Dewi Nurul Makhabah1, Federica Martino2and Nicolino Ambrosino1,2,3*
Postoperative pulmonary complications (PPC) are a major cause of morbidity, mortality, prolonged hospital stay,
and increased cost of care. Physiotherapy (PT) 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 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. 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.
A postoperative pulmonary complication (PPC) is defined
as any pulmonary abnormality occurring during the post-
operative period and resulting in clinically significant
disease or dysfunction, adversely affecting the clinical
course . The respiratory system is directly influ-
enced by the type of surgery, the organ involved and
the method used. Postoperative pulmonary complica-
tions are a major cause of morbidity, mortality, prolonged
hospital stay, and increased cost of care . They may be
associated to respiratory muscle dysfunction which may
start at induction of anesthesia and continue into the post-
operative period. As a matter of fact, the surgical lesion,
possible involvement of the phrenic nerve, drugs for sed-
ation, all can lead to ventilation derangement. As a conse-
quence a reduction in functional residual (FRC) and vital
(VC) capacity can be observed resulting in higher likeli-
hood 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 multidis-
ciplinary 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 hospitaliza-
tions. 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 reduc-
tion of risk factors, improving preoperative status, patient
education, smoking cessation, intra-operative and post-
operative pulmonary care. Different PT techniques, as a
part of the comprehensive management of patients under-
going 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 con-
ditions 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 PTshould therefore be assessed im-
mediately upon surgical ICU admission in all patients and
continue throughout the acute admission .
* Correspondence: email@example.com
1Pulmonary Rehabilitation and Weaning Center, Auxilium Vitae, Volterra, Italy
2Pulmonary Unit, University Hospital, Pisa, Italy
Full list of author information is available at the end of the article
© 2013 Makhabah et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Makhabah et al. Multidisciplinary Respiratory Medicine 2013, 8:4
Prolonged immobility is a main cause of muscle weakness
in patients admitted to ICU, conversely early PT has an
important role in the recovery of these patients. Early
mobilization and muscle training can improve functional
outcomes, cognitive and respiratory conditions, reducing
the risks of venous stasis and deep vein thrombosis. For
this reason the exercise in the early stages after surgery,
when possible, can be helpful in preventing PPC such
as atelectasis, reducing the need of painkillers, im-
proving recovery and avoiding neuromuscular compli-
Suggested goals of early mobilization, although not
always demonstrated, may be :
1. Increase in lung volumes, optimization of ventila-
tion to perfusion ratio (VA/Q) and better airway clear-
ance; 2. Reduction of risk of immobility associated with
PPC; 3. Improvement in level of consciousness; 4. In-
crease in functional independence; 5. Improvement in
cardiovascular fitness; 6. Psychological benefit.
Respiratory muscle training
Respiratory muscle weakness, imbalance between muscle
strength and the load of the respiratory system and car-
diovascular impairment are major determinants of wean-
ing failure in ventilated patients, including post-surgery.
In ICU patients these factors and the excessive use of
controlled mechanical ventilation may lead to rapid dia-
phragmatic atrophy and dysfunction . In many stud-
ies high risk patients waiting for elective coronary artery
bypass graft (CABG) surgery get a benefit from pre-
operative PT programs including respiratory muscle train-
ing. A reduction of PPC and hospital stay was observed in
patients undergoing respiratory muscle training compared
to controls [23-25]. Nomori et al.  showed that in-
spiratory muscle training before thoracic surgery may
prevent PPC. A systematic review of studies on ICU
ventilator-dependent COPD patients showed that inspira-
tory muscle training significantly increased inspiratory
muscle strength. However this study failed to clarify
whether the increase in inspiratory muscle strength may
lead to a shorter duration of mechanical ventilation, if it
improved weaning success, or improved survival. Further
large randomized studies are required to clarify the impact
of inspiratory muscle training on patients receiving mech-
anical ventilation .
Neuromuscular electrical stimulation
Neuromuscular electrical stimulation (NMES) can in-
duce changes in muscle function without any form of
ventilatory stress . NMES can be easily performed in
the ICU, applied to lower limb muscles of patients laying
in bed. Nevertheless, to date, no clinical studies have yet
completely demonstrated the additional effect of NMES
on exercise tolerance when compared with conventional
training. A study suggests that both conventional chest
physiotherapy and conventional chest physiotherapy +
transcutaneous electric diaphragmatic stimulation pre-
vent the reduction of pulmonary function during the
Roux-en-Y gastric bypass postoperative period, and that
transcutaneous electric diaphragmatic stimulation also
contributes to expiratory muscle strength . A small
study reported that transcutaneous electrical nerve
stimulation (TENS) was considerably active in reducing
pain, and the increase in respiratory muscle strength at
first-day after CABG surgery . A randomized study
confirmed that TENS is a valuable approach to reduce
post-thoracotomy pain with decrease of cytokine pro-
duction and of analgesic intake, and with positive effects
on pulmonary ventilation function .
In a meta-analysis of Thomas et al. there was a benefit
from the use of Incentive Spirometry (IS) and breathing
exercises after abdominal surgery. It remains, however,
unclear the benefit on the incidence of some PPC as
atelectasis and infection . Carvalho et al  per-
formed a systematic review to evaluate the evidence of
the use of IS for the prevention of PPC and for the re-
covery of lung function in patients undergoing abdom-
inal, cardiac and thoracic surgeries. There was no
evidence to support the use of IS in the management of
surgical patients. Despite this, the use of IS remains
widely used without standardisation in clinical practice.
Other meta-analysis were conducted to evaluate the
effectiveness of the PT in preventing the PPC. In a study
of Overend et al.  patients undergoing cardiac or ab-
dominal surgery did not seem to get any help from IS.
In a systematic review Pasquina et al.  have assessed
whether respiratory PT prevents PPC after cardiac sur-
gery evaluating 18 trials. Anyway most of them were of
low quality. They tested physical therapy (13 trials), IS
(8), continuous positive airway pressure (CPAP:5), and
intermittent positive pressure breathing (IPPB: 3). The
authors did not show any advantage from the practice of
PT. A few years later Pasquina et al.  found no evi-
dence for the application of PT routine in patients
undergoing abdominal surgery.
Fast-track rehabilitation programs include easy methods
that have the potential to decline morbidity, hospital stay,
and increase pain control when compared with conven-
tional care. Patients with lung cancer who undergo lob-
ectomy can be treated with fast-track rehabilitation.
Fast-track rehabilitation is based on: minimally invasive
Makhabah et al. Multidisciplinary Respiratory Medicine 2013, 8:4
Page 2 of 6
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 .
Patients undergoing upper abdominal and thoracic sur-
gery have a decreased postoperative VC, which leads to
VA/Q mismatch and contributes to development of hyp-
oxaemia. 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
Clinical outcomes and costs of 119 patients undergo-
ing 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.
. 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 ex-
piratory pressure (PEP) treatment versus other physio-
therapy breathing techniques in patients who underwent
thoracic surgery .
A reduction in exercise tolerance and QoL is fre-
quently observed, as a consequence of a lobectomy. In a
randomized study of Arbane et al.  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, exer-
cise 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 .
The usefulness of IS in preventing PPC has not been
confirmed by a recent meta-analysis on patients under-
going upper abdominal surgery . Lunardi et al. found
that PPC after oesophagectomy are reduced in patients
who had undergone chest PT before surgery. Neverthe-
less the hospital length of stay did not differ in patients
treated with PT compared to control patients . Sev-
eral 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  that chest PT
after abdominal surgery can improve oxygen haemoglo-
bin saturation without worsening abdominal pain.
A recent systematic review  analyzed the effect of
PT to prevent PPC in patients undergoing upper ab-
dominal surgery. They excluded studies on patients with
comorbidities and undergoing IS and mechanical venti-
lation 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.  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 .
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 re-
ducing 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 sur-
gery. There is a lack of evidence that preoperative PT
reduces postoperative pneumothorax, prolonged mechan-
ical ventilation or all-cause deaths [47-49].
Castillo and Haas  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 re-
ducing respiratory infections. Robinson et al.  and
Felcar et al.  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
. 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 .
Makhabah et al. Multidisciplinary Respiratory Medicine 2013, 8:4
Page 3 of 6
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 recov-
ery after surgery . It has been recently shown that in-
spiratory muscle training may improve inspiratory muscle
strength and increase paralyzed diaphragm mobility after
major cardiac surgery . There is no evidence that a
specific modality of exercise, either walking or cycling can
influence the outcome of PT in these cases .
Lung cancer patients seem to be a good population to
undergo a PT program . 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 . The conclu-
sions were that current evidence suggests that exercise
training, an intervention able to improve exercise toler-
ance, 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 . Patients with lung cancer who underwent
to a program of perioperative intensive chest PT seem to
have a less overall pulmonary morbidity after surgery .
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) com-
pared to conventional chest PT. In patients who under-
went 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 . 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 inten-
sive rehabilitation showed a better blood gas exchange,
VA/Q and a reduction in hospital stay . 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 .
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  is weak.
The authors declare that they have no competing interests.
1Pulmonary Rehabilitation and Weaning Center, Auxilium Vitae, Volterra, Italy.
2Pulmonary Unit, University Hospital, Pisa, Italy.3Respiratory Unit,
Cardio-Thoracic Department University Hospital, Pisa, Italy.
Received: 2 December 2012 Accepted: 2 January 2013
Published: 23 January 2013
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Cite this article as: Makhabah et al.: Peri-operative physiotherapy.
Multidisciplinary Respiratory Medicine 2013 8:4.
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Makhabah et al. Multidisciplinary Respiratory Medicine 2013, 8:4
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