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  • Inom hjärtkirurgin är kranskärlskirurgi idag det vanligaste kirurgiska ingreppet. Vener från patientens ben och/eller blodkärl som finns på insidan av bröstkorgen används för att förstärka patientens egna kranskärl och på så vis förbättra blodförsörjningen till hjärtat. Bröstkorgen öppnas med ett snitt som delar sternum sk sternotomi. I samband med operationen påverkas lungfungfunktionen påtagligt. Orsakerna till nedsättningen är förutom det kirurgiska ingreppet bland annat narkos, användandet av hjärt-lung-maskin, respiratorbehandling, smärta, smärtlindring, vissa läkemedel och immobilisering. Resultatet blir en restriktivt nedsatt lungfunktion, försämrad syresättning, atelektaser och shunt. Andningsgymnastik används rutinmässigt efter hjärtkirurgin i många länder. Ingen studie har hittills visat om man med specifika voluntära andningsövnungar kan påverka atelektaser och syresättning postoperativt.
  • Hjärtkirurgi medför en hög risk för lungkomplikationer. Ledande orsak till postoperativ mortalitet (atelektaser, lungödem, nedre luftvägsinfektion, andningsinsufficiens. Definitionen av en lungkomplikation oklar. Olika kombinationer av variabler används i olika vetenskapliga studier (feber, mått på lungfunktion, subjektiv upplevelse etc).
  • I samband med bukirurgi väl dokumenterat om effekt av andningsgymnastik. I samband med hjärtkirurgi har vetenskaplig dokumentation saknats. Frågan om nyttan av andningsgymnastik har tom blivit ifrågasatt. Kathy Stiller Sjukgymnast från Australien som är orsaken till att jag började forska. Publicerat studier som ifrågasätter om andningsgymnastik behövs efter hjärtkirurgi. Före 94 ingen studie gjord med en riktig KG. Kvaliten skiftat på de studier som gjorts.
  • Randomiserade kontrollerade multicenter studier Adekvat patientantal Väl definierade och beskrivna behandlings- och mätmetoder Vem ser till att den nya kunskapen tillämpas? Vilka drivkrafter finns att främja tillämpning av klinisk evidens? Vilka krafter hindrar att denna kunskap används? Vi har en tradition att lita på auktoriteter. Varför varierar praxis utan rationella skäl? Kunskapsmassan är mycket stor och komplex! Tillämpa systematiskt granskad och sammanställd kunskap i klinisk praxis.
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    • 1. Current practice for chest physiotherapy First Joint Scandinavian Conference in Cardiothoracic Surgery Stockholm 2009 PhD, RPT Elisabeth Westerdahl
    • 2.  
    • 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
      • P revent the accumulation of secretions
      • I mprove the mobilization of secretions
      • I mprove the distribution of ventilation
      • Enhance gas exchange
      • P romote more efficient breathing patterns
      • Reduce the work of breathing
      • I mprove 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
    • 10.  
    • 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   LINKÖPING 1,65   LUND 4,45   STOCKHOLM 4,15   UMEÅ 5,05   UPPSALA 2,30   ÖREBRO 2
    • 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?
      • No 28%
      • Yes 72%
    • 25. Are any written physiotherapy guidelines or protocol for physiotherapy management of the cardiac surgery patients at your Thoracic Surgery department? No n=6 Yes n=21 Don´t know n=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 time n=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 all 90%
      • 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?
      • No n=3
      • Yes n=26
    • 29. How do the patients usually receive the preoperative information?
      • Individually 21%
      • In group 76%
      • Missing value 3%
    • 30. Mobilization Which of the following treatments you usually provide to the patient on the first postoperative days after surgery? POD 1 POD 2 POD 3 Sitting on bed or in chair 28 15 14 Standing 27 16 14 Walking in the room 8 23 15 Walking in corridor 8 19 27
    • 31. Stair climbing Perform 69% Don´t perform 31%
    • 32. Thoracic/upper extremities ROM exercises Postop day I II III IV Unilateral 1 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 sitting 83% their arms to push up from sitting to standing 3% stomach muscles to raise from lying to sitting 59% arms and shoulders, full active movement 93% arms and shoulders with 1-2 kg weights 52% rollator (rolling walker) 97% walker 100% Crutches 17%
    • 34. Does the physiotherapist provide any group training for the patients admitted for care at your Thoracic Surgery department? No 38% Yes 62%
    • 35. If so, what kind of breathing exercises are patients instructed to perform? (Check as many as apply) Routinely If needed Never Deep breathing exercises 18 8 1 Diaphragmatic breathing 11 11 3 Pursed lip breathing 6 18 1   Sustained (continual) maximal inspiration 3 1 21  Incentive spirometry (Voldyne, Triflo etc)   0 5 21 PEP device breathing 24 5 0 IR-PEP (inspiratory resistance-PEP)…cm H 2 O   7 9 12 IMT (inspiratory muscle training)…….cm H 2 O 0 6 20   CPAP………….cm H 2 O 0 26 3  
    • 36. Physiotherapy in the ICU (n=20)
      • Do you perform manual hyperinflation/bagging?
      • No 90%
      • Yes 10%
      • Do you perform suction of airways via nose, mouth or tracheostomy?
      • No 65%
      • Yes 35%
      • Do you participate actively in weaning off respirator?
      • No 75%
      • 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?
      • No 0%
      • Only certain patients 15%
      • Yes, all patients 85%
    • 38. When is physiotherapy given to cardiac surgery patients at your Thoracic Surgery department? ( postoperative day 1) Routinely If needed Never Evenings 100% Saturdays 59% 41% Sundays 31% 14% 55% Holidays 48% 52%
    • 39. When is physiotherapy given to cardiac surgery patients at your Thoracic Surgery department? ( postoperative day 2) Routinely If needed Never Evenings 100% Saturdays 17% 83% Sundays 48% 48% 56% Holidays 10% 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 : Routinely If needed Postoperative day 1 1-3 times 90% 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?
      • No n=0
      • Yes, to some patients n=3
      • Yes, to all patients n=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?
      • No n=1
      • Yes n=25
      • Don´t know n=3
    • 44. Do you consider the physiotherapy treatment offered at the Thoracic Surgery Department where you work as optimal? No n=9 Yes n=16 Don´t know n=4
    • 45. Thanks to all Physiotherapists for answering all questions and Thankyou for your attention!

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