1. Scandinavian Conference in Cardiothoracic Surgery 2009 National guidelines for chest- and abdominal physiotherapy

2. Scandinavian Conference in Cardiothoracic Surgery 2009 Members in the working group Maria Antonsson BSc, Akademiska sjukhuset, Uppsala Monika Fagevik Olsén, Associate professor, Sahlgrenska Universitetssjukhuset, Göteborg Henrik Johansson MSc, Akademiska sjukhuset, Uppsala Lena Sandström MSc, Karolinska universitetssjukhuset, Stockholm Charlotte Urell, PhD student, Akademiska sjukhuset, Uppsala Elisabeth Westerdahl PhD, Universitetssjukhuset i Örebro Malin Wiklund PhD student, Sahlgrenska Universitetssjukhuset, Göteborg

3. Scandinavian Conference in Cardiothoracic Surgery 2009  Why do we need national guidelines ? The aim of the guidelines is to gather the effects of respiratory physiotherapy treatments in thorax- and abdominal surgery and put it together with clinical experience.

4. Scandinavian Conference in Cardiothoracic Surgery 2009 How did we start?  Respiratory physiotherapy treatments between 1980-2008  Written in english  Extensive search in seven medical data bases

5. Scandinavian Conference in Cardiothoracic Surgery 2009 Search words thoracic surgery lung surgery postoperative chest physical therapy breathing exercises CPAP Incentive spirometry IPPB positive expiratory pressure pursed-lip breathing resistance breathing

6. Scandinavian Conference in Cardiothoracic Surgery 2009 What studies did we choose? Randomized controlled studies Outcomes; secretion, hypoxia/hypercapnia, pulmonary volume, pneumonia, hospital time, ICD time, post pulmonary complications (atelectases, pneumonia), death.

7. Scandinavian Conference in Cardiothoracic Surgery 2009 The review 34 cardiac- and 5 pulmonary studies were reviewed 1.Classifying on the basis of Verhagen (Delphi method) 2.Systematic selection 3.SBU

8. Scandinavian Conference in Cardiothoracic Surgery 2009 Verhagen scoring Questions about: Randomization Blinding Selection

9. Scandinavian Conference in Cardiothoracic Surgery 2009 The review 34 cardiac- and 5 pulmonary studies were reviewed 1.Classifying on the basis of Verhagen (Delphi method) 2.Systematic selection 3.SBU

10. Scandinavian Conference in Cardiothoracic Surgery 2009 1. Specific respiratory treatment against an untreated control group 2. Specific respiratory treatment included in ordinary treatment compared with only ordinary treatment 3. One specific respiratory treatment against another specific respiratory treatment Systematic selection

11. Scandinavian Conference in Cardiothoracic Surgery 2009 The review 34 cardiac- and 5 pulmonary studies were reviewed 1.Classifying on the basis of Verhagen (Delphi method) 2.Systematic selection 3.SBU

12. Scandinavian Conference in Cardiothoracic Surgery 2009 Result 34 cardiac studies Verhagen score (0-10) 4( > 7) 30(4-6) 0(0-3) Systematic selection 7 (1) 9 (2) 19 (3) 5 pulmonary studies Verhagen score (0-10) 0(>7) 5(4-6) 0(0-3) Systematic selection 3 (1) 2 (2)

13. Scandinavian Conference in Cardiothoracic Surgery 2009 What kind of treatments has been studied? Preoperative: fitness training, IS, IPPB, inspiratory muscle training Postoperative: DB, ACBT, IS, PEP, IR- PEP, CPAP, IPPB, Bilevel-PAP, huff, cough, early mobilization, manual techniques

14. Scandinavian Conference in Cardiothoracic Surgery 2009 Where did the studies come from? Cardiac studies 15 Europe 6 Canada 5 USA 4 Brazil 3 Australia 1 Israel Pulmonary studies 4 Europe 1 Israel

15. Scandinavian Conference in Cardiothoracic Surgery 2009 National guidelines Differences Discussions Evidence situation and clinical experience national guidelines Finished during 2009 (www.LSR.se)

16. Scandinavian Conference in Cardiothoracic Surgery 2009 Possibilities Read a lot of articles Critical review Discuss with experieced collegues Run into ”new” treatments National network Create guidelines for colleagues

17. Scandinavian Conference in Cardiothoracic Surgery 2009 Difficulties Frustration Time

18. Scandinavian Conference in Cardiothoracic Surgery 2009 What about clinical guidelines in the other Nordic countries? Have some of you worked with national guidelines?

19. Scandinavian Conference in Cardiothoracic Surgery 2009 Discussion 1. Do you have local guidelines at your hospital? 2.In what extent do you use guidelines in your clinical work? 3.What kind of things is important in a guideline document for the clinical physiotherapist? 4.How should we work with implementation of the guidelines?

20. Scandinavian Conference in Cardiothoracic Surgery 2009