Breath Training Before Surgery Halves Postoperative Pneumonia Risk

Marcia Frellick

January 24, 2018

Major abdominal surgery is associated with an increased risk for postoperative pneumonia. Now, a randomized trial shows that teaching patients breathing exercises to be practiced immediately after waking from surgery drops pneumonia incidence by half.

"These results are directly applicable to the tens of millions of patients listed for elective major abdominal surgery worldwide. This service could be considered for all patients awaiting upper abdominal surgery," write Ianthe Boden, BAppSc, from the Department of Physiotherapy at Launceston General Hospital, Tasmania, Australia, and the Department of Physiotherapy at the University of Melbourne, and colleagues.

The researchers published their findings online January 24 in the BMJ .

Researchers enrolled 441 adults in Australia and New Zealand who were within 6 weeks of elective upper abdominal surgery. They randomly assigned them to receive either 30 minutes of education and face-to-face breathing exercise instruction (n=222) or an information booklet about postoperative pulmonary complications (PPCs) and potential benefit of early ambulation and breathing exercises (n=219). Patients in both groups received standard postoperative care, including a physiotherapist-directed early ambulatory program that started in the first postoperative day.

PPCs within 2 weeks after surgery, which was the primary endpoint, occurred in 20% of all patients. In the intent-to-treat analysis, 12% (27/218) patients in the intervention group developed a PPC vs 27% (58/214) in the control group.

After adjusting for comorbidities, patient demographics, and surgical factors, the risk for PPC dropped by 52% with the intervention (adjusted hazard ratio, 0.48; 95% confidence interval [CI], 0.30 - 0.75; P = .001).

The number needed to treat to avoid postoperative pulmonary complications was 7 (95% CI, 5 - 14).

The authors found that the intervention had the greatest effect in men, in people younger than 65 years, in patients having colorectal surgery, and when an experienced physiotherapist provided the coaching.

The experience of the physiotherapist is an area to explore in future research, the authors say, to see why that makes a significant difference. In this study, the most experienced physiotherapists delivered the intervention 124 times vs a maximum of 25 times for junior physiotherapists.

The number of physiotherapists may also be important, the researchers say.

"Preoperative education provided by two physiotherapists, including the most experienced, was found to be highly memorable and impactful for patients," according to the paper.

No differences were found in secondary outcomes, which included length of stay, readiness for discharge, readmissions, or ambulation.

One explanation for success of the intervention may be that the coaching leads patients to start the breathing exercises immediately after surgery, according to the authors.

"Commonly in a postoperative only physiotherapy service, coaching begins on the first or second postoperative day; which may be too late, as most PPCs have already occurred," they write.

In addition, "Pain, nausea, analgesia, anxiety, and persisting sedation can also compromise a patient's ability to comprehend instructions when first contact with physiotherapy is only in the postoperative phase."

Among the limitations are that the trial included only English speakers and was conducted in only in two developed, Western countries. Also, although the trial was conducted in three centers (a small rural hospital, a medium-sized regional tertiary referral hospital, and a large major metropolitan, university-affiliated hospital), the authors acknowledge a large proportion of the participants came from one hospital in Australia.

The authors have disclosed no relevant financial relationships .

BMJ. Published online January 24, 2018. Article

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