To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections.
Randomized controlled trial.
University hospital, intensive care unit, and surgical department.
Sixty-seven patients (age, 59 +/- 13 yrs; forced expiratory volume in 1 sec, 93% +/- 22% predicted) undergoing elective thoracic surgery for lung (n = 40) or esophagus (n = 27) resection.
Physiotherapy (breathing exercises, huffing, and coughing) (PT) plus incentive spirometry (IS) was compared with PT alone.
Lung function, body temperature, chest radiograph, white blood cell count, and number of hospital and intensive care unit days were all measured. Pulmonary function was significantly reduced after surgery (55% of the initial value) and improved significantly in the postoperative period in both groups. However, no differences were observed in the recovery of pulmonary function between the groups. The overall score of the chest radiograph, based on the presence of atelectasis, was similar in both treatment groups. Eight patients (12%) (three patients with lobectomy and five with esophagus resection) developed a pulmonary complication (abnormal chest radiograph, elevated body temperature and white blood cell count), four in each treatment group. Adding IS to regular PT did not reduce hospital or intensive care unit stay.
Pulmonary complications after lung and esophagus surgery were relatively low. The addition of IS to PT did not further reduce pulmonary complications or hospital stay. Although we cannot rule out beneficial effects in a subgroup of high-risk patients, routine use of IS after thoracic surgery seems to be ineffective.
"Both these techniques are dependent on specialized equipment and therefore costly to the patient. Two systematic reviews reported no added benefit to deep breathing exercises [13,14,35]. In addition, IPPB would be the last choice because abdominal distention has been reported as potentially harmful and the technique is therapist dependent [14,18]. "
[Show abstract][Hide abstract] ABSTRACT: Postoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal.
The objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n=5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR)<0.5-were collated into the algorithm.
The five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential.
An expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population.
BMC Medical Informatics and Decision Making 02/2012; 12(1):5. DOI:10.1186/1472-6947-12-5 · 1.83 Impact Factor
"The assessment of criteria for the BBS and GS was performed as described in the papers by Brooks-Brunn  and Gosselink et al . Further clarification regarding the GS was needed in order to confirm how microbiology results contribute to the score as it was unclear as described in the paper by Gosselink et al ; a positive sputum microbiology report constituted a positive second criteria, even if white cell count (WCC) is negative (personal communication with author), see Table 1. Detailed information/instruction regarding the application of the MGS  was used to facilitate its application, and where necessary advice was sought (personal communication with author). "
[Show abstract][Hide abstract] ABSTRACT: To evaluate the recognition of postoperative pulmonary complications (PPC) following thoracotomy and lung resection using three PPC scoring tools.
Prospective observational study.
Regional thoracic centre.
One hundred and twenty-nine consecutive thoracotomy and lung resection patients (October 2007 and April 2008).
PPC assessment was performed on a daily basis using three sets of criteria described by Brooks-Brunn, Gosselink et al. and Reeve et al.: the Brooks-Brunn Score (BBS), Gosselink Score (GS) and Melbourne Group Scale (MGS), respectively. The results were compared with treatment for PPC and clinical outcomes including mortality, postoperative length of stay and high dependency unit length of stay.
PPC frequency was 13% (17/129) with the MGS, 6% (8/129) with the GS and 40% (51/129) with the BBS. The clinically observed incidence of treated (requiring antibiotic therapy or bronchoscopy) PPC was 12% (16/129).
PPC treatment following thoracotomy is common. Of the three scoring tools, the MGS outperforms the BBS and the GS in terms of PPC recognition following thoracotomy and lung resection. Patients with a PPC-positive MGS score have a worse outcome as defined by mortality, high dependency unit length of stay and postoperative length of stay. The MGS is an easy-to-use multidisciplinary scoring tool, but further work is required into its use in minimally invasive surgery and in targeting high-risk groups for therapy.
"It is therefore difficult to determine exactly what has been compared. Gosselink et al.  performed a randomised controlled trial on subjects following lung (n = 40) and oesophageal (n = 27) surgery; selection was based upon the subject's ability to perform incentive spirometry adequately before surgery. These subjects were randomised to two groups; postoperative physiotherapy comprising deep breathing exercises , huff and cough (n = 35), and volume-orientated incentive spirometry (Voldyne), huff and cough (n = 32). "
[Show abstract][Hide abstract] ABSTRACT: Thoracic surgery may cause reduced respiratory function and pulmonary complications, with associated increased risk of mortality. Postoperative physiotherapy aims to reverse atelectasis and secretion retention, and may include incentive spirometry.
To review the evidence for incentive spirometry, examining the physiological basis, equipment and its use following thoracic surgery.
MEDLINE was searched from 1950 to January 2008, EMBASE was searched from 1980 to January 2008, and CINAHL was searched from 1982 to January 2008, all using the OVID interface. The search term was: '[incentive spirometry.mp]'. The Cochrane Library was searched using the terms 'incentive spirometry' and 'postoperative physiotherapy'. The Chartered Society of Physiotherapy Resource Centre was also searched, and a hand search was performed to follow-up references from the retrieved studies.
Non-scientific papers were excluded, as were papers that did not relate to thoracic surgery or the postoperative treatment of patients with incentive spirometry.
Initially, 106 studies were found in MEDLINE, 99 in EMBASE and 42 in CINAHL. Eight references were found in the Cochrane Library and one paper in the Chartered Society of Physiotherapy Resource Centre. Four studies and one systematic review investigating the effects of postoperative physiotherapy and incentive spirometry in thoracic surgery patients were selected and reviewed.
Physiological evidence suggests that incentive spirometry may be appropriate for lung re-expansion following major thoracic surgery. Based on sparse literature, postoperative physiotherapy regimes with, or without, the use of incentive spirometry appear to be effective following thoracic surgery compared with no physiotherapy input.
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