPC and length of hospital stay. Nevertheless, further and systematic studies are required to corroborate these encouraging studies and to avoid equivocal interpretations[46].

Interventions such as breathing and coughing exercises, early ambulating, and pulmonary clearing techniques are often used by physical therapists to prevent PPC after CABG surgery. However, there is controversy concerning both the efficacy of these postoperative procedures in reducing the incidence of PPCs and the proper strategy for the identification of patients who might benefit from such interventions. In contrast to the controversy that exists relative to patients undergoing general surgery, similar procedures performed before CABG surgery were shown to be effective and able to lower the risk of PPCs. Evidence derived from small trials suggests that preoperative PT reduces PPC (atelectasis and pneumonia) and length of hospital stay in patients undergoing elective cardiac surgery. There is a lack of evidence that preoperative PT reduces postoperative pneumothorax, prolonged mechanical ventilation or all-cause deaths[47‐49].

Castillo and Haas[50] have shown the effectiveness of pre- and post-operative PT in reducing significantly the number of patients who develop atelectasis after surgery. On the contrary, they did not show any benefit in reducing respiratory infections. Robinson et al.[51] and Felcar et al.[52] evaluated the potential benefit of pre- and post-operative PT in a selected group of patients after cardiac surgery. The first authors analyzed severe COPD patients while the others analyzed a pediatric population. They found comparable results: PPC were less when PT was performed also before surgery. Yanez-Brage et al. also found a lower number of pulmonary atelectasis in patients who underwent a respiratory PT before surgery of CABG[12]. Valkenet in a systematic review described a benefit of preoperative respiratory PT in the number of PPC and in hospital stay both after cardiac or abdominal surgery[45]. Furthermore, when the PT program aimed at early mobilization is tailored to the age, needs and possible pathologies of the patient, best results are found in recovery after surgery[53]. It has been recently shown that inspiratory muscle training may improve inspiratory muscle strength and increase paralyzed diaphragm mobility after major cardiac surgery[54]. There is no evidence that a specific modality of exercise, either walking or cycling can influence the outcome of PT in these cases[55].

Lung cancer patients seem to be a good population to undergo a PT program[56]. For this reason the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) proposed and published evidence-based guidelines on the use of PT programs in lung cancer patients after lung resection[57]. The conclusions were that current evidence suggests that exercise training, an intervention able to improve exercise tolerance, may improve surgical risk and/or recovery, symptom control, and possibly, risk of dying following a lung cancer diagnosis. Exercise training is acknowledged as one of the most effective interventions to improve exercise tolerance[58]. Patients with lung cancer who underwent to a program of perioperative intensive chest PT seem to have a less overall pulmonary morbidity after surgery[59].

Park et al. evaluated the effects of high frequency chest wall oscillation therapy after pulmonary lobectomy in patients with non-small cell lung cancer (NSCLC) compared to conventional chest PT. In patients who underwent high frequency chest wall oscillation therapy there was a better and quicker recovery of pulmonary function than patients who were treated with conventional chest PT. No side effects were highlighted[60]. Pehlivan et al. observed 60 patients with NSLCL waiting for surgery and divided them into two groups. Every patient was treated with a PT program, but one of the two groups was treated with an intensive rehabilitation program while the other group with a conventional one. Patients undergoing intensive rehabilitation showed a better blood gas exchange, VA/Q and a reduction in hospital stay[61]. Nagarajan et al. in 2011 evaluated literature about preoperative PT for patients waiting for a lung resection. They concluded that many studies show a gain in exercise capacity and a better maintenance of pulmonary function, but they do not find a certain gain in the number of PPC[62].

There are many evidences that the number of PPC after abdominal surgery and open-heart surgery is reduced by preoperative PT programs. The preoperative PT results in a reduction of radiographic changes, a modification of objectivity chest, an improved gas exchange as well as improved QoL and a decrease in hospital stay[63‐66]. However, at present no PT treatment has been identified as more effective than others.

The evidence of the effectiveness of preoperative physiotherapy protocols in reducing PPC in critically ill patients[67] is weak.