1. Current practice for chest physiotherapy First Joint Scandinavian Conference in Cardiothoracic Surgery Stockholm 2009 PhD, RPT Elisabeth Westerdahl

3. Cardiac surgery Influence on respiratory function A restrictive ventilatory defect Retained airway secretions and ineffective coughing Gas exchange abnormalities, shunt Adult respiratory distress syndrome (ARDS)

4. Pulmonary function the first postoperative days after open- heart surgery

5. Because decreased lung volumes and atelectasis leads to hypoxemia and may predispose to the development of pneumonia, a number of postoperative interventions have been designed to prevent or overcome it. The standard therapy is chest physiotherapy. Forshag-92

6. Goals of chest physiotherapy Reduse airway obstruction Prevent the accumulation of secretions Improve the mobilization of secretions Improve the distribution of ventilation Enhance gas exchange Promote more efficient breathing patterns Reduce the work of breathing Improve cardiopulmonary exercise tolerance E Dean/J Pryor

7. Chest physiotherapy Treatment hierarchy (E Dean, Kanada) 1 Mobilisation & activity 2 Positioning 3 Breathing control 4 Hough maneouvres 5 Relax and energyconsumption control 6 Movements/ROM exercises 7 Postural drainage 8 Manual techniques 9 Suctioning

8. We know that our treatment work – or do we?

9. Prophylactic respiratory physiotherapy after cardiac surgery is widely used Evidence is lacking on benefit from any method. It is likely that there are adverse effects and costs only! Systematic review by Pasquina BMJ 2003;327(7428):1379

11. Research idea WCPT Vancouver, Canada den 2-6 juni 2007 Professor Tom Overend, The University of Western Ontario, School of Physical Therapy in Ontario Physiotherapist, PhD, Beatrice Tucker School of Physiotherapy, Perth, Australia

12. What scientific documentation is needed to change ordinary clinical practice?

13. Physiotherapy management of patients undergoing cardiac surgery in Sweden - a questionnaire survey Elisabeth Westerdahl, Phd, reg Physiotherapist Margareta M ö ller, professor, head of the clinic, Centre for Health Care Sciences, Ö rebro County Council

14. Purpose To review the usual or routine physiotherapy management of the uncomplicated postoperative open- heart surgery patient in Sweden.

15. Design Postal questionnaire survey to all Physiotherapists working at Departments of Thoracic surgery in Sweden december 2007.

16. Departments of Thoracic surgery Sahlgrenska universitetssjukhuset Karolinska universitetssjukhuset Blekingesjukhuset Universitetssjukhuset i Linköping Universitetssjukhuset i Lund Norrlands Universitetssjukhus Akademiska sjukhuset Universitetssjukhuset Örebro

17. We would like to investigate Routine postoperative physiotherapy management of patients undergoing uncomplicated open-heart surgery. Not treatment of patients who develop neurological symptoms, circulatory instability, prolonged intubation, or other conditions requiring individualised programmes.

18. This survey only applies to physiotherapy treatment of adult patients who have undergone cardiac surgery (coronary artery bypass graft surgery (CABG), mitral, aortic or tricuspid valve surgery, or a combination.

19. Physiotherapist employment at the Thoracic surgery departments in dec 2007 GÖTEBORG 5 full time employments KARLSKRONA 1 LINKÖPING1,65 LUND4,45 STOCKHOLM4,15 UMEÅ 5,05 UPPSALA2,30 ÖREBRO2

20. Sample In total 36 Physiotherapists identified (3 not included because of parental leave or working with other patients)

21. Response rate Of the 33 questionnaires 29 were returned (response rate 88%)

22. Which of the following departments do you work in at the moment? - Thoracic surgery ward n= 24 - Intermediate ward (IMA) n= 15 - Intensive care unit n=20

23. Working experience Working as PT 10 ± 7 year (1 – 33 year) Working with Thoracic surgery patients 6 ± 4 year (1-16 year)

24. Have you completed any specific courses in the cardiopulmonary area? No28% Yes72%

25. Are any written physiotherapy guidelines or protocol for physiotherapy management of the cardiac surgery patients at your Thoracic Surgery department? Non=6 Yes n=21 Don´t known=2

26. If you have guidelines or protocol, do you usually follow them when you treat cardiac surgery patients? Yes, always n=10 Yes, most of the timen=11 Yes, sometimes - No- Don’t know n=8

27. Does the physiotherapist automatically meet all patients who have undergone cardiac surgery or only certain patients? Meets all90% Only meets certain patients 10%

28. Do all patients undergoing open-heart surgery (non-emergency) at your Thoracic Surgery department usually receive preoperative information from a physiotherapist? Non=3 Yesn=26

29. How do the patients usually receive the preoperative information? Individually21% In group76% Missing value3%

30. Mobilization Which of the following treatments you usually provide to the patient on the first postoperative days after surgery? POD 1POD 2POD 3 Sitting on bed or in chair28 15 14 Standing27 16 14 Walking in the room8 23 15 Walking in corridor8 19 27

31. Stair climbing Perform 69% Don´t perform 31%

32. Thoracic/upper extremities ROM exercises Postop dayIIIIIIIV Unilateral1 5 10 9 Bilateral 3 20 22 19

33. Which sternal precautions are ordered for the healing period during the first postoperative weeks at your department? Patients are allowed to use: their arms to push up from lying to sitting83% their arms to push up from sitting to standing3% stomach muscles to raise from lying to sitting 59% arms and shoulders, full active movement93% arms and shoulders with 1-2 kg weights52% rollator (rolling walker)97% walker100% Crutches17%

34. Does the physiotherapist provide any group training for the patients admitted for care at your Thoracic Surgery department? No38% Yes 62%

35. If so, what kind of breathing exercises are patients instructed to perform? (Check as many as apply) RoutinelyIf neededNever Deep breathing exercises 1881 Diaphragmatic breathing11113 Pursed lip breathing 6181 Sustained (continual) maximal inspiration3121 Incentive spirometry (Voldyne, Triflo etc) 0521 PEP device breathing2450 IR-PEP (inspiratory resistance-PEP)…cm H 2 O 7912 IMT (inspiratory muscle training)…….cm H 2 O0620 CPAP………….cm H 2 O0263

36. Physiotherapy in the ICU (n=20) Do you perform manual hyperinflation/bagging? No90% Yes 10% Do you perform suction of airways via nose, mouth or tracheostomy? No65% Yes 35% Do you participate actively in weaning off respirator? No75% Yes 25%

37. Physiotherapy in the ICU (n=20) Do patients who have undergone cardiac surgery usually receive physiotherapy in the Thoracic ICU on postoperative day 1? No0% Only certain patients 15% Yes, all patients85%

38. When is physiotherapy given to cardiac surgery patients at your Thoracic Surgery department? (postoperative day 1) RoutinelyIf needed Never Evenings 100% Saturdays59% 41% Sundays31% 14% 55% Holidays48% 52%

39. When is physiotherapy given to cardiac surgery patients at your Thoracic Surgery department? (postoperative day 2) RoutinelyIf needed Never Evenings 100% Saturdays17% 83% Sundays48% 48% 56% Holidays10% 90%

40. Which of the following days do you or your colleagues usually treat patients and on average how many sessions does the patient receive per day? (ordinary routines Monday to Friday) Treatment on:RoutinelyIf needed Postoperative day 1 1-3 times90% 3% Postoperative day 2 1-2 times 93% 3% Postoperative day 3 1-2 times 69% 28% Postoperative day 4 1 times 28% 69% Postoperative day 5 1 times 28% 69%

41. Do you consider physiotherapy necessary after cardiac surgery? Non=0 Yes, to some patientsn=3 Yes, to all patientsn=26

42. What do you consider the main purpose of physiotherapy in connection with cardiac surgery? Prevent postoperative complications Start rehabilitation Prevent movement fear avoidance Make patients aware of the importance of physical activity Prevent problems related to the sternum Help the patient start breathing exercises and mobilisation so they can manage by themselves Second prevention/ motivate physical activity Optimizing the lung function Avoid cardiorespiratory complications (DVT, pneumonia, atelectasis, secretion problems) Empower breathing and circulation Prevent and treat pulmonary problems

43. Is there scientific evidence that physiotherapy is necessary after cardiac surgery? Non=1 Yesn=25 Don´t known=3

44. Do you consider the physiotherapy treatment offered at the Thoracic Surgery Department where you work as optimal? Non=9 Yesn=16 Don´t known=4

45. Thanks to all Physiotherapists for answering all questions and Thankyou for your attention!