Phase 2: RESULTS

Group 1: Abdominal Surgery

• REFORMULATED BEST PRACTICE RECOMMENDATIONS
• Recommendation 1
• Recommendation 2
• STEPS IN THE CLINICAL ALGORITHM
  • Subject 1 : Importance of coughing
  • Subject 2 : Stability criteria for patient mobilization
  • Subject 3 : Breathing techniques
  • Subject 4 : Need and content of the directed mobilization protocol

BASED ON THE FEEDBACK THE RECOMMENDATIONS HAVE BEEN REFORMULATED

Recommendation 1

Following upper abdominal surgery, patients must be positioned upright. The patient should be assisted in effectively clearing any secretions through directed cough. Further management should include either targeted mobilization or breathing exercises. Mobilization is the first choice of management. Only when targeted mobilization is not possible breathing techniques must be incorporated into the management. The choice of breathing exercise must be based on patient preference and performance and can include DBE with pursed lips breathing; or breathing exercises facilitated by equipment PEP; blow bottle; IS or IPPB.
WEAK RECOMMENDATION: The cost benefit of post operative pulmonary physiotherapy is not clear largely due to the inconsistent and undefined clinical outcomes that have been measured. This recommendation is based on MODERATE QUALITY EVIDENCE. One updated systematic review of secondary research and a single primary research report (Conde et al 2006) concluded that there is sufficient evidence to recommend the routine application of post operative intervention for all patients following abdominal surgery. One systematic review of primary research (Pasquina et al 2006) was hesitant to make recommendations for clinical practice and recommended further high quality research. Due to poor quality of primary studies; variable outcome measure; and imprecision of data there is not consistent evidence of benefit and thus the quality of the evidence is downgraded.

NOTE: This is an additional recommendation formulated based on feedback from panel

Recommendation 2 :

INITIATION OF CPAP: In the presence of persisted hypoxemia following abdominal surgery CPAP could be initiated. This intervention should be applied for at least 6 hours, and interrupted only when normal oxygenation is established.

WEAK RECOMMENDATION The introduction of CPAP resulted in risk reduction in PPC's; atalectasis and pneumonia. The effect on mortality, intubation rate and LOS is still unclear. This recommendation is based on MODERATE QUALITY EVIDENCE. A well conducted meta analysis of 9 RCT's (Ferreyra et al 2008) including 654 patients. Even though only one study was independently associated with reduction in PPC's when the results of the 9 studies were pooled CPAP intervention was associated with a significant risk reduction of PPC's 0.35 (95% CI, 0.05–0.56); atelectasis risk ratio 0.25 (95% CI, 0.03–0.42), and pneumonia risk ratio 0.67 (95% CI, 0.25–0.86). The evidence is downgraded due to imprecision of results and heterogeneity between primary research reports included.

Ferreyra et al 2008 Continuous Positive Airway Pressure for Treatment of Respiratory Complications after Abdominal Surgery: A Systematic Review and Meta-Analysis. Annals of Surgery 247:617-626

POSTED COMMENT:

I basically agree with the recommnedation that in the presence of persistent hypoxaemia that is not responsive to first line physiotherapy management ( deep breathing exercises, mobilisation) CPAP may be an efective alternative treatment.
However I do not think that the evidence for 6 hrs of continuous CPAP is strong enough to support this part of the statement. It is possible that intermittent application would also be as beneficial. in the paper by Denehy et al 2001 (although not reported), the number needed to treat for CPAP application compared with standard physiotherapy was clinically significant for reduction in PPC. This research utilised intermittent 15 to 30 min applications of CPAP

Clinical Algorithm

COMPARE YOUR RATING WITH THE MEDIAN SCORE OF THE GROUP

SUBJECT 1: Importance of coughing

SUBJECT 2: Stability criteria for patient mobilization

SUBJECT 3: Breathing techniques

SUBJECT 4: Directed mobilization protocol