The Efficacy of Inpatient vs. Home-Based Physiotherapy Following Coronary Artery Bypass Grafting

Clinical and functional outcomes associated with pulmonary complications after coronary artery bypass grafting

INTRODUCTION

Coronary artery bypass grafting(CABG) is a surgical treatment for coronary artery disease aiming at improving symptoms and life expectancy. Despite this, there are pulmonary and functional complications that may arise during the postoperative period due to invasive mechanical ventilation(IMV), cardiopulmonary bypass and immobility, leading to longer hospital stays.

OBJECTIVE

To evaluate the clinical and functional outcomes related to pulmonary complications in the postoperative period of CABG.

METHODS

Prospective cohort. During the ICU stay the patients were divided into: Non Complicated Group(NCG) who did not present complications and Complicated Group(CG) who presented complication. Functional variables were applied as the six-minute walk test(6MWT), gait speed, sit up and stand up test, Timed Up and Go, peripheral muscle strength, ventilatory, pulmonary function and Functional Independence Measure. These tests were applied preoperatively, at ICU discharge, hospital discharge and six months after surgery.

RESULTS

The study evaluated 90 patients, 59 in the NCG and 31 CG. In the 6MWT there was a 2%(p = 0.43) decrease in the NCG, while the decrease was 13%(p < 0.01) in the CG. In the MRC the drop was 2%(p = < 0.01) in the CNG, while in the CG the drop was 14%(p = < 0.01). In MIP the NCG had a 6%(p = 0.67) decrease, while the CG had a 16%(p = < 0.01) decrease.

CONCLUSION

Patients with postoperative complications of CABG may have reduced functional performance, muscle strength, and pulmonary function at hospital discharge and after six months.

Effects of prehabilitation resistance training in mild to moderate clinically frail patients awaiting coronary artery bypass graft surgery

Coronary artery disease is one of the main causes of mortality and morbidity among chronic heart diseases worldwide. Patients reported chronic chest pain as the primary symptom of coronary artery disease. Due to its progressive nature, it affects the health status and functional capacity of the patients. The current study was planned to compare the effects of prehabilitation resistance training in mild to moderate clinically frail patients awaiting coronary artery bypass graft (CABG). A randomized controlled trial was conducted on 74 patients awaiting CABG at the Faisalabad Institute of Cardiology, Faisalabad, Pakistan. A Modified Healthy Heart Questionnaire was used for screening of the patients. Interventions applied were resistance training by using cuff weights/dumbbells at light intensity (40%-50%) of a maximum of one repetition (10-15 repetitions for one to three times a day) per major muscle groups of upper and lower limbs of the body on weekly basis. The main outcome measures were the 6-minute walk test (6MWT), the New York Heart Association (NYHA) for heart failure, the clinical frailty score, and the essential frailty toolset. Significant differences between group A (resistance training group) and group B (conventional physical therapy group) patients were observed. The mean ranks for 6MWT in group A and group B were 1.70 and 1.55, respectively. The mean ranks of NYHA in group A and group B were 1.68 and 2.84, respectively. Clinical frailty scores in group A and group B were 2.68 and 2.74, respectively, with the essential frailty toolset in group A and group B were 1.14 and 1.11, respectively. There were significant (p < 0.05) differences within and between groups for prehabilitation resistance training after CABG. The study showed that the resistance training group had improved the clinical frailty score, strength, endurance, and functional capacity in patients who underwent elective CABG.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Patient Satisfaction Using a Home-Based Rehabilitation Protocol for the Non-Surgical Treatment of Proximal Humeral Fractures: A Prospective Longitudinal Cohort Study

Supervised, center-based, daily physiotherapy presents limitations: transport, need for an accompanying person, or risk of infection. Home-based rehabilitation protocols (HBRP) can be effective alternatives. We use a HBRP for the non-surgically treated proximal humeral fractures (PHF) in older patients.

Role of peri-operative exercise in patients undergoing coronary artery bypass grafting

Peri-operative exercise regimes are important to minimize complications in patients undergoing coronary artery bypass grafting (CABG). Apart from inspiratory muscle training, aerobics, resistance training, and stretching have all been reported with the potential to promote recovery after cardiac surgery. In the postoperative period, breathing exercises, aerobic and resistance exercises walking, and yoga have all been practiced. However, there is no clarity on the ideal physiotherapy regime in patients undergoing CABG or the intensity of exercise these patients can be subjected to. Future studies need to focus on these unanswered questions.