1. 1

2. AWARENESS OF CHEST PHYSIOTHERAPY
TREATMENT AND TECHNIQUES AMONG
PHYSIOTHERAPIST WORKING IN
CARDIOTHORACIC UNITS IN KARACHI
by
Hina Al Fatiamh Siddiqui
PPDPT (Batch I)
Isra University, Karachi Campus
14 September 2012
2

3. AIM OF THE STUDY
The aim of the present study is to determine
physiotherapy practice regarding chest
physiotherapy and breathing exercises for patients
undergoing open heart surgery in Karachi
To explore about the awareness of chest
physiotherapy treatment and techniques among
physiotherapist working in cardiothoracic units in
Karachi
3

4. INTRODUCTION
 Pulmonary complications like atelectasis and
arterial hypoxemia are frequently seen in
patients after cardiac surgery (westerdahl E et al., 2001; Wynne R, 2004).
 Pulmonary dysfunction is an ever-present result
of cardiac surgery, and every clinician well-
known with the postoperative care of cardiac
surgery patients anticipates complications.
4

5. INTRODUCTION (Cond)
 There is an accord on the importance of pre- and post-
operative breathing exercises and physiotherapy
treatment.
 In addition to early mobilization, chest physical therapy
and breathing exercises are commonly prescribed
preoperatively as well as post operatively to patients
undergoing cardiac surgery to facilitate prevention or
reduction of post-operative pulmonary complications.
(Westerdahl E et a.l, 2005; Hulzebos EH et al.,2006; Haeffener MP et
al.,2008; ,Herdy AH et al.,2008).
5

6. INTRODUCTION (Cond)
 There is argument regarding which breathing techniques
are the most helpful (westerdahl E et al.,2011),as different
chest physical therapy and breathing exercises
techniques with and without mechanical devices are
carried out after cardiac surgery.( Urella C et al.,2011; Haeffener
MP et al.,2008;Zarbock A et al.,2009; Renault JA et al.,2009 Agostini P et
al.,2009)
 Up till now, no survey describing the use of pre and post-
operative breathing exercises for cardiac surgery
patients in Pakistan has been carried out.
6

7. METHODOLOGY
 Questionnaire survey (cross sectional study) is carried out on a total
population of 40 physiotherapists working in cardiothoracic unit
which were randomly selected during January 2012 to August 2012.
 Data is collected from following hospitals across Karachi namely :
 National Institute of Cardio Vascular Diseases Karachi (NICVD),
 Ziauddin Medical University Hospital Karachi (ZMUH),
 National Medical Center (NMC),
 Health Care Hospital (HCH),
 Liaquat National Hospital (LNH) and
 Karachi Institute of Heart Diseases (KIHD).
7

8. METHODOLOGY (Cond)
 The questionnaire designed by Westerdahl E et al in 2011 for their
survey conducted in Sweden related to Chest physiotherapy and
breathing exercises for cardiac surgery patients in Sweden is used
for this study.
 The questionnaire consists of total 27 questions and includes both
open ended and close ended questions about preoperative and
postoperative chest physiotherapy treatment of cardiac patients for
uncomplicated open heart surgery.
 Data is analyzed using descriptive statistics, and mean, median and
range were calculated, the SPSS version 10 software package is
used for the statistical analysis.
8

9. METHODOLOGY (Cond)
 INCLUSION CRITERIA:
 Physiotherapist having working experience of more than one year
in cardiothoracic unit are included in the study and
 this survey only applies to physiotherapy treatment of adult patients
who have undergone cardiac surgery (uncomplicated open heart
surgery) including: coronary artery bypass graft surgery (CABG),
mitral, aortic or tricuspid valve surgery, or a combination of CABG &
valve surgery,( including off- pump surgery).
9

10. METHODOLOGY (Cond)
 EXCLUSION CRITERIA:
 Physiotherapist not having working experience in cardiothoracic unit
 Physiotherapist having work experience less than one year in
cardiothoracic unit
 Patients who develop neurological symptoms, circulatory instability,
prolonged intubation, or other conditions requiring individualized
programs are not included
 Children and patients under gone complicated open heart surgery
are not included in the study.
10

11. RESULT
 According to this survey the average age of the participant
physiotherapists was 31.20±6.8 years.
 The total mean work experience as a physiotherapist was 7.592±6.7
years.
 Similarly average working experience as physiotherapist in a
thoracic surgery department was 4.51±5.21 years.
 Out of 40 participants, 19(47.5%) were female and 21(52.5%) were
male.
 Seven (7.5%) of the respondents had completed specific courses in
the cardiopulmonary area.
11

12. RESULT (Cond)
 80% physiotherapist provides preoperative information to patients
about surgical procedure in general, sternotomy, reparatory
treatment/ extubation, post operative pulmonary function /
complication, breathing exercise and coughing technique.
 Identification of patients at high risk for postoperative pulmonary
complication was noted by 35% of the physiotherapists.
 Most of the cardiac patients received physiotherapist treatment in
the ICU during the first postoperative day one after surgery
(77.5%).
 Written guideline or protocol for the physiotherapy treatment of
extubated patients in the ICU were available according to 35% of
the respondents, whereas physiotherapy guideline for intubation
patients was less accessible (10% cases).
12

13. RESULT (Cond)
 37.5% physiotherapists performed manual hyperinflation
 92.5% performed suction of airway via nose, mouth or tracheotomy
 35% actively participated in the procedure for weaning a patient off
the respirator.
 During the initial postoperative days the cardiac surgery patients
usually received treatment sessions by the physiotherapist from the
day of surgery to fifth post operative day , patients usually receive
treatment “if needed” at the day of surgery and “routinely”
afterwards.
 Breathing Exercise, Relaxation techniques, Coughing/huffing
techniques and Positioning are mostly provided treatment regimes
during the first four postoperative days after surgery
13

14. RESULT (Cond)
 Eighty percent physiotherapist instructed the patients to performed
breathing exercise on a regular basis post-operatively.
Specific Breathing Exercises given to pts postoperatively
“ROUTINELY” “IF NEEDED” “NEVER”
Deep breath exercise positive expiratory Inspiratory resistance
n=40(100%), pressure (PEP) positive expiratory
n= 19(47.5%) pressure (IR-PEP) ,
Diaphragmatic breathing
n=36(90%) Inspiratory muscle
Training (IMT)
Incentive spirometry
n=39(97.5%). Continuous positive
airway pressures (CPAP)
Pursed lip breathing
n=15(37.5%)
Sustained maximal
inspiration n=5(12.5%) 14

15. RESULT (Cond)
 80% physiotherapist instructed the patients to perform the
recommended breathing practice once an hour during the first two
postoperative days.
 Number of breath at each training session as instructed by
physiotherapists ranges between 5 to 30 breaths and, most
physiotherapist educate patients to perform 10 to 20 breaths
15

16. RESULT (Cond)
Responses regarding Physiotherapist provided, coughing support to the
patients facing secretion problem,
patients performing with the
small pillow 97.5%,
manually by physiotherapist 55.0%
without pillow 45.0%,
sternal support with a device such as heart Hugger harness is not used.
16

17. RESULT (Cond)
Recommendation to continue breathing exercises at
home after discharge is 82.5%
deep breathing exercises is mostly recommended
R whereas spirometry, huffing / coughing and chest
expansion exercises are other suggested regimes.
E
S 55.4% physiotherapist recommends device for
breathing exercise at home after discharge and
U spirometry is the device that is recommended mostly.
L
Considerable variation in instruction to patients about
T the duration to continue breathing exercises after
discharge is observed, which ranges from 1 week to 13
weeks
17

18. DISCUSSION
 This is the first survey in Karachi to determine physiotherapy practice
regarding chest physiotherapy and breathing exercises for patients
undergoing open heart surgery in Karachi and to explore about the
awareness of chest physiotherapy treatment and techniques among
physiotherapist working in cardiothoracic units in Karachi.
 Chest physiotherapy practice in Karachi has many similarities to other
international surveys of clinical practice. (Tucker B et al., 1996, Overend TJ et al., 2010, Fiore
JF et al., 2010, Westerdahl E et al., 2011)
 Several breathing exercises are applied, in the present study, all
physiotherapists instructed the patients to perform breathing exercises, with
or without PEP, on a regular basis postoperatively. Deep breathing
exercises was the first choice of breathing technique and this in agreement
with the results from Overend TJ et al., who demonstrated that treatment on
the first postoperative days primarily consisted of deep breathing exercises
and coughing (Overend TJ et al., 2010).
18

19. DISCUSSION (Cond)
 The earlier study by Tucker et al , performed in Australia and New Zealand
in the 90´s, also demonstrated that deep breathing exercises was the most
commonly used technique, the same results were observed in Sweden by
Westerdahl et al (Tucker B et al., 1996 ,Westerdahl E et al., 2011)
 according to this survey breathing exercises with positive pressure devices
is not often used in Karachi ,however in Brazil and Sweden the use of
breathing exercises with positive pressure devices post operatively is
extensive (Fiore JF et al., 2010 Westerdahl E et al., 2011), the same technique is also used
in Australia and New Zealand after thoracic surgery (Reeve J et al., 2007)
 however as compared with conventional breathing exercises there is
scarcity in evidence of advantage of breathing exercises with positive
pressure devices (Ingwersen UM et al.,1993; Richter Larsen K et al.,1995; Westerdahl E et al.,2003;
Borghi-Silva A et al.,2005).
19

20. DISCUSSION (Cond)
 The Incentive spirometry device is rarely used in Sweden however it is
commonly advised in other countries to visualize and facilitate inspiration
(Tucker B et al., 1996; Overend TJ et al., 2010), and it is extensively used in Karachi as
compared to Inspiratory resistance positive expiratory pressure (IR-PEP),
Inspiratory muscle training (IMT), and Continuous positive airway pressure
(CPAP) which were seldom used.
 There was no agreement on how frequently breathing exercises should be
performed, but the physiotherapists’ most frequently proposal of hourly
treatment in this study, was reliable with the existing literature on the
suggested frequency (Westerdahl E et al.,2003; Westerdahl E et al., 2011; Muller AP et al., 2006 ;
Yanez-Brage I et al., 2009 )
 Literature also propose execution of a higher rate of deep breathing
exercises in the initial phase after cardiac surgery. (Urella, C et al, .2011) and
according to our survey most physiotherapist educate patients to perform
10 to 20 breaths which is also in accord with the survey performed in
Sweden by Westerdahl E et al (Westerdahl E et al., 2011)
20

21. DISCUSSION (Cond)
 As 80% of physiotherapist provides preoperative information which
is in pact with literature.
 92.5% patients agrees that they provide physiotherapy treatment in
the thoracic ICU on Postoperative day 1
 80%s of physiotherapist provide instruction of breathing exercise on
a regular basis postoperative. and
 82.5% recommend patients to continue performing breathing
exercises at home after discharge
 These all parameters shows the awareness of chest
physiotherapist working in Karachi about the
treatment and techniques used after open heart
surgery.
21

22. DISCUSSION (Cond)
 Responses were received from physiotherapists at all hospitals to which the
survey was sent. The number of respondents was rather small in this
survey, although representing six cardiac surgical units in Karachi.
 However various strategies were employed to achieve the high response
rate which includes a face to face interview with the respondent and clear
instructions were given about the questionnaires.
 no validated questionnaire was used, the inquiry was ample, and
assortment or reporting bias may have influenced the validity
 Despite these limitations, it is believed that the results from this survey
could reflect current clinical practice in Karachi and that the physiotherapist
working in cardiothoracic unit in Karachi are aware of chest physiotherapy
techniques used after open heart surgery.
22

23. CONCLUSION
 This study provides an overview of physiotherapy practice regarding chest
physiotherapy and breathing exercises for patients undergoing open heart
surgery in Karachi and the awareness of chest physiotherapy treatment and
techniques among physiotherapist working in cardiothoracic units in
Karachi.
 Physiotherapy treatment is frequently given to cardiac patients
preoperatively as well as post operatively in hospitals. According to this
survey typically preoperative information is commonly provided by
physiotherapist to open heart surgery patients and nearly all
physiotherapists regularly advised postoperative breathing exercises.
23

24. CONCLUSION (Cond)
 The most frequently used techniques were deep breathing without a device
and incentive spirometry .The breathing exercises were most frequently
performed hourly. Recommended repetitions at each training session varied
considerably and conflicting recommendations to continue breathing
exercises after discharge was given.
 Incentive spirometry is the device which is usually recommended by chest
physiotherapist to cardiac patients after discharge at home. Deep breathing
exercise , spirometry, coughing and huffing and chest expansion exercises
are usually recommended type of breathing exercise after discharge .
 Identification of high risk patients for post operative pulmonary complication
is quite low and written guidelines or protocols for physiotherapy
management of Intubated and extubated patients is also not frequently
provided by chest physiotherapists
24

25. RECOMMENDATION
 As a result of the lack of consistent positive evidence, respiratory
physiotherapy for patients undergoing CABG remains controversial. Clearly
more work, expanding upon traditional respiratory physiotherapy treatment
approaches, is needed in this area of research.
 Identification of high risk patients for post operative pulmonary complication
is relatively low i.e. only 35% , physiotherapist should enhance their back
ground knowledge about the risk factors associated with post operative
pulmonary complication , so they can easily identify patients at high risk and
can treat them pre and post operatively more competently
 Written guideline or protocols for physiotherapy management of Intubated
and extubated patients is very rarely provided to patients, this issue should
be looked in to and proper guide lines for Intubated as well as extubated
patients should be provided timely so as to enhance the standard of patient
care.
25

26. RECOMMENDATION (Cond)
 Literature has shown the effectiveness of PEP and blow bottle devices in
reducing post operative pulmonary complication after cardiac surgery so
these devices and techniques should be incorporated in cardiac patients’
chest physiotherapy management
 Sternal support with device e.g. heart hugger is not used by chest
physiotherapist according to the survey, it is recommended that such
devices should be used when needed and steps should be made for easily
availability of these devices in Pakistan as these will enhance the quality of
patient care.
26

27. RECOMMENDATION (Cond)
 In hospitals, chest physiotherapy usually is routinely offered after cardiac
surgery. It is additionally important to consider if the practice is uniform
among all physiotherapists in each unit.
 This study heaves further questions about the best means to treat cardiac
patients and highlights the need for future research to optimize
physiotherapy treatment following cardiac surgery. There are a variety of
treatment option and opinions about the best way to treat cardiac patients,
and this survey indicates the need for internationally approved guidelines to
establish the optimal content and timing of post-operative breathing
exercises
27

28. REFERENCES
Journals:
1. Agostini P, Singh S. (2009) Incentive spirometry following thoracic
surgery: What should we be doing? Physiotherapy;.VOL.95, pp. 76-82.
2. ARCÊNCIO L., SOUZA MD., BORTOLIN BS. FERNANDES ACM.,
RODRIGUES AJ., EVORA PRB. (2008) Pre-and postoperative care in
cardiothoracic surgery: a physiotherapeutic approach. Rev Bras Cir
Cardiovascular, VOL. 23, NO. 3, pp. 400-410.
3. Brasher PA Mendes RG, Costa Fde S, Di Lorenzo VA, Oliveira CR, Luzzi
S.(2003) Does removal of breathing exercises from a physiotherapy
program including pre operative education and early mobilization after
cardiac surgery alter patient outcome?.Australian journal of physiotherapy.
VOL.49, pp. 165-173.
4. Borghi-Silva A Borghi-Silva A, Mendes RG, Costa Fde S, Di Lorenzo VA,
Oliveira CR, Luzzi S.(2005) The influences of positive end expiratory
pressure (PEEP) associated with physiotherapy intervention in phase I
cardiac rehabilitation. Clinics. VOL. 60, pp. 465-72.
28

29. REFERENCES (Cond)
5. Carr L, Smith RE, Pryor JA, Partridge C.( 1996) Cystic fibrosis patients' views and
beliefs about chest clearance and exercise - a pilot study. Physiotherapy; VOL 82, pp
621-627.
6. Fiore JF, Chiavegato LD, Paisani DM, Colucci DB. (2010) Utilization of positive-
pressure devices for breathing exercises in the hospital setting: A regional survey in
Sao Paulo, Brazil . Respiratory Care, VOL. 55, pp. 719-24.
7. Haeffener MP, Ferreira GM, Barreto SS, Arena R, Dall’Ago P., (2008). Incentive
spirometry with expiratory positive airway pressure reduces pulmonary
complications, improves pulmonary function and 6-minute walk distance in
patients undergoing coronary artery bypass graft surgery. Am Heart J, VOL. 156,
pp. 900.
8. Herdy AH, Marcchi PLB, Vila A, et al., (2008) Pre- and postoperative
cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery
bypass surgery: A randomized controlled trial. Am J Phys Med Rehabil, VOL. 87, pp.
714-9.
9. Hulzebos EH, Helders PJ, Favie NJ, et al. (2006) Preoperative intensive inspiratory
muscle training to prevent postoperative pulmonary complications in high-risk
patients undergoing CABG surgery: a randomized clinical trial. JAMA, VOL.18,
NO. 296, pp.1851-7.
29

30. REFERENCES (Cond)
10. Ingwersen UM, Larsen KR, Bertelsen MT, et al. (1993) Three different mask
physiotherapy regimens for prevention of post- operative pulmonary complications
after heart and pulmonary surgery. Intensive Care Med, VOL.19,pp. 294-8.
11. Jenkins SC, Soutar SA, Loukota JM, Johnson LC, Moxham J. (1989) Physiotherapy
after coronary artery surgery: are breathing exercises necessary? Thorax, VOL.44,
pp. 634-9.
12. Muller AP, Olandoski M, Macedo R, Costantini C, Guarita-Souza LC. (2006)
Comparative study between intermittent (Muller Reanimator) and continuous
positive airway pressure in the postoperative period of coronary artery bypass
grafting. Arq Bras Cardiol, VOL. 86, pp. 232-9.
13. Overend TJ, Anderson CM, Jackson J, Lucy SD, Prendergast M, Sinclair S. (2010)
Physical therapy management for adult patients undergoing cardiac surgery: A
Canadianpractice survey. Physiother Can, VOL.62, pp. 215-21.
14. Pasquina P.Tramer MR, Walder B.(2003) Prophylactic respiratory physiotherapy
after cardiac surgery: systematic review.BMJ,VOL.327,pp. 1379.
15. Pryor J.A. (1999.) Physiotherapy for airway clearance in adults European Respiratory
Journal, Vol 14, pp. 1418-1424
16. Richter Larsen K, Ingwersen U, Thode S, Jakobsen S. (1995) Mask physiotherapy
in patients after heart surgery: A controlled study. Intensive Care Med, VOL.21, pp.
469-74
30

31. REFERENCES (Cond)
17. Reeve J, Denehy L, Stiller K. (2007). The physiotherapy management of patients
undergoing thoracic surgery: A survey of current practice in Australia and New
Zealand. Physiother Res Int; VOL.12, pp. 59-71
18. Renault JA, Costa-Val R, Rosseti MB, Houri Neto M(2009). Comparison between
deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir
Cardiovasc. VOL.24, pp.165-72.
19. Savci S, Sakinc S, Ince DI, et al. (2006) Active cycle of breathing techniques and
incentive spirometer in coronary artery bypass graft surgery. Fizyoterapi
Rehabilitasyon, VOL.17, pp. 61-9.
20. Stiller K, Montarello J, Wallace M, et al. (1994) Efficacy of breathing and coughing
exercises in the prevention of pulmonary complications after coronary artery
surgery. Chest, VOL.105, pp. 741-7.
21. Tucker B, Jenkins S, Davies K, McGann R, Waddell J, King R.(1996) The
physiotherapy management of patients undergoing coronary artery surgery: A
questionnaire survey. Aust J Physiother;, VOL.42,pp. 129-37.
22. Urella, C, Emtner M, Hedenström H, Tenling A, Breidenskog M, Westerdahl E.
(2011) Deep breathing exercises with positive expiratory pressure at a higher rate
improve oxygenation in the early period after cardiac surgery — a randomised
controlled trial European journal Cardiothoracic Surgery ,VOL.40,NO.1,pp. 162-167
31

32. REFERENCES (Cond)
23. Westerdahl E, Lindmark B, Almgren SI, Tenling A (2001) chest
physiotherapy after coronary artery bypass graft surgery—a comparison of
three different deep breathing techniques.J Raehab Med,VOL 33,pp.79-84.
24. Westerdahl E, Lindmark B, Eriksson T, Hedenstierna G, Tenling (2003) A.
The immediate effects of deep breathing exercises on atelectasis and
oxygenation after cardiac surgery. Scand Cardiovascular Journal, VOL. 37, pp.
363-7.
25. Westerdahl E, Lindmark B, Eriksson T, Friberg O,Hedenstierna G,
Tenling (2005) A. Deep-breathing exercisesreduce atelectasis and improve
pulmonary function after coronary artery bypass surgery. Chest, VOL.128,
pp. 3482-8.
26. Westerdahl E,Moller M (2010) physiotherapy-supervised mobilization and
exercise following cardiac surgery: a national questionnaire survey in
Sweden, journal of Cardiothoracic Surgery.VOL.5,pp.67.
27. Westerdahl E, Olsén MF (2011) Chest physiotherapy and breathing
exercises for cardiac surgery patients in Sweden - A National survey of
practice. Monaldi Arch Chest Dis, VOL.75, NO. 2, pp.112-119
32

33. REFERENCES (Cond)
28. Wynne R et al., (2004) Postoperative Pulmonary Dysfunction in Adults after
Cardiac Surgery with Cardiopulmonary Bypass: Clinical Significance and
Implications for Practice. American Journal of Critical Care, Vol 13, pp 384-393
29. Yanez-Brage I, Pita-Fernandez S, Juffe-Stein A, Martinez- Gonzalez U,
Pertega-Diaz S, Mauleon-Garcia A.( 2009) Respiratory physiotherapy and
incidence of pulmonary complications in off-pump coronary artery bypass
graft surgery: An observational follow up study. BMC Pulm Med,VOL. 9,pp.
36.
30. Zarbock A, Mueller E, Netzer S, Gabriel A, Feindt P, Kindgen-Milles D.
( 2009) Prophylactic nasal continuous positive airway pressure following
cardiac surgery protects from postoperative pulmonary complications: a
prospective, randomized, controlled trial in 500 patients. Chest.VOL.135, pp.
1252-9.
33

34. REFERENCES (Cond)
URLs:
31. Chest physiotherapy”, (2008), (PhysiotherapyTreatment.net)
Available:
http://www.physiotherapytreatment.net/Chest-Physiotherapy.html
(accessed:2012 February 16).
32. “Types of Heart Surgery”, (march 23, 2012), (nhlbi.nih.gov/health)
Available:
http://www.nhlbi.nih.gov/health/health-topics/topics/hs/types.html
(accessed: 2012 march 25)
34

35. 35