April 1998

A Randomized Controlled Trial of Prophylactic Chest Physiotherapy in Major Abdominal Surgery
Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K; Br J Surg 1997; 84:1535-1538.


This British study suggests that preoperative instruction combined with postoperative administration of chest physiotherapy reduces postoperative pulmonary complications (6% vs. 27%), and increases postoperative oxygen saturation in patients having open abdominal surgery. An even more marked impact on postoperative pulmonary complications (15% vs. 51%) was shown on those patients at high risk - recent smoking history, pulmonary disease with daily medication, age >50, obesity.

Chest physiotherapy included instruction on huffing and coughing, pursed lip breathing, and breathing against both inspiratory and expiratory resistance. Study patients were also instructed on the importance of early mobilization. The training and information were delivered by specialized chest physiotherapists (about the equivalent of respiratory therapists in America). The time involved was minimal -- 10-15 minutes preoperatively, and 15-20 minutes daily each day postoperatively.

Control patients received no preoperative instruction and routine postoperative care unless a pulmonary complication was diagnosed. General anesthesia was given to all patients. Pain control was via epidural analgesia only for fundoplication or morbid obesity gastroplasty surgery.

The control group had a higher percentage of the operations severe enough to require epidural analgesia (fundoplication or gastroplasty), and a higher percentage of ASA 3 and 4 patients (10% vs. 15%). Despite the fact that the title suggests a controlled prospective trial, the groups were evaluated in month long blocks and the attending physicians could not be blinded to the study groups and were relied upon to make the clinical diagnosis of pneumonia. While there were 13 diagnosed pneumonias in the control group and only 1 in the treatment group, this did not significantly impact length of stay. A pulmonary complication was diagnosed as an oxygen saturation less than 92%, or two of the following -- temperature greater than 38.2 degrees Celsius, pathological lung auscultation, and radiological evidence of pneumonia or atelectasis.

Of note, objective criteria such as FVC and peak expiratory flow rates values did not differ between the two groups. 19 "complications" consisted solely of an oxygen saturation of 89% in the control group. While mobilization period was reduced, total length of stay was not different.

This is the type of study which can classically be described as a total waste of time. It sounded good when I ran across it quoted in some article. Actual reading of the article suggests however that the results and conclusions are: 1) invalid for diagnosis of pneumonia due to the lack of blinding, and 2) unimportant due to the definition of pulmonary complications as an oxygen saturation less than 92% (19 patients had 89%, a value with no clinical implications). Objective measures like FVC were not any different. The authors might have achieved exactly the same results by simply telling their patients to get mobilized early, and all the pulmonary benefits might accrue to the earlier mobilization emphasis alone. Nothing in this article proves that preoperative instruction in and postoperative administration of chest physiotherapy has any real clinical value.

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ABSTRACT