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AWARENESS OF CHEST PHYSIOTHERAPY AWARENESS OF CHEST PHYSIOTHERAPY TREATMENT AND TECHNIQUES AMONG TREATMENT AND TECHNIQUES AMONG

PHYSIOTHERAPIST WORKING IN PHYSIOTHERAPIST WORKING IN CARDIOTHORACIC UNITS IN KARACHICARDIOTHORACIC UNITS IN KARACHI

bybyHina Al Fatiamh SiddiquiHina Al Fatiamh Siddiqui

PPDPT (Batch I)PPDPT (Batch I)Isra University, Karachi CampusIsra University, Karachi Campus

14 September 2012

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AIM OF THE STUDY AIM OF THE STUDY

The aim of the present study is to determine physiotherapy practice regarding chest physiotherapy and breathing exercises for patients undergoing open heart surgery in Karachi

To explore about the awareness of chest physiotherapy treatment and techniques among physiotherapist working in cardiothoracic units in Karachi

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INTRODUCTIONINTRODUCTION

Pulmonary complications like atelectasis and arterial hypoxemia are frequently seen in patients after cardiac surgery (westerdahl E et al., 2001; Wynne R, 2004).

Pulmonary dysfunction is an ever-present result of cardiac surgery, and every clinician well-known with the postoperative care of cardiac surgery patients anticipates complications.

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INTRODUCTION (Cond)INTRODUCTION (Cond)

There is an accord on the importance of pre- and post-operative breathing exercises and physiotherapy treatment.

In addition to early mobilization, chest physical therapy and breathing exercises are commonly prescribed preoperatively as well as post operatively to patients undergoing cardiac surgery to facilitate prevention or reduction of post-operative pulmonary complications. (Westerdahl E et a.l, 2005; Hulzebos EH et al.,2006; Haeffener MP et al.,2008; ,Herdy AH et al.,2008).

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INTRODUCTION (Cond)INTRODUCTION (Cond)

There is argument regarding which breathing techniques are the most helpful (westerdahl E et al.,2011),as different chest physical therapy and breathing exercises techniques with and without mechanical devices are carried out after cardiac surgery.( Urella C et al.,2011; Haeffener MP et al.,2008;Zarbock A et al.,2009; Renault JA et al.,2009 Agostini P et al.,2009)

Up till now, no survey describing the use of pre and post-operative breathing exercises for cardiac surgery patients in Pakistan has been carried out.

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METHODOLOGYMETHODOLOGY

Questionnaire survey (cross sectional study) is carried out on a total population of 40 physiotherapists working in cardiothoracic unit which were randomly selected during January 2012 to August 2012.

Data is collected from following hospitals across Karachi namely :

National Institute of Cardio Vascular Diseases Karachi (NICVD), Ziauddin Medical University Hospital Karachi (ZMUH), National Medical Center (NMC), Health Care Hospital (HCH), Liaquat National Hospital (LNH) and Karachi Institute of Heart Diseases (KIHD).

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METHODOLOGY (Cond)METHODOLOGY (Cond)

The questionnaire designed by Westerdahl E et al in 2011 for their survey conducted in Sweden related to Chest physiotherapy and breathing exercises for cardiac surgery patients in Sweden is used for this study.

The questionnaire consists of total 27 questions and includes both open ended and close ended questions about preoperative and postoperative chest physiotherapy treatment of cardiac patients for uncomplicated open heart surgery.

Data is analyzed using descriptive statistics, and mean, median and range were calculated, the SPSS version 10 software package is used for the statistical analysis.

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METHODOLOGY (Cond)METHODOLOGY (Cond) INCLUSION CRITERIA:

Physiotherapist having working experience of more than one year in cardiothoracic unit are included in the study and

this survey only applies to physiotherapy treatment of adult patients who have undergone cardiac surgery (uncomplicated open heart surgery) including: coronary artery bypass graft surgery (CABG), mitral, aortic or tricuspid valve surgery, or a combination of CABG & valve surgery,( including off- pump surgery).

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METHODOLOGY (Cond)METHODOLOGY (Cond) EXCLUSION CRITERIA:

Physiotherapist not having working experience in cardiothoracic unit

Physiotherapist having work experience less than one year in cardiothoracic unit

Patients who develop neurological symptoms, circulatory instability, prolonged intubation, or other conditions requiring individualized programs are not included

Children and patients under gone complicated open heart surgery are not included in the study.

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RESULTRESULT According to this survey the average age of the participant According to this survey the average age of the participant

physiotherapists was 31.20±6.8 years. physiotherapists was 31.20±6.8 years.

The total mean work experience as a physiotherapist was 7.592±6.7 The total mean work experience as a physiotherapist was 7.592±6.7 years. years.

Similarly average working experience as physiotherapist in a Similarly average working experience as physiotherapist in a thoracic surgery department was 4.51±5.21 years. thoracic surgery department was 4.51±5.21 years.

Out of 40 participants, 19(47.5%) were female and 21(52.5%) were Out of 40 participants, 19(47.5%) were female and 21(52.5%) were male. male.

Seven (7.5%) of the respondents had completed specific courses in Seven (7.5%) of the respondents had completed specific courses in the cardiopulmonary area. the cardiopulmonary area.

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RESULT (Cond)RESULT (Cond) 80% physiotherapist provides preoperative information to patients

about surgical procedure in general, sternotomy, reparatory treatment/ extubation, post operative pulmonary function / complication, breathing exercise and coughing technique.

Identification of patients at high risk for postoperative pulmonary complication was noted by 35% of the physiotherapists.

Most of the cardiac patients received physiotherapist treatment in the ICU during the first postoperative day one after surgery (77.5%).

Written guideline or protocol for the physiotherapy treatment of extubated patients in the ICU were available according to 35% of the respondents, whereas physiotherapy guideline for intubation patients was less accessible (10% cases).

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RESULT (Cond)RESULT (Cond) 37.5% physiotherapists performed manual hyperinflation 92.5% performed suction of airway via nose, mouth or tracheotomy 35% actively participated in the procedure for weaning a patient off

the respirator.

During the initial postoperative days the cardiac surgery patients usually received treatment sessions by the physiotherapist from the day of surgery to fifth post operative day , patients usually receive treatment “if needed” at the day of surgery and “routinely” afterwards.

Breathing Exercise, Relaxation techniques, Coughing/huffing techniques and Positioning are mostly provided treatment regimes during the first four postoperative days after surgery

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“ROUTINELY”

Deep breath exercise n=40(100%),

Diaphragmatic breathing n=36(90%)

Incentive spirometry n=39(97.5%).

Pursed lip breathing n=15(37.5%)

Sustained maximal inspiration n=5(12.5%)

“IF NEEDED”

positive expiratory pressure (PEP) n= 19(47.5%)

“NEVER”

Inspiratory resistance positive expiratory pressure (IR-PEP) ,

Inspiratory muscle Training (IMT)

Continuous positive airway pressures (CPAP)

Eighty percent physiotherapist instructed the patients to performed

breathing exercise on a regular basis post-operatively.

Specific Breathing Exercises given to pts postoperatively

RESULT (Cond)RESULT (Cond)

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RESULT (Cond)RESULT (Cond)

80% physiotherapist instructed the patients to perform the recommended breathing practice once an hour during the first two postoperative days.

Number of breath at each training session as instructed by physiotherapists ranges between 5 to 30 breaths and, most physiotherapist educate patients to perform 10 to 20 breaths

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Responses regarding Physiotherapist provided, coughing support to the patients facing secretion problem,

patients performing with the small pillow 97.5%,

without pillow 45.0%,

manually by physiotherapist 55.0%

sternal support with a device such as heart Hugger harness is not used.

RESULT (Cond)RESULT (Cond)

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Recommendation to continue breathing exercises at home after discharge is 82.5% deep breathing exercises is mostly recommended whereas spirometry, huffing / coughing and chest expansion exercises are other suggested regimes.

55.4% physiotherapist recommends device for breathing exercise at home after discharge and

spirometry is the device that is recommended mostly.

Considerable variation in instruction to patients about the duration to continue breathing exercises after discharge is observed, which ranges from 1 week to 13 weeks

RESULT (Cond)

RR

EE

SS

UU

LL

TT

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DISCUSSIONDISCUSSION This is the first survey in Karachi to determine physiotherapy practice

regarding chest physiotherapy and breathing exercises for patients undergoing open heart surgery in Karachi and to explore about the awareness of chest physiotherapy treatment and techniques among physiotherapist working in cardiothoracic units in Karachi.

Chest physiotherapy practice in Karachi has many similarities to other international surveys of clinical practice. (Tucker B et al., 1996, Overend TJ et al., 2010, Fiore JF et al., 2010, Westerdahl E et al., 2011)

Several breathing exercises are applied, in the present study, all physiotherapists instructed the patients to perform breathing exercises, with or without PEP, on a regular basis postoperatively. Deep breathing exercises was the first choice of breathing technique and this in agreement with the results from Overend TJ et al., who demonstrated that treatment on the first postoperative days primarily consisted of deep breathing exercises and coughing (Overend TJ et al., 2010).

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DISCUSSION (Cond)DISCUSSION (Cond) The earlier study by Tucker et al , performed in Australia and New Zealand

in the 90´s, also demonstrated that deep breathing exercises was the most commonly used technique, the same results were observed in Sweden by Westerdahl et al (Tucker B et al., 1996 ,Westerdahl E et al., 2011)

according to this survey breathing exercises with positive pressure devices is not often used in Karachi ,however in Brazil and Sweden the use of breathing exercises with positive pressure devices post operatively is extensive (Fiore JF et al., 2010 Westerdahl E et al., 2011), the same technique is also used in Australia and New Zealand after thoracic surgery (Reeve J et al., 2007)

however as compared with conventional breathing exercises there is scarcity in evidence of advantage of breathing exercises with positive pressure devices (Ingwersen UM et al.,1993; Richter Larsen K et al.,1995; Westerdahl E et al.,2003;

Borghi-Silva A et al.,2005).

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DISCUSSION (Cond)DISCUSSION (Cond) The Incentive spirometry device is rarely used in Sweden however it is

commonly advised in other countries to visualize and facilitate inspiration (Tucker B et al., 1996; Overend TJ et al., 2010), and it is extensively used in Karachi as compared to Inspiratory resistance positive expiratory pressure (IR-PEP), Inspiratory muscle training (IMT), and Continuous positive airway pressure (CPAP) which were seldom used.

There was no agreement on how frequently breathing exercises should be performed, but the physiotherapists’ most frequently proposal of hourly treatment in this study, was reliable with the existing literature on the suggested frequency (Westerdahl E et al.,2003; Westerdahl E et al., 2011; Muller AP et al., 2006 ; Yanez-Brage I et al., 2009 )

Literature also propose execution of a higher rate of deep breathing exercises in the initial phase after cardiac surgery. (Urella, C et al, .2011) and according to our survey most physiotherapist educate patients to perform 10 to 20 breaths which is also in accord with the survey performed in Sweden by Westerdahl E et al (Westerdahl E et al., 2011)

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DISCUSSION (Cond)DISCUSSION (Cond) As As 80% of physiotherapist provides preoperative information which

is in pact with literature. 92.5% patients agrees that they provide physiotherapy treatment in

the thoracic ICU on Postoperative day 1 80%s of physiotherapist provide instruction of breathing exercise on

a regular basis postoperative. and 82.5% recommend patients to continue performing breathing

exercises at home after discharge

These all parameters shows the awareness of chest physiotherapist working in Karachi about the treatment and techniques used after open heart surgery.

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DISCUSSION (Cond)DISCUSSION (Cond) Responses were received from physiotherapists at all hospitals to which the

survey was sent. The number of respondents was rather small in this survey, although representing six cardiac surgical units in Karachi.

However various strategies were employed to achieve the high response rate which includes a face to face interview with the respondent and clear instructions were given about the questionnaires.

no validated questionnaire was used, the inquiry was ample, and

assortment or reporting bias may have influenced the validity

Despite these limitations, it is believed that the results from this survey could reflect current clinical practice in Karachi and that the physiotherapist working in cardiothoracic unit in Karachi are aware of chest physiotherapy techniques used after open heart surgery.

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CONCLUSIONCONCLUSION

This study provides an overview of physiotherapy practice regarding chest physiotherapy and breathing exercises for patients undergoing open heart surgery in Karachi and the awareness of chest physiotherapy treatment and techniques among physiotherapist working in cardiothoracic units in Karachi.

Physiotherapy treatment is frequently given to cardiac patients preoperatively as well as post operatively in hospitals. According to this survey typically preoperative information is commonly provided by physiotherapist to open heart surgery patients and nearly all physiotherapists regularly advised postoperative breathing exercises.

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CONCLUSION (Cond)CONCLUSION (Cond) The most frequently used techniques were deep breathing without a device

and incentive spirometry .The breathing exercises were most frequently performed hourly. Recommended repetitions at each training session varied considerably and conflicting recommendations to continue breathing exercises after discharge was given.

Incentive spirometry is the device which is usually recommended by chest physiotherapist to cardiac patients after discharge at home. Deep breathing exercise , spirometry, coughing and huffing and chest expansion exercises are usually recommended type of breathing exercise after discharge .

Identification of high risk patients for post operative pulmonary complication is quite low and written guidelines or protocols for physiotherapy management of Intubated and extubated patients is also not frequently provided by chest physiotherapists

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RECOMMENDATIONRECOMMENDATION

As a result of the lack of consistent positive evidence, respiratory physiotherapy for patients undergoing CABG remains controversial. Clearly more work, expanding upon traditional respiratory physiotherapy treatment approaches, is needed in this area of research.

Identification of high risk patients for post operative pulmonary complication is relatively low i.e. only 35% , physiotherapist should enhance their back ground knowledge about the risk factors associated with post operative pulmonary complication , so they can easily identify patients at high risk and can treat them pre and post operatively more competently

Written guideline or protocols for physiotherapy management of Intubated and extubated patients is very rarely provided to patients, this issue should be looked in to and proper guide lines for Intubated as well as extubated patients should be provided timely so as to enhance the standard of patient care.

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RECOMMENDATION (Cond)RECOMMENDATION (Cond)

Literature has shown the effectiveness of PEP and blow bottle devices in reducing post operative pulmonary complication after cardiac surgery so these devices and techniques should be incorporated in cardiac patients’ chest physiotherapy management

Sternal support with device e.g. heart hugger is not used by chest physiotherapist according to the survey, it is recommended that such devices should be used when needed and steps should be made for easily availability of these devices in Pakistan as these will enhance the quality of patient care.

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RECOMMENDATION (Cond)RECOMMENDATION (Cond)

In hospitals, chest physiotherapy usually is routinely offered after cardiac surgery. It is additionally important to consider if the practice is uniform among all physiotherapists in each unit.

This study heaves further questions about the best means to treat cardiac patients and highlights the need for future research to optimize physiotherapy treatment following cardiac surgery. There are a variety of treatment option and opinions about the best way to treat cardiac patients, and this survey indicates the need for internationally approved guidelines to establish the optimal content and timing of post-operative breathing exercises

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