Critically appraised paper: Preoperative physiotherapy education halved postoperative pulmonary complications in patients after upper abdominal surgery [synopsis]

摘要

Summary of: Boden I, Skinner EH, Browning L, Reeve J, Anderson L, Hill C, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ. 2018;360:j5916.Question: Does preoperative physiotherapy reduce postoperative pulmonary complications in adults after elective, major, open upper abdominal surgery? Design: Randomised, controlled trial with concealed allocation and blinding of participants and assessors. Setting: Three tertiary public hospitals in Australia and New Zealand. Participants: Adults (≥ 18?years) within 6?weeks of elective upper abdominal surgery requiring general anaesthesia, a minimum overnight hospital stay, an incision?≥?5?cm above the umbilicus, and attendance at an outpatient preadmission clinic. Key exclusion criteria were: current hospital inpatients, organ transplant recipients, abdominal hernia repairs, being unable to walk?≥?1?minute, or unable to attend the preoperative physiotherapy session. Randomisation of 441 participants allocated 222 to the intervention group and 219 to the control group. Interventions: Both groups attended the preadmission clinic and received preoperative physiotherapy comprising a standardised assessment and a booklet containing information about postoperative pulmonary complications, potential prevention with early ambulation and breathing exercises, and a prescription for deep breathing exercises starting immediately after surgery. In addition, the intervention group received a 30-minute education and breathing exercise coaching session with a physiotherapist immediately after the preoperative session. This included: details on risk of postoperative pulmonary complications, individualised risk assessment, education about the impact of surgery, instructions on breathing exercises, and memory cues. Outcome measures: The primary outcome was presence of postoperative pulmonary complications within 14 postoperative days assessed daily using the Melbourne Group Scale. Secondary outcomes were: hospital-acquired pneumonia, length of hospital stay, use of intensive care services, hospital costs, health-related quality of life (at 6?weeks), and all-cause mortality (at 12?months). Results: A total of 432 participants completed the trial. The incidence of postoperative pulmonary complications was halved (adjusted hazard ratio 0.48, 95% CI 0.30 to 0.75) in the intervention group compared with the control group, with an absolute risk reduction of 15% (95% CI 7 to 22) and a number needed to treat of seven (95% CI 5 to 14). No significant differences in other secondary outcomes were detected. Conclusion: In adults undergoing upper abdominal surgery, adding a single preoperative physiotherapy session, which comprised education and breathing exercise coaching, to a standardised assessment and delivery of information on postoperative physiotherapy via a booklet halved the incidence of postoperative pulmonary complications.Provenance: Invited. Not peer reviewed.