Yu TWDYu TWD11, Cheung W, Cheung W11, , Yung Yung WMMWMM22, , Lam MYMLam MYM11, Chan MPM, Chan MPM11, , Fung Fung MCIMCI11

11Physiotherapy Department, Kowloon HospitalPhysiotherapy Department, Kowloon Hospital22Respiratory Medical Department, Kowloon HospitalRespiratory Medical Department, Kowloon Hospital

Preoperative Physiotherapy Preoperative Physiotherapy Intervention Program (PPIP) Intervention Program (PPIP)

for reducing for reducing Pulmonary Complications Pulmonary Complications

after Thoracic Surgeryafter Thoracic Surgery

IntroductionIntroduction

Pulmonary complications are the major contributors of mortality and morbidity after thoracic surgery.

The incidence of postoperative pulmonary complications varies from 8% to 39% in previous studies.

(Nagasaki F et al 1982, Busch E et al. 1994, Deslauriers J et al 1994)

Preoperative chest physiotherapy is considered to be beneficial but study in this area is limited.

(Stein N & Cassara EL 1970, Castillo R & Haas A 1985, Ingwersen UM 1993)

The Preoperative PhysiotherapyThe Preoperative PhysiotherapyIntervention Programme (PPIP)Intervention Programme (PPIP)

Day-patient base program launched since April 2000

Multidisciplinary service involving chest physicians of Respiratory Medical Department & respiratory physiotherapists of KH

9 sessions, 3 times per week for 3 weeks

1.5 hours for each session

Program Program CContentsontents

Chest and ET assessments

Patient education

Cardio-pulmonary training

Bronchial hygiene toileting

Breathing exercises

Effective coughing techniques

Patient Patient SSelection election CCriteriariteria

Marginal lung function test (Preoperative FEV1< 80% predicted)

Current smokers or recent smokers who have quitted smoking < 8 weeks

Concomitant of other lung diseases e.g COPD, bronchiectasis

Reduction in exercise tolerance

Patient’s motivation

Purposes of the Purposes of the SStudytudy

To assess the effectiveness of the PPIP in reducing

a. 30-day mortality rate

b. Length of stay in the acute setting

c. The incidence rate of the post-op pulmonary complications

Postoperative Pulmonary ComplicationsPostoperative Pulmonary Complications

Pneumonia

Lobar atelectasis requiring bronchoscopic intervention

Hypercapnia (PaCO2 > 50mmHg)

Respiratory failure requiring invasive or non-invasive mechanical ventilation

Pulmonary compromise required post-op ICU care

MethodMethod

Intervention group (n=65)( Attended the PPIP before thoracic surgery )

Control group (n=94)(Without PPIP before thoracic

surgery)

Matching with intervention group based on gender, age, past medical history, lung function, disease nature and types of surgery received

Excluded those with exploratorythoracotomy, VATS, or operation done in other hospitals

Subjects (N=159)

Retrospective longitudinal study (April 2002 to Jan 2006)

Statistical analysisStatistical analysis

Descriptive analysis for demographic data and 30-day mortality rate

Independent t-test to compare the LOS of both groups

McNemar test for categorical data (the incidence rate of the post-op pulmonary complications)

p < 0.05 considered significant result

Results Results –– Baseline characteristicsBaseline characteristics

0.4513.4713.01PO2

Nature of the lung diseases

0.3315%12.5%Benign

0.117.407.42pH

0.345.065.42PaCO2

0.4985%87.5%Malignancy

ABG

0.3281% ( ± 13%)80% (± 16%)%FEV1

0.6965.0 (± 11.7)67.6 (± 9.1)Age

SignificanceControl Groupn=94

(68 male, 26 female)

Intervention Groupn=65

(45 male, 20 female)

Intervention Group

10% 0%

63%

3%

24%

Types of Types of SSurgeryurgery

Control Group

13%0%

64%

4%

19%

Wedge resection

Segmenectomy resection

Single lobectomy

Double lobectomy

Pneumonectomy

3030--day mortality rate and day mortality rate and LOS in acute settingLOS in acute setting

0

9

10.62

12.59

0

2

4

6

8

10

12

14

30 days mortality rate Length of stay

Intervention GroupControl Group

(9.5%)

Incidence of Incidence of Postoperative Postoperative CComplicationsomplications

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Inci

denc

e ra

te o

f P

ost-

op

com

plic

atio

ns

Pneumonia Atelectasis Hypercapnia

(PCO2>50mmHg)

Respiratory failure Post-op ICU care

Intervention Group

Control Group

Incidence rate of Incidence rate of Postoperative Postoperative CComplicationsomplications

p=0.04319.5%13.3%Post-op ICU care

p=0.028Chi-square= 4.86

28.7%14.1%Overall incidence rate

p=0.01217.1%0%Respiratory failure

p=0.060%6.7%Hypercapnia (PCO2>50mmHg)

p=0.01529.3%6.6%Atelectasis

p=0.03231.7%13.3%Pneumonia

SignificanceControl Group

Intervention Group

Types of complications

DiscussionDiscussionStrong patient education component to promote understanding and adherence to the peri-operative care and rehabilitation for better psychological preparation, empowerment and compliance of the program.

Encourage / motivate patients’ active participation with vigorous home bronchial hygiene toileting, breathing exercises and effective coughing techniques.

Prophylactic intensive chest physiotherapy reduce the post-op pulmonary complications.

(Stein N & Cassara EL 1970, C.G. Morran et al 1983, M. Fagevil Olsen et al 1997))

Post-resection complication rate was inversely proportional to exercise capacity.

(Bolton JW et al 1987, Olsen GN et al 1991, Alessandro B et al 2002)

Emphasis on intensive cardio-pulmonary training. Aims at 60% VO2max in each training session or home therapy programme.

An average improvement in exercise capacity by 18.5% and 14.2% was observed in VO2max and 6MWT respectively.

DiscussionDiscussion

Significance of the studySignificance of the study

The PPIP can minimize the the expenses in tertiary care settings by reducing postoperative pulmonary complications and mortality rate.

The PPIP has a role of encouraging smoking cessation with 66.7% smoking quit rate after the programme.

Limitations of the studyLimitations of the study

The current study was not a RCT design.

Small sample size in the intervention group as difficult to recruit “motivate” patients and no recruitment during SARS period.

ConclusionConclusion

Day-patient Preoperative Physiotherapy Intervention Program (PPIP) is effective in improving patient’s outcomes

Further study with larger sample size is highly recommended

Thank YouThank You