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The aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery UAS in reducing the incidence of atelectasis and length of hospital stay in the postoperative period..
Patients in the pre-intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the post-intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies EPAP, incentive spirometry and early mobilization..
There was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the post-intervention period. No patient who adhered totally to the guideline in the post-intervention period developed atelectasis.
Individuals in the post-intervention period presented a shorter length of hospital stay 9. The implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period..
Postoperative pulmonary complications PPCs are common in patients undergoing abdominal surgery and are responsible for the increased morbidity and mortality as well as length of hospital stay and health related cost of care.
Surgical and anesthetic factors such as the time of surgery, type of surgery, and the effects of anesthetic drugs on the respiratory system also contribute to the development of PPCs. Atelectasis, pneumonia, acute respiratory failure, tracheobronchitis, wheezing, and prolonged mechanical ventilation are the most commonly observed PPCs. Chest physical therapy acting with thoracic expansion exercises and diaphragmatic breathing exercises immediately after the UAS appears to improve oxygenation without triggering increase in pain or other complications.
The main objective of the present study was to evaluate the effectiveness of the implementation of a guideline for physical therapy assistance for patients undergoing elective open UAS in reducing the incidence of atelectasis and length of hospital stay in the postoperative period.
We analyzed data from patients hospitalized in intensive care units, semi-intensive units, and wards. It excluded patients undergoing lower abdominal surgeries, laparoscopic surgeries, emergency surgeries, surgeries with associated chest manipulation, those who underwent more than one surgical procedure during hospitalization, patients who did not adhere properly to the physical therapy treatment performing physical therapy attendances hours.
Teams of physical therapists were trained in the standardization of the new model of care during the month of January During this period, no data of patients undergoing UAS were collected. A training program for guideline implementation was carried out by the area of Continuing Education of the Rehabilitation Service of the institution for a period of 30 days.
Fifteen training meetings were arranged in small groups for all the physical therapists of the institution, acting in intensive care units, semi-intensive units, and wards, in relation to the guideline.
During the training sessions, we presented flow diagrams for treatment, the standardization of approaches of treatment, orientations for hospital discharge, and the scientific evidence that supported the elaboration of the guidelines.
Furthermore, the training aimed to guide professionals in the use of physical therapy resources recommended in the care model i. To disseminate the guideline, printed copies of the document in the operating units were distributed, in addition to providing the electronic file in the computerized system of the institution for consultations. This material contains information about care flowcharts, indications and contraindications, criteria for discontinuing the program, resources and frequency of physical therapy sessions Fig.
The document presented a total of 11 pages including flowcharts. Physical therapy program for patients undergoing open upper abdominal surgery intervention group. Patients included in the study in the pre-intervention period control group underwent a program of postoperative physical therapy treatment in which the therapeutic planning to be applied was determined by the professional providing patient care non-standard model.
In contrast, patients who were included in the post-intervention intervention group underwent a standardized program of physical therapy treatment which structured the model of patient care, focusing on the use of additional therapeutic resources volumetric incentive spirometry and positive expiratory pressure in the airways , 17,18 early sitting position and ambulation onset h after surgery 19 Fig.
Patients undergoing the program preconized by the guideline should undergo at least two sessions of physical therapy daily until the 5th postoperative day. In the present study, total adhesion to the guideline was defined by the use of all the features recommended in the guideline. When one of the resources was not applied, it was considered partial compliance, and when two or more features were not used, it was considered as non-adherence to the guideline.
Data were collected from the analysis of medical records and electronic database of the hospital. The information extracted from these sources was stored in electronic format previously designed for this study.
We collected data concerning characterization of each patient medical history, demographics, clinical and anthropometric data , the surgical procedure type of surgery, surgical technique, surgical time, and surgical risk , and the physical therapy assistance provided to patients during hospitalization features used and treatment adherence.
Regarding the outcomes investigated, the incidence of atelectasis was considered as the primary variable and the length of hospital stay as the secondary variable. The diagnosis of atelectasis was considered in the presence of imaging studies confirming this alteration. All patients included in the study, both in the control group CG and in the intervention group IG , had radiographic evaluation from the first to fifth postoperative day.
We considered only the presence of pure atelectasis not associated with other complications such as pleural effusion or pneumothorax since the aim of the study was to determine the incidence of atelectasis secondary only to the surgery, and not to other complications. Radiologists who had read all the examinations did not know the study objectives. We considered as possible risk factors for developing atelectasis: age, female gender, high body mass index BMI , lung disease, history of smoking, hypertension, diabetes, dyslipidemia, heart disease, cancer, type of surgery, surgical technique, time of surgery, and surgical risk American Society of Anesthesiologists scale.
To reach this number, we calculated that we needed 6 months for the post-intervention period. For the final analysis, a sensitive analysis was performed including only the patients with full adherence to the guideline as well as an analysis of all patients included in the post-intervention period. Comparisons between groups were made by Mann—Whitney test nonparametric data , in the case of numerical variables, and by the chi-square test in the case of categorical variables.
Statistical analysis was performed using the statistical program SigmaPlot There was waiver shall of the Consent Form, because it is a retrospective observational study analyzing standardization of institutional care process. We analyzed medical records of patients undergoing UAS in the total period of the study, belonging to the stage prior to guideline implementation and belonging to the subsequent stage.
After evaluation of inclusion and exclusion criteria, were eligible for the study. Of the patients included in the IG, 32 Flowchart for inclusion and exclusion of patients in the study for the CG pre-guideline and IG post-guideline. The clinical and demographic characteristics of the population studied in each group are presented in Table 1. There was significant difference between the groups only in relation to smoking history and gender.
The IG patients presented a higher prevalence of tobacco use and a higher proportion of males. There was no difference between groups in relation to surgical risk, technique or surgery time. Demographic and clinical characteristics of individuals included in the study. The guideline implementation optimized the use of additional therapeutic resources during physical therapy assistance, causing a significant increase in the use of incentive spirometry and expiratory positive airway pressure EPAP p 0.
Furthermore, it was observed that early ambulation occurred in all patients in the post-intervention period. Regarding the clinical outcomes, no patient in the IG showed pure atelectasis, whereas the frequency of atelectasis in the CG was There was also difference between groups in the length of hospital stay.
CG individuals remained hospitalized for a longer period of time Frequency of use of different therapeutic resources and clinical outcomes incidence of atelectasis and length of hospital stay. EPAP: expiratory positive airway pressure.
Table 3 describes possible risk factors for the development of atelectasis. These data are related only to the CG, since there was no development of atelectasis in the IG. In the present study, the only risk factor associated with the development of atelectasis was the surgical technique. The individuals undergoing subcostal incisions were more likely to develop this complication p 0. Possible risk factors associated with the development of atelectasis.
The present study showed that the optimization and standardization of the use of additional therapeutic resources through the implementation of a guideline for physical therapy assistance, guiding the care of patients undergoing UAS, is effective in reducing the incidence of atelectasis and length of hospital stay in the postoperative period. The intention-to-treat analysis including 37 patients who adhered partially to the guideline did not show a statistically significant difference in the rate of atelectasis or length of hospital stay when compared to the CG.
This finding reinforces the need for total adherence of the intervention packages for the clinical outcomes to be achieved. Although the ITT analysis did not demonstrate a statistically significant difference for the length of hospital stay, a reduction of up to 48 h in hospitalization can be considered clinically relevant and can be associated with a reduction in healthcare costs.
In association with these findings, it was also observed that the length of hospitalization was higher among patients who developed atelectasis. The longer length of stay among patients who develop pulmonary complications is a common finding in the literature. Although physical therapy assistance is routinely used in the processes of functional rehabilitation of patients undergoing UAS, 11 the results demonstrating its effectiveness in preventing atelectasis are still inconsistent.
In this context, the development of care guidelines has been widely used in the routine in different fields of medical activity, 15,16 providing practical recommendations when scientific evidence is still limited or questionable.
Therapeutic resources such as incentive spirometry, CPAP, EPAP, early mobilization, and conventional physical therapy, based on deep breathing exercises, are often used to prevent atelectasis in patients undergoing UAS. Recent systematic reviews have found no evidence regarding the effectiveness of the use of incentive spirometry for preventing pulmonary complications in the postoperative period of UAS.
Despite these inconsistent results, the latest recommendations on the use of incentive spirometry in preventing postoperative pulmonary complications indicate that this feature should be applied in combination with deep breathing techniques, assisted cough, early mobilization, and optimized analgesia to obtain better preventive results. Ricksten et al. Other authors have also demonstrated that EPAP is as effective as CPAP for the prevention of PPCs after thoracic surgery and should be used concomitantly with conventional respiratory physical therapy.
In the post-intervention period, EPAP was used in all patients who adhered to the guideline. The reduction in the rate of atelectasis may have been largely explained as a result of the inclusion of this feature in clinical practice. Finally, early mobilization was another important feature recommended in the approach of patients undergoing open UAS after guideline implementation.
It is believed that early mobilization results in increased lung volume, with consequent prevention of atelectasis. These findings further emphasize the importance of early mobilization in the postoperative period for UAS.
Risk factors such as age over 60, smoking history, presence of chronic lung disease and surgical time over min are often related to the occurrence of pulmonary complications in the postoperative period of open UAS.
The relationship between subcostal incisions and the development of pulmonary complications after abdominal surgery has been previously demonstrated. The main limitation of the present study relates to the methodological design.
Although the use of a historical control hinders the establishment of a causal association, its application in an institutional context becomes a more viable alternative. It should also be noted that the implementation of the guideline was the only change incorporated into the care of these patients during the study period.
Another factor worth mentioning is the fact that radiological assessors were blinded to the study objectives ensuring the reliability of the diagnosis of atelectasis primary variable.
Moreover, the short time between the historical control and the intervention period strengthens the assumption of a true association between the interventions and the observed outcomes.
Effects of positive airway pressure on pulmonary function parameters
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Epap recurso fisioterapia
Foram selecionados para o estudo 31 pacientes em POCC. Hemodynamic management of patients in the first 24 hours after cardiac surgery. Crit Care Med. Pulmonary dysfunction after cardiac surgery. Stiller K.