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Current practice for chest physiotherapy. First Joint Scandinavian Conference in Cardiothoracic Surgery Stockholm 2009 PhD, RPT Elisabeth Westerdahl. Cardiac surgery Influence on respiratory function. A restrictive ventilatory defect Retained airway secretions and ineffective coughing

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current practice for chest physiotherapy

Current practice for chest physiotherapy

First Joint Scandinavian Conference in Cardiothoracic Surgery

Stockholm 2009

PhD, RPT Elisabeth Westerdahl

cardiac surgery influence on respiratory function
Cardiac surgery Influence on respiratory function
  • A restrictive ventilatory defect
  • Retained airway secretions and ineffective coughing
  • Gas exchange abnormalities, shunt
  • Adult respiratory distress syndrome (ARDS)
forshag 92

Because decreased lung volumes and atelectasis leads to hypoxemia and may predispose to the development of pneumonia, a number of postoperative interventions have been designed to prevent or overcome it. The standard therapy is chest physiotherapy.

Forshag-92

goals of chest physiotherapy
Goals of chest physiotherapy
  • Reduse airway obstruction
  • Prevent the accumulation of secretions
  • Improve the mobilization of secretions
  • Improve the distribution of ventilation
  • Enhance gas exchange
  • Promote more efficient breathing patterns
  • Reduce the work of breathing
  • Improve cardiopulmonary exercise tolerance

E Dean/J Pryor

chest physiotherapy treatment hierarchy e dean kanada
Chest physiotherapyTreatment hierarchy(E Dean, Kanada)
  • 1 Mobilisation & activity
  • 2 Positioning
  • 3 Breathing control
  • 4 Hough maneouvres
  • 5 Relax and energyconsumption control
  • 6 Movements/ROM exercises
  • 7 Postural drainage
  • 8 Manual techniques
  • 9 Suctioning
prophylactic respiratory physiotherapy after cardiac surgery is widely used

Prophylactic respiratory physiotherapy after cardiac surgery is widely used

Evidence is lacking

on benefit from any method.

It is likely that there are adverse effects and costs only!

Systematic review by Pasquina BMJ 2003;327(7428):1379

research idea

Research idea

WCPT Vancouver, Canada den 2-6 juni 2007

Professor Tom Overend, The University of Western Ontario, School of PhysicalTherapy in Ontario

Physiotherapist, PhD, Beatrice Tucker

School of Physiotherapy, Perth, Australia

physiotherapy management of patients undergoing cardiac surgery in sweden a questionnaire survey

Physiotherapy management of patients undergoing cardiac surgery in Sweden- a questionnaire survey

Elisabeth Westerdahl, Phd, reg Physiotherapist Margareta Möller, professor, head of the clinic, Centre for Health Care Sciences, Örebro County Council

purpose

Purpose

To review the usual or routine physiotherapy management of the uncomplicated postoperative open-heart surgery patient in Sweden.

slide15

Design Postal questionnaire survey to all Physiotherapists working at Departments of Thoracic surgery in Sweden december 2007.

departments of thoracic surgery
Departments of Thoracic surgery
  • Sahlgrenska universitetssjukhuset
  • Karolinska universitetssjukhuset
  • Blekingesjukhuset
  • Universitetssjukhuset i Linköping
  • Universitetssjukhuset i Lund
  • Norrlands Universitetssjukhus
  • Akademiska sjukhuset
  • Universitetssjukhuset Örebro
slide17

We would like to investigate

Routine postoperative physiotherapy management of patients undergoing uncomplicated open-heart surgery.

Not treatment of patients who develop neurological symptoms, circulatory instability, prolonged intubation, or other conditions requiring individualised programmes.

slide18

This survey only applies to physiotherapy treatment of adult patients who have undergone cardiac surgery (coronary artery bypass graft surgery (CABG), mitral, aortic or tricuspid valve surgery, or a combination.

physiotherapist employment at the thoracic surgery departments in dec 2007

Physiotherapist employment at the Thoracic surgery departments in dec 2007

GÖTEBORG 5 full time employments

KARLSKRONA 1  

LINKÖPING 1,65

LUND 4,45

STOCKHOLM 4,15

UMEÅ 5,05

UPPSALA 2,30

ÖREBRO2

sample

Sample

In total 36 Physiotherapists identified

(3 not included because of parental leave or working with other patients)

response rate

Response rate

Of the 33 questionnaires

29 were returned

(response rate 88%)

slide22

Which of the following departments do you work in at the moment? - Thoracic surgery ward n= 24 - Intermediate ward (IMA) n= 15- Intensive care unit n=20

working experience

Working experience

Working as PT

10 ± 7 year (1 – 33 year)

Working with Thoracic surgery patients

6 ± 4 year (1-16 year)

have you completed any specific courses in the cardiopulmonary area
Have you completed any specific courses in the cardiopulmonary area?
  • No 28%
  • Yes 72%
slide25

Are any written physiotherapy guidelines or protocol for physiotherapy management of the cardiac surgery patients at your Thoracic Surgery department?No n=6Yes n=21Don´t know n=2

slide26

If you have guidelines or protocol, do you usually follow them when you treat cardiac surgery patients?

Yes, always n=10

Yes, most of the time n=11

Yes, sometimes -

No -

Don’t know n=8

slide27
Does the physiotherapist automatically meet all patients who have undergone cardiac surgery or only certain patients?

Meets all 90%

Only meets certain patients 10%

slide28

Do all patients undergoing open-heart surgery (non-emergency) at your Thoracic Surgery department usually receive preoperative information from a physiotherapist?

  • No n=3
  • Yes n=26
how do the patients usually receive the preoperative information
How do the patients usually receive the preoperative information?
  • Individually 21%
  • In group 76%
  • Missing value 3%
slide30

MobilizationWhich of the following treatments you usuallyprovide to the patient on the first postoperative days after surgery?

POD 1 POD 2 POD 3

Sitting on bed or in chair 28 15 14

Standing 27 16 14

Walking in the room 8 23 15

Walking in corridor 8 19 27

stair climbing

Stair climbing

Perform 69%

Don´t perform 31%

thoracic upper extremities rom exercises

Thoracic/upper extremities ROM exercises

Postop day I II III IV

Unilateral 1 5 10 9

Bilateral 3 20 22 19

slide33

Which sternal precautions are ordered for the healing period during the first postoperative weeks at your department?

Patients are allowed to use:

their arms to push up from lying to sitting 83%

their arms to push up from sitting to standing 3%

stomach muscles to raise from lying to sitting 59%

arms and shoulders, full active movement 93%

arms and shoulders with 1-2 kg weights 52%

rollator (rolling walker) 97%

walker 100%

Crutches 17%

slide34

Does the physiotherapist provide any group training for the patients admitted for care at your Thoracic Surgery department?

No 38%

Yes 62%

if so what kind of breathing exercises are patients instructed to perform check as many as apply

If so, what kind of breathing exercises are patients instructed to perform? (Check as many as apply)

Routinely If needed Never

Deep breathing exercises 18 8 1

Diaphragmatic breathing 11 11 3

Pursed lip breathing 6 18 1  

Sustained (continual) maximal inspiration 3 1 21 

Incentive spirometry (Voldyne, Triflo etc)   0 5 21

PEP device breathing 24 5 0

IR-PEP (inspiratory resistance-PEP)…cm H2O   7 9 12

IMT (inspiratory muscle training)…….cm H2O 0 6 20  

CPAP………….cm H2O 0 26 3  

physiotherapy in the icu n 20
Physiotherapy in the ICU (n=20)
  • Do you perform manual hyperinflation/bagging?
  • No 90%
  • Yes 10%
  • Do you perform suction of airways via nose, mouth or tracheostomy?
  • No 65%
  • Yes 35%
  • Do you participate actively in weaning off respirator?
  • No 75%
  • Yes 25%
physiotherapy in the icu n 2037
Physiotherapy in the ICU (n=20)
  • Do patients who have undergone cardiac surgery usually receive physiotherapy in the Thoracic ICU on postoperative day 1?
  • No 0%
  • Only certain patients 15%
  • Yes, all patients 85%
slide38

When is physiotherapy given to cardiac surgery patients at your Thoracic Surgery department? (postoperative day 1)

Routinely If needed Never

Evenings 100%

Saturdays 59% 41%

Sundays 31% 14% 55%

Holidays 48% 52%

slide39

When is physiotherapy given to cardiac surgery patients at your Thoracic Surgery department? (postoperative day 2)

Routinely If needed Never

Evenings 100%

Saturdays 17% 83%

Sundays 48% 48% 56%

Holidays 10% 90%

slide40

Which of the following days do you or your colleagues usually treat patients and on average how many sessions does the patient receive per day? (ordinary routines Monday to Friday)

Treatment on: Routinely If needed

Postoperative day 1 1-3 times 90% 3%

Postoperative day 2 1-2 times 93% 3%

Postoperative day 3 1-2 times 69% 28%

Postoperative day 4 1 times 28% 69%

Postoperative day 5 1 times 28% 69%

do you consider physiotherapy necessary after cardiac surgery
Do you consider physiotherapy necessary after cardiac surgery?
  • No n=0
  • Yes, to some patients n=3
  • Yes, to all patients n=26
what do you consider the main purpose of physiotherapy in connection with cardiac surgery
What do you consider the main purpose of physiotherapy in connection with cardiac surgery?
  • Prevent postoperative complications
  • Start rehabilitation
  • Prevent movement fear avoidance
  • Make patients aware of the importance of physical activity
  • Prevent problems related to the sternum
  • Help the patient start breathing exercises and mobilisation so they can manage by themselves
  • Second prevention/ motivate physical activity
  • Optimizing the lung function
  • Avoid cardiorespiratory complications (DVT, pneumonia, atelectasis, secretion problems)
  • Empower breathing and circulation
  • Prevent and treat pulmonary problems
is there scientific evidence that physiotherapy is necessary after cardiac surgery
Is there scientific evidence that physiotherapy is necessary after cardiac surgery?
  • No n=1
  • Yes n=25
  • Don´t know n=3
slide44

Do you consider the physiotherapy treatment offered at the Thoracic Surgery Department where you work as optimal?

No n=9

Yes n=16

Don´t know n=4