Jean Crowe, Mary Ann O’Brien
You have recently started working as a physiotherapist on a post-surgical unit. The unit is very busy and you are the only physiotherapist. You are wondering whether you should provide prophylactic physiotherapy for all patients undergoing upper abdominal surgical procedures. You decide to visit the hospital librarian to plan a search for up to date information. Your questions is : ‘Is prophylactic physiotherapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?’
Search Terms:
physical therapy (MeSH), postoperative pulmonary complications (textword) were used to search the current MEDLINE file. You located the following article:Citation:
Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery.
British Journal of Surgery 1997;84:1535-1538.
Read the article and decide:
- Is the evidence from this randomised trial valid?
- If valid, is this evidence important?
- If valid and important, can you apply this evidence in caring for your patient?
Completed Therapy Worksheet for Evidence-Based Physiotherapy Practice
Citation
Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:1535-1538.
Are the results of this single preventive or therapeutic trial valid?
- Was the assignment of patients to treatments randomised?
- And was the randomisation list concealed?
- Yes
- No
- Were all patients who entered the trial accounted for at its conclusion?
- And were they analysed in the groups to which they were randomised?
- Yes (control 192/194; experimental 172/174)
- No
- Were patients and clinicians kept “blind” to which treatment was being received?
- Not possible to blind patients. Outcome assessors were not blind.
- Aside from the experimental treatment, were the groups treated equally?
- Yes
- Were the groups similar at the start of the trial?
- Yes
Are the valid results of this randomised trial important?
| Post-operative Pulmonary Complications (all patients) | Relative Risk Reduction RRR |
Absolute Risk Reduction ARR |
Number Needed to Treat NNT |
|
|---|---|---|---|---|
| CER | EER | (CER-EER)/CER | CER-EER | 1/ARR |
| 0.27 | 0.06 |
79% 52% to 100% |
21% 14% to 29% |
5 (4-8) |
Your Calculations
| Post-operative Pulmonary Complications (high risk patients) | Relative Risk Reduction RRR |
Absolute Risk Reduction ARR |
Number Needed to Treat NNT |
|
|---|---|---|---|---|
| CER | EER | (CER-EER)/CER | CER-EER | 1/ARR |
| 0.51 | 0.15 |
71% 33% to 100% |
36% 17% to 56% |
3 (2-6) |
Can you apply this valid, important evidence about a treatment in caring for your patient?
Do these results apply to your patient?
- Is your patient so different from those in the trial that its results can’t help you?
- Similar.
- How great would the potential benefit of therapy actually be for your individual patient?
-
Similar. Method I: f
Risk of the outcome (school absence) in your patient, relative to patients in the trial. expressed as a decimal: 1
$$ mathit{NNT}/mathit{f} = 5/1 = 5\\
text{($NNT$ for patients like yours)}$$ -
Method II: 1 / (PEER x RRR)
Your patient’s expected event rate if they received the control treatment:
$$ mathit{PEER}: underline{qquadqquad} \\
1/(mathit{PEER} times mathit{RRR}) \\
= 1/underline{qquadqquad} \\
= underline{qquadqquad} \\
text{($NNT$ for patients like yours)}$$
Are your patient’s values and preferences satisfied by the regimen and its consequences?
- Do your patient and you have a clear assessment of their values and preferences?
- Needs to be addressed in each patient.
- Are they met by this regimen and its consequences?
- Needs to be addressed in each patient.
Additional Notes
Need to know the post-operative pulmonary complication rate for my unit.
Upper Abodominal Surgery – Periop physio decreases postop pulmonary complications
Clinical Bottom Line
Perioperative physio decreases post-op pulmonary complications in patients undergoing upper abdominal surgery (NNT=5).
Citation
Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery.
British Journal of Surgery 1997;84:1535-1538.
Clinical Question
Is prophylactic physiotherapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?
Search Terms
physical therapy (MeSH), postoperative pulmonary complications (textword) were used to search the current MEDLINE file
The Study
- Non-blinded non-randomised trial without intention-to-treat.
- The Study Patients: Series of 368 consecutive patients aged 19-92 (mean 53.4 years) undergoing elective open abdominal surgery in Goteborg, Sweden. The baseline characteristics (sex, age, height, weight, smoking status, existing lung disease, high risk status, and American Society of Anesthesiologists score) were similar in both groups. The study design was described as randomized but used alternation by month.
- Control group (N = 194; 192 analysed): Patients did not receive any information or training
- Experimental group (N = 174; 172 analysed): Patients were seen the day before surgery and post operatively and given information and training. The training consisted of pursed lip breathing exercises, huffing, and coughing to be done hourly as well as information about positioning changes while in bed and early mobilization. High risk patients received positive respiratory pressure (PEP) masks. Patients were told to take 30 deep breaths with huffing and coughing after every 10th breath every hour during the daytime after the surgery. The duration of physiotherapy was 10-15 minutes prior to surgery and 15-20 minutes after the operation.
The Evidence
| Outcome | Time to Outcome | CER | EER | RR | ARR | NNT |
|---|---|---|---|---|---|---|
| Post-operative pulmonary complication PPC(all patients) | 1-6 days | 27% | 6% | 79% | 21% | 5 |
| 95% Confidence Intervals: | 52% to 100% | 14% to 29% | 4 to 8 | |||
| PPC (high risk patients) | PPC (high risk patients) | 51% | 15% | 71% | 36% | 3 |
| 95% Confidence Intervals: | 33% to 100% | 17% to 56% | 2 to 6 | |||
| Pneumonia (all patients) | 1-6 days | 0.068 | 0.006 | 91% | 6% | 17 |
| 95% Confidence Intervals: | 36% to 100% | 3% to 10% | 11 to 41 |
Comments
- The limitations of the study were lack of true randomisation (alternation by month was used) and lack of blind outcome assessment.
- A post-operative pulmonary complication was defined as oxygen saturation less than 92% OR two of the following three criteria: temperature greater than 38.2 degrees C, auscultation findings and x-ray changes.
Appraised By
Jean Crowe, Mary Ann O’Brien.
