Oxygen Transport: A Physiologically-based Conceptual Framework for the Practice of Cardiopulmonary Physiotherapy

Quantifying postoperative mobilisation following oesophagectomy

OBJECTIVE

Early mobilisation is in integral component of postoperative recovery following complex surgical procedures such as oesophageal cancer resections, however evidence to guide early mobilisation protocols in critical care settings is limited. Furthermore, little is known about actual mobilisation levels postoperatively. This study quantified postoperative mobilisation post- oesophagectomy and investigated barriers to mobility.

DESIGN

Prospective observational study.

SETTING

Postoperative critical care setting in a tertiary care referral centre for oesophagectomy.

PARTICIPANTS

Thirty participants (mean age 65 (SD 7) years, n=19 males) scheduled for oesophagectomy.

MAIN OUTCOME MEASURES

The primary outcome, postoperative physical activity, was measured objectively using the Actigraph GT3X+. Medical records were examined for a range of outcomes including medical status, pain scores and physiotherapy comments to identify factors which may have influenced mobility.

RESULTS

During postoperative day (POD) 1-5, participants spent the majority of time (>96%) sedentary. Participation in light intensity activity was low but did increase daily from a median of 12 (IQR 19) minutes/day on POD1 to a median of 53 (IQR 73.25) minutes/day on POD5 p<0.001), with a corresponding increase in daily step count. Haemodynamic instability was the most common reason reported by physiotherapists for either not attempting mobility or limiting postoperative mobilisation levels.

CONCLUSIONS

These data demonstrate that despite daily physiotherapy, there are multiple challenges to postoperative mobilisation. Haemodynamic instability, likely related to thoracic epidurals, was the key limitation to early mobilisation. Goal-directed mobilisation in collaboration with the multidisciplinary team may play a considerable role in overcoming modifiable barriers to postoperative mobilisation.

The physiotherapist and the esophageal cancer patient: from prehabilitation to rehabilitation

Esophageal cancer is a serious malignancy often treated with multimodal interventions and complex surgical resection. As treatment moves to centers of excellence with emphasis on enhanced recovery approaches, the role of the physiotherapist has expanded. The aim of this review is to discuss the rationale behind both the evolving prehabilitative role of the physiotherapist and more established postoperative interventions for patients with esophageal cancer. While a weak association between preoperative cardiopulmonary fitness and post-esophagectomy outcome is reported, cardiotoxicity during neoadjuvant chemotherapy and/or radiotherapy may heighten postoperative risk. Preliminary studies suggest that prehabilitative inspiratory muscle training may improve postoperative outcome. Weight and muscle loss are a recognized sequelae of esophageal cancer and the functional consequences of this should be assessed. Postoperative physiotherapy priorities include effective airway clearance and early mobilization. The benefits of respiratory physiotherapy post-esophagectomy are described by a small number of studies, however, practice increasingly recognizes the importance of early mobilization as a key component of postoperative recovery. The benefits of exercise training in patients with contraindications to mobilization remain to be explored. While there is a strong basis for tailored physiotherapy interventions in the management of patients with esophageal cancer, this review highlights the need for studies to inform prehabilitative and postoperative interventions.

Effect of body position on preterm newborns receiving continuous positive airway pressure

AIM

To evaluate the effect of body position on the cardiorespiratory indicators of preterm newborns receiving nasal continuous positive airway pressure (CPAP).

METHODS

Analytical, observational, prospective, cross-sectional, randomised crossover study was carried out on sixteen newborns that received nasal CPAP. The infants had a mean gestational age of 29.7 ± 2 weeks and birthweight of 1353 ± 280 g. Cardiorespiratory indicators (respiratory rate, heart rate and oxygen saturation) were evaluated in each infant in the supine, prone and right and left lateral decubitus positions at intervals of 10 min over a period of 60 min.

RESULTS

The cardiorespiratory indicators were similar and within the normal range in the four decubitus positions. There was no difference in respiratory or heart rate between body positions. Although they showed desirable values, oxygen saturation was significantly lower in left lateral decubitus (96.6 ± 1.7%) when compared to the supine (97.1 ± 1.3%) and prone positions (97.4 ± 1.1%) (p = 0.00) and was also significantly lower in right lateral decubitus (96.9 ± 1.4%) when compared to the prone position (p = 0.00).

CONCLUSION

We found no preferential decubitus position for preterm newborns receiving nasal CPAP, the supine position may be a choice, but the left and right lateral positions were less advantageous in terms of oxygen saturation.

Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study

BACKGROUND

Bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU) have detrimental effects. Studies in medical ICUs show that early mobilization is safe, does not increase costs, and can be associated with decreased ICU and hospital lengths of stay (LOS).

OBJECTIVE

The purpose of this study was to assess the effects of an early mobilization protocol on complication rates, ventilator days, and ICU and hospital LOS for patients admitted to a trauma and burn ICU (TBICU).

DESIGN

This was a retrospective cohort study of an interdisciplinary quality-improvement program.

METHODS

Pre- and post-early mobility program patient data from the trauma registry for 2,176 patients admitted to the TBICU between May 2008 and April 2010 were compared.

RESULTS

No adverse events were reported related to the early mobility program. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post-early mobility program. Ventilator days and TBICU and hospital lengths of stay were not significantly decreased.

LIMITATIONS

Using a historical control group, there was no way to account for other changes in patient care that may have occurred between the 2 periods that could have affected patient outcomes. The dose of physical activity both before and after the early mobility program were not specifically assessed.

CONCLUSIONS

Early mobilization of patients in a TBICU was safe and effective. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the ICU.

Reaching consensus on the physiotherapeutic management of patients following upper abdominal surgery: a pragmatic approach to interpret equivocal evidence

BACKGROUND

Postoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal.

METHODS

The objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n=5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR)<0.5-were collated into the algorithm.

RESULTS

The five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential.

CONCLUSION

An expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population.

Early physiotherapy in the respiratory intensive care unit

Physiotherapy is an integral part of the management of patients in respiratory intensive care units (RICUs). The most important aim in this area is to enhance the overall patient's functional capacity and to restore his/her respiratory and physical independence, thus decreasing the risks of bed rest associated complications. This article is a review of evidence-based effectiveness of weaning practices and physiotherapy treatment for patients with respiratory insufficiency in a RICU. Literature searches were performed using general and specialty databases with appropriate keywords. The evidence for applying a weaning process and physiotherapy techniques in these patients has been described according to their individual rationale and efficacy. The growing number of patients treated in RICUs all over the world makes this non pharmacological approach both welcome and interesting. However, to date, there are only strong recommendations concerning the evidence-based strategies to speed weaning. Early physiotherapy may be effective in ICU: however, most techniques (postures, limb exercise and percussion/vibration in particular) need to be further studied in a large population. Evidence supporting physiotherapy intervention is limited as there are no studies examining the specific effects of interventions on long-term outcome.

Positive expiratory pressure (PEP) treatment in children with multiple severe disabilities

BACKGROUND

Children with multiple severe disabilities cannot be spontaneously physically active and therefore lack the ventilatory stimulation of physical activity. They often produce large quantities of airway mucus, which they have difficulty to evacuate on their own. The accumulation of mucus may lead to respiratory insufficiency.

AIM

To investigate whether chest physiotherapy with positive expiratory pressure (PEP) could improve the blood oxygen tension (PO(2)) and/or decrease carbon dioxide tension (PCO(2)) in severely disabled children with airway mucus accumulation.

METHODS

Eighteen disabled children (mean age 7.5 y, SD 4.3, range 1.7-17.8 y) participated in the study. Transcutaneous (tc) PO(2), tcPCO(2) and respiratory rate (RR) were recorded before and after PEP treatment. The reproducibility of the effect of the treatment was tested by repeating the recordings.

RESULTS

The mean tcPO(2) increased 1.0 kPa (range -0.2 to 3.4 kPa) immediately after PEP treatment (p=0.0001). No significant changes in tcPCO(2) or RR were noted. The reproducibility of the effect of PEP treatment was good, with a significant increase in tcPO(2) at all retests. All children accepted the treatment well.

CONCLUSION

PEP increases blood oxygen tension immediately after treatment in severely disabled children with airway mucus accumulation. Long-term effects remain to be proven.

Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient

The aim of this study was to investigate the effects of mobilisation on respiratory and haemodynamic variables in the intubated, ventilated abdominal surgical patient. Mobilisation was defined as the progression of activity from supine, to sitting over the edge of the bed, standing, walking on the spot for one minute, sitting out of bed initially, and sitting out of bed for 20 minutes. Seventeen patients with age (mean +/- SD) 71.4 +/- 7.1 years satisfied inclusion criteria. Respiratory and haemodynamic parameters were measured in each of the above positions and compared with supine. In the 15 subjects who completed the protocol, standing resulted in significant increases in minute ventilation (VE) from 15.1 +/- 3.1 l/min in supine to 21.3 +/- 3.6 l/min in standing (p < 0.001). The increase in VE in standing was achieved by significant increases in tidal volume (VT) from 712.7 +/- 172.8 ml to 883.4 +/- 196.3 ml (p = 0.008) and in respiratory rate (fR) from 21.4 +/- 5.0 breaths/min to 24.9 +/- 4.5 breaths/min (p = 0.03). No further increases were observed in these parameters beyond standing when activity was progressed to walking on the spot for one minute. When supine values were compared with walking on the spot for one minute, inspiratory flow rates (VT/TI) increased significantly from 683 +/- 131.8 ml/sec to 985.1 +/- 162.3 ml/sec (p = 0.001) with significant increases in rib cage displacement (p = 0.001) and no significant increase in abdominal displacement (p = 0.23). Arterial blood gases displayed no improvements following mobilisation. Changes in VT, fR, and VE were largely due to positional changes when moving from supine to standing.

Effects of deep breathing exercise and ambulation on pattern of ventilation in post-operative patients

Deep breathing and ambulation are used by physiotherapists for patients after surgery, however the precise effects of these on ventilation have not been investigated. This study was designed to compare the effects of deep breathing and ambulation on pattern of breathing in patients after upper abdominal surgery. A similar increase was found in minute ventilation, however the pattern of breathing seen during each treatment was very different. During the deep breathing exercises patients had large, significant increases in tidal volume (mean change 488.5ml), while respiratory rate decreased non-significantly. By comparison, ambulation caused small and non-significant increases in both tidal volume (163.4ml) and respiratory rate. It appears that if one of the aims of ambulation is to increase tidal volume, patients may need to be encouraged to augment their tidal volumes.