Pulmonary complications after cardiac surgery: breathing down the patient's neck.

In Italy more than 50,000 cardiac interventions are currently performed every year, 40% of which require valve implantation. The clinical characteristics of patients who undergo cardiac surgery have changed radically over the last decade: due to advances in perioperative care, older and moderateto-severe risk patients are now more frequently being referred to cardiac surgery, highlighting a need for increased improvement and stabilisation of surgical and medical issues. Structured rehabilitation, mainly offered through inpatient programmes, is now recognized as a standard form of care for cardiac surgery patients. Historically, the primary role of rehabilitation after cardiac surgery is to treat disability and improve functional capacity. Exercise training after heart valve replacement increases peak VO2, cardiovascular response at submaximal workloads, and quality of life with higher rates of returning to work [1], while in patients following coronary revascularisation it is known to reduce cardiovascular events as well as hospital readmissions [2]. In order to achieve better rehabilitation outcomes, patients’ symptoms and needs after cardiac surgery must be comprehensively addressed. Apart from functional recovery and cardiovascular risk reduction, a multidisciplinary integrated team approach can also positively affect post-operative pain, complications at surgical site, cardioprotective drug titration, and lifestyle modifications. Importantly, comorbidities markedly affect patients’ health status after cardiac surgery, and require adequate attention. In the current issue of Monaldi Archives for Chest Disease Pulmonary series, Westerdahl and Olsén [3] carried out a national survey in Sweden aimed at establishing the current practice of chest physiotherapy for patients undergoing cardiac surgery. Through a questionnaire sent to about thirty physiotherapists working in eight departments of cardiothoracic surgery, the authors obtained information on the use of breathing exercises after cardiac surgery and found that: i) advice for post-operative breathing exercise is regularly prescribed in Sweden, ii) the two most frequently used techniques are deep breathing with or without a PEP device, and iii) there is still a considerable heterogeneity in treatment options and timing of intervention. The strengths of the study include the national coverage of the survey (almost all Swedish cardiac surgery units were represented), and the well-designed questionnaire (suitable for future comparison among different institutions and different countries). Among the study limitations is the short time horizon of the survey, i.e. the evaluation of chest physiotherapy was limited to the first five post-operative days and did not include other interventions offered during a structured cardiac rehabilitation programme. A second limitation is the exclusion of patients with complicated open-heart surgery due to neurological, circulatory or ventilation-related conditions; such patients are now becoming more common as an effect of the increased age and comorbidity of “clear for surgery” subjects. Conceptually, a strong rationale for chest physiotherapy after cardiac surgery exists. In addition to the intervention per se, thoracotomy and general anesthesia contribute to reducing diaphragm excursion, lung volumes and functional capacity, to the point even of inducing a ventilation/perfusion mismatch and bronchial stasis. In addition to major pulmonary complications such as pneumonia, pulmonary embolism and respiratory distress, cardiac surgery is also associated with increased risk of lung atelectasis, pleural effusion, and paralysis of the frenic nerve. Both obstructive and restrictive pulmonary impairment may develop as a consequence of cardiac surgery, and conventional chest physical therapy (whose main goals are to improve mucus clearance and pulmonary function) can help prevent this event. Unfortunately, there is not a wide consensus about the most appropriate program for this patient population. A still unsolved question is the role of incentive spirometry in preventing pulmonary complications after cardiac surgery: a recent Monaldi Arch Chest Dis 2011; 75: 2, 109-111.