|A clinical practice guideline on peri-operative cardiorespiratory physical therapy
|Brooks D, Crowe J, Kelsey C J, Lacy J B, Parsons J, Solway S
To evaluate cardiorespiratory physical therapy (CPT) in the management of patients after thoracic, cardiac and abdominal surgery.
CINAHL (from 1982 to August 1999) and MEDLINE (from 1966 to March 2000) were searched; the search terms were reported. EMBASE was searched for a limited time period then discontinued when no additional relevant citations were found. In addition, the Cochrane Database of Systematic Reviews was searched and the reference lists of included studies and reviews were checked for additional studies. The searches were restricted to English language publications; no attempt to identify unpublished literature was made.
Study designs of evaluations included in the review
Randomised controlled trials (RCTs), including crossover trials, were eligible. Studies using quasi-random allocation were not included. Studies without data and statistical analyses were excluded. The authors also excluded studies that they judged to have had significant methodological and/or statistical problems.
Specific interventions included in the review
Studies of CPT for surgery were eligible, specifically studies of pre-operative physical therapy, breathing exercises, incentive spirometry (IS), intermittent positive pressure breathing (IPPB), positive expiratory pressure mask (PEP), flutter, inspiratory muscle training, positioning, mucocilliary clearance techniques (percussion, vibrations) and transcutaneous electrical nerve stimulation (TENS). Studies reporting on diagnostic test or risk factors were excluded.
Participants included in the review
Studies of patients who had undergone abdominal, thoracic or cardiac surgery were eligible. For TENS, only studies of patients undergoing upper abdominal, thoracic or cardiac surgery were included. The studies reviewed considered upper and lower abdominal surgery, mixed orthopaedic and abdominal surgery, open cholecystectomy, abdominal hysterectomy, upper abdominal laparotomy, inguinal hernia repair, thoracic surgery, oesophageal surgery, head and neck surgery, adult and paediatric cardiac surgery, coronary artery bypass grafting, adrenalectomy, laparascopic gastroplasty, laparoscopic fundoplication, partial gastrectomy, gastric bypass, lung resection, and post thoracotomy and low-risk mixed post-surgical patients.
Outcomes assessed in the review
The outcomes of interest appeared to be post-operative pulmonary complications and the length of hospital stay. Measures of post- operative pulmonary complications included chest radiographs, pulmonary function and clinical signs. The main findings of the individual studies appear to have been used in the review.
How were decisions on the relevance of primary studies made?
Two researchers assessed the studies for inclusion.
Assessment of study quality
The included studies were assessed for quality using the Jadad 5-point scale to assess randomisation, blinding and withdrawals. Each study was also assigned a level of evidence. Level 1 included RCTs of sufficient size to be either positive with a small risk of false-positive conclusions, or negative with a small risk of false-negative conclusions. Level 2 included small RCTs that showed either a non statistically-significant positive trend with a big risk of false-positive conclusions, or no impressive trends with a large risk of false-negative conclusions. Two researchers independently assessed the included studies for quality and resolved any differences by consensus.
One researcher extracted data relating to study design. Another reviewer verified these data then extracted outcomes, results and other methodological or clinical data.
Methods of synthesis
How were the studies combined?
The authors provided a narrative summary and tables of studies grouped by intervention and population. The findings were only synthesised into evidence-based recommendations if at least one level 1 or two level 2 studies showed a statistically and clinically important difference between the treatment groups, or at least one adequately powered study showed no statistically-significant difference.
How were differences between studies investigated?
One reviewer examined the studies for clinical differences in the population, intervention and outcomes. In the narrative, the studies were grouped by intervention and population.
Results of the review
The authors stated that 68 RCTs met the inclusion criteria, of which 9 were rejected on the basis of undefined methodological or statistical problems. However, the number of studies actually included did not appear to be consistent throughout the report: one summary table showed 69 included studies, while data tables suggested that 52 studies were used to derive the recommendations. We estimated that 66 RCTs (n=5,354) were summarised in the review.
The main findings of the individual studies were tabulated in the report, but it was unclear which of these the authors classified as included studies. All the authors presented were recommendations based on their interpretation of selected study results, but it was not possible to decipher from the report the particular results that were used.
The authors concluded that their clinical practice guideline provides a rigorous analysis of the literature and translates evidence into practice.
The purpose of this review was to develop clinical practice guidelines. The authors specified inclusion criteria for the study design and a broad definition of the participants and intervention. Restricting the search to English language publications means that relevant studies could have been missed and bias could have been introduced. The authors appear to have made some attempt to reduce bias in the initial selection of studies and the data extraction, but the procedures described were not thorough and studies were subsequently excluded. Quality scores were assigned to the studies but were not discussed in relation to their findings, less transparent levels of evidence developed for practice guidelines were used instead. It was unclear how many of the studies met the inclusion criteria or which data the authors' recommendations were derived from. The authors' conclusion cannot be verified from the report. Whether the recommendations are appropriate cannot be determined since the relationship between them and the research evidence is unclear.
Implications of the review for practice and research
Practice: The authors stated eleven practice recommendations, some of which are summarised here.
Prevention of post-operative pulmonary complications: CPT is recommended for upper, but not lower, abdominal surgery patients. Deep breathing exercises are also recommended for abdominal surgery patients. The combination of IS and deep breathing or IS and CPT is not recommended for abdominal, cardiac, thoracic and oesophageal surgery patients. IPPB is recommended for abdominal surgery patients, but the addition of IPPB to CPT is not recommended for mixed abdominal surgery patients. The addition of PEP or inspiratory resistance-PEP to CPT is not recommended for thoracic, cardiac or abdominal surgery patients.
TENS is recommended for pain relief in thoracic and abdominal surgery patients, but not for cardiac surgery patients.
The addition of postural drainage, vibration and percussion to breathing exercises, coughing and suctioning in paediatric cardiac surgery patients may increase the risk of atelectasis.
Research: The authors stated that studies of sufficient sample size and power are needed. In particular, to determine whether CPT is better than control in adults undergoing cardiac, thoracic and peripheral surgery, and in patients with pre-existing lung diseases undergoing cardiac, upper abdominal and thoracic surgery; if IS alone is better than CPT for upper abdominal, thoracic and cardiac surgery, and which IS device is the most effective; and, in all surgical groups, to determine whether pre-operative CPT is better than post-operative CPT alone, and whether positioning, flutter or mucocilliary clearance techniques alone are better than control.
Canadian Physiotherapy Cardiorespiratory Society of the Lung Association.
Brooks D, Crowe J, Kelsey C J, Lacy J B, Parsons J, Solway S. A clinical practice guideline on peri-operative cardiorespiratory physical therapy. Physiotherapy Canada 2001; 53(1): 9-25
Subject indexing assigned by CRD
Abdomen /surgery; Breathing Exercises; Cardiac Surgical Procedures /rehabilitation; Physical Therapy Modalities /methods; Postoperative Care /methods; Respiratory Function Tests; Spirometry; Thoracic Surgical Procedures /rehabilitation
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.