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Delphi Study Results

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Delphi Study Results
 

Phase 3: RESULTS

Group 1: Abdominal Surgery


BEST PRACTICE RECOMMENDATIONS:
CONSENSUS FORMULATION BY ABDOMINAL SURGERY PANEL

 

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; sustained maximal inspiration 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.

POSTED COMMENTS:

  • I think breathing exercises should be used in all not in those unable to mobilize. Primary priority is mobilizing but not at exclusion of breathing

  • I actually do agree with this recommendation, except that we never use pursed lips breathing rather we teach sustained maximal inspiration (breath hold at end expiration). The reasoning is that inspiration is the important volume to address in surgery and SMI maintains transpleural pressure that MAY facilitate collateral flow in lungs with atelectasis. Where as PLB is an expiry technique that we would use for COPD to maintain a patent airway to allow more expiration. I should have picked this up and commented earlier earlier. Would it be possible to have both in the statement?


Recommendation 2 :

In the presence of persisted hypoxemia following abdominal surgery which is not responsive to first line physiotherapy management, CPAP could be initiated. This intervention might be applied intermittently over a 24 hour period or continuously 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 of primary research

POSTED COMMENT:

  • I agree with the comment that the evidence for 6 hours of continuous CPAP is not strong enough to support this part of the statement. Intermittent use 15-30 minutes/ session is preferable and is probably easier to apply in the clinical situation
 
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