Preoperative physical therapy for elective cardiac surgery patients

Abstract

Background: After cardiac surgery, physical therapy is a routine procedure delivered with the aim of preventing postoperative pulmonary complications.

Objectives: To determine if preoperative physical therapy with an exercise component can prevent postoperative pulmonary complications in cardiac surgery patients, and to evaluate which type of patient benefits and which type of physical therapy is most effective.

Search methods: Searches were run on the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (2011, Issue 12 ); MEDLINE (1966 to 12 December 2011); EMBASE (1980 to week 49, 2011); the Physical Therapy Evidence Database (PEDro) (to 12 December 2011) and CINAHL (1982 to 12 December 2011).

Selection criteria: Randomised controlled trials or quasi-randomised trials comparing preoperative physical therapy with no preoperative physical therapy or sham therapy in adult patients undergoing elective cardiac surgery.

Data collection and analysis: Data were collected on the type of study, participants, treatments used, primary outcomes (postoperative pulmonary complications grade 2 to 4: atelectasis, pneumonia, pneumothorax, mechanical ventilation > 48 hours, all-cause death, adverse events) and secondary outcomes (length of hospital stay, physical function measures, health-related quality of life, respiratory death, costs). Data were extracted by one review author and checked by a second review author. Review Manager 5.1 software was used for the analysis.

Main results: Eight randomised controlled trials with 856 patients were included. Three studies used a mixed intervention (including either aerobic exercises or breathing exercises); five studies used inspiratory muscle training. Only one study used sham training in the controls. Patients that received preoperative physical therapy had a reduced risk of postoperative atelectasis (four studies including 379 participants, relative risk (RR) 0.52; 95% CI 0.32 to 0.87; P = 0.01) and pneumonia (five studies including 448 participants, RR 0.45; 95% CI 0.24 to 0.83; P = 0.01) but not of pneumothorax (one study with 45 participants, RR 0.12; 95% CI 0.01 to 2.11; P = 0.15) or mechanical ventilation for > 48 hours after surgery (two studies with 306 participants, RR 0.55; 95% CI 0.03 to 9.20; P = 0.68). Postoperative death from all causes did not differ between groups (three studies with 552 participants, RR 0.66; 95% CI 0.02 to 18.48; P = 0.81). Adverse events were not detected in the three studies that reported on them. The length of postoperative hospital stay was significantly shorter in experimental patients versus controls (three studies with 347 participants, mean difference -3.21 days; 95% CI -5.73 to -0.69; P = 0.01). One study reported a reduced physical function measure on the six-minute walking test in experimental patients compared to controls. One other study reported a better health-related quality of life in experimental patients compared to controls. Postoperative death from respiratory causes did not differ between groups (one study with 276 participants, RR 0.14; 95% CI 0.01 to 2.70; P = 0.19). Cost data were not reported on.

Authors' conclusions: Evidence derived from small trials suggests that preoperative physical therapy reduces postoperative pulmonary complications (atelectasis and pneumonia) and length of hospital stay in patients undergoing elective cardiac surgery. There is a lack of evidence that preoperative physical therapy reduces postoperative pneumothorax, prolonged mechanical ventilation or all-cause deaths.

Conflict of interest statement

EH, PH and NvM were involved in one or two of the included studies (Hulzebos 2006A; Hulzebos 2006B).

YS has no known conflicts of interest.

Figures

1

Study flow diagram.

2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

1.1. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 1: PPC grade 2 (atelectasis)

1.2. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 2: PPC grade 2 (any type)

1.3. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 3: PPC grade 3 (pneumonia)

1.4. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 4: PPC grade 3 (pneumothorax)

1.5. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 5: PPC grade 3 (any type)

1.6. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 6: PPC grade 4 (mechanical ventilation > 48 hours)

1.7. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 7: PPC grade 4 (all type)

1.8. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 8: PPC grade ≥ 2 (any type)

1.9. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 9: Postoperative death (all causes)

1.10. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 10: Length of postoperative hospital stay (days)

1.11. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 11: Physical function measures (six minute walking test)

1.12. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 12: Postoperative death (respiratory causes)

1.13. Analysis

Comparison 1: Preoperative physical therapy versus no preoperative physical therapy, Outcome 13: Quality of life (short‐form‐36 physical composite score)