Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis.

OBJECTIVE: To evaluate whether preoperative inspiratory muscle training is effective in preventing postoperative pulmonary complications and reducing length of hospital stay in people undergoing cardiothoracic or upper abdominal surgery. DATA SOURCES: Medline, CINAHL, AMED, PsychINFO, Scopus, PEDro, and the Cochrane Library. REVIEW METHODS: A systematic review and meta analysis of randomized controlled trials (or quasi-randomized controlled trials) investigating a form of preoperative inspiratory muscle training, compared with sham or no inspiratory muscle training. Participants were adults (16 years and over) awaiting elective open cardiac, thoracic, or upper abdominal surgery. Methodological quality was assessed using the PEDro scale. RESULTS: Eight studies involving 295 participants were eligible for inclusion. The trained group had significantly higher maximal inspiratory pressure at the end of the preoperative training period (mean difference: 15 cm H2O, 95% confidence interval (CI): 9 to 21). This benefit was maintained through the early postoperative period, when lung function also recovered significantly more quickly in the trained group. Inspiratory muscle training also substantially reduced postoperative pulmonary complications (relative risk 0.48, 95% CI 0.26 to 0.89). Although not statistically significant, length of hospital stay also tended to favour the trained group. There were no statistically significant differences between the groups for the remaining outcomes. Participant satisfaction with inspiratory muscle training was high. CONCLUSION: Preoperative inspiratory muscle training significantly improves respiratory (muscle) function in the early postoperative period, halving the risk of pulmonary complications. The training does not increase length of stay, but more data are required to confirm whether it reduces length of stay.

Future of specialised roles in allied health practice: who is responsible?

Allied health professions have developed specialised advanced and extended scope roles over the past decade, for the benefit of patient outcomes, allied health professionals' satisfaction and to meet labour and workforce demands. There is an essential need for formalised, widely recognised training to support these roles, and significant challenges to the delivery of such training exist. Many of these roles function in the absence of specifically defined standards of clinical practice and it is unclear where the responsibility for training provision lies. In a case example ofphysiotherapy practice in the intensive care unit, clinical placements and independence of practice are not core components of undergraduate physiotherapy degrees. Universities face barriers to the delivery of postgraduate specialised training and, although hospital physiotherapy departments are ideally placed, resources for training are lacking and education is not traditionally considered part of healthcare service providers' core business. Substantial variability in training, and its evaluation, leads to variability in practice and may affect patient outcomes. Allied health professionals working in specialised roles should develop specific clinical standards ofpractice, restructure models ofhealth care delivery to facilitate training, continue to develop the evidence base for their roles and target and evaluate training efficacy to achieve independent practice in a cost-effective manner. Healthcare providers must work with universities, the vocational training sector and government to optimise the ability of allied health to influence decision making and care outcomes for patients.

Instillation of normal saline before suctioning reduces the incidence of pneumonia in intubated and ventilated adults.

QUESTION: Does the instillation of normal saline before suctioning reduce the incidence of ventilator-associated pneumonia in intubated and ventilated adults? DESIGN: Randomised, controlled trial with blinded outcome assessment. SETTING: The medical/surgical intensive care unit of a tertiary oncology hospital in Brazil. PARTICIPANTS: Adults expected to require at least 72 hours of mechanical ventilation via an endotracheal or tracheostomy tube. Previous ventilation within the past month and contraindications to bronchoscopy were exclusion criteria. Randomisation of 262 participants allotted 130 to the intervention group and 132 to a control group. INTERVENTIONS: Closed tracheal suction systems with heat and moisture exchangers were used with both groups and were changed regularly. All patients were nursed with backrest elevation to 45 degrees. medical or nursing staff, who were blinded to group allocations, requested suctioning when any of the following occurred: visible or audible secretions, ventilator-patient asynchrony, and increased peak inspiratory pressures or decreased tidal volumes attributed to secretions. Respiratory therapists performed the suctioning according to a standardised procedure that included preoxygenation. The therapists instilled 8 mL of normal saline prior to suctioning in the intervention group only. OUTCOME MEASURES: The primary outcome was the incidence of ventilator-associated pneumonia (VAP). If VAP was suspected because of radiographic evidence plus either fever, leukocytosis, or purulent secretions, a bronchoscopy with standardised lavage was performed. VAP was considered confirmed if the bacterial density of the lavage fluid exceeded 1000 colony-forming units/mL. Secondary outcome measures included time to VAP, duration of mechanical ventilation, length of stay and mortality in the intensive care unit, unscheduled ventilation circuitry changes due to secretions, and number of suctions per day. RESULTS: all participants completed the study. Significantly fewer participants in the saline group developed VAP (14/130) than in the control group (31/132), relative risk reduction 0.54 (95% CI 0.18 to 0.74). This indicates that one patient will avoid developing VAP for every 8 patients in which saline instillation is used. Significant benefits of saline instillation were also seen in the incidence of VAP (9 vs 21 per 1000 days of mechanical ventilation, p = 0.01) and in the time to first VAP (p = 0.02). The groups did not differ significantly on the remaining secondary outcomes. CONCLUSION: Instillation of normal saline before tracheal suctioning decreases the incidence of VAP in mechanically ventilated adults.

Minimum standards of clinical practice for physiotherapists working in critical care settings in Australia and New Zealand: A modified Delphi technique.

OBJECTIVE: Achieving competency in critical care in entry-level physiotherapy courses across Australia and New Zealand is not essential, and accredited training for qualified physiotherapists working in critical care units is lacking. As a result, practice standards and training may vary. The objective was to establish consensus-based minimum clinical practice standards for physiotherapists working in critical care settings in Australia and New Zealand. DESIGN: A modified Delphi technique, which consisted of three rounds of questionnaires, was used to obtain consensus on items. SETTING: Australian and New Zealand critical care settings. PARTICIPANTS: A panel (n = 61) was invited from a pool of eligible physiotherapists throughout Australia and New Zealand (n = 93). Eligibility criteria were defined a-priori on the basis of possession of expertise and experience in the practice and teaching of critical care physiotherapy clinical skills. MAIN OUTCOME MEASURE: Questionnaires were disseminated electronically (either via email, or SurveyMonkey®). Items were designated by participants as being 'Essential/Unsure/Not Essential'. Consensus for inclusion was achieved when items were ranked 'Essential' by more than 70% of participants. RESULTS: Fifty physiotherapists consented and participated in the initial Delphi round, of whom 45 (90%) completed all rounds. Consensus was reached on 199 (89%) items. The panel agreed that 132 (58%) items were 'Essential' items for inclusion in the final framework. CONCLUSIONS: This is the first study to develop a consensus framework of minimum standards of practice for physiotherapists working in critical care. The clinical utility of this framework now requires assessment.

Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing open cardiothoracic or upper abdominal surgery: protocol for a systematic review.

BACKGROUND: In patients undergoing open cardiothoracic and upper abdominal surgery, postoperative pulmonary complications remain an important cause of postoperative morbidity and mortality, impacting upon hospital length of stay and health care resources. Adequate preoperative respiratory muscle strength may help protect against the development of postoperative pulmonary complications and therefore preoperative inspiratory muscle training has been suggested to be of potential value in improving postoperative outcomes. METHODS/DESIGN: A systematic search of electronic databases will be undertaken to identify randomized trials of preoperative inspiratory muscle training in patients undergoing elective open cardiothoracic and upper abdominal surgery. From these trials, we will extract available data for a list of predefined outcomes, including postoperative pulmonary complications, hospital length of stay and respiratory muscle strength. We will meta-analyze comparable results where possible, and report a summary of the available pool of evidence. DISCUSSION: This review will provide the most comprehensive answer available to the question of whether preoperative inspiratory muscle training is clinically useful in improving postoperative outcomes in patients undergoing cardiothoracic and upper abdominal surgery. It will help inform clinicians working in the surgical arena of the likely effectiveness of instituting preoperative inspiratory muscle training programs to improve postoperative outcomes.

Uptake of pulmonary rehabilitation in New Zealand by people with chronic obstructive pulmonary disease in 2009.

AIMS: To estimate of uptake of pulmonary rehabilitation (PR) by people with chronic obstructive pulmonary disease (COPD) in New Zealand in 2009. METHOD: A postal survey sent to all District Health Boards (DHBs), Primary Health Organisations (PHOs), and other non-government organisations (NGOs) identified as providers of PR. The survey requested information on the characteristics of PR programmes, estimates of the total number of people with COPD who were offered PR, entered PR, and completed PR in 2009. RESULTS: In 2009 PR was provided in 19 of 21 DHB regions by 23 organisations (16 DHBs, five PHOs, one DHB/PHO partnership, and 1 NGO). Twenty-one of these 23 organisations (91%) responded to the survey. In total, 2569 people with COPD were offered PR, 1786 entered PR, and 1378 completed a PR programme in 2009. CONCLUSIONS: There is a marked shortfall between the national levels of provision of PR and the prevalence of COPD, with less than 1% of people with COPD participating in PR each year in New Zealand. Incentives, leadership and coordination of services are required at a national level to increase the uptake of PR.

Inspiratory muscle training to facilitate weaning from mechanical ventilation: protocol for a systematic review.

BACKGROUND: In intensive care, weaning is the term used for the process of withdrawal of mechanical ventilation to enable spontaneous breathing to be re-established. Inspiratory muscle weakness and deconditioning are common in patients receiving mechanical ventilation, especially that of prolonged duration. Inspiratory muscle training could limit or reverse these unhelpful sequelae and facilitate more rapid and successful weaning. METHODS: This review will involve systematic searching of five electronic databases to allow the identification of randomised trials of inspiratory muscle training in intubated and ventilated patients. From these trials, we will extract available data for a list of pre-defined outcomes, including maximal inspiratory pressure, the duration of the weaning period, and hospital length of stay. We will also meta-analyse comparable results where possible, and report a summary of the available pool of evidence. DISCUSSION: The data generated by this review will be the most comprehensive answer available to the question of whether inspiratory muscle training is clinically useful in intensive care. As well as informing clinicians in the intensive care setting, it will also inform healthcare managers deciding whether health professionals with skills in respiratory therapy should be made available to provide this sort of intervention. Through the publication of this protocol, readers will ultimately be able to assess whether the review was conducted according to a pre-defined plan. Researchers will be aware that the review is underway, thereby avoid duplication, and be able to use it as a basis for planning similar reviews.

Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial.

OBJECTIVE: This study investigates whether targeted postoperative respiratory physiotherapy decreased the incidence of postoperative pulmonary complications and length of stay for patients undergoing elective pulmonary resection via open thoracotomy. METHODS: Seventy-six patients participated in a prospective, single-blind, parallel-group, randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. Treatment group participants received daily respiratory physiotherapy interventions until discharge. Control group participants received standard medical/nursing care involving a clinical pathway. The presence of postoperative pulmonary complications was assessed on a daily basis during hospitalisation using a standardised diagnostic tool. Length of stay was recorded. RESULTS: Postoperative pulmonary complications developed in two participants (4.8%) in the treatment group and in one participant (2.9%) in the control group; the difference (treatment minus control) was 1.8% (95% confidence interval (CI) -10.6% to 13.1%) (p=1.00). No significant difference was found between groups for length of stay (treatment group, median 6.0 days; control group 6.0 days) (p=0.87). A preoperative forced expiratory volume in 1s of 1.5l or less (p=0.005) and a history of chronic obstructive pulmonary disease (p=0.008) were associated with a greater number of criteria for a postoperative pulmonary complication being met. CONCLUSIONS: In this patient population, given the low incidence of postoperative pulmonary complications, targeted respiratory physiotherapy may not be required in addition to standard care involving a clinical pathway following pulmonary resection via open thoracotomy. These results should be extrapolated with caution to those patients undergoing pulmonary resection with poor preoperative lung function.

Does physiotherapy reduce the incidence of postoperative complications in patients following pulmonary resection via thoracotomy? a protocol for a randomised controlled trial.

BACKGROUND: Postoperative pulmonary and shoulder complications are important causes of postoperative morbidity following thoracotomy. While physiotherapy aims to prevent or minimise these complications, currently there are no randomised controlled trials to support or refute effectiveness of physiotherapy in this setting. METHODS/DESIGN: This single blind randomised controlled trial aims to recruit 184 patients following lung resection via open thoracotomy. All subjects will receive a preoperative physiotherapy information booklet and following surgery will be randomly allocated to a Treatment Group receiving postoperative physiotherapy or a Control Group receiving standard care nursing and medical interventions but no physiotherapy. The Treatment Group will receive a standardised daily physiotherapy programme to prevent respiratory and musculoskeletal complications. On discharge Treatment Group subjects will receive an exercise programme and exercise diary to complete. The primary outcome measure is the incidence of postoperative pulmonary complications, which will be determined on a daily basis whilst the patient is in hospital by a blinded assessor. Secondary outcome measures are the length of postoperative hospital stay, severity of pain, shoulder function as measured by the self-reported shoulder pain and disability index, and quality of life measured by the Medical Outcomes Study Short Form 36 v2 New Zealand standard version. Pain, shoulder function and quality of life will be measured at baseline, on discharge from hospital, one month and three months postoperatively. Additionally a subgroup of subjects will have measurement of shoulder range of movement and muscle strength by a blinded assessor. DISCUSSION: Results from this study will contribute to the increasing volume of evidence regarding the effectiveness of physiotherapy following major surgery and will guide physiotherapists in their interventions for patients following thoracotomy. TRIAL REGISTRATION: The study protocol is registered with the Australian and New Zealand Clinical Trials registry (ANZCTRN12605000201673).