L i t e r a t u r e R e v i e w C h e s t P h y s i o t h e r a p y a f t e r C a r d i a c S u r g e r y - t h e m issin g l i n k A B S T R A C T : The ph ysiotherapy literature pertain in g to the treatm ent o f cardiac surgery p a tien ts in the p e r io d 1977 to 1995 w as reviewed. The p u rp o se o f this review w as to analyse the results o f the research and d ra w up guidelines f o r the ph ysioth erapy treatm ent o f cardiac surgery patien ts. This review revealed that there is no indication f o r routine chest p h y sio ­ therapy in the uncom plicated cardiac surgery patien t. K E Y W O R D S : C A R D IA C SU R G E RY, C H E S T P H Y S IO T H E R A P Y , B R E A T H IN G E X E R C IS E S S DE CHARMOY, CJ EALES University of the Witwatersrand INTRODUCTION O pen heart surgery and the use o f car­ diopulm onary bypass have long been re c o g n ise d as c re atin g a n u m b e r o f severe p u lm onary ab norm alities post- operatively. U ntil recently, post-opera- tive chest physiotherapy w as thought to play a role in reducing these abnorm ali­ ties and returning pulm onary function to norm al. The recent research in this area suggests that the routine use o f post­ o p era tiv e c h e st p h y sio th erap y in the u ncom plicated patient is o f no benefit. T his literature review was conducted to establish the trends in physiotherapy m anagem ent o f the post-operative car­ diac patient o ver the last tw enty years. C onclusions w ill be draw n from the liter­ ature and recom m endations for practice m ade according to the findings. LITERATURE REVIEW CHEST PHYSIOTHERAPY O n return from theatre cardiac surgery patients typically spend the firs t 12 to 18 hours intubated and ventilated in the intensive care unit. Eales et a l (1995) conducted a study to determ ine if routine physiotherapy fo r the intubated patient was indicated. T hey divided their patient p o p u la tio n in to th ree g ro u p s. T he patients in all three groups were pre-oxy- genated and suctioned. In addition the patients in G roup Two w ere m anually h yperinflated six tim es and then suc­ tioned. T he patients in G roup T hree re c e iv e d six m an u al h y p erin fla tio n s to g e th e r w ith ch e st w all v ib ratio n s, a d m in iste re d d u rin g the ex p ira to ry phase, plus suctioning. T hey found no sig n ifican t differences in co m pliance, partial pressure o f oxygen in arterial b lood ( P a 0 2) and the partial pressure o f oxygen in arterial blood to the fraction o f in sp ire d o x y g en ( P a 0 2/ F I 0 2 ratio ), betw een any o f the three groups after treatm ent. T hey concluded that a single physiotherapy treatm ent to the intubated post-operative cardiac patient w as o f no significant benefit. In 1977 Varciu and Varciu studied a group of patients undergoing open heart surgery w hom they divided into a high risk and low risk group. P atients consid­ ered at h igh risk for developing post­ o perative pulm onary com plications had one o r m ore o f the follow ing features: • sm okers o r those w ho had ceased to sm oke in the previous six w eeks an FV C less than 80% and a F E V ,/F V C less than 75 • older than 60 years o f age E ach o f the above tw o groups w as then further divided into an experim ental and a control group. The experim ental group w as seen by a physiotherapist tw ice daily d uring w hich tim e the patients w ere treated w ith deep breathing exercises in various positions and w ere encouraged to cough. In addition they also received the ro u tin e w ard reg im e. T h is in c lu d ed incentive spirom etry tw o hourly, nebuli- satio n fo u r h o urly and turning, deep breathing and coughing every h o u r as adm inistered by the nursing staff. The control group p articipated in the w ard regim e only. Varciu and Varciu (1977) concluded that the use o f breathing exercises in high risk patients reduces the incidence o f post-operative pulm onary com plications, but is o f no b enefit in the low risk group. T he follow ing factors should be borne in m ind w hen interpreting this research. It is not stipulated in the m ethodology w hether the control groups received any input from the physiotherapist either pre- operatively o r post-operatively. In this study percutaneous catheters w ere used to assist in lung clearance in patients w ith excessive secretions w ho w ere unable to cough effectively. In the experim ental high risk group, none o f the patients re q u ire d the use o f a p erc u tan e o u s catheter, in contrast 6 out o f 13 patients in the control h igh risk group required their use. It is possible that the need to use percutaneous catheters arose as a result o f the p atien ts’ lack o f training or instruction in coughing, and not as a result o f not having the breathing exer­ cises. Lastly, the researchers om itted to m ention the am o u n t o f active exercising in bed or w alking, w hether independent­ ly o r assisted by the therapist, that the patients did post-operatively. T he m iss­ ing d ata from th is research study may affect the interpretation o f the results. In a study by Iv erso n et a l (1978) three groups o f patients undergoing open heart surgery received one o f three treatm ents. A ll three groups received instruction in b re a th in g ex e rcise s and co u g h in g to w hich was added either interm ittent p o s­ itive pressure breathing, blow bottles or in c en tiv e sp iro m etry . T h e ir resu lts sh o w ed th a t the in te rm itte n t positive pressure breathing group fared the w orst w ith a g reater n u m b er o f respiratory com plications than the other tw o groups w hile the group using blow bottles had the few est com plications. T he results also show ed that none o f the above tech­ niques prevented atelectasis from occur­ ring o r im proved it during the 72 hour study period. O nce again the interpretation o f these results should be m ade w ith the fo llo w ­ ing factors in m ind. N o m ention is m ade o f the p atien ts’ position during these treatm ents, or w hether o r n o t the patients w ere w alking alone o r w ith help at any stage. The definition o f a pulm onary com plication is n o t clearly stated and this m akes com parisons w ith other studies difficult. The findings fo r the group who u sed in c en tiv e sp iro m e try sh o u ld be v iew ed w ith caution. The authors state that pum p tim es fo r this group were sig­ nificantly lo n g er than those o f the other tw o groups, a result o f a change in o per­ ativ e p ro ce d u re . H ad the in cen tiv e spirom etry group not had this confound- 8 SA J o u r n a l o f Ph y sio t h e r a p y 1997 V o l 53 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ing factor their results m ay have been different. G ale and Saunders (1980) com pared a B artlett-E dw ards incentive spirom eter to interm ittent positive pressure breathing in a group o f patients who had undergone open heart surgery. A regim e o f pre-o p er­ ative training w ith the chosen m odality was follow ed w ith fo u r hourly po st-o p er­ ative use o f the m odality for three days. T hey concluded that incentive spirom e­ try is not significantly b etter than inter­ m ittent positive pressure breathing in p rev e n tin g p o st-o p e ra tiv e atele ctasis. Fol low ing J io th Jo rm sjaf.tre atm en t-th e re , w as_ ajtren d to hypoxaem ia w hich was Jslightly g reater in the interm ittent p o si­ tive pressure breathing group. T he results o f this study are difficult to com pare w ith other studies as no details are given concerning chest p hysiothera­ py. It is thus presum ed th at patients received no chest physiotherapy. T here is also no m ention o f w alking o r active bed exercise program m es that patients m ay have follow ed during this tim e. It seems unlikely that a regim e o f ten incentive spirom etry breaths, or tw enty interm it­ tent positive pressure breaths alone, in a tw enty m inute treatm ent session is insuf­ ficient to have an effect on atelectasis. O ulton et a l (1981) considered w hether d iffe re n t in c en tiv e b rea th in g d ev ices added any benefit to a regim e o f standard chest physiotherapy, in a group o f coro­ nary artery surgery patients. T hey co m ­ pared chest physiotherapy alone (which consisted o f encouragem ent to cough, deep breathing, postural drainage, vibra­ tio n and percussion) to chest ph y sio th er­ apy plus eith er a Triflo spirom eter o r a Spirocare spirometer. A ll patients were taught how to use their chosen device pre-o p erativ ely . T h eir re s u lts show ed th a t the _ g r o u p _ u s in g _ th e J S p iro care sp iro m e ter had less p o st-o p e ra tiv e "atelectasis on chest x-rays throughout the first four post-operative days than the other tw o gmiipsJThis-w-as-thought to be due to the; Spirocare spirom eter having an additional visual stim ulus to hold m axim um inspiration for three seconds. W ith the Triflo- spirom eter a f a s tf lo w rate^ can bring about a relatively large volum e ch an g e, and in sp ira to ry h o ld is no t encouraged. It should be n o te d th a t p o stu ra l drainage positions and the position o f the patient w hile using the spirom eters were no t described. In addition, no inform a­ tion is given about patient mobility. The authors state th at after five patients had been entered into each group it was o b v i­ ous that the group using the Spirocare spirom eter was faring the best. In inter­ preting the results o f this research, it is im portant to note that the groups were no t well m atched for age and this may have influenced the results. T he m ean age o f the chest physiotherapy group was 45 y ears w hile the gro u p usin g the S pirocare had a m ean age o f 60 years. Stock et a l (1984) com pared co n tin u ­ ous positive airw ay pressure, incentive spirom etry and conservative chest p h y s­ iotherapy in a group o f elective open heart surgery patients (n=38). Conserva- / tive therapy was considered fo u r to five m axim al inhalations, huffing and instruc­ tion to “cough h eartily ” . N o details were given about patient positioning fo r treat­ m ent o r how soon the patients w ere m ade to walk. E ach treatm ent lasted fifteen m inutes and occurred every tw o w aking hours fo r the first three post-operative days. This could lead to confounding results as it is felt that in clinical practice the effect o f a treatm ent should be ev alu ­ ated on the clinical outcom es and no t be determ ined by a tim e period. T hey co n ­ cluded that neither conservative chest physiotherapy, incentive spirom etry or c o n tin u o u s p o sitiv e airw a y p ressu re im proved the restrictive lung function defect w ithin the first 72 hours post-oper- atively. O ikkonen et a l (1991) found sim ilar results in a study in w hich interm ittent positive pressure breathing o r incentive spirom etry w ere given together w ith co n ­ ventional chest physiotherapy in a group of patients w ho had undergone coronary artery surgery (n=52). This conventional chest physiotherapy consisted o f “breath­ ing techniques, deep diaphragm atic ven- 1 tilatio n and efficien t co u g h in g ” . T he ^patients w ere trained in these techniques for tw o days pre-operatively. Post-opera- tively the patients received this co n v en ­ tional physiotherapy a m inim um o f once jj a day. T hey also received interm ittent positive pressure breathing on four o cca­ sions during the day or, incentive spirom ­ etry every alternate w aking hour. T hey concluded that the incidence o f atelecta­ sis in both groups increased durin study period. In other w o rd s,.(intermittent p o sitiv e p ressu re b reath in g , in cen tiv e spirom etry and conventional chest p h y s­ io th erap y w ere u nable to p rev e n t o r im prove the p o st-o p erativ e atelectasis that occurs follow ing open heart surgery- O nce again this research does not m en ­ tion a bed exercise program m e or at what stage the patients w alked. T he position in w hich the physiotherapy w as done in, is also not included. It is d iffic u lt to an a ly se th e d ata because o f the inconsistency o f the stud­ ies. Som e o f these difficulties have been highlighted already, those n o t m entioned before will now be discussed. T he patient groups fo r the different studies w ere not standardised. Som e groups consisted o f patients undergoing different kinds o f surgical procedures, w hile others were p atients all undergoing the sam e p ro ce­ dure. This m ay have resulted in different results as the problem s o f a valvular surgery patient are different from those o f a coronary artery surgery patient. The inclusion and exclusion criteria are not alw ays clearly stated and differ betw een studies. As has been m entioned p rev io u s­ ly, w alking the p atien t has no t been addressed, and thus is a poorly controlled variable. P atien t positio n fo r “p h y sio ­ th erap y ” techniques are also not co n sis­ tently recorded and thus could play a role in the results o f these studies. C hest physiotherapy it w ould seem has m u lti­ ple definitions as no tw o studies used the sam e c h e st p h y sio th e ra p y regim e. Control groups receiving no p hysiothera­ py w ere never considered, and thus it is difficult to isolate the effect o f p h y sio ­ therapy. THE ROLE OF ACTIVE EXERCISE AND WALKING THE PATIENT D ull and D ull (1983) com pared early m obilisation alone to early m obilisation p lu s b reath in g ex ercises o r in cen tiv e sp iro m etry . E arly m o b ilisa tio n w as defined as “ankle circum duction, range o f m otion to all extrem ities, three m ax i­ m al co u g h s, and en c o u rag em en t and assistance to turn from side to side, sit up, o r stand u p ”. T h e study group includ­ ed 29 patients w ho had coronary artery surgery and 20 w ho had valve replace­ m ent surgery. T hey found that neither o f th e “ a d d e d ” m o d a lities (in ce n tiv e spirom etry o r breathing exercises) were beneficial to the early m obilisation p ro ­ gram m e alone. In addition, none o f the th ree p ro g ram m es im proved the lung function changes seen post-operatively. For the purposes o f this study a pul­ monary complication was defined as: • a tem perature elevation o f 4° F ab o v e th e m ean p re -o p e ra tiv e SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) tem perature • a te m p eratu re e le v a tio n o f 2 to 3° F above the m ean pre-operative tem perature in addition to abnorm al auscultatory findings p urulent sputum . U sin g these d efin itio n s the authors fo u n d that 77% o f the p atien ts w ho u n d erw en t co ro n ary artery surgery, and 92% o f the v alv u lar surgery patients d ev elo p ed a p o st-o p era tiv e co m p lic a­ tion d u ring th e ir resp ectiv e treatm en t p ro g ram m es. T h ey thus co n clu d ed that no n e o f the treatm en t p ro g ram m es was effectiv e at p rev en tin g p o st-o p erativ e pu lm o n ary co m p licatio n s. It is also p o s­ sib le th at the d efin itio n o f a p o st-opera- tive pu lm o n ary co m p licatio n w as too b ro ad thus ac co u n tin g fo r betw een 77% and 92% o f p atien ts d ev elo p in g such a co m p licatio n . In a study o f 110 w hite m ales undergo­ ing coronary artery surgery three differ­ ent treatm ent protocols w ere assessed (Jenkins et a l 1989, 1990). T he study population was divided into three groups. A ll the study p articipants w ere seen pre- o p era tiv ely by a p h y sio th erap is t and w ere taught huffing, coughing with ster­ nal support and active upper and low er lim b exercises. T he need to m ove about p o st-o p e ra tiv e ly an d e x p e c to ra te bronchial secretions w as also explained. T his was the only physiotherapy that the p atients in the control group received post-operatively. T he patients in the other tw o g ro u p s re c e iv e d e ith e r lo c alised breathing exercises, (w ith vibrations and p ercussion in a postural drainage position if d ee m e d n ec es sary ) o r in c en tiv e spirometry. T h e patients in b oth these groups w ere taught their respective tech­ niques pre-operatively and encouraged to p ractise them . T hey found that adding breathing exercises o r incentive spirom e- tery to the p ro gram m e o f the control group, did not alter their treatm ent ou t­ com e. frh e authors recom m ended that fu n co m p licated coronary artery surgery I p atien t b e taught and h elp ed w ith a ( m obility regim e. | A further study by Jenkins e t a l (1994), in w hich patients undergoing coronary artery surgery, w ere sim ply encouraged to take deep breaths, cough and w ere m obilised by the nursing and surgical staff revealed results sim ilar to the stud­ ies cited above. T he incidence o f resp ira­ to ry co m p lic a tio n s p o st-o p e ra tiv e ly rem ained low (9%) despite the lack of chest physiotherapy. P atients excluded from this study included those w ho had had previous coronary artery surgery or pulm onary surgery, and those w ho had a pre-operative respiratory abnorm ality. S tiller et al. (1994) included a control group in their study w hich received no pre-o r post-operative physiotherapy. This w as the first study in w hich ph y sio th era­ py w as com pletely excluded. T h e control group follow ed the norm al m obilisation f itocol ofL theJiospital _wJhich included ing out o f bed on day tw o and w alking m day three. jThe study population was m ade up exclusively o f patients undergo­ ing coronary artery surgery. T he results from this study w ere in agreem ent w ith the above tw o studies. T h e incidence and severity o f hypoxaem ia, fever, chest x- ray abnorm alities and significant pu l­ m onary com plications w ere not notably hig h er fo r the control group. Patients excluded from this study included those who w ere m echanically ventilated for m ore than 24 hours post-operatively, and those w ho developed a neurological or cardiac com plication that rendered them unable to participate in the study. The recom m endation o f this study is that all patients be continually assessed fo r clin ­ ically significant pulm onary co m p lica­ t i o n s , and treated w ith physiotherapy if / L and w hen the need arisesJR o u tin e post- # -f operative chest p h y siotherapy is not indi- £ cated in this patient population ,, /~ S tiller e t a l (1994) m ake the follow ing p o in t. A lth o u g h th e c o n tro l gro u p receiv ed no pre-operative physiotherapy they did w atch a video pre-operatively w hich m entions chest physiotherapy. In the process o f giving inform ed consent to participate in the study, the patients were m ade aw are o f the rationale for doing breathing exercises and coughing post- operatively. B oth these factors m ay have affected the beh av io u r in the control group. In 1995 S tille r et a l in v e stig a te d w h eth er the incidence o f clinically sig­ n ifican t p u lm onary com plications had increased since the recom m endation that routine post-operative physiotherapy was not necessary in the uncom plicated co ro ­ nary artery surgery patient. T he 1995 study included all patients undergoing heart surgery requiring cardiopulm onary ~jj by-pass. T h e only difference in this study from the 1994 study w as that it included 13 patients w ho had undergone valve surgery w ithout coronary artery surgery. C linically significant p u lm onary co m p li­ cations w ere found in 7.1% (nine out of 127 patients) o f the total p atien t p o p u la­ tion. A n im portant consideration in this study is that all patients undergoing ca r­ diac surgery w ere in clu d ed and thus patients w ith sig n ifican t p re-operative risk factors w ere also included. CONCLUSIONS It w ould seem then that the follow ing conclusions can be draw n from the liter­ ature described previously. TABLE I Jenkins (1989) Jenkins (1994) Stiller (1994) Stiller (1995) Sex: M/F (n) 110/0 165/0 9 8 /2 9 9 8 /2 2 Age (years)1 55.7 ± 8 . 0 58.7 ± 9 . 6 61.3 ± 9.9 62.0 ± 9.4 CABG 110 165 115 115 Valve Replacement 0 0 12 5 No. of patients with Pulmonary complications 11 (10%) 5 (3.4%) 9 (7 .1 % ) 9 (7.5%) ' Recorded as mean ± standard deviation 10 SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) A considerable am ount o f research has been conducted into the effects o f various post-operative physiotherapy treatm ent protocols for the cardiac surgery patient. The trend in the recent research is away from routine physiotherapy treatm ents w ith the em phasis on assessm ent and appropriate intervention. This is possibly due to the im provem ent in anaesthetic techniques, cardiopulm onary bypass equipm ent and the use there of, im proved surgical techniques and shorter periods o f m echanical ventilation post-operativelv.___________________________________ ^ R e s t r i c t i v e lung function post-operatively is to be expected and p h ysiotherapy seem s to h ave little im pact on Jen k in s et al (1990) found that the patients w ho had w alked prior to their lung function test on the second p o st­ operative day had a significant increase in functional resid ­ ual capacity as com pared to th o se patients w ho had not walked._This__woul(i supporL-the ' rationale behind a pro­ gram m e o f early m obilisation and w alking. N o one treatm ent technique or device has been show n to be superior to another. This is due to the inability to co m ­ pare different studies as a result o f inconsistencies in study protocols. B ased on the results o f the S tiller e t a l (1995) study p re ­ operative physiotherapy is also o f no benefit in preventing clinically significant pulm onary com plications p ost-opera­ tively. (Physiotherapy is no t indicated- in a group- o f patients [undergoing elective cardiac surgery w ho are w alk in g_well / from day tw o onw ards. T h i^ c o n c lu sio n does no t include patients w ho have a com plicated post-operative course. This w ould include patients w ho are intubated for longer than 24 hours post-operatively and patients w ho develop neurological com plications. Patients should be assessed daily in the post-operative period for clinically significant pulm onary com plications. Signs and sym ptom s o f a significant pulm onary co m p li­ cation should include: • a tem perature o f greater than 38.50 C the necessity for antibiotics post-operatively over and above the usual treatm ent. • ra d io lo g ic a l e v id en c e o f s ig n ific an t co lla p se or consolidation signs o f respiratory distress. In sum m ary the follow ing “ m issing lin k s” have been identified.__________________________ __________________ J ^ K e r e is currently no evidence to S u p p o rt routine chest^f (physiotherapy after cardiac surgery. ere is no role for preventative chest physiotherapy in the post-operative cardiac surgery patient. J REFERENCES 1. Dull JL and Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobiliza­ tion after cardiopulmonary bypass. Physical Therapy 1983, 63: 655 - 659. 2. Eales CJ, Barker M and Cubberley NJ. Evaluation o f a sin­ gle chest physiotherapy treatment to post-operative, mechan­ ically ventilated cardiac surgery patients. Physiotherapy Theory and Practice 1995, 11: 23 - 28 3. Gale GD and Sanders DE. Incentive spirometry: Its value after cardiac surgery. Canadian Anaesthetists’ Society Journal 1980, 2 7 :4 7 5 - 480. 4. Iverson LIG, Ecker RR, Fox HE and May IAA comparative study o f IPPB, the incentive spirometer, and blow bottles: The prevention o f atelectasis following cardiac surgery. The Annals o f Thoracic Surgery 1978, 25: 197-200 5. Jenkins SC, Soutar SA, Loukota JM, Johnson LC and Moxham J. Physiotherapy after coronary artery surgery: Are breathing exercises necessary? Thorax 1989, 44: 634-639 6. Jenkins SC, Soutar SA, Loukota JM, Johnson LC and Moxham J. A comparison of breathing exercises, incentive spirometry and mobilisa­ tion after coronary artery surgery. Physiotherapy Theory and Practice 1990, 6: 117-126 7. Jenkins S, Akinkugbe Y, Corry G and Johnson L. Physiotherapy man­ agement following coronary artery surgery. Physiotherapy Theory and Practice 1994, 10: 3-8 8. Oikkonen M, Karjalainen K, Kadara V, Kuosa R and Schavikin L. Comparison o f incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft. Chest 1991, 99: 60 - 65 9. Oulton J L, Hobbs GM and Hicken P. Incentive breathing devices and chest physiotherapy: A controlled trial. The Canadian Journal o f Surgery 1981, 24: 638-640 1 10. Stiller K, Montarello J, Wallace M, Daff M, Grant R, Jenkins S, Hall B and Yates H. Are breathing and coughing exercises necessary after coronary artery surgery? Physiotherapy Theory and Practice 1994, 10: 143-152 11. Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, Alster JM and Imrey PB. Comparison of continuous posi­ tive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Critical Care M edicine 1984, 12: 969-972 12. Vraciu JK and Vraciu RA. Effectiveness o f breathing exercises in preventing pulmonary complications following open heart surgery. Physical Therapy 1977,57: 1367-1371 SPECIALISTS IN THE PLACEMENT OF PT's ACROSS THE USA $ h M EtffSTAFF - A division o f Worldwide Staffing Inc. SA J o u r n a l o f Ph y s io t h e r a p y 1997 V o l 53 No 3 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )