Questioning the role of targeted respiratory physiotherapy over and above a standard clinical pathway in the postoperative management of patients following open thoracotomy.

Unlabelled: Summary of: Reeve JC et al (2010) Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial. Eur J Cardiothorac Surg 37: 1158-1166. [Prepared by Kylie Hill, CAP Editor.]

Question: Does routine prophylactic targeted respiratory physiotherapy after elective pulmonary resection via open thoracotomy decrease the incidence of postoperative pulmonary complications and reduce length of hospital stay?

Design: Randomised, controlled trial with concealed allocation in which those who collected outcome measures were blinded to group allocation.

Setting: Hospital ward of a tertiary referral centre in Auckland, New Zealand.

Participants: Adults scheduled for pulmonary resection via open thoracotomy.

Exclusion Criteria: (i) unable to understand written and spoken English, (ii) tumour invasion of the chest wall or brachial plexus, (iii) physiotherapy for a respiratory or shoulder problem within 2 weeks prior to admission, (iv) development of a postoperative pulmonary complication prior to randomisation on Day 1 postoperatively, or (v) intubation and mechanical ventilation ≥ 24 hours following surgery. Randomisation of 76 patients allocated 42 to the intervention group and 34 to the control group.

Interventions: Both groups received usual medical and nursing care via a standardised clinical pathway, which included early and frequent position changes, sitting out of bed on the first postoperative day, early ambulation and frequent pain assessment. In addition, the intervention group received daily targeted respiratory physiotherapy, which comprised deep breathing and coughing exercises, assistance with ambulation, and progressive shoulder and thoracic cage exercises.

Outcome Measures: The primary outcome was incidence of postoperative pulmonary complications, defined using a standardised diagnostic tool. The secondary outcome was the length of hospital stay.

Results: The primary and secondary outcomes were available for all enrolled patients. Neither the incidence of postoperative pulmonary complications [mean difference intervention-control 1.8% (95% CI -10.6 to 13.1%)] nor the hospital length of stay [intervention group median 6.0 days, control group median 6.0 days; p=0.87) differed significantly between groups. The overall incidence of postoperative pulmonary complications (3.9%) was lower than expected.

Conclusion: In adults following open thoracotomy, the addition of targeted respiratory physiotherapy to a standardised clinical pathway that included early mobilisation did not reduce the incidence of postoperative pulmonary complications or change length of hospital stay.