preoperative physiotherapy intervention program (ppip) for
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Yu TWDYu TWD11, Cheung W, Cheung W11, , Yung Yung WMMWMM22, , Lam MYMLam MYM11, Chan MPM, Chan MPM11, , Fung Fung MCIMCI11
11Physiotherapy Department, Kowloon HospitalPhysiotherapy Department, Kowloon Hospital22Respiratory Medical Department, Kowloon HospitalRespiratory Medical Department, Kowloon Hospital
Preoperative Physiotherapy Preoperative Physiotherapy Intervention Program (PPIP) Intervention Program (PPIP)
for reducing for reducing Pulmonary Complications Pulmonary Complications
after Thoracic Surgeryafter Thoracic Surgery
IntroductionIntroduction
Pulmonary complications are the major contributors of mortality and morbidity after thoracic surgery.
The incidence of postoperative pulmonary complications varies from 8% to 39% in previous studies.
(Nagasaki F et al 1982, Busch E et al. 1994, Deslauriers J et al 1994)
Preoperative chest physiotherapy is considered to be beneficial but study in this area is limited.
(Stein N & Cassara EL 1970, Castillo R & Haas A 1985, Ingwersen UM 1993)
The Preoperative PhysiotherapyThe Preoperative PhysiotherapyIntervention Programme (PPIP)Intervention Programme (PPIP)
Day-patient base program launched since April 2000
Multidisciplinary service involving chest physicians of Respiratory Medical Department & respiratory physiotherapists of KH
9 sessions, 3 times per week for 3 weeks
1.5 hours for each session
Program Program CContentsontents
Chest and ET assessments
Patient education
Cardio-pulmonary training
Bronchial hygiene toileting
Breathing exercises
Effective coughing techniques
Patient Patient SSelection election CCriteriariteria
Marginal lung function test (Preoperative FEV1< 80% predicted)
Current smokers or recent smokers who have quitted smoking < 8 weeks
Concomitant of other lung diseases e.g COPD, bronchiectasis
Reduction in exercise tolerance
Patient’s motivation
Purposes of the Purposes of the SStudytudy
To assess the effectiveness of the PPIP in reducing
a. 30-day mortality rate
b. Length of stay in the acute setting
c. The incidence rate of the post-op pulmonary complications
Postoperative Pulmonary ComplicationsPostoperative Pulmonary Complications
Pneumonia
Lobar atelectasis requiring bronchoscopic intervention
Hypercapnia (PaCO2 > 50mmHg)
Respiratory failure requiring invasive or non-invasive mechanical ventilation
Pulmonary compromise required post-op ICU care
MethodMethod
Intervention group (n=65)( Attended the PPIP before thoracic surgery )
Control group (n=94)(Without PPIP before thoracic
surgery)
Matching with intervention group based on gender, age, past medical history, lung function, disease nature and types of surgery received
Excluded those with exploratorythoracotomy, VATS, or operation done in other hospitals
Subjects (N=159)
Retrospective longitudinal study (April 2002 to Jan 2006)
Statistical analysisStatistical analysis
Descriptive analysis for demographic data and 30-day mortality rate
Independent t-test to compare the LOS of both groups
McNemar test for categorical data (the incidence rate of the post-op pulmonary complications)
p < 0.05 considered significant result
Results Results –– Baseline characteristicsBaseline characteristics
0.4513.4713.01PO2
Nature of the lung diseases
0.3315%12.5%Benign
0.117.407.42pH
0.345.065.42PaCO2
0.4985%87.5%Malignancy
ABG
0.3281% ( ± 13%)80% (± 16%)%FEV1
0.6965.0 (± 11.7)67.6 (± 9.1)Age
SignificanceControl Groupn=94
(68 male, 26 female)
Intervention Groupn=65
(45 male, 20 female)
Intervention Group
10% 0%
63%
3%
24%
Types of Types of SSurgeryurgery
Control Group
13%0%
64%
4%
19%
Wedge resection
Segmenectomy resection
Single lobectomy
Double lobectomy
Pneumonectomy
3030--day mortality rate and day mortality rate and LOS in acute settingLOS in acute setting
0
9
10.62
12.59
0
2
4
6
8
10
12
14
30 days mortality rate Length of stay
Intervention GroupControl Group
(9.5%)
Incidence of Incidence of Postoperative Postoperative CComplicationsomplications
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Inci
denc
e ra
te o
f P
ost-
op
com
plic
atio
ns
Pneumonia Atelectasis Hypercapnia
(PCO2>50mmHg)
Respiratory failure Post-op ICU care
Intervention Group
Control Group
Incidence rate of Incidence rate of Postoperative Postoperative CComplicationsomplications
p=0.04319.5%13.3%Post-op ICU care
p=0.028Chi-square= 4.86
28.7%14.1%Overall incidence rate
p=0.01217.1%0%Respiratory failure
p=0.060%6.7%Hypercapnia (PCO2>50mmHg)
p=0.01529.3%6.6%Atelectasis
p=0.03231.7%13.3%Pneumonia
SignificanceControl Group
Intervention Group
Types of complications
DiscussionDiscussionStrong patient education component to promote understanding and adherence to the peri-operative care and rehabilitation for better psychological preparation, empowerment and compliance of the program.
Encourage / motivate patients’ active participation with vigorous home bronchial hygiene toileting, breathing exercises and effective coughing techniques.
Prophylactic intensive chest physiotherapy reduce the post-op pulmonary complications.
(Stein N & Cassara EL 1970, C.G. Morran et al 1983, M. Fagevil Olsen et al 1997))
Post-resection complication rate was inversely proportional to exercise capacity.
(Bolton JW et al 1987, Olsen GN et al 1991, Alessandro B et al 2002)
Emphasis on intensive cardio-pulmonary training. Aims at 60% VO2max in each training session or home therapy programme.
An average improvement in exercise capacity by 18.5% and 14.2% was observed in VO2max and 6MWT respectively.
DiscussionDiscussion
Significance of the studySignificance of the study
The PPIP can minimize the the expenses in tertiary care settings by reducing postoperative pulmonary complications and mortality rate.
The PPIP has a role of encouraging smoking cessation with 66.7% smoking quit rate after the programme.
Limitations of the studyLimitations of the study
The current study was not a RCT design.
Small sample size in the intervention group as difficult to recruit “motivate” patients and no recruitment during SARS period.
ConclusionConclusion
Day-patient Preoperative Physiotherapy Intervention Program (PPIP) is effective in improving patient’s outcomes
Further study with larger sample size is highly recommended
Thank YouThank You