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Pre-op breathing exercise training prevents complications

The benefits of a single physiotherapy education and breathing exercise training session

Upper abdominal surgery is the most frequent major surgical procedure performed in developed countries. A postoperative pulmonary complication (PPC) is the most common serious complication after this type of surgery; the reported incidence is between 10% and 50% of patients. 

A PPC is strongly associated with increased mortality, morbidity, and healthcare costs. Pulmonary complications (including pneumonia and severe atelectasis) are caused by postoperative pathophysiological reductions in lung volumes, respiratory muscle function, mucociliary clearance, and pain inhibition of respiratory muscles.

Education and breathing exercise training are associated with a 75% relative risk reduction, but advances in minimally invasive surgery, differing levels of experience of therapists and timing of education have never been evaluated.

Primary outcome was the incidence of a PPC within 2 weeks of surgery, scored with a standardised tool. Further outcomes were length of hospital stay, number of days in the ICU, QoL at 6 weeks, hospital readmissions, and 12 month mortality.

20% of participants developed a PPC, 12% in the intervention group, and 27% in the control group. The incidence of PPCs halved, but no other differences were detected.

There was a gradient in PPC reduction according to surgical category, with the greatest response to preoperative physiotherapy in colorectal surgery, then upper gastrointestinal surgery, with the least difference between groups for urology. PPC reduction attributable to the preoperative intervention was greatest in participants educated by an experienced physiotherapist, in men, and in those younger than 65 years.

These results are important considering existing evidence for other methods to prevent PPCs. These include preoperative inspiratory muscle training, “prehabilitation”, incentive spirometry, and postoperative chest physiotherapy.

Considering how effective preoperative education is in independently reducing PPCs, the benefit attributed to inspiratory muscle training may come from just educating the patients preoperatively on breathing exercises rather than the effect of the training device itself. 

> From: Boden et al., BMJ 360 (2018) j5916 (Epub ahead of print). All rights reserved to BMJ Publishing Group Ltd.. Click here for the online summary.

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