Mpt (Cardio Respiratory Including Intensive Care)

RESEARCH PROPOSAL

THE EFFECT OF EARLY MOBILIZATION VERSUS ROUTINE PHYSIOTHERAPY IN PREVENTION OF POST OPERATIVE PULMONARY COMPLICATIONS FOLLOWING UPPER ABDOMINAL SURGERY- A COMPARITIVE STUDY.

MPT (CARDIO RESPIRATORY INCLUDING INTENSIVE CARE)

MR.ARIJIT KUMAR DAS

DEPARTMENT OF PHYSIOTHERAPY

FR. MULLER MEDICAL COLLEGE

MANGALORE-575002

RajivGandhiUniversity of Health Science, Karnataka, Bangalore

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate
and
Address
(in block letter) / ARIJIT KUMAR DAS
DEPT. OF PHYSIOTHERAPY
FATHERMULLERMEDICALCOLLEGE
KANKANADY,
MANGALORE-575002
2. / Name of the Institution / FATHERMULLERMEDICALCOLLEGE
3. / Course of the study and subject / MASTER OF PHYSIOTHERAPY
(CARDIO RESPIRATORY INCLUDING INTENSIVE CARE)
4. / Date of admission to Course / 01-06-2008
5. / Title of the Topic
THE EFFECT OF EARLY MOBILIZATION VERSUS ROUTINE PHYSIOTHERAPY IN PREVENTION OF POST OPERATIVE PULMONARY COMPLICATIONS FOLLOWING UPPER ABDOMINAL SURGERY - A COMPARITIVE STUDY.
6. / BRIEF RESUME OF THE INTENDED WORK
6.1 Need of the study
The incidence of postoperative pulmonary complications after upper abdominal surgery reported in the literature varies from 5% to 30% 1. In upper abdomen surgery, patients develop a restricted pattern of breathing postoperatively with a decrease in vital capacity (VC) and functional residual capacity (FRC). This decrease in lung volume is associated with hypoxemia, broncho-pulmonary infection, pneumonia, airway obstruction and hypercapnea and eventually progresses to postoperative respiratory failure 2, 3. Decreased mucociliary clearance, diaphragm dysfunction, shallow and monotonous breathing also develop postoperatively in upper abdominal surgery patientsand cause pulmonary complications4.
Post operative pulmonary complication is the leading cause of postoperative morbidity and mortality, increased hospital length of stay and hence cost5. Postoperative pain intensity also is more among the elderly abdominal surgery patients who develop postoperative pulmonary complications6.
Chest physiotherapy is frequently used in the prevention and treatment of postoperative pulmonary complications after major abdominal surgery7. Chest physiotherapy techniques include deep breathing exercises and splinted coughing.
Early mobilization also is an important treatment component of postoperative care following upper abdominal surgery. There is no standard definition for early mobilization and it has been reported to include: moving in bed, sitting out of bed, standing, and ambulation on the spot, hallway ambulation, low intensity exercises8. Low intensities of mobilization can have a direct and profound effect on oxygen transport in patients with acute cardiopulmonary dysfunction 9.
Few studies have been performed to evaluate the efficacy of the different physiotherapy techniques and early mobilization. Hence it is important to compare the effect of both the techniques in the reduction of pulmonary complicationsfollowing upper abdominal surgery.
Operational Definition
Routine physiotherapy includesdeep breathing exercises, splinted coughingand mobilization from 3rd post operative day.
Research Question
Isthere any reduction in the incidence of clinically significant, postoperative pulmonary complications in high risk upper abdominal surgery patient due to early mobilization in comparison to routine physiotherapy?
Hypothesis
There will be a significant reduction in the incidence of postoperative pulmonary complications in upper abdominal surgery patients due to early mobilization.
Null hypothesis
There will be no significant reduction in the incidence of postoperative pulmonary complications in upper abdominal surgery patients due to early mobilization.
6.2Review of Literature
Watson2 conducted a study in post operative pulmonary complications associated with anesthesia and concluded that post operative pulmonary complications are a significant concern for anesthesia caregivers because they use drugs and techniques that temporarily decrease lung volume, impair airway reflexes, limit immune function, and depress secretion mobilization. To prevention or limit post operative pulmonary complications they developed a perioperative pulmonary risk management strategy and concluded that the patient should be ambulated as soon as possible.
Stiller and Munday7said in their study of “Chest physiotherapy for the surgical patient”, thatchest physiotherapy is effective in the prevention and treatment of pulmonary complication after major abdominal and thoracic surgery.
Browning, Denehy, Rebecca, Scholes8 conducted an observation study on early upright mobilization performed following upper abdominal surgery. Fifty patients who had undergone upper abdominal surgery after receiving standardized preoperative education and physiotherapy intervention on the first postoperative day. They used postoperative factors such as postoperative pulmonary complication, surgical attachments, pain relief, duration of anesthesia, intensive care admission in first four postoperative days as outcome measures. The results showed that the quantity of upright mobilization performed was low and increased, early, upright mobilization might have a positive effect on reducing length of stay following upper abdominal surgery.
Mackay and her colleagues10 conducted a randomized clinical trial of physiotherapy after open abdominal surgery in high risk patient. They took fifty-six patients undergoing open abdominal surgery, at high risk of developing postoperative pulmonary complications andrandomized them before operation to an early mobilization-only group or an early mobilization-plus-deep breathing and coughing group. Mobility duration, frequency and intensity of breathing interventions were quantified for both groups. Outcomes included incidence of clinically significant postoperative pulmonary complications, fever, length of stay, and restoration of mobility. They concluded that addition of deep breathing and coughing exercises tophysiotherapy directed program of early mobilization does not significantly reduce the incidence of post operative pulmonary complication.
6.3 Objective of the study
To find out the effect of early mobilization in prevention of post operative pulmonary complications followed by upper abdominal surgery subjects.
To find out the effectof routine physiotherapy in prevention of post operative pulmonary complications followed by upper abdominal surgery subjects.
To compare the effect of early mobilization vs. routine physiotherapy in prevention of post operative pulmonary complications followed by upper abdominal surgery subjects.
7. / MATERIAL AND METHODS
7.1Source of date
Thirty subjectsposted for elective upper abdominal surgeries in FatherMullerMedicalCollegeHospital will be recruited for this study with surgeon consent.
7.2 Method of data collection including sampling procedure:
Study Design:
Experimental Study design
SampleProcedure:
The patientswho areposted for upper abdominalsurgery is referred to physiotherapy andfulfill the inclusion criteria will be included in the study. Written informed consent will be obtained from the subjects.
Sample Size, Method and outcome measures :
30 subjects will be selected based on inclusion and exclusion criteria based on purposive sampling technique. These selective subjects will be randomly assigned in 2 groups by using simple randomization procedure. All subjects will be given an extensive preoperative physiotherapy session which will includes:Patient education: about the surgery, postoperative stays, importance of post operative physiotherapy, medications.
All subjects will undergo PFT (Pulmonary Function Test), a 2 Minute Walk Test, and MIP (Mouth Inspiratory Pressure) prior to the surgery.
Group 1 → Subject receiving early mobilization. (Experimental Group)
Group 2 → Subject receiving routine physiotherapy. (Control Group)
Post operatively;
Group 1 patients will receive only early mobilization in 1st POD itself once hemodynamically stable. No other regular physiotherapy management. Treatment will be given thrice a day. Early mobilization gradually starts from
- sit on the bed
- sit out of the bed
- walk 5 m with assistance
- walk 15 m with assistance
- walk 30 m with assistance
- walk 30 m without assistance
Group 2 will receive routine physiotherapy(deep breathing exercises and splinted coughing). They will be mobilized only by 3rd POD. These deep breathing exercises consist of lateral basal expansion maneuvers (deep breathing followed by splinted cough, huff, or forced expiratory maneuver).
The incidence of postoperative pulmonary complications will be assessed daily according to the “criteria for a clinically significant pulmonary complication - in postoperative open abdominal surgery ”10 modified from “Brook-Brunn 1997”, “ Hall et al 1996”. Arterial Blood Gas (ABG), fever, respiratory rate, auscultation changes and chest radiography will be analyzed to document and record the occurrence of post operative pulmonary complication.
On the 4th POD all the patients i.e., group 1 & group 2 will undergo PFT (Pulmonary Function Test), 2 Minute Walk Test, MIP (Mouth Inspiratory Pressure) and the parameters will be compared.
Measurement tools :
Spiro meter – (For PFT) [Micro Loop Spida 5 Spiro meter].
Chest x-ray.
Stethoscope (For auscultation).
Thermometer (For Temperature).
Walking distance in 2 minute walk test.
Inclusion Criteria for the study :
All patients who areposted for upper abdominal surgery with
History of smoking > 20yrs.
Age 40 – 60yrs males & female.
Haemodynamically stable.
Obesity.
Exclusion Criteria for the study :
Non smokers.
Emergency upper abdominal surgery patients.
Respiratory insufficiency requiring artificial airway.
Systemic disorders.
Uncooperative and unmotivated patient.
Statistical analysis:
Collected data will be analyzed by Paired t Test, Unpaired t Test and by Chi-sqare Test.
7.3 Does the study require and investigation or intervention to be conducted on patient or other humans or animals? If so please describe briefly.
Yes
7.4 Has ethical clearance been obtained from your institution in case of 7.3 –
Yes
8. / LIST OF REFERENCES
1.Dronkers Jaap, Veldman Andre, Hoberg Ellen, Wall Cees van der, Meeteren Nico van – “Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: a randomized controlled pilot study”. Clinical Rehabilitation 2008;22:134-142
2. WatsonCharles B. –“Respiratory complications associated with anesthesia”.Anesthesiology Clin N Am 20(2002) 513-537
3. Richardson, Jonathan, Sabanathan, Sabaratnam -“Prevention of respiratory complications after abdominal surgery”. Thorax 3Aprile 1997.Volume 52(3S)Supplement:35S-40S
4. Overend Tom J., Anderson Catherine M., LucyS.Deborah, Bhatia Christina, JonssonBirgittaI.and Timmermans Catherine - “The effect of incentive spirometry on postoperative pulmonary: a systemic review”. Chest2001;120;971-978
5.Ravimohan SM, Kaman L, Tindal R, Sing R, Jindal SK - “ Postoperative Pulmonary function in laparoscopic versus open cholecystectomy ; a prospective comparative study”.Indian Journal of Gastroenterology 2005Jan-Feb;24(1);6-8
6.Shen PA., Crooke RA., Dayhoff NE., Reck J. - “Pain intensity and postoperative pulmonary complication among the elderly after abdominal surgery” Heart Lung. 2002 Nov-Dec ; 31(6) : 440-8
7.Stiller K. R., Munday R. M.- “ Chest Physiotherapy for Surgical Patient” Br. J. Surg. 1992 Vol 79, August, 745-749
8.Browning Laura, Denehy Linda, Scholes Rebecca L –“The quantity of early upright mobilization performed following upper abdominal surgery is low: an observational study” Australian Journal of Physiotherapy2007 Vol53: 47-52.
9. Pryor Jenifer A, Prasad S Ammani. Physiotherapy for Respiratory and Cardiac Problem, Adult and Paediatrics: Churchill Livingstone, Third Edition, 143-159 pp.
10. Mackay Margaret R, Ellis Elizabeth and Johnston Catherine (2005) - “Randomized clinical trail of physiotherapy after open abdomen surgery in high risk patient”. Australian Journal of Physiotherapy2005 Vol.51:151-159
9. / SIGNATURE OF CANDIDATE
10. / REMARK OF THE GUIDE
11. / NAME AND DESIGNATION OF
11.1 GUIDE / MR.NARASIMMAN.S
ASSOC.PROFESSOR
DEPT OF PHYSIOTHERAPY
11.2SIGNATURE
11.3CO-GUIDE / DR. P. SATHYAMOORTHY AITHALA
PROFESSOR & HEAD OF THE DEPARTMENT
DEPT. OF SURGERY
11.4SIGNATURE
11.5 NAME OF THE HEAD OF THE DEPARTMENT / MR. NARASIMMAN.S
ASSOC.PROFESSOR
11.6 SIGNATURE
12. / 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL
12.2SIGNATURE

CONSENT FORM

Mr. Arijit Kumar Das Date-

M.P.T. (Cardio Respiratory Including Intensive Care)

FatherMullerMedicalCollege,

Mangalore-575002

You are requested to be a part of this research study, which is a part of the curriculum for the course of M.P.T. run by the Rajiv Gandhi University of Health Science. The purpose of the study is to evaluate the effectiveness of two types of physiotherapy technique on post operative pulmonary complication in subjects undergoing upper abdominal surgery.

On entering in this study you will be made to perform a PFT (Pulmonary Function Test), MIP (Mouth Inspiratory Pressure), 2Minute Walk Test. Then you will be assigned to one of the groups. Following the surgery you will be made to perform a specific technique and after period of 3 days you will be made to perform thePFT (Pulmonary Function Test), MIP (Mouth Inspiratory Pressure), 2 Minute Walk Test again. This procedure will not cause any harm to you. Permission for this study has been acquired from the hospital authorities.

We will clarify any of your queries regarding the study. Your Identity will remain confidential. You are free to leave this study at any time.

You are requested to sign this consent form.

I, ______voluntarilyagree to participate in this research study. I am fully aware of the procedure that will be carried out.

Signature of the patient

DATA COLLECTION FORM

Identification no:Word/BED No:Age:

Sex:Weight:Consent-Y/NGroup-1/2:

Referred by:

Occupation:

Present history:

Past history:

Smoking history:

Allergic history:

Drug History:

Surgical history: Date of surgery:

Incision:

Type/Duration of anesthesia:

Recovery time:

Any other specifies:

Vital: Preoperative: RR:PR:Temp.:BP:

Post operative / 1st post operative day / 2nd post operative day / 3rd post operative day
RR
PR
Temp
BP

Auscultation findings:

Preoperative:

Postoperative:

Pulmonary Function Test:

Parameter / Preoperative / 4th Postoperative Day
FEV1
FVC
PEFR

Mouth Inspiratory Pressure:

Preoperative:

Postoperative:

2 minute walk test:

Preoperative:

Postoperative:

Chest X ray finding:

ABG (Postoperative):

1