Pre-operative Physiotherapy in Oesophageal Surgery

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Pre-operative Physiotherapy in Oesophageal Surgery

• Alex Wilson MSc
• Team Lead Physiotherapist Critical Care and
  Surgery
• Cancer Centre, Churchill Hospital

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Content

• Background
• Evidence
• Conclusion

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Why I think this is important

• Post-operative Pulmonary complications
• Increased morbidity
• Increased mortality
• Increased LOS
• Poor patient experience
• Poor family experience

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Patient pathway
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Enhanced Recovery
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Supporting Evidence
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Improve pre-operative care

• Involve family and carers in all pre-operative
  education
• Maximises patient understanding 
• Pre-operative assessment is to ensure
  that        
• Patient has the maximum opportunity to get their
  bodies as fit as possible
• Staff identify and co-ordinate all essential
  resources and discharge requirements

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Increase comfort post-operatively

• The focus is to get patients moving as soon as
  possible after their operation
• 'Vigorously treat' post-operative pain to reduce
  surgical stress responses
• Use suitable low dose epidural

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Improve post-operative care

• Focus on enabling patients to move and achieve
  nutritional requirements
• Continue to mange post-operative pain
• Clear discharge and post discharge arrangements

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Inspiratory Muscle Training(IMT)
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Respiratory musculature
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Power Breathe Medic
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Contraindications

• IMT is NOT recommended for patients with a
  history of spontaneous pneumothorax
• IMT is only recommended for patients with a
  history of traumatic pneumothorax after complete
  recovery
• IMT is NOT suitable for asthma patients who have
  low symptom perception and who suffer from
  frequent sever exacerbations
• IMT is NOT suitable for anyone who has recently
  experienced a perforated eardrum

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Hulzebos et al. JAMA 2006

• Pre-operative IMT in high-risk
  patients undergoing CABG surgery
• PPC major source of morbidity and mortality,
  Increases LOS and resource utilization
• Pre-hospitalization period before surgery may be
  used to improve a patient's pulmonary condition
• A single-blind RCT
• 655 patients referred for elective CABG surgery,
  299 (45.6) met criteria for high risk of
  developing PPCs, of whom 279 were enrolled and
  followed up until discharge from hospital
• Randomly assigned to receive either pre-operative
  IMT (n  140) or usual care (n  139)
• Incidence of PPCs, especially pneumonia, and
  duration of postoperative hospitalization
• After  surgery
• 18.0 of the IMT group had PPCs
• 35.0 of usual care group had PPCs
• 60 less pneumonia in IMT
• LOS 7 days in the IMT group vs. 8 days

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Dronkers Clinical Rehab 2008

• Effects of preoperative IMT on the incidence of
  atelectasis in patients at high risk of PPCs
  scheduled for elective AAA surgery
• Single-blind pilot RCT
• 20 high-risk patients undergoing elective AAA
  surgery were randomly assigned to receive
  preoperative IMT or usual care
• Incidence of atelectasis, inspiratory muscle
  strength and vital capacity, and feasibility
  outcome variables were adverse effects and
  patient satisfaction with inspiratory muscle
  training
• Results
• 8 in control group and three in the intervention
  group developed atelectasis
• No adverse effects of preoperative IMT were
  observed and patients considered that inspiratory
  muscle training was a good preparation for
  surgery
• Conclusion
• Preoperative IMT was well tolerated and
  appreciated
• Seems to reduce the incidence of atelectasis in
  patients scheduled for elective AAA surgery

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IMT Research
Sig Plt0.05
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Cost Analysis

• IMT device cost lt20
• 1-hour Physiotherapy 20
• vs.
• Extra ward bed day 500
• Extra ICU bed day gt1500

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Prehabilitation
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Dronkers et al. Clinical Rehab 2010

• Preoperative therapeutic programme for elderly
  patients scheduled for elective abdominal
  oncological surgery a randomized controlled
  pilot study
• Single-blind pilot RCT 42 elderly patients (gt60
  years)
• Short-term intensive therapeutic exercise
  programme to improve muscle strength, aerobic
  capacity, and functional activities
• Intervention group n22
• Home-based exercise advice, control group n20
• Preoperative functional capacity and
  postoperative course
• Results
• The intensive training programme was feasible,
  with a high compliance and no adverse events.
• Respiratory muscle endurance increased in the
  preoperative period in the intervention group and
  differed significantly from that in the control
  group
• No significant difference in PPC and LOS between
  the groups
• Conclusion
• The intensive therapeutic exercise programme was
  feasible and improved the respiratory function of
  patients due to undergo elective abdominal
  surgery compared with home-based exercise advice

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COnclusion
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Planned Intervention

• Physiotherapist in Surgery Clinic
• Early Post-op mobilisation program explained to
  patient and relatives
• Patient taught to use IMT device
• Respiratory pressures measured
• Device resistance set
• IMT device taken by patient
• Used for 20 minutes daily for gt2 weeks prior to
  surgery

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Refs

• Dronkers J (2008) Prevention of pulmonary
  complications after upper abdominal surgery by
  preoperative intensive inspiratory muscle
  training a randomized controlled pilot study.
  Clin Rehab, 22, 2, 134-42.
• Dronkers et al. (2010) Preoperative therapeutic
  programme for elderly patients scheduled for
  elective abdominal oncological surgery a
  randomized controlled pilot study Clin
  Rehabil 201024614-622.
• Hulzebos EH (2006) Feasibility of preoperative
  inspiratory muscle training in patients
  undergoing coronary artery bypass surgery with a
  high risk of postoperative pulmonary
  complications a randomized controlled pilot
  study. Clin Rehab, 20, 11, 94959 
• Hulzebos EH, Helders PJM, Favie NJ (2006)
  Preoperative intensive inspiratory muscle
  training to prevent postoperative pulmonary
  complications in high-risk patients undergoing
  CABG surgery a randomized clinical trial. JAMA,
  296, 15, 185157 
• Nomori et al. (1994) Pre-operative respiratory
  muscle training. Assessment in thoracic surgery
  patients with special reference to post-operative
  pulmonary complications. CHEST 105 1782-88
• Weiner et al. (1998) Prophylactic inspiratory
  muscle training in patients undergoing coronary
  artery bypass graft. World J Surgery. 22 427-31

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Questions?

• alex.wilson_at_orh.nhs.uk