Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay

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www.revportpneumol.org

ORIGINAL

ARTICLE

Implementation

of

a

guideline

for

physical

therapy

in

the

postoperative

period

of

upper

abdominal

surgery

reduces

the

incidence

of

atelectasis

and

length

of

hospital

stay

S. Souza

Possa

a,b

,

C. Braga

Amador

a

,

A. Meira

Costa

a

,

E. Takahama

Sakamoto

a

,

C. Seiko

Kondo

a,c

,

A.L.

Maida

Vasconcellos

a,d

,

C.M.

Moran

de

Brito

a

,

W. Pereira

Yamaguti

a,∗

a_{Rehabilitation}_Service,_Hospital_{Sírio-Libanês,}_São_Paulo,_SP,_Brazil b_School_of_Medicine,_University_of_São_Paulo,_São_Paulo,_Brazil

c_{Rehabilitation}_Service,_Federal_University_of_São_Paulo,_São_Paulo,_Brazil d_Physical_Therapy_Service,_Hospital_{Sírio-Libanês,}_São_Paulo,_Brazil

Received24April2013;accepted16July2013 Availableonline27November2013

KEYWORDS

Physicaltherapy modalities; Earlyambulation; Guideline; Pulmonary atelectasis; Hospitalization; Postoperativecare

Abstract

Objective: Theaimofthisstudywastoevaluatetheeffectivenessofimplementinga physi-caltherapyguidelineforpatientsundergoingupperabdominalsurgery(UAS)inreducingthe incidenceofatelectasisandlengthofhospitalstayinthepostoperativeperiod.

Materialsandmethods: A‘‘beforeandafter’’studydesignwithhistoricalcontrolwasused. The‘‘before’’periodincludedconsecutivepatientswhounderwentUASbeforeguideline imple-mentation(intervention). The‘‘after’’period includedconsecutive patients afterguideline implementation.Patientsinthepre-interventionperiodweresubmittedtoaprogramof phys-icaltherapyinwhichthetreatmentplanningwasbasedontheindividualexperienceofeach professional.Ontheotherhand,patients whowereincludedinthepost-interventionperiod underwentastandardizedprogramofphysicaltherapywithafocusontheuseofadditional strategies(EPAP,incentivespirometryandearlymobilization).

Results:Therewasasignificantincreaseintheuseofincentivespirometryandpositive expi-ratoryairwaypressureafterguidelineimplementation.Moreover, itwasobservedthatearly ambulationoccurredinallpatients inthepost-interventionperiod.Nopatientwhoadhered totallytotheguidelineinthepost-interventionperioddevelopedatelectasis.Individualsinthe post-interventionperiodpresentedashorterlengthofhospitalstay(9.2±4.1days)compared topatientsinthepre-interventionperiod(12.1±8.3days)(p<0.05).

∗_{Corresponding}_author.

E-mailaddresses:wellington.psyamaguti@hsl.org.br,wellpsy@yahoo.com.br(W.PereiraYamaguti).

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Conclusion:TheimplementationofaphysicaltherapyguidelineforpatientsundergoingUAS resultedinreduced incidenceofatelectasisand reductioninlengthofhospital stayinthe postoperativeperiod.

PALAVRAS-CHAVE

Modalidadesde fisioterapia; Deambulac¸ão precoce; Orientac¸ão; Atelectasia pulmonar; Internamento; Cuidados pós-operatórios

Aimplementac¸ãodeumadiretrizparaafisioterapianoperíodopós-operatórioda cirurgiaabdominalalta,reduzaincidênciadeatelectasiaeotempodeinternamento

Resumo

Objetivo:O objetivodeste estudo foi avaliaraeficácia daimplementac¸ãode uma diretriz defisioterapia para doentessubmetidos acirurgia abdominalsuperior (UAS) nareduc¸ãoda incidênciadeatelectasiaenotempodeinternamentonopós-operatório.

MateriaiseMétodos: Foi usado um desenho de estudo de ‘‘antes e depois com controlo histórico.Operíodo‘‘antes’’incluiudoentesconsecutivosqueforamsubmetidosaUASantes daimplementaçãodadiretriz(intervenção).Operíodo‘‘depois’’incluiudoentesconsecutivos apósaimplementaçãodadiretriz.Osdoentesnoperíodo pré-intervençãoforamsubmetidos aumprogramadefisioterapiaondeoplaneamentodotratamentofoibaseadonaexperiência individualdecadaprofissional.Poroutrolado,osdoentesqueforamincluídosnoperíodo pós-intervençãoforamsubmetidosaumprogramapadronizadodefisioterapiacomumfoconouso deestratégiasadicionais(EPAP,espirometriadeincentivoemobilizaçãoprecoce).

Resultados: Ocorreuumaumentosignificativodousodeespirometriadeincentivoepressão expiratóriapositivanasviasaéreasapósaimplementaçãodasdiretrizes.Alémdisso, observou-sequeocorreuolevantamentoprecoceemtodososdoentesduranteoperíodopós-intervenção. Nenhum doente que aderiu totalmente à diretriz no período pós-intervenção desenvolveu atelectasia.Osindivíduosnoperíodopós-intervençãoapresentaramummenortempode inter-namentohospitalar(9.2±4.1dias)emcomparaçãocomosdoentesnoperíodopré-intervenção (12.1±8.3dias)(p<0.05).

Conclusão:Aimplementaçãodeumadiretrizdefisioterapiaparadoentessubmetidos aUAS resultounareduçãodaincidênciadeatelectasiaenareduçãodotempodeinternamentono pós-operatório.

Introduction

Postoperativepulmonarycomplications(PPCs)arecommon inpatients undergoingabdominalsurgery andare respon-siblefor the increasedmorbidityand mortalityaswell as lengthof hospitalstay andhealth relatedcost of care.1,2 ThePPCsoccurmorefrequentlyinsurgerieswherethe inci-sionis madeabovetheumbilical scar,thesocalledupper abdominalsurgeries(UAS).3_The_incidence_of_PPCs_in_these subjectsisrelatedtotheexistenceofpreoperativerisk fac-torssuchasadvancedage,smoking,malnutrition,obesity, lungdiseases,andclinicaldiseases.Surgicalandanesthetic factorssuchasthetimeofsurgery,typeofsurgery,andthe effectsof anestheticdrugs ontherespiratory system also contributetothedevelopmentofPPCs.4

Atelectasis, pneumonia, acute respiratory failure, tracheobronchitis, wheezing, and prolonged mechanical ventilation are the most commonly observed PPCs.2 _It _is knownthat the decrease in lung volumes and capacities, abnormal respiratory pattern, abnormal gas exchange, andpulmonary defensesin patients undergoing open UAS start with anesthetic induction and perpetuate in the postoperative period, contributing to the occurrence of

thesePPCs.5,6 _The_respiratory _muscle_dysfunction_has_also been attributed to the development of PPCs.7,8 _Multiple factors may be involved in diaphragmatic dysfunction, suchasirritationandinflammationcausedbytraumafrom manipulation close to the diaphragm, reflex inhibition of afferentabdominalreceptors,andpostoperativepain.7

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Themainobjectiveofthepresentstudywastoevaluate theeffectivenessoftheimplementationofaguidelinefor physicaltherapyassistanceforpatientsundergoingelective openUASinreducingtheincidenceofatelectasisandlength ofhospitalstayinthepostoperativeperiod.

Materials

and

methods

The study was conducted in a private and tertiary care center of 497 beds in the state of São Paulo, Brazil. We analyzeddatafrompatients hospitalizedin intensivecare units,semi-intensiveunits,andwards.The studyincluded adult patients (age≥18 years) undergoing elective open UASandwhoreceivedphysicaltherapyinthepostoperative period. It excluded patients undergoing lower abdomi-nalsurgeries,laparoscopicsurgeries,emergencysurgeries, surgeries with associated chest manipulation, those who underwent more than one surgical procedure during hos-pitalization, patients whodid not adhere properlyto the physical therapy treatment (performing physical therapy attendances <75% of scheduled therapy), patients who initiatedinpatientphysicaltherapybeforethesurgery (pre-operative physical therapy), individuals who died during hospitalization,andpatientsrequiringinvasivemechanical ventilationover24hours.

We used a ‘‘before and after’’model of retrospective studywithhistoricalcontrol.15,16_The_{‘‘before’’}_period (pre-intervention)included allconsecutive patientsundergoing electiveopenUASwhometthecriteriaforinclusioninthe studyoversixmonths(fromJulytoDecember2010)before guidelineimplementation(intervention).Teamsofphysical therapistswere trainedinthe standardization ofthe new modelofcareduringthemonthofJanuary2011.Duringthis period,nodataofpatientsundergoingUASwerecollected. The‘‘after’’period(post-intervention)includedall consec-utive patientswhomet theinclusioncriteriaof thestudy duringthesixmonthsafterguidelineimplementation(from FebruarytoJuly2011).

A training program for guideline implementation was carried out by the area of Continuing Education of the Rehabilitation Service of the institution for a period of 30days.Fifteen trainingmeetingswerearrangedinsmall groups for all the 126 physical therapists of the institu-tion, acting in intensive care units, semi-intensive units, and wards, in relation tothe guideline. During the train-ing sessions, we presented flow diagrams for treatment, the standardization of approaches of treatment, orienta-tions for hospital discharge, and the scientific evidence thatsupported theelaborationof theguidelines. Further-more,thetrainingaimedtoguideprofessionalsintheuseof physicaltherapyresourcesrecommendedinthecaremodel (i.e.incentivespirometryandpositive expiratorypressure intheairways).Todisseminatetheguideline,printedcopies of the document in the operatingunits were distributed, in addition to providing the electronic file in the com-puterizedsystem of theinstitution for consultations. This materialcontains informationabout care flowcharts, indi-cationsandcontraindications,criteriafordiscontinuingthe program,resourcesandfrequencyofphysicaltherapy ses-sions(Fig.1).The documentpresentedatotalof11pages includingflowcharts.

Patients included in the study in the pre-intervention period(control group) underwenta program of postoper-ativephysicaltherapy treatmentin whichthetherapeutic planningtobeappliedwasdeterminedbytheprofessional providing patient care (non-standard model). In con-trast,patientswhowereincluded inthepost-intervention (intervention group) underwent a standardized program ofphysicaltherapytreatmentwhichstructuredthemodelof patientcare, focusing onthe use of additional therapeu-ticresources(volumetricincentivespirometryandpositive expiratorypressure in theairways),17,18 _early _sitting posi-tionandambulation(onset<48hafter surgery)19 ₍_Fig.₁_). Patientsundergoingtheprogrampreconizedbythe guide-lineshouldundergoatleasttwosessionsofphysicaltherapy dailyuntilthe5thpostoperativeday.13 _Therapeutic treat-mentwas discussed again andre-planned by theteam of physicaltherapistsafterthe5thpostoperativeday,to rede-finetheneedfortwosessionsdaily.

Inthepresentstudy,totaladhesiontotheguidelinewas definedbytheuseofallthefeaturesrecommendedinthe guideline. When one of theresources was not applied,it wasconsideredpartialcompliance,andwhentwoormore featureswerenotused,itwasconsideredasnon-adherence totheguideline.

Datawerecollectedfromtheanalysisofmedicalrecords and electronic database of the hospital. The information extractedfromthesesourceswasstoredinelectronic for-matpreviouslydesigned for this study.We collecteddata concerningcharacterization of each patient(medical his-tory,demographics,clinicalandanthropometricdata),the surgical procedure (type of surgery, surgical technique, surgical time, and surgical risk), and the physical ther-apy assistanceprovided to patients duringhospitalization (features used and treatment adherence). Regarding the outcomesinvestigated,theincidenceofatelectasiswas con-sideredastheprimaryvariableand thelengthofhospital stayasthesecondaryvariable.

Thediagnosisofatelectasiswasconsideredinthe pres-ence of imaging studies confirming this alteration. All patients included in the study, both in the control group (CG)and in theintervention group (IG),had radiographic evaluationfromthefirsttofifthpostoperativeday.We con-sideredonlythepresenceofpureatelectasis(notassociated withothercomplicationssuchaspleuraleffusionor pneu-mothorax)sincetheaimofthestudywastodeterminethe incidenceofatelectasissecondaryonlytothesurgery,and nottoothercomplications.Radiologistswhohadreadallthe examinationsdidnotknowthestudyobjectives.We consid-eredaspossibleriskfactorsfordevelopingatelectasis:age, femalegender,highbodymassindex(BMI),lungdisease, his-toryofsmoking,hypertension,diabetes,dyslipidemia,heart disease,cancer,typeofsurgery,surgicaltechnique,timeof surgery,andsurgicalrisk(AmericanSocietyof Anesthesiol-ogistsscale).

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Patients undergoing open UAS (Intervention group)

Yes

No No

Yes

Angina, arrhythmias, shock or axillary temperature >38ºC

Physiotherapeutic program contraindicated

Start/Restart the physiotherapeutic program

after resolution of the contraindication

Awake and collaborative, hemodinamically stable,

without dyspnea at reat pain <8 on the numerical scale

Immediate postoperative day: patient in bed (bedside to 45º)

CP + IS + EPAP

VTE, Hb <7 g/dl or platelets <20.000mm3

1st postoperative day: patient seated in chair previous conducts + free motor PT

+ ambulation of at least 5 meters

2nd postoperative day: patient seated in chair previous conducts + ambulation of

at least 15 meters

Motor physical therapy and/or ambulation

contraindicated

Stard/Restart motor physical therapy and/or ambulation

after resolution of the contraindication or medical

release

3rd to 5th postoperative day: previous conducts + exercises in

orthostatism + ambulation of at least 30 meters

Yes

Figure1 Physical therapyprogram for patients undergoing open upperabdominal surgery (interventiongroup). UAS: upper abdominalsurgery;CP:chestphysicaltherapy; IS:incentivespirometry;EPAP:expiratorypositiveairwaypressure;VTE:venous thromboembolism;Hb:hemoglobin.

determined to be 66 patients for each group. To reach thisnumber, we calculated that we needed 6 months for thepost-interventionperiod.Forthefinalanalysis,a sen-sitive analysis was performed including only the patients withfull adherence to the guideline aswell as an analy-sisofallpatientsincludedinthepost-interventionperiod. Categoricalvariablesarepresentedasfrequency,whereas continuous variables are expressed as mean±standard deviation. Comparisons between groups were made by Mann---Whitney test (nonparametric data), in the case of numericalvariables,andbythechi-squaretestinthecase ofcategorical variables.The level of significancewas5%. Statisticalanalysiswasperformedusingthestatistical pro-gramSigmaPlot11.0(SystatSoftwareInc.,CA,USA).

This study was approved by the Ethics Committee of thehospital(Registrationnumber:HSL2010-58).Therewas waiver shall of the Consent Form, because it is a retro-spective observational study analyzing standardization of institutionalcareprocess.

Results

We analyzed medical records of 535 patients undergoing UASinthe totalperiodof thestudy,249belongingtothe stagepriortoguidelineimplementationand286belonging tothesubsequentstage.Afterevaluationofinclusionand exclusioncriteria, 202wereeligibleforthestudy.TheCG consistedof133patientsandtheIGof69patients(Fig.2). Of the patients included in the IG, 32 (46.4%) had total adherence tothe guideline, whereas37 (53.6%) had par-tialadherencetotheguideline(didnotundergooneofthe additionaltherapeuticresourcesintheproposedguideline).

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Patients undergoing open UAS in the total period of the stu day

n=535

Control group (per-guideline)

n=286 Intervention group

(post-guideline)

n=249

116 medical records excluded 217 medical records excluded

• More than one surgical procedure during hospitalization (n=53)

• More than one surgical procedure during hospitalization (n=40)

• Laparoscopic surgery (n=40) • Lack of adherence to physical therapy treatment (n=5)

• Lower abdominal surgery (n=3) • Death (n=4)

• Emergency surgery (n=3) • Preoperative physiotherapy (n=3) • Chest manipulation associated with the abdominal surgery (n=4) • Mechanical ventilation >24 hours (n=1)

Patients included n=133

Patients included n=69

Total adhesion n=32

Partial adhesion n=37 • Laparoscopic surgery (n=59)

• Lack of adherence to physical therapy treatment (n=14)

• Lower abdominal surgery (n=14) • Death (n=3)

• Lack of adherence to the guideline (n=54)

• Emergency surgery (n=16) • Preoperative physiotherapy (n=4) • Chest manipulation associated with the abdominal surgery (n=8) • Mechanical ventilation >24 hours (n=5)

Figure2 FlowchartforinclusionandexclusionofpatientsinthestudyfortheCG(pre-guideline)andIG(post-guideline).

Table1 Demographicandclinicalcharacteristicsofindividualsincludedinthestudy.

Characteristic Controlgroup(n=133) Interventiongroup(n=32) p-Value

Gender(male:female) 57:76 22:10 0.008a

Age(years) 59.9±15.2 57.1±15.8 0.44

BMI(kg/m2₎ _26.1_±_0.5 _26.1_±_0.7 _0.58

Respiratorydisease 12(9%) 0(0%) 0.08

Tobaccohistory 10(7.5%) 7(21.2%) 0.02a

Hypertension 49(36.8%) 9(28.1%) 0.35

Diabetes 20(15%) 2(6.3%) 0.19

Dyslipidemia 16(12%) 4(12.5%) 0.94

Heartdisease 24(18%) 3(2.3%) 0.23

Neoplasia 121(91%) 26(81.2%) 0.11

Typeofsurgery

Tumorresection 114(85.7%) 24(75%) 0.14

Othercauses 19(14.3%) 8(25%)

Surgicaltechnique

Median 57(42.9%) 10(31.2%)

Subcostal+median 44(33.1%) 11(34.4%) 0.38

Subcostal 32(24.1%) 11(34.4%)

Timeofsurgery(min) 427±249.9 369.8±146.7 0.49

ASAscale

Lowrisk(1---2) 106(89.8%) 25(86.2%) 0.57

Highrisk(3) 12(10.2%) 4(13.8%)

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Table2 Frequency ofuseofdifferenttherapeuticresources andclinicaloutcomes(incidenceofatelectasisandlengthof hospitalstay).

Resourcesandclinicaloutcomes Controlgroup(n=133) Interventiongroup(n=32) p-Value

Conventionalphysicaltherapy 133(100%) 32(100%)

Incentivespirometry 88(66.2%) 32(100%) <0.001a

EPAP 0(0%) 32(100%) <0.001a

Earlyambulation(<48h) 16(12%) 32(100%) <0.001a

Incidenceofatelectasis(%) 21(15.8%) 0(0%) <0.001a

Hospitalstay(days) 12.1±8.3 9.2±4.1 0.036a

EPAP:expiratorypositiveairwaypressure.

a_{Statistically}_significant_difference_between_groups.

Table3 describes possiblerisk factors forthe develop-mentofatelectasis.ThesedataarerelatedonlytotheCG, sincetherewasnodevelopmentofatelectasisintheIG.In thepresentstudy,theonlyriskfactor associatedwiththe developmentofatelectasiswasthesurgicaltechnique.The individualsundergoingsubcostalincisionsweremorelikely todevelopthiscomplication(p<0.05).

Discussion

Thepresent studyshowedthattheoptimizationand stan-dardizationof theuse ofadditionaltherapeutic resources throughtheimplementationofaguidelineforphysical ther-apyassistance,guidingthecareofpatientsundergoingUAS,

is effective in reducing the incidence of atelectasis and lengthofhospitalstayinthepostoperativeperiod.

Previous studies have reported that the incidence of atelectasis observed in thepostoperative periodcan vary from6%to42%.21,22_In _the_present_study,_the_incidence_of atelectasisamongtheCGpatients(pre-interventionperiod) was15.8%,whichisconsistentwiththesepreviousreports. The optimization of physical therapy treatment in the IG (post-intervention)reducedtheincidenceofatelectasisto 0%inthosepatientswhoadheredtotallytotheguideline, highlighting the importance of the adequacy of physical therapy in the postoperative care. The intention-to-treat analysis(including37patientswhoadheredpartiallytothe guideline)didnotshowastatisticallysignificantdifference in the rate of atelectasis or length of hospitalstay when

Table3 Possibleriskfactorsassociatedwiththedevelopmentofatelectasis.

Characteristic Withatelectasis(n=21) Withoutatelectasis(n=112) p-Value

Gender(male:female) 11:10 65:47 0.63

Age(years) 63.1±13.5 59.2±15.5 0.27

BMI(kg/m2₎ _26.9_±_4.4 _26.5_±_5.5 _0.14

Respiratorydisease 3(14.3%) 9(8%) 0.36

Tobaccohistory 3(14.3%) 7(6.2%) 0.2

Hypertension 8(38%) 41(36.6%) 0.9

Diabetes 3(14.3%) 17(15.2%) 0.92

Dyslipidemia 2(9.5%) 14(12.5%) 0.7

Heartdisease 5(23.8%) 19(17%) 0.45

Neoplasia 18(85.7%) 95(84.8%) 0.92

Typeofsurgery

Tumorresection 18(85.7%) 96(85.7%) 1

Othercauses 3(14.3%) 16(14.3%)

Surgicaltechnique

Median 5(23.8%) 52(46.4%)

Subcostal+median 5(23.8%) 39(34.8%) 0.004a

Subcostal 11(52.4%) 21(18.8%)

Timeofsurgery(min) 474±306.3 419.7±239 0.68

ASAscale

Lowrisk(1---2) 16(76.2%) 90(90.9%) 0.38

Highrisk(3) 3(15.8%) 9(9.1%)

Lateambulation 10(47.6%) 33(29.5%) 0.12

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comparedto theCG. This finding reinforcesthe need for totaladherenceoftheinterventionpackagesforthe clini-caloutcomestobeachieved.AlthoughtheITTanalysisdid notdemonstrateastatisticallysignificantdifferenceforthe lengthof hospitalstay,areductionofupto48h in hospi-talizationcanbeconsideredclinicallyrelevantandcanbe associatedwithareductioninhealthcarecosts.In associa-tionwiththesefindings,itwasalsoobservedthatthelength ofhospitalizationwashigheramongpatientswhodeveloped atelectasis.Thelongerlengthof stayamongpatientswho developpulmonarycomplicationsisacommonfindinginthe literature.2

Althoughphysicaltherapyassistanceisroutinelyusedin theprocessesoffunctionalrehabilitationofpatients under-goingUAS,11 _the_results _{demonstrating}_its_{effectiveness}_in preventingatelectasisarestillinconsistent.13 _The_absence of consolidated scientific evidence can leadthe therapist tocarrytheir professionalpracticeusingclinicaldecisions based on their own experience, which results in a wide rangeofcarepracticesinaservice.23_{Standardizing}_practical approachesbecomesnecessarytohelpteamstomake the mostappropriatedecision,favoringtheclinicaloutcomesof patients.Inthiscontext,thedevelopmentofcareguidelines has been widely used in theroutine in different fieldsof medicalactivity,15,16 _providing_practical _{recommendations} whenscientificevidenceisstilllimitedorquestionable.23

Therapeutic resources such as incentive spirometry, CPAP, EPAP, early mobilization, and conventional physi-caltherapy,basedondeepbreathingexercises,areoften used toprevent atelectasisin patients undergoingUAS.24 Among these commonly used features, incentive spirom-etry appears to be involved in more controversy. Recent systematic reviews have found noevidence regarding the effectivenessoftheuseofincentivespirometryfor prevent-ingpulmonarycomplicationsinthepostoperativeperiodof UAS.25,26 _However, _many _of _the _studies _{investigating} _the effectiveness of this device still present methodological flaws,makingtheelaborationofmorerigorousstudies nec-essary to define the realbenefits of the use of incentive spirometry. Despite these inconsistent results, the latest recommendations on the use of incentive spirometry in preventingpostoperativepulmonarycomplicationsindicate that this feature should be applied in combination with deepbreathingtechniques,assistedcough,early mobiliza-tion,and optimizedanalgesia toobtain betterpreventive results.27 _In _the _present _study, _incentive _spirometry _was usedin combination withother techniques recommended forpostoperative,whichprobablycontributedtothe reduc-tionoftheincidenceofatelectasis.

Anotherfeaturepreconizedforprophylaxisofatelectasis inpatientsundergoingUASistheuseofbreathingexercises associated with positive pressure through EPAP or CPAP.9 Although the use of CPAP is a strategy recommended for prophylaxisofatelectasisforUAS,9_its_application_in_clinical practiceisquitelimitedbytheriskofabdominaldistension related to aerophagia, which can be particularly harmful intheoccurrenceoffistulasor anastomosisleakage. Rick-stenetal.18 _have_demonstrated_that_both_the_use_of_CPAP andEPAPwereeffectiveinpreservinglungvolumesand pre-ventingthedevelopmentofatelectasisinthepostoperative period of abdominalsurgeries, and that the use of these resourcesweresuperiortodeepbreathingexercises.Other

authorshavealsodemonstratedthatEPAPisaseffectiveas CPAPforthepreventionofPPCsafterthoracicsurgeryand shouldbeusedconcomitantlywithconventionalrespiratory physicaltherapy.28,29_In_the_present_study,_it_was_found_that intheperiodbeforeguidelineimplementationEPAPwasnot astrategyusedinroutine.Inthepost-interventionperiod, EPAPwas usedin all patients who adhered tothe guide-line.Thereductionintherateofatelectasismayhavebeen largelyexplainedasaresultoftheinclusionofthisfeature inclinicalpractice.

Finally,earlymobilizationwasanotherimportantfeature recommendedintheapproachofpatientsundergoingopen UASafterguidelineimplementation.Itisbelievedthatearly mobilizationresultsin increasedlungvolume,with conse-quentpreventionofatelectasis.30_Brasher_et_al.31_have_even suggestedthatearlymobilizationseemstobemore effec-tive than deep breathing exercises for the prevention of PPCs. These findings further emphasize the importance ofearlymobilizationinthepostoperativeperiodforUAS.

Risk factors such as age over 60, smoking history, presence of chronic lung disease and surgical time over 210min areoften relatedtotheoccurrenceof pulmonary complications in the postoperative period of open UAS.4 Interestingly,theonlyriskfactorassociatedwiththe devel-opmentofatelectasis,inthepresentstudy,wasthesurgical technique,withpatientsundergoingsubcostalincisions pre-sentinghigherincidenceofcomplications.Therelationship between subcostal incisions and the development of pul-monary complications after abdominal surgery has been previouslydemonstrated.3

Themain limitationofthepresent studyrelatestothe methodological design. Although the use of a historical controlhinders theestablishment of a causalassociation, itsapplication inan institutionalcontextbecomesamore viablealternative.It shouldalsobenotedthatthe imple-mentationoftheguidelinewastheonlychangeincorporated into the care of these patients during the study period. Anotherfactorworthmentioningisthefactthatradiological assessorswereblindedtothestudyobjectivesensuringthe reliabilityofthediagnosisofatelectasis(primaryvariable). Moreover,theshorttimebetweenthehistoricalcontroland the intervention period strengthens the assumption of a trueassociationbetweentheinterventionsandtheobserved outcomes. Another limitation of the present study was thedifferenceinthesamplesizeofpatientsundergoingthe guidelineinthe post-intervention periodcomparedtothe pre-interventionperiod.Itwasobservedthatthereduction inthenumberofpatientsincludedinthepost-intervention periodwasmainlyfor theaccuracy oftheselection crite-riaandapoor adherencetotheguideline bythe physical therapists.However,pooradherenceinperiodsimmediately aftertheimplementationofhealthcareguidelineswasalso observedinprevious studies.15,32 _This_fact_emphasizes_the needforcontinuingeducationworkfortheconsolidationof long-termprocesses.

Conclusions

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todemonstratethatthephysiotherapeuticapproachbased onpackagesofinterventionsresultedinreducedincidence of atelectasis and reduced length of hospital stay among patientsundergoingelectiveopen UAS.Theverificationof these favorable outcomes strengthens initiatives for the developmentof otherphysical therapy practicesbasedon managedguidelines,providingfoundationfortheawareness of the teams on the importance of following these care models.

Ethical

disclosures

Protection of human and animal subjects.The authors declarethat the proceduresfollowed were in accordance withtheregulationsoftherelevantclinicalresearchethics committeeandwiththoseoftheCodeofEthicsoftheWorld MedicalAssociation(DeclarationofHelsinki).

Confidentialityofdata.Theauthorsdeclarethattheyhave followedtheprotocolsoftheirworkcenteronthe publica-tionofpatientdataandthatallthepatientsincludedinthe studyreceivedsufficientinformationandgavetheirwritten informedconsenttoparticipateinthestudy.

Righttoprivacyandinformedconsent.Theauthorshave obtainedthe written informed consentof the patients or subjectsmentionedinthearticle.Thecorrespondingauthor isinpossessionofthisdocument.

Conflicts

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

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