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Respiratory Physiotherapy To Prevent Pulmonary Complications After Abdominal Surgery*: A Systematic Review FREE TO VIEW

Patrick Pasquina; Martin R. Tramèr, MD, DPhil; Jean-Max Granier; Bernhard Walder, MD
Author and Funding Information

*From the Division of Intensive Care (Mr. Pasquina and Mr. Granier) and the Division of Anesthesiology (Drs. Tramèr and Walder), Department APSI (Anesthésie, Pharmacologie et Soins Intensifs), Geneva University Hospitals, Geneva, Switzerland.

Correspondence to: Patrick Pasquina, Division of Intensive Care, Geneva University Hospitals, 1211 Geneva 14, Switzerland; e-mail: Patrick.Pasquina@hcuge.ch



Chest. 2006;130(6):1887-1899. doi:10.1378/chest.130.6.1887
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Objectives: To examine the efficacy of respiratory physiotherapy for prevention of pulmonary complications after abdominal surgery.

Methods: We searched in databases and bibliographies for articles in all languages through November 2005. Randomized trials were included if they investigated prophylactic respiratory physiotherapy and pulmonary outcomes, and if the follow-up was at least 2 days. Efficacy data were expressed as risk differences (RDs) and number needed to treat (NNT), with 95% confidence intervals (CIs).

Results: Thirty-five trials tested respiratory physiotherapy treatments. Of 13 trials with a “no intervention” control group, 9 studies (n = 883) did not report on significant differences, and 4 studies (n = 528) did: in 1 study, the incidence of pneumonia was decreased from 37.3 to 13.7% with deep breathing, directed cough, and postural drainage (RD, 23.6%; 95% CI, 7 to 40%; NNT, 4.3; 95% CI, 2.5 to 14); in 1 study, the incidence of atelectasis was decreased from 39 to 15% with deep breathing and directed cough (RD, 24%; 95% CI, 5 to 43%; NNT, 4.2; 95% CI, 2.4 to 18); in 1 study, the incidence of atelectasis was decreased from 77 to 59% with deep breathing, directed cough, and postural drainage (RD, 18%; 95% CI, 5 to 31%; NNT, 5.6; 95% CI, 3.3 to 19); in 1 study, the incidence of unspecified pulmonary complications was decreased from 47.7% to 21.4 to 22.2% with intermittent positive pressure breathing, or incentive spirometry, or deep breathing with directed cough (RD, 25.5 to 26.3%; NNT, 3.8 to 3.9). Twenty-two trials (n = 2,734) compared physiotherapy treatments without no intervention control subjects; no conclusions could be drawn.

Conclusions: There are only a few trials that support the usefulness of prophylactic respiratory physiotherapy. The routine use of respiratory physiotherapy after abdominal surgery does not seem to be justified.

Figures in this Article

More than 4 million abdominal surgeries are performed in the United States every year.1Patients undergoing abdominal surgery are at increased risk for pulmonary complications postoperatively.2Postoperative pulmonary complications increase hospital morbidity, prolong hospital stay, and contribute to additional health-care costs.3

Postoperative pulmonary complications seem to be related to the disruption of the normal activity of respiratory muscles, a phenomenon that starts at induction of anesthesia and continues into the postoperative period.4Anesthetics, phrenic nerve dysfunction, and surgical trauma all impair the function of respiratory muscles after surgery. These mechanisms lead to a decrease in functional residual and vital capacity for many days, and subsequently to atelectasis. In an animal study,5 atelectasis was shown to promote bacterial growth due to reduced function of alveolar macrophage and reduced functional surfactant, explaining the risk of pneumonia.

Postoperative chest physiotherapy was implemented in the beginning of the 20th century; deep breathing exercise was one of the first methods.6Subsequently, a variety of manual treatments including percussion, clapping, vibration, or shaking were developed to improve bronchial drainage. More recently, mechanical breathing devices such as incentive spirometry (IS), blow bottles, intermittent positive pressure breathing (IPPB), and continuous positive airway pressure (CPAP) were introduced into clinical practice. In 1994, a metaanalysis7concluded that prophylactic incentive spirometry and deep-breathing exercises were beneficial after abdominal surgery; however, an amalgamation of a variety of different pulmonary end points (for instance, atelectasis, pneumonia, or bronchitis) was analyzed. Thus, the clinical relevance of this positive finding remained unclear. Subsequently, two further metaanalyses89 studied the impact of prophylactic respiratory physiotherapy on more specific postoperative pulmonary complications, ie, atelectasis or pneumonia. Overend et al,8concluded that incentive spirometry was of no use after cardiac or abdominal surgery, and we were unable to find any evidence that a variety of physiotherapy treatments were beneficial after cardiac surgery.9

Some methods of respiratory physiotherapy are labor intensive and costly, and some may even induce specific adverse effects.9 To justify the routine use of prophylactic respiratory physiotherapy after major surgery, we need to be confident that the efficacy is worthwhile and that there is a minimal likelihood of harm. Discrepancies in the conclusions of previous metaanalyses may be explained by differences in the selection of analyzed trials and by variations in the choice of analyzed end points. We set out to review the evidence that prophylactic respiratory physiotherapy prevented pulmonary complications after abdominal surgery.

As in a previous, similar analysis,9 we took two pre hoc decisions to ensure that our conclusions were based on both clinically relevant and methodologically valid data. First, in the context of postoperative pulmonary complications, a reduction of pneumonia was of primary interest. Second, in the absence of a “gold standard” intervention, a randomized comparison between a physiotherapy method and a “no intervention” control was the most valid study design to establish the relative efficacy of physiotherapy.,9

Studies were identified using MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register. The search strategy included the free-text terms physical therapy, respiratory therapy, breathing exercise, chest physiotherapy, continuous positive airway pressure, incentive spirometry, intermittent positive pressure breathing, noninvasive positive pressure ventilation, bilevel positive airway pressure ventilation, blow bottles, positive expiratory pressure, postural drainage, abdominal surgery, cholecystectomy, gastrectomy, pancreas, colectomy, laparotomy, biliary tract, gastric, and random. The last electronic search was in November 2005. Reference lists from retrieved reports and from review articles78,1011 were reviewed to identify additional studies. Articles in all languages were considered. We contacted the original investigators by letter and asked for supplementary data related to their study, and for unpublished data.

Criteria for Inclusion

We included full reports of randomized trials of patients undergoing open abdominal surgery. As in a previous similar analysis,9 we did not consider trials with inadequate randomization methods (for instance, group assignment according to patients’ date of birth, or alternate). Relevant trials had to compare any technique of prophylactic respiratory physiotherapy (active intervention) with no intervention (inactive control) or with another method of respiratory physiotherapy (active control). Studies that tested therapeutic physiotherapy to treat pulmonary complications were not considered. Trials had to report on one of five end points: atelectasis, pneumonia, postoperative pulmonary complications, oxygenation (Pao2/fraction of inspired oxygen [Fio2] ratio), and vital capacity. Trials were included if they reported on an observation period of at least 2 days. If end points were reported at different time points, we considered the longest observation period. Information on adverse effects that could be attributed to physiotherapy was also extracted.

Assessment of Quality of Data Reporting

Data abstraction was carried out by one investigator and independently reviewed by two others. We assessed for each included study the method of randomization and of concealment of treatment allocation, the degree of blinding, and completeness of follow-up.12 We assumed that in this specific clinical setting, patient and care givers could not be blinded. Extracted data and quality scores were compared; in case of disagreement, consensus was reached by discussion.

Data Analysis

We recalculated dichotomous data on absence or presence of pulmonary complications as risk differences (RDs) with 95% confidence intervals (CIs).13When the 95% CI around the RD excluded zero, we assumed that the difference between groups was statistically significant. For statistically significant results, the number needed to treat (NNT), the reciprocal of the RD, was computed as an estimate of the clinical relevance of a treatment effect.14 Event rate scatters were used to explore the variability in the incidence of outcomes.

Trial Characteristics

We screened 437 reports; 62 were considered for inclusion, but 27 were subsequently excluded (Fig 1 ). There was one redundancy unit15; we regarded the more detailed article as the original report16and excluded the duplicate.17 We eventually analyzed data from 35 randomized trials with data on 4,145 adult patients (Table 1 ).,16,1851 Trials came from 12 countries and were published between 1952 and 2005. Six authors2324,3233,35,42,46 responded to our inquiry; all provided supplementary information that could be used for analysis. Of the 14 trials that were included in the systematic review by Thomas and McIntosh,7 we included 11 trials16,19,22,2627,36,41,43,4748 but rejected 3 trials (2 used a pseudorandomization,5253 and 1 was published as an abstract only54). Average group size was 51 patients (range, 8 to 445). Eleven trials (31%) described an adequate method of randomization; in 5 trials (14%), treatment allocation was concealed; in 16 trials (46%), observers were blinded; and in 13 trials (37%), follow-up of patients was complete. A large variety of physiotherapy treatments and combinations thereof were tested; they were administered for a period of 1 to 9 days (average, 4 days). Observation periods were 2 to 15 days (average, 5 days).

Active Intervention vs No Intervention Control

Thirteen trials16,1920,22,24,31,37,40,4243,45,48,51 (n = 1,411) had a no intervention control group (Table 1). Six trials,16,20,24,4243,48 (n = 614) with no intervention control subjects reported on pneumonia (Fig 2 ). In one trial,,43 the incidence of pneumonia without physiotherapy was 37.3% and was significantly decreased to 13.7% with deep breathing and directed cough and postural drainage (RD, 23.6%; 95% CI, 7 to 40%; NNT, 4.3; 95% CI, 2.5 to 14). This trial43 reported on the highest incidence of pneumonia in control subjects of all trials; in the other studies,16,20,24,42,48 the incidence of pneumonia in control subjects was much lower and very similar, between 2% and 5%. In two studies,16,42 deep breathing with directed cough with or without postural drainage increased the incidence of pneumonia; differences, however, were not statistically significant.

Nine trials16,22,24,31,37,4243,48,51 (n = 861) with no intervention control subjects reported on atelectasis (Fig 3 ). In two trials,,24,51 incidences of atelectasis without physiotherapy were 39% and 77%, respectively; these were significantly decreased to 15% with deep breathing and directed cough (RD, 24%; 95% CI, 5 to 43%; NNT, 4.2; 95% CI, 2.4 to 18), and to 59% with deep breathing and directed cough and postural drainage (RD, 18%; 95% CI, 5 to 31; NNT, 5.6; 95% CI, 3.3 to 19). These trials24,51 reported a high incidence of atelectasis in control subjects; in the other studies,16,22,31,37,4243,48 the incidence of atelectasis in control subjects was much lower and very similar, between 20% and 25%. In four studies, IS,22,48 IPPB,22 and deep breathing and directed cough with or without postural drainage22,31,43 all increased the incidence of atelectasis; differences, however, were not statistically significant.

Eight trials19,22,24,31,40,42,45,48 (n = 743) with no intervention control subjects reported on unspecified pulmonary complications (Fig 4 ). Definitions varied widely and included symptoms of acute bronchitis, signs of pneumonia or atelectasis, and combinations of those; diagnoses were clinical or radiologic but never bacteriologic (Table 2 ). On the event-rate scatter, a large variability in incidences of unspecified pulmonary complications with active and control groups became apparent, ranging from 0 to approximately 50% (Fig 4). In a four-arm trial,,22 the incidence of unspecified pulmonary complications was significantly decreased from 47.7% without physiotherapy, to 21.4 to 22.2% with IS, deep breathing and directed cough, or IPPB; RD point estimates were 25.5 to 26.3%, and NNTs were 3.8 to 3.9. IPPB,19 IS,48 CPAP,40 and deep breathing with or without directed cough31,42,45 increased the incidence of unspecified pulmonary complications in one study each; differences, however, were not statistically significant.

Five trials16,20,24,40,48 (n = 526) had a no intervention control group and reported Pao2/Fio2 ratios (Table 3 ). Values varied from 255 to 381 mm Hg; no significant differences were reported.

Three trials24,40,48 (n = 185) had a no intervention control group and reported on vital capacity (Table 4 ). Values varied from 2,120 to 2,816 mL; no significant differences were reported.

Active Intervention vs Active Intervention (Without No Intervention Control Subjects)

Twenty-two trials18,21,23,2530,3236,3839,41,44,4647,4950 (n = 2,734) compared 15 different methods of physiotherapy without a no intervention control group (Tables 56789 ). There were no significant differences in the incidence of pneumonia (Table 5) or atelectasis (Table 6).

Significant results were reported in five studies.26,30,35,39,46 There were fewer unspecified pulmonary complications with IS compared with a not-well-defined physical therapy (Table 7).,26 There was a better Pao2/Fio2 ratio with a positive expiratory pressure mask compared with CPAP, and both interventions were more efficacious than IS (Table 8).,46 Finally, four studies reported on significant differences in vital capacity values in favor of different physiotherapy treatments (Table 9): bilevel positive airway pressure was better than IS,,30,35 positive expiratory pressure mask and CPAP were more efficacious than IS,46 and CPAP was more efficacious than deep breathing with directed cough and postural drainage therapy.39

Adverse Effects

In two trials,30,35 3 of 20 patients (15%) and 4 of 14 patients (29%), respectively, did not tolerate bilevel positive airway pressure due to discomfort. In one study,20 9 of 99 patients (9%) did not tolerate CPAP for > 12 h due to claustrophobia, and 4 of 99 patients (4%) had superficial nose ulcers.20 Abdominal distension occurred in 8 of 45 patients (18%) treated with IPPB.22 Finally, in one study,32 an incision hernia developed in 1 of 445 patients during chest physiotherapy. Twenty-six trials16,1819,21,2529,31,3334,3641,4345,4751 did not mention any adverse effects, and 4 trials2324,42,46 reported that none had occurred.

Conclusions of the Original Investigators

Authors of 4 of the 13 trials with no intervention control subjects concluded that prophylactic respiratory physiotherapy after abdominal surgery was useful; 1 trial each reported on a significant effect on atelectasis,24,51 pneumonia,43 or unspecified pulmonary complications.22 Authors of 5 of the 22 active-controlled trials26,30,35,39,46 concluded that one of the tested interventions was superior.

Six of 13 trials16,20,24,4243,48 with a no intervention control group, the most valid trial design in this context, reported on the clinically most relevant end point, pneumonia. Only one of these trials43 showed a beneficial effect of physiotherapy on pneumonia. In that trial, the incidence of pneumonia in control subjects was extraordinarily high, challenging external validity of these data. Thus, the usefulness of prophylactic respiratory physiotherapy for the prevention of clinically relevant postoperative pulmonary complications after abdominal surgery remains unproven.

Most investigators preferred to report on vital capacity, Pao2/Fio2 ratios, atelectasis, or unspecified pulmonary complications. The significance of vital capacity and Pao2/Fio2 ratios are unclear; they may be regarded as surrogate end points, and there was actually no evidence of any improvement in these parameters with any of the tested physiotherapy treatments. The main problem with the end points “atelectasis” or “unspecified pulmonary complications” was the lack of a clear and universally accepted definition. And, as for vital capacity and Pao2/Fio2 ratios, there was uncertainty about the clinical relevance of these outcomes. For instance, “unspecified pulmonary complications” is a composite end point that includes diverse pathologies such as bronchitis, pneumonia, or atelectasis. Perhaps as a consequence of the variability in definitions of unspecified pulmonary complications, control event rates varied widely, ranging from 0% to almost 50%. Composite outcomes are appropriate only when the individual symptoms are well defined, when the components are of equal importance, and occur with similar frequencies, and when the active intervention leads to a similar relative risk reduction of all components.55 This is not the case for unspecified pulmonary complications. A metaanalysis7 reported a positive impact of prophylactic respiratory physiotherapy after abdominal surgery; interestingly, that favorable result was based exclusively on the analysis of unspecified pulmonary complications.

Our analysis has some limitations; most are related to weaknesses in the original studies. For instance, these trials were of limited methodologic quality; in less than half, observers were blinded; one third only reported on details of randomization and follow-up; and in a minority, treatment allocation was concealed. One inherent problem of physiotherapy trials is that the observer only can be blinded. We do not know whether the trials were badly designed or the data inadequately reported; most were published before the first Consolidated Standards of Reporting Trials statement.56The problem is that trials of low methodologic quality may exaggerate estimates of efficacy.57 Many trials were of limited size. Small trial size may partly explain the variability in event rates. Also, small trials may be associated with low statistical power to detect statistically significant effects, even if true effects exist. Moreover, small trials are less likely to identify rare events, for instance, intervention-related adverse effects. Twenty-four of the 31 trials did not mention any adverse effects; however, not reporting of adverse effects does not mean that none had occurred. Most adverse effects were minor and we may assume that they are preventable through adequate handling of devices and appropriate training of chest therapists. Yet, the combination of potential for harm and doubtful efficacy further challenges the usefulness of routine prophylactic respiratory physiotherapy in these patients. Finally, as in similar previous analyses,9 a large variety of physiotherapy regimens were tested. This variability suggests that there is no consensus among physiotherapists on how to use these therapies and of what the “gold standard” intervention consists. In the absence of a “gold standard,” trials should be designed to include a placebo group or, in this case, a no intervention control group.58 A minority only of the retrieved trials fulfilled that criterion. Finally, we had to assume that patients were treated in upright position and that they were mobilized, although this was not specified in the original trials. The necessary information to perform subgroup analyses to estimate the impact of such measurements on the efficacy of physiotherapy treatments was lacking.

What are the implications of this analysis? There are clinical settings, in which the usefulness of respiratory physiotherapy is based on strong evidence, for instance, therapeutic noninvasive positive pressure ventilation in patients with acute exacerbations of severe COPD,5960 pulmonary rehabilitation in patients with COPD,6162 chest physical therapy in patients with cystic fibrosis,63or CPAP for the treatment of postoperative hypoxemia.64 Yet, considering the available evidence, routine use of prophylactic respiratory physiotherapy in patients after abdominal surgery does not seem to be justified. These trials were published between 1952 and 2005, they tested a large variety of physiotherapy treatments after different abdominal surgeries, and the majority of the studies were of only limited methodologic quality. It is, therefore, difficult to draw specific conclusions. For deep breathing with directed cough, the only method that showed some efficacy, we have to assume that the positive results were biased by trials that reported on very high control event rates or end points with doubtful clinical relevance.

The agenda is one of further research rather than of clinical recommendations. With > 4 million abdominal surgeries performed each year in the United States alone,1 it is of economic importance whether a labor-intensive and thus costly intervention with doubtful efficacy is routinely performed. Thus, the usefulness of prophylactic respiratory physiotherapy after abdominal surgery needs to be established in valid clinical trials before this intervention can be recommended for routine use. To avoid methodologic pitfalls in future studies, some issues that have been identified through this systematic review need to be addressed. All patients randomized to the experimental group should be treated with an identical technique of physiotherapy, including similar frequency and duration, and administered by trained physiotherapists. In all patients, further procedures, such as analgesia or mobilization, should also be identical. Trials should be of reasonable size to overcome random variations, and to identify with confidence small but clinically relevant benefits and rare adverse effects. Perhaps the most important potential benefit of respiratory physiotherapy, both from a clinical and the patient’s point of view, is the prevention of pneumonia. This end point needs a clear definition; the most appropriate in the context of nosocomial pneumonia may be from the Centers for Disease Control and Prevention.65When ever feasible, assessments should be done by observers who are unaware of treatment allocation. The observation period should be expanded until hospital discharge. Length of stay (in the ICU and in the hospital) has important implications for costs; these data should be reported. Pulmonary high-risk patients need to be included in future trials. Risk scores, such as the multifactorial risk index for predicting postoperative respiratory failure in patients undergoing major noncardiac surgery,6667 may be used to stratify patients to those who are most likely to profit from prophylactic respiratory physiotherapy.

Abbreviations: CI = confidence interval; CPAP = continuous positive airway pressure; Fio2 = fraction of inspired oxygen; IPPB = intermittent positive pressure breathing; IS = incentive spirometry; NNT = number needed to treat; RD = risk difference

Mr. Pasquina initiated, designed, and organized the study, searched trials, and extracted data. Dr. Tramèr designed the study and cross-checked extracted data. Mr. Granier cross-checked extracted data. Dr. Walder initiated and designed the study and cross-checked extracted data. All authors participated in interpreting the results of the trials and in writing the article.

Figure Jump LinkFigure 1. Flow chart of screened, excluded, and eventually analyzed reports.Grahic Jump Location
Table Graphic Jump Location
Table 1. Analyzed Randomized Trials*
* 

References are in alphabetical order. PT = physical therapy.

 

Less intensive/more intensive therapy.

 

Deep breathing and directed cough.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough and postural drainage therapy and bronchodilator aerosol.

 

Deep breathing.

# 

Physical therapy not defined.

** 

Three different types of IS.

†† 

Positive expiratory pressure mask.

‡‡ 

Inspiratory resistance and positive expiratory pressure mask.

§§ 

Regimen-associated IS and physical therapy.

∥∥ 

Bilevel positive airway pressure.

¶¶ 

Blow bottle.

## 

Less intensive/more intensive bilevel positive airway pressure.

*** 

Blow glove.

††† 

Less intensive/more intensive regimen-associated IS, physical therapy, IPPB.

‡‡‡ 

Data from personal communication with main author.

Table Graphic Jump Location
Table 1A. Continued
Figure Jump LinkFigure 2. Pneumonia in trials with a no intervention control group. aDeep breathing and directed cough; bdeep breathing and directed cough and postural drainage therapy; cdeep breathing and directed cough and postural drainage therapy and bronchodilatator aerosol; *data from personal communication with main author. On the event-rate scatter, the size of the symbols is proportional to the size of the trials. NNT is displayed for statistically significant results only. PhysTher = physical therapy.Grahic Jump Location
Figure Jump LinkFigure 3. Atelectasis in trials with a no intervention control group. aDeep breathing and directed cough; bdeep breathing and directed cough and postural drainage therapy; cdeep breathing and directed cough and postural drainage therapy and bronchodilatator aerosol; *data from personal communication with main author. On the event-rate scatter, the size of the symbols is proportional to the size of the trials. NNT is displayed for statistically significant results only. See Figure 2 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 4. Unspecified pulmonary complications in trials with a no intervention control group. aDeep breathing; bdeep breathing and directed cough; &more intensive therapy. On the event-rate scatter, the size of the symbols is proportional to the size of the trials. NNT is displayed for statistically significant results only. See Figure 2 legend for expansion of abbreviation.Grahic Jump Location
Table Graphic Jump Location
Table 2. Unspecified Pulmonary Complications in Trials With a No Intervention Control Group
Table Graphic Jump Location
Table 3. Pao2/Fio2 in Trials With a No Intervention Control Group*
* 

Data are presented as mean ± SD. No statistical differences were reported.

 

SD not available.

 

Deep breathing and directed cough.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough and postural drainage therapy and bronchodilatator aerosol.

Table Graphic Jump Location
Table 4. Vital Capacity in Trials With a No Intervention Control Group*
* 

Data are presented as mean ± SD unless otherwise indicated.

 

Data presented as % of preoperative volume.

 

Deep breathing and directed cough.

Table Graphic Jump Location
Table 5. Incidence of Pneumonia in Trials Without a No Intervention Control Group*
* 

Data are presented as %.

 

Three different types of IS.

 

Less intensive/more intensive therapy.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Physical therapy not defined.

 

Deep breathing and directed cough.

# 

Deep breathing.

** 

Positive expiratory pressure mask.

†† 

Inspiratory resistance and positive expiratory pressure mask.

‡‡ 

Regimen-associated IS and physical therapy.

§§ 

Blow glove.

∥∥ 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

Table Graphic Jump Location
Table 6. Incidence of Atelectasis in Trials Without a No Intervention Control Group*
* 

Data are presented as %.

 

Three different types of IS.

 

Incidence of major atelectasis.

§ 

Less intensive/more intensive therapy.

 

Deep breathing and directed cough and postural drainage therapy.

 

Physical therapy not defined.

# 

Deep breathing and directed cough.

** 

Deep breathing.

†† 

Positive expiratory pressure mask.

‡‡ 

Inspiratory resistance and positive expiratory pressure mask.

§§ 

Regimen-associated IS and physical therapy.

∥∥ 

Blow bottle.

¶¶ 

Blow glove.

## 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

*** 

Statistically significant differences between interventions.

Table Graphic Jump Location
Table 7. Incidence of Unspecified Pulmonary Complications in Trials Without a No Intervention Control Group*
* 

Data are presented as %.

 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough.

§ 

Less intensive/more intensive therapy.

 

Physical therapy not defined.

 

Deep breathing.

# 

Positive expiratory pressure mask.

** 

Inspiratory resistance and positive expiratory pressure mask.

†† 

Regimen-associated IS and physical therapy.

‡‡ 

Statistically significant differences between interventions.

Table Graphic Jump Location
Table 8. Pao2/Fio2 Ratio in Trials Without a No Intervention Control Group*
* 

Data are presented as mean ± SD.

 

Statistically significant differences between interventions.

 

SD not available.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Physical therapy not defined.

 

Positive expiratory pressure mask.

# 

Inspiratory resistance and positive expiratory pressure mask.

** 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

Table Graphic Jump Location
Table 9. Vital Capacity in Trials Without a No Intervention Control Group*
* 

Data are presented as mean ± SD unless otherwise indicated.

 

Statistically significant differences between interventions.

 

SD not available.

§ 

Data presented as % of predicted value.

 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough.

# 

Physical therapy not defined.

** 

Three different types of IS.

†† 

Positive expiratory pressure mask.

‡‡ 

Inspiratory resistance and positive expiratory pressure mask.

§§ 

Bilevel positive airway pressure.

∥∥ 

Less intensive/more intensive bilevel positive airway pressure.

¶¶ 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

## 

Regimen-associated IS and physical therapy.

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Chumillas, S, Ponce, JL, Delgado, F, et al Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study.Arch Phys Med Rehabil1998;79,5-9. [CrossRef] [PubMed]
 
Condie, E, Hack, K, Ross, A An investigation of the value of routine provision of post-operative chest physiotherapy in non-smoking patients undergoing elective abdominal surgery.Physiotherapy1993;79,547-552. [CrossRef]
 
Craven, JL, Evans, GA, Davenport, PJ, et al The evaluation of the incentive spirometer in the management of postoperative pulmonary complications.Br J Surg1974;61,793-797. [CrossRef] [PubMed]
 
Crawford, BL, Blunnie, WP, Elliott, AG The value of self-administered peri-operative physiotherapy.Ir J Med Sci1990;159,51-52. [CrossRef] [PubMed]
 
Denehy, L, Carroll, S, Ntoumenopoulos, G, et al A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery.Physiother Res Int2001;6,236-250. [CrossRef] [PubMed]
 
Dohi, S, Gold, MI Comparison of two methods of postoperative respiratory care.Chest1978;73,592-595. [CrossRef] [PubMed]
 
Ebeo, CT, Benotti, PN, Byrd, RP, Jr, et al The effect of bi-level positive airway pressure on postoperative pulmonary function following gastric surgery for obesity.Respir Med2002;96,672-676. [CrossRef] [PubMed]
 
Giroux, JM, Lewis, S, Holland, LG, et al Postoperative chest physiotherapy for abdominal hysterectomy patients.Physiother Can1987;39,89-93
 
Hall, JC, Tarala, R, Harris, J, et al Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery.Lancet1991;337,953-956. [CrossRef] [PubMed]
 
Hall, JC, Tarala, RA, Tapper, J, et al Prevention of respiratory complications after abdominal surgery: a randomised clinical trial.BMJ1996;312,148-152. [CrossRef] [PubMed]
 
Heisterberg, L, Johansen, TS, Larsen, HW, et al Postoperative pulmonary complications in upper abdominal surgery: a randomized clinical comparison between physiotherapy and blow-bottles.Acta Chir Scand1979;145,505-507. [PubMed]
 
Joris, JL, Sottiaux, TM, Chiche, JD, et al Effect of bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty.Chest1997;111,665-670. [CrossRef] [PubMed]
 
Jung, R, Wight, J, Nusser, R, et al Comparison of three methods of respiratory care following upper abdominal surgery.Chest1980;78,31-35. [CrossRef] [PubMed]
 
Laszlo, G, Archer, GG, Darrel, JH, et al The diagnosis and prophylaxis of pulmonary complications of surgical operation.Br J Surg1973;60,129-134. [CrossRef] [PubMed]
 
Lederer, DH, Van de Water, JM, Indech, RB Which deep breathing device should the postoperative patient use?Chest1980;77,610-613. [CrossRef] [PubMed]
 
Lindner, KH, Lotz, P, Ahnefeld, FW Continuous positive airway pressure effect on functional residual capacity, vital capacity and its subdivisions.Chest1987;92,66-70. [CrossRef] [PubMed]
 
Lotz, P, Heise, U, Schaffer, J, et al The effect of intraoperative PEEP ventilation and postoperative CPAP breathing on postoperative lung function following upper abdominal surgery.Anaesthesist1984;33,177-188. [PubMed]
 
Lyager, S, Wernberg, M, Rajani, N, et al Can postoperative pulmonary conditions be improved by treatment with the Bartlett-Edwards incentive spirometer after upper abdominal surgery?Acta Anaesthesiol Scand1979;23,312-319. [CrossRef] [PubMed]
 
Mackay, MR, Ellis, E, Johnston, C Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients.Aust J Physiother2005;51,151-159. [CrossRef] [PubMed]
 
Morran, CG, Finlay, IG, Mathieson, M, et al Randomized controlled trial of physiotherapy for postoperative pulmonary complications.Br J Anaesth1983;55,1113-1117. [CrossRef] [PubMed]
 
O’Connor, M, Tattersall, MP, Carter, JA An evaluation of the incentive spirometer to improve lung function after cholecystectomy.Anaesthesia1988;43,785-787. [CrossRef] [PubMed]
 
Palmer, KN, Sellick, BA Effect of procaine penicillin and breathing exercises in postoperative pulmonary complications.Lancet1952;,345-346
 
Ricksten, SE, Bengtsson, A, Soderberg, C, et al Effects of periodic positive airway pressure by mask on postoperative pulmonary function.Chest1986;89,774-781. [CrossRef] [PubMed]
 
Schuppisser, JP, Brandli, O, Meili, U Postoperative intermittent positive pressure breathing versus physiotherapy.Am J Surg1980;140,682-686. [CrossRef] [PubMed]
 
Schwieger, I, Gamulin, Z, Forster, A, et al Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy: a controlled randomized study.Chest1986;89,652-656. [CrossRef] [PubMed]
 
Stock, MC, Downs, JB, Gauer, PK, et al Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy.Chest1985;87,151-157. [CrossRef] [PubMed]
 
Torrington, KG, Sorenson, DE, Sherwood, LM Postoperative chest percussion with postural drainage in obese patients following gastric stapling.Chest1984;86,891-895. [CrossRef] [PubMed]
 
Wiklander, O, Norlin, U Effect of physiotherapy on post-operative pulmonary complications: a clinical and roentgenographic study of 200 cases.Acta Chir Scand1957;112,246-254. [PubMed]
 
Roukema, JA, Carol, EJ, Prins, JG The prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status.Arch Surg1988;123,30-34. [CrossRef] [PubMed]
 
Van de Water, JM, Watring, WG, Linton, LA, et al Prevention of postoperative pulmonary complications.Surg Gynecol Obstet1972;135,229-233. [PubMed]
 
Stock, MC, Downs, JB, Gauer, PK, et al Prevention of atelectasis after upper abdominal operations [abstract]. Anesthesiology. 1982;;57 ,.:A457. [CrossRef]
 
Montori, VM, Permanyer-Miralda, G, Ferreira-Gonzalez, I, et al Validity of composite end points in clinical trials.BMJ2005;330,594-596. [CrossRef] [PubMed]
 
Begg, C, Cho, M, Eastwood, S, et al Improving the quality of reporting of randomized controlled trials: the CONSORT statement.JAMA1996;276,637-639. [CrossRef] [PubMed]
 
Schulz, KF, Chalmers, I, Hayes, RJ, et al Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials.JAMA1995;273,408-412. [CrossRef] [PubMed]
 
Tramèr, MR, Reynolds, DJ, Moore, RA, et al When placebo controlled trials are essential and equivalence trials are inadequate.BMJ1998;317,875-880. [CrossRef] [PubMed]
 
Bach, PB, Brown, C, Gelfand, SE, et al Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence.Ann Intern Med2001;134,600-620. [PubMed]
 
Soto, FJ, Varkey, B Evidence-based approach to acute exacerbations of COPD.Curr Opin Pulm Med2003;9,117-124. [CrossRef] [PubMed]
 
Lacasse, Y, Wong, E, Guyatt, GH, et al Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease.Lancet1996;348,1115-1119. [CrossRef] [PubMed]
 
Cambach, W, Wagenaar, RC, Koelman, TW, et al The long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease: a research synthesis.Arch Phys Med Rehabil1999;80,103-111. [CrossRef] [PubMed]
 
Thomas, J, Cook, DJ, Brooks, D Chest physical therapy management of patients with cystic fibrosis: a meta-analysis.Am J Respir Crit Care Med1995;151,846-850. [PubMed]
 
Squadrone, V, Coha, M, Cerutti, E, et al Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.JAMA2005;293,589-595. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention. Criteria for Defining Nosocomial Pneumonia. Available at: www.cdc.gov/ncidod/hip/NNIS/members/pneumonia/Final/PneumoCriteriaV1.pdf. Accessed September 12, 2005.
 
Arozullah, AM, Daley, J, Henderson, WG, et al Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery: the National Veterans Administration Surgical Quality Improvement Program.Ann Surg2000;232,242-253. [CrossRef] [PubMed]
 
Arozullah, AM, Khuri, SF, Henderson, WG, et al Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery.Ann Intern Med2001;135,847-857. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Flow chart of screened, excluded, and eventually analyzed reports.Grahic Jump Location
Figure Jump LinkFigure 2. Pneumonia in trials with a no intervention control group. aDeep breathing and directed cough; bdeep breathing and directed cough and postural drainage therapy; cdeep breathing and directed cough and postural drainage therapy and bronchodilatator aerosol; *data from personal communication with main author. On the event-rate scatter, the size of the symbols is proportional to the size of the trials. NNT is displayed for statistically significant results only. PhysTher = physical therapy.Grahic Jump Location
Figure Jump LinkFigure 3. Atelectasis in trials with a no intervention control group. aDeep breathing and directed cough; bdeep breathing and directed cough and postural drainage therapy; cdeep breathing and directed cough and postural drainage therapy and bronchodilatator aerosol; *data from personal communication with main author. On the event-rate scatter, the size of the symbols is proportional to the size of the trials. NNT is displayed for statistically significant results only. See Figure 2 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 4. Unspecified pulmonary complications in trials with a no intervention control group. aDeep breathing; bdeep breathing and directed cough; &more intensive therapy. On the event-rate scatter, the size of the symbols is proportional to the size of the trials. NNT is displayed for statistically significant results only. See Figure 2 legend for expansion of abbreviation.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Analyzed Randomized Trials*
* 

References are in alphabetical order. PT = physical therapy.

 

Less intensive/more intensive therapy.

 

Deep breathing and directed cough.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough and postural drainage therapy and bronchodilator aerosol.

 

Deep breathing.

# 

Physical therapy not defined.

** 

Three different types of IS.

†† 

Positive expiratory pressure mask.

‡‡ 

Inspiratory resistance and positive expiratory pressure mask.

§§ 

Regimen-associated IS and physical therapy.

∥∥ 

Bilevel positive airway pressure.

¶¶ 

Blow bottle.

## 

Less intensive/more intensive bilevel positive airway pressure.

*** 

Blow glove.

††† 

Less intensive/more intensive regimen-associated IS, physical therapy, IPPB.

‡‡‡ 

Data from personal communication with main author.

Table Graphic Jump Location
Table 1A. Continued
Table Graphic Jump Location
Table 2. Unspecified Pulmonary Complications in Trials With a No Intervention Control Group
Table Graphic Jump Location
Table 3. Pao2/Fio2 in Trials With a No Intervention Control Group*
* 

Data are presented as mean ± SD. No statistical differences were reported.

 

SD not available.

 

Deep breathing and directed cough.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough and postural drainage therapy and bronchodilatator aerosol.

Table Graphic Jump Location
Table 4. Vital Capacity in Trials With a No Intervention Control Group*
* 

Data are presented as mean ± SD unless otherwise indicated.

 

Data presented as % of preoperative volume.

 

Deep breathing and directed cough.

Table Graphic Jump Location
Table 5. Incidence of Pneumonia in Trials Without a No Intervention Control Group*
* 

Data are presented as %.

 

Three different types of IS.

 

Less intensive/more intensive therapy.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Physical therapy not defined.

 

Deep breathing and directed cough.

# 

Deep breathing.

** 

Positive expiratory pressure mask.

†† 

Inspiratory resistance and positive expiratory pressure mask.

‡‡ 

Regimen-associated IS and physical therapy.

§§ 

Blow glove.

∥∥ 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

Table Graphic Jump Location
Table 6. Incidence of Atelectasis in Trials Without a No Intervention Control Group*
* 

Data are presented as %.

 

Three different types of IS.

 

Incidence of major atelectasis.

§ 

Less intensive/more intensive therapy.

 

Deep breathing and directed cough and postural drainage therapy.

 

Physical therapy not defined.

# 

Deep breathing and directed cough.

** 

Deep breathing.

†† 

Positive expiratory pressure mask.

‡‡ 

Inspiratory resistance and positive expiratory pressure mask.

§§ 

Regimen-associated IS and physical therapy.

∥∥ 

Blow bottle.

¶¶ 

Blow glove.

## 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

*** 

Statistically significant differences between interventions.

Table Graphic Jump Location
Table 7. Incidence of Unspecified Pulmonary Complications in Trials Without a No Intervention Control Group*
* 

Data are presented as %.

 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough.

§ 

Less intensive/more intensive therapy.

 

Physical therapy not defined.

 

Deep breathing.

# 

Positive expiratory pressure mask.

** 

Inspiratory resistance and positive expiratory pressure mask.

†† 

Regimen-associated IS and physical therapy.

‡‡ 

Statistically significant differences between interventions.

Table Graphic Jump Location
Table 8. Pao2/Fio2 Ratio in Trials Without a No Intervention Control Group*
* 

Data are presented as mean ± SD.

 

Statistically significant differences between interventions.

 

SD not available.

§ 

Deep breathing and directed cough and postural drainage therapy.

 

Physical therapy not defined.

 

Positive expiratory pressure mask.

# 

Inspiratory resistance and positive expiratory pressure mask.

** 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

Table Graphic Jump Location
Table 9. Vital Capacity in Trials Without a No Intervention Control Group*
* 

Data are presented as mean ± SD unless otherwise indicated.

 

Statistically significant differences between interventions.

 

SD not available.

§ 

Data presented as % of predicted value.

 

Deep breathing and directed cough and postural drainage therapy.

 

Deep breathing and directed cough.

# 

Physical therapy not defined.

** 

Three different types of IS.

†† 

Positive expiratory pressure mask.

‡‡ 

Inspiratory resistance and positive expiratory pressure mask.

§§ 

Bilevel positive airway pressure.

∥∥ 

Less intensive/more intensive bilevel positive airway pressure.

¶¶ 

Less intensive/more intensive association of IS, physical therapy, and IPPB.

## 

Regimen-associated IS and physical therapy.

References

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MacMahon, C Breathing and physical exercises for the use in cases of wounds in pleura, lung and diaphragm.Lancet1915;2,769-770
 
Thomas, JA, McIntosh, JM Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis.Phys Ther1994;74,3-16. [PubMed]
 
Overend, TJ, Anderson, CM, Lucy, SD, et al The effect of incentive spirometry on postoperative pulmonary complications: a systematic review.Chest2001;120,971-978. [CrossRef] [PubMed]
 
Pasquina, P, Tramèr, MR, Walder, B Prophylactic respiratory physiotherapy after cardiac surgery: systematic review.BMJ2003;327,1379-1381. [CrossRef] [PubMed]
 
Brooks, D, Crowe, J, Kelsey, CJ, et al A clinical practice guideline on peri-operative cardiorespiratory physical therapy.Physiother Can2001;53,9-25
 
Richardson, J, Sabanathan, S Prevention of respiratory complications after abdominal surgery.Thorax1997;52,S35-S40. [CrossRef] [PubMed]
 
Elia, N, Tramèr, MR Ketamine and postoperative pain: a quantitative systematic review of randomised trials.Pain2005;113,61-70. [CrossRef] [PubMed]
 
Gardner, MJ, Altman, DG Calculating confidence intervals for proportions and their differences. Gardner, MJ Altman, DG eds. Statistics with confidence: confidence intervals and statistical guidelines. 1995; BMJ. London, UK:.
 
Tramèr, MR, Walder, B Number needed to treat (or harm).World J Surg2005;29,576-581. [CrossRef] [PubMed]
 
von Elm, E, Poglia, G, Walder, B, et al Different patterns of duplicate publication: an analysis of articles used in systematic reviews.JAMA2004;291,974-980. [CrossRef] [PubMed]
 
Hallbook, T, Lindblad, B, Lindroth, B, et al Prophylaxis against pulmonary complications in patients undergoing gall-bladder surgery: a comparison between early mobilization, physiotherapy with and without bronchodilatation.Ann Chir Gynaecol1984;73,55-58. [PubMed]
 
Arvidsson, L, Hallbook, T, Lindblad, B, et al Is physiotherapeutic respiratory care valuable for prophylactic purpose after an operation [in Swedish]?Lakartidningen1982;79,1480-1481. [PubMed]
 
Ali, J, Serrette, C, Wood, LDH, et al Effect of postoperative intermittent positive pressure breathing on lung function.Chest1984;85,192-196. [CrossRef] [PubMed]
 
Baxter, WD, Levine, RS An evaluation of intermittent positive pressure breathing in the prevention of postoperative pulmonary complications.Arch Surg1969;98,795-798. [CrossRef] [PubMed]
 
Böhner, H, Kindgen-Milles, D, Grust, A, et al Prophylactic nasal continuous positive airway pressure after major vascular surgery: results of a prospective randomized trial.Langenbecks Arch Surg2002;387,21-26. [CrossRef] [PubMed]
 
Campbell, T, Ferguson, N, McKinlay, RGC The use of a simple self-administered method of positive expiratory pressure (PEP) in chest physiotherapy after abdominal surgery.Physiotherapy1986;72,498-500
 
Celli, BR, Rodriguez, KS, Snider, GL A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery.Am Rev Respir Dis1984;130,12-15. [PubMed]
 
Christensen, EF, Schultz, P, Jensen, OV, et al Postoperative pulmonary complications and lung function in high-risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia.Acta Anaesthesiol Scand1991;35,97-104. [PubMed]
 
Chumillas, S, Ponce, JL, Delgado, F, et al Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study.Arch Phys Med Rehabil1998;79,5-9. [CrossRef] [PubMed]
 
Condie, E, Hack, K, Ross, A An investigation of the value of routine provision of post-operative chest physiotherapy in non-smoking patients undergoing elective abdominal surgery.Physiotherapy1993;79,547-552. [CrossRef]
 
Craven, JL, Evans, GA, Davenport, PJ, et al The evaluation of the incentive spirometer in the management of postoperative pulmonary complications.Br J Surg1974;61,793-797. [CrossRef] [PubMed]
 
Crawford, BL, Blunnie, WP, Elliott, AG The value of self-administered peri-operative physiotherapy.Ir J Med Sci1990;159,51-52. [CrossRef] [PubMed]
 
Denehy, L, Carroll, S, Ntoumenopoulos, G, et al A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery.Physiother Res Int2001;6,236-250. [CrossRef] [PubMed]
 
Dohi, S, Gold, MI Comparison of two methods of postoperative respiratory care.Chest1978;73,592-595. [CrossRef] [PubMed]
 
Ebeo, CT, Benotti, PN, Byrd, RP, Jr, et al The effect of bi-level positive airway pressure on postoperative pulmonary function following gastric surgery for obesity.Respir Med2002;96,672-676. [CrossRef] [PubMed]
 
Giroux, JM, Lewis, S, Holland, LG, et al Postoperative chest physiotherapy for abdominal hysterectomy patients.Physiother Can1987;39,89-93
 
Hall, JC, Tarala, R, Harris, J, et al Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery.Lancet1991;337,953-956. [CrossRef] [PubMed]
 
Hall, JC, Tarala, RA, Tapper, J, et al Prevention of respiratory complications after abdominal surgery: a randomised clinical trial.BMJ1996;312,148-152. [CrossRef] [PubMed]
 
Heisterberg, L, Johansen, TS, Larsen, HW, et al Postoperative pulmonary complications in upper abdominal surgery: a randomized clinical comparison between physiotherapy and blow-bottles.Acta Chir Scand1979;145,505-507. [PubMed]
 
Joris, JL, Sottiaux, TM, Chiche, JD, et al Effect of bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty.Chest1997;111,665-670. [CrossRef] [PubMed]
 
Jung, R, Wight, J, Nusser, R, et al Comparison of three methods of respiratory care following upper abdominal surgery.Chest1980;78,31-35. [CrossRef] [PubMed]
 
Laszlo, G, Archer, GG, Darrel, JH, et al The diagnosis and prophylaxis of pulmonary complications of surgical operation.Br J Surg1973;60,129-134. [CrossRef] [PubMed]
 
Lederer, DH, Van de Water, JM, Indech, RB Which deep breathing device should the postoperative patient use?Chest1980;77,610-613. [CrossRef] [PubMed]
 
Lindner, KH, Lotz, P, Ahnefeld, FW Continuous positive airway pressure effect on functional residual capacity, vital capacity and its subdivisions.Chest1987;92,66-70. [CrossRef] [PubMed]
 
Lotz, P, Heise, U, Schaffer, J, et al The effect of intraoperative PEEP ventilation and postoperative CPAP breathing on postoperative lung function following upper abdominal surgery.Anaesthesist1984;33,177-188. [PubMed]
 
Lyager, S, Wernberg, M, Rajani, N, et al Can postoperative pulmonary conditions be improved by treatment with the Bartlett-Edwards incentive spirometer after upper abdominal surgery?Acta Anaesthesiol Scand1979;23,312-319. [CrossRef] [PubMed]
 
Mackay, MR, Ellis, E, Johnston, C Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients.Aust J Physiother2005;51,151-159. [CrossRef] [PubMed]
 
Morran, CG, Finlay, IG, Mathieson, M, et al Randomized controlled trial of physiotherapy for postoperative pulmonary complications.Br J Anaesth1983;55,1113-1117. [CrossRef] [PubMed]
 
O’Connor, M, Tattersall, MP, Carter, JA An evaluation of the incentive spirometer to improve lung function after cholecystectomy.Anaesthesia1988;43,785-787. [CrossRef] [PubMed]
 
Palmer, KN, Sellick, BA Effect of procaine penicillin and breathing exercises in postoperative pulmonary complications.Lancet1952;,345-346
 
Ricksten, SE, Bengtsson, A, Soderberg, C, et al Effects of periodic positive airway pressure by mask on postoperative pulmonary function.Chest1986;89,774-781. [CrossRef] [PubMed]
 
Schuppisser, JP, Brandli, O, Meili, U Postoperative intermittent positive pressure breathing versus physiotherapy.Am J Surg1980;140,682-686. [CrossRef] [PubMed]
 
Schwieger, I, Gamulin, Z, Forster, A, et al Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy: a controlled randomized study.Chest1986;89,652-656. [CrossRef] [PubMed]
 
Stock, MC, Downs, JB, Gauer, PK, et al Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy.Chest1985;87,151-157. [CrossRef] [PubMed]
 
Torrington, KG, Sorenson, DE, Sherwood, LM Postoperative chest percussion with postural drainage in obese patients following gastric stapling.Chest1984;86,891-895. [CrossRef] [PubMed]
 
Wiklander, O, Norlin, U Effect of physiotherapy on post-operative pulmonary complications: a clinical and roentgenographic study of 200 cases.Acta Chir Scand1957;112,246-254. [PubMed]
 
Roukema, JA, Carol, EJ, Prins, JG The prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status.Arch Surg1988;123,30-34. [CrossRef] [PubMed]
 
Van de Water, JM, Watring, WG, Linton, LA, et al Prevention of postoperative pulmonary complications.Surg Gynecol Obstet1972;135,229-233. [PubMed]
 
Stock, MC, Downs, JB, Gauer, PK, et al Prevention of atelectasis after upper abdominal operations [abstract]. Anesthesiology. 1982;;57 ,.:A457. [CrossRef]
 
Montori, VM, Permanyer-Miralda, G, Ferreira-Gonzalez, I, et al Validity of composite end points in clinical trials.BMJ2005;330,594-596. [CrossRef] [PubMed]
 
Begg, C, Cho, M, Eastwood, S, et al Improving the quality of reporting of randomized controlled trials: the CONSORT statement.JAMA1996;276,637-639. [CrossRef] [PubMed]
 
Schulz, KF, Chalmers, I, Hayes, RJ, et al Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials.JAMA1995;273,408-412. [CrossRef] [PubMed]
 
Tramèr, MR, Reynolds, DJ, Moore, RA, et al When placebo controlled trials are essential and equivalence trials are inadequate.BMJ1998;317,875-880. [CrossRef] [PubMed]
 
Bach, PB, Brown, C, Gelfand, SE, et al Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence.Ann Intern Med2001;134,600-620. [PubMed]
 
Soto, FJ, Varkey, B Evidence-based approach to acute exacerbations of COPD.Curr Opin Pulm Med2003;9,117-124. [CrossRef] [PubMed]
 
Lacasse, Y, Wong, E, Guyatt, GH, et al Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease.Lancet1996;348,1115-1119. [CrossRef] [PubMed]
 
Cambach, W, Wagenaar, RC, Koelman, TW, et al The long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease: a research synthesis.Arch Phys Med Rehabil1999;80,103-111. [CrossRef] [PubMed]
 
Thomas, J, Cook, DJ, Brooks, D Chest physical therapy management of patients with cystic fibrosis: a meta-analysis.Am J Respir Crit Care Med1995;151,846-850. [PubMed]
 
Squadrone, V, Coha, M, Cerutti, E, et al Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.JAMA2005;293,589-595. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention. Criteria for Defining Nosocomial Pneumonia. Available at: www.cdc.gov/ncidod/hip/NNIS/members/pneumonia/Final/PneumoCriteriaV1.pdf. Accessed September 12, 2005.
 
Arozullah, AM, Daley, J, Henderson, WG, et al Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery: the National Veterans Administration Surgical Quality Improvement Program.Ann Surg2000;232,242-253. [CrossRef] [PubMed]
 
Arozullah, AM, Khuri, SF, Henderson, WG, et al Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery.Ann Intern Med2001;135,847-857. [PubMed]
 
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