Current practice for chest physiotherapy

First Joint Scandinavian Conference in Cardiothoracic Surgery

Stockholm 2009

PhD, RPT Elisabeth Westerdahl

Physiotherapy management of the Open-heart surgery patient in Sweden

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)

Pulmonary function the first postoperative days after open-

heart surgery

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

• 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 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

We know that our treatment work – or do we?

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

WCPT Vancouver, Canada den 2-6 juni 2007WCPT Vancouver, Canada den 2-6 juni 2007

Professor Tom Overend, The University of Western Professor Tom Overend, The University of Western Ontario, School of Physical Therapy in OntarioOntario, School of Physical Therapy in Ontario

Physiotherapist, PhD, Beatrice TuckerPhysiotherapist, PhD, Beatrice Tucker

School of Physiotherapy, Perth, AustraliaSchool of Physiotherapy, Perth, Australia

What scientific documentation is needed to change ordinary

clinical practice?

Physiotherapy management of patients Physiotherapy management of patients undergoing cardiac surgery in Swedenundergoing cardiac surgery in Sweden

- a questionnaire survey- a questionnaire survey

Elisabeth Westerdahl, Phd, reg Physiotherapist Elisabeth Westerdahl, Phd, reg Physiotherapist Margareta MMargareta Mööller, professor, head of the clinic, ller, professor, head of the clinic, Centre for Health Care Sciences, Centre for Health Care Sciences, ÖÖrebro County Councilrebro County Council

Purpose

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

Design  

Postal questionnaire survey to all Physiotherapists working at

Departments of Thoracic surgery in Sweden december 2007.

Departments of Thoracic surgery

• Sahlgrenska universitetssjukhuset• Karolinska universitetssjukhuset• Blekingesjukhuset• Universitetssjukhuset i Linköping• Universitetssjukhuset i Lund• Norrlands Universitetssjukhus• Akademiska sjukhuset• Universitetssjukhuset Örebro

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.

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 2007GÖTEBORG 5 full time employments  KARLSKRONA 1  

LINKÖPING 1,65  

LUND 4,45  

STOCKHOLM 4,15  

UMEÅ 5,05  

UPPSALA 2,30 

ÖREBRO 2

Sample

In total 36 Physiotherapists identified(3 not included because of parental leave or

working with other patients)

Response rate

Of the 33 questionnaires

29 were returned

(response rate 88%)

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 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?

• No 28%

• Yes 72%

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

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

Does the physiotherapist automatically meet all patients who have undergone

cardiac surgery or only certain patients?

   Meets all 90%

Only meets certain patients 10%

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?

• Individually 21%

• In group 76%

• Missing value 3%

MobilizationWhich of the following treatments you usually

provide 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

Perform 69%

Don´t perform 31%

Thoracic/upper extremities ROM exercises

Postop day I II III IV

Unilateral 1 5 10 9

Bilateral 3 20 22 19

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%

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)

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)

• 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=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%

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%

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%

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?

• 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?• 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?

• No n=1

• Yes n=25

• Don´t know n=3

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

Thanks to all Physiotherapists for answering all questions and Thankyou for your attention!