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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Braga Amador, A. Meira Costa, E. Takahama Sakamoto, C. Seiko Kondo, A.L. Maida Vasconcellos, C.M. Moran de Brito, W. Pereira Yamaguti" "autores" => array:8 [ 0 => array:3 [ "nombre" => "S." "apellidos" => "Souza Possa" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Braga Amador" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Meira Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Takahama Sakamoto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "C." 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"apellidos" => "Pereira Yamaguti" "email" => array:2 [ 0 => "wellington.psyamaguti@hsl.org.br" 1 => "wellpsy@yahoo.com.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Rehabilitation Service, Hospital Sírio-Libanês, São Paulo, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "School of Medicine, University of São Paulo, São Paulo, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Rehabilitation Service, Federal University of São Paulo, São Paulo, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Physical Therapy Service, Hospital Sírio-Libanês, São Paulo, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A implementação de uma diretriz para a fisioterapia no período pós-operatório da cirurgia abdominal alta, reduz a incidência de atelectasia e o tempo de internamento" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1901 "Ancho" => 2304 "Tamanyo" => 281469 ] ] "descripcion" => array:1 [ "en" => "Flowchart for inclusion and exclusion of patients in the study for the CG (pre-guideline) and IG (post-guideline)." ] ] ] "textoCompleto" => "IntroductionPostoperative pulmonary complications (PPCs) are common in patients undergoing abdominal surgery and are responsible for the increased morbidity and mortality as well as length of hospital stay and health related cost of care.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> The PPCs occur more frequently in surgeries where the incision is made above the umbilical scar, the so called upper abdominal surgeries (UAS).<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The incidence of PPCs in these subjects is related to the existence of preoperative risk factors such as advanced age, smoking, malnutrition, obesity, lung diseases, and clinical diseases. Surgical and anesthetic factors such as the time of surgery, type of surgery, and the effects of anesthetic drugs on the respiratory system also contribute to the development of PPCs.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Atelectasis, pneumonia, acute respiratory failure, tracheobronchitis, wheezing, and prolonged mechanical ventilation are the most commonly observed PPCs.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> It is known that the decrease in lung volumes and capacities, abnormal respiratory pattern, abnormal gas exchange, and pulmonary defenses in patients undergoing open UAS start with anesthetic induction and perpetuate in the postoperative period, contributing to the occurrence of these PPCs.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> The respiratory muscle dysfunction has also been attributed to the development of PPCs.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Multiple factors may be involved in diaphragmatic dysfunction, such as irritation and inflammation caused by trauma from manipulation close to the diaphragm, reflex inhibition of afferent abdominal receptors, and postoperative pain.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>In this context, physical therapy assistance to open UAS aims to preserve pulmonary function and reverse physiological and/or functional changes that may occur in the postoperative period due to these complications.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> Therefore, physical therapy provides a variety of interventions that must be individually selected according to the needs of the patient. Chest physical therapy acting with thoracic expansion exercises and diaphragmatic breathing exercises immediately after the UAS appears to improve oxygenation without triggering increase in pain or other complications.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Furthermore, interventions that increase lung volume such as deep breathing exercises, incentive spirometry and continuous positive airway pressure (CPAP) are associated with lower frequency PPCs.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> However, the number of clinical studies that highlight the benefits of applying prophylactic therapy in patients undergoing open UAS is still quite limited.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>The main objective of the present study was to evaluate the effectiveness of the implementation of a guideline for physical therapy assistance for patients undergoing elective open UAS in reducing the incidence of atelectasis and length of hospital stay in the postoperative period.Materials and methodsThe study was conducted in a private and tertiary care center of 497 beds in the state of São Paulo, Brazil. We analyzed data from patients hospitalized in intensive care units, semi-intensive units, and wards. The study included adult patients (age≥18 years) undergoing elective open UAS and who received physical therapy in the postoperative period. It excluded patients undergoing lower abdominal surgeries, laparoscopic surgeries, emergency surgeries, surgeries with associated chest manipulation, those who underwent more than one surgical procedure during hospitalization, patients who did not adhere properly to the physical therapy treatment (performing physical therapy attendances <75% of scheduled therapy), patients who initiated inpatient physical therapy before the surgery (preoperative physical therapy), individuals who died during hospitalization, and patients requiring invasive mechanical ventilation over 24hours.We used a “before and after” model of retrospective study with historical control.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> The “before” period (pre-intervention) included all consecutive patients undergoing elective open UAS who met the criteria for inclusion in the study over six months (from July to December 2010) before guideline implementation (intervention). Teams of physical therapists were trained in the standardization of the new model of care during the month of January 2011. During this period, no data of patients undergoing UAS were collected. The “after” period (post-intervention) included all consecutive patients who met the inclusion criteria of the study during the six months after guideline implementation (from February to July 2011).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 30 days. Fifteen training meetings were arranged in small groups for all the 126 physical therapists of the institution, acting in intensive care units, semi-intensive units, and wards, in relation to the guideline. During the training sessions, we presented flow diagrams for treatment, the standardization of approaches of treatment, orientations for hospital discharge, and the scientific evidence that supported the elaboration of the guidelines. Furthermore, the training aimed to guide professionals in the use of physical therapy resources recommended in the care model (i.e. incentive spirometry and positive expiratory pressure in the airways). To disseminate the guideline, printed copies of the document in the operating units were distributed, in addition to providing the electronic file in the computerized system of the institution for consultations. This material contains information about care flowcharts, indications and contraindications, criteria for discontinuing the program, resources and frequency of physical therapy sessions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The document presented a total of 11 pages including flowcharts.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Patients included in the study in the pre-intervention period (control group) underwent a program of postoperative physical therapy treatment in which the therapeutic planning to be applied was determined by the professional providing patient care (non-standard model). In contrast, patients who were included in the post-intervention (intervention group) underwent a standardized program of physical therapy treatment which structured the model of patient care, focusing on the use of additional therapeutic resources (volumetric incentive spirometry and positive expiratory pressure in the airways),<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> early sitting position and ambulation (onset <48h after surgery)<a class="elsevierStyleCrossRef" href="#bib0095">19</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Patients undergoing the program preconized by the guideline should undergo at least two sessions of physical therapy daily until the 5th postoperative day.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Therapeutic treatment was discussed again and re-planned by the team of physical therapists after the 5th postoperative day, to redefine the need for two sessions daily.In the present study, total adhesion to the guideline was defined by the use of all the features recommended in the guideline. When one of the resources was not applied, it was considered partial compliance, and when two or more features were not used, it was considered as non-adherence to the guideline.Data were collected from the analysis of medical records and electronic database of the hospital. The information extracted from these sources was stored in electronic format previously designed for this study. We collected data concerning characterization of each patient (medical history, demographics, clinical and anthropometric data), the surgical procedure (type of surgery, surgical technique, surgical time, and surgical risk), and the physical therapy assistance provided to patients during hospitalization (features used and treatment adherence). Regarding the outcomes investigated, the incidence of atelectasis was considered as the primary variable and the length of hospital stay as the secondary variable.The diagnosis of atelectasis was considered in the presence of imaging studies confirming this alteration. All patients included in the study, both in the control group (CG) and in the intervention group (IG), had radiographic evaluation from the first to fifth postoperative day. We considered only the presence of pure atelectasis (not associated with other complications such as pleural effusion or pneumothorax) since the aim of the study was to determine the incidence of atelectasis secondary only to the surgery, and not to other complications. Radiologists who had read all the examinations did not know the study objectives. We considered as possible risk factors for developing atelectasis: age, female gender, high body mass index (BMI), lung disease, history of smoking, hypertension, diabetes, dyslipidemia, heart disease, cancer, type of surgery, surgical technique, time of surgery, and surgical risk (American Society of Anesthesiologists scale).The sample size calculation was performed based on a pilot study that showed a percentage of 25% for the incidence of atelectasis among patients undergoing UAS who were not submitted to the guideline. We also considered one previous study showing a reduction to a proportion of 6% of atelectasis among patients undergoing a protocol of physical therapy in the postoperative.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> With a 5% significance level and a power test of 90%, the sample was determined to be 66 patients for each group. To reach this number, we calculated that we needed 6 months for the post-intervention period. For the final analysis, a sensitive analysis was performed including only the patients with full adherence to the guideline as well as an analysis of all patients included in the post-intervention period. Categorical variables are presented as frequency, whereas continuous variables are expressed as mean±standard deviation. Comparisons between groups were made by Mann–Whitney test (nonparametric data), in the case of numerical variables, and by the chi-square test in the case of categorical variables. The level of significance was 5%. Statistical analysis was performed using the statistical program SigmaPlot 11.0 (Systat Software Inc., CA, USA).This study was approved by the Ethics Committee of the hospital (Registration number: HSL 2010-58). There was waiver shall of the Consent Form, because it is a retrospective observational study analyzing standardization of institutional care process.ResultsWe analyzed medical records of 535 patients undergoing UAS in the total period of the study, 249 belonging to the stage prior to guideline implementation and 286 belonging to the subsequent stage. After evaluation of inclusion and exclusion criteria, 202 were eligible for the study. The CG consisted of 133 patients and the IG of 69 patients (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Of the patients included in the IG, 32 (46.4%) had total adherence to the guideline, whereas 37 (53.6%) had partial adherence to the guideline (did not undergo one of the additional therapeutic resources in the proposed guideline).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The clinical and demographic characteristics of the population studied in each group are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. There was significant difference between the groups only in relation to smoking history and gender. The IG patients presented a higher prevalence of tobacco use and a higher proportion of males. The main reason for the surgery was the presence of tumor with resection indication for both CG (91%) and IG (81.2%). There was no difference between groups in relation to surgical risk, technique or surgery time.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The guideline implementation optimized the use of additional therapeutic resources during physical therapy assistance, causing a significant increase in the use of incentive spirometry and expiratory positive airway pressure (EPAP) (p<0.001). Furthermore, it was observed that early ambulation occurred in all patients in the post-intervention period. In contrast, only 12% of patients in the pre-intervention period managed early ambulation (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Regarding the clinical outcomes, no patient in the IG showed pure atelectasis, whereas the frequency of atelectasis in the CG was 15.8% (n=21) with statistically significant difference between groups (p<0.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). When the intention-to-treat (ITT) analysis was performed (including patients with partial adherence to the guideline), the rate of atelectasis was 13% (n=9) without statistically significant difference compared to the CG (p=0.362). There was also difference between groups in the length of hospital stay. CG individuals remained hospitalized for a longer period of time (12.1±8.3 days) when compared to the IG (9.2±4.1 days) in the postoperative period (p<0.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The ITT analysis also revealed that the length of hospital stay was still lower in the IG (10.8±6.4 days) when compared to the CG (12.1±8.3 days), but without statistically significant difference (p=0.24).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes possible risk factors for the development of atelectasis. These data are related only to the CG, since there was no development of atelectasis in the IG. In the present study, the only risk factor associated with the development of atelectasis was the surgical technique. The individuals undergoing subcostal incisions were more likely to develop this complication (p<0.05).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe present study showed that the optimization and standardization of the use of additional therapeutic resources through the implementation of a guideline for physical therapy assistance, guiding the care of patients undergoing UAS, is effective in reducing the incidence of atelectasis and length of hospital stay in the postoperative period.Previous studies have reported that the incidence of atelectasis observed in the postoperative period can vary from 6% to 42%.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> In the present study, the incidence of atelectasis among the CG patients (pre-intervention period) was 15.8%, which is consistent with these previous reports. The optimization of physical therapy treatment in the IG (post-intervention) reduced the incidence of atelectasis to 0% in those patients who adhered totally to the guideline, highlighting the importance of the adequacy of physical therapy in the postoperative care. The intention-to-treat analysis (including 37 patients who adhered partially to the guideline) did not show a statistically significant difference in the rate of atelectasis or length of hospital stay when compared to the CG. This finding reinforces the need for total adherence of the intervention packages for the clinical outcomes to be achieved. Although the ITT analysis did not demonstrate a statistically significant difference for the length of hospital stay, a reduction of up to 48h in hospitalization can be considered clinically relevant and can be associated with a reduction in healthcare costs. In association with these findings, it was also observed that the length of hospitalization was higher among patients who developed atelectasis. The longer length of stay among patients who develop pulmonary complications is a common finding in the literature.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Although physical therapy assistance is routinely used in the processes of functional rehabilitation of patients undergoing UAS,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> the results demonstrating its effectiveness in preventing atelectasis are still inconsistent.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The absence of consolidated scientific evidence can lead the therapist to carry their professional practice using clinical decisions based on their own experience, which results in a wide range of care practices in a service.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Standardizing practical approaches becomes necessary to help teams to make the most appropriate decision, favoring the clinical outcomes of patients. In this context, the development of care guidelines has been widely used in the routine in different fields of medical activity,<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> providing practical recommendations when scientific evidence is still limited or questionable.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Therapeutic resources such as incentive spirometry, CPAP, EPAP, early mobilization, and conventional physical therapy, based on deep breathing exercises, are often used to prevent atelectasis in patients undergoing UAS.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Among these commonly used features, incentive spirometry appears to be involved in more controversy. Recent systematic reviews have found no evidence regarding the effectiveness of the use of incentive spirometry for preventing pulmonary complications in the postoperative period of UAS.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> However, many of the studies investigating the effectiveness of this device still present methodological flaws, making the elaboration of more rigorous studies necessary to define the real benefits of the use of incentive spirometry. Despite these inconsistent results, the latest recommendations on the use of incentive spirometry in preventing postoperative pulmonary complications indicate that this feature should be applied in combination with deep breathing techniques, assisted cough, early mobilization, and optimized analgesia to obtain better preventive results.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> In the present study, incentive spirometry was used in combination with other techniques recommended for postoperative, which probably contributed to the reduction of the incidence of atelectasis.Another feature preconized for prophylaxis of atelectasis in patients undergoing UAS is the use of breathing exercises associated with positive pressure through EPAP or CPAP.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Although the use of CPAP is a strategy recommended for prophylaxis of atelectasis for UAS,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> its application in clinical practice is quite limited by the risk of abdominal distension related to aerophagia, which can be particularly harmful in the occurrence of fistulas or anastomosis leakage. Ricksten et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> have demonstrated that both the use of CPAP and EPAP were effective in preserving lung volumes and preventing the development of atelectasis in the postoperative period of abdominal surgeries, and that the use of these resources were superior to deep breathing exercises. Other authors have also demonstrated that EPAP is as effective as CPAP for the prevention of PPCs after thoracic surgery and should be used concomitantly with conventional respiratory physical therapy.<a class="elsevierStyleCrossRefs" href="#bib0140">28,29</a> In the present study, it was found that in the period before guideline implementation EPAP was not a strategy used in routine. In the post-intervention period, EPAP was used in all patients who adhered to the guideline. The reduction in the rate of atelectasis may have been largely explained as a result of the inclusion of this feature in clinical practice.Finally, early mobilization was another important feature recommended in the approach of patients undergoing open UAS after guideline implementation. It is believed that early mobilization results in increased lung volume, with consequent prevention of atelectasis.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Brasher et al.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> have even suggested that early mobilization seems to be more effective than deep breathing exercises for the prevention of PPCs. These findings further emphasize the importance of early mobilization in the postoperative period for UAS.Risk factors such as age over 60, smoking history, presence of chronic lung disease and surgical time over 210min are often related to the occurrence of pulmonary complications in the postoperative period of open UAS.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Interestingly, the only risk factor associated with the development of atelectasis, in the present study, was the surgical technique, with patients undergoing subcostal incisions presenting higher incidence of complications. The relationship between subcostal incisions and the development of pulmonary complications after abdominal surgery has been previously demonstrated.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The main limitation of the present study relates to the methodological design. Although the use of a historical control hinders the establishment of a causal association, its application in an institutional context becomes a more viable alternative. It should also be noted that the implementation of the guideline was the only change incorporated into the care of these patients during the study period. Another factor worth mentioning is the fact that radiological assessors were blinded to the study objectives ensuring the reliability of the diagnosis of atelectasis (primary variable). Moreover, the short time between the historical control and the intervention period strengthens the assumption of a true association between the interventions and the observed outcomes. Another limitation of the present study was the difference in the sample size of patients undergoing the guideline in the post-intervention period compared to the pre-intervention period. It was observed that the reduction in the number of patients included in the post-intervention period was mainly for the accuracy of the selection criteria and a poor adherence to the guideline by the physical therapists. However, poor adherence in periods immediately after the implementation of healthcare guidelines was also observed in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0075">15,32</a> This fact emphasizes the need for continuing education work for the consolidation of long-term processes.ConclusionsIn the present study, the efficacy of isolated conventional physical therapy, incentive spirometry, EPAP or early mobilization was not evaluated. However, it was possible to demonstrate that the physiotherapeutic approach based on packages of interventions resulted in reduced incidence of atelectasis and reduced length of hospital stay among patients undergoing elective open UAS. The verification of these favorable outcomes strengthens initiatives for the development of other physical therapy practices based on managed guidelines, providing foundation for the awareness of the teams on the importance of following these care models.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres547653" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec565532" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres547652" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiais e Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec565533" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-04-24" "fechaAceptado" => "2013-07-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565532" "palabras" => array:6 [ 0 => "Physical therapy modalities" 1 => "Early ambulation" 2 => "Guideline" 3 => "Pulmonary atelectasis" 4 => "Hospitalization" 5 => "Postoperative care" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565533" "palabras" => array:6 [ 0 => "Modalidades de fisioterapia" 1 => "Deambulação precoce" 2 => "Orientação" 3 => "Atelectasia pulmonar" 4 => "Internamento" 5 => "Cuidados pós-operatórios" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThe aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery (UAS) in reducing the incidence of atelectasis and length of hospital stay in the postoperative period. Materials and methodsA “before and after” study design with historical control was used. The “before” period included consecutive patients who underwent UAS before guideline implementation (intervention). The “after” period included consecutive patients after guideline implementation. Patients in the pre-intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional. On the other hand, patients who were included in the post-intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies (EPAP, incentive spirometry and early mobilization). ResultsThere was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation. Moreover, it was observed that early ambulation occurred in all patients in the post-intervention period. No patient who adhered totally to the guideline in the post-intervention period developed atelectasis. Individuals in the post-intervention period presented a shorter length of hospital stay (9.2±4.1 days) compared to patients in the pre-intervention period (12.1±8.3 days) (p<0.05). ConclusionThe implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoO objetivo deste estudo foi avaliar a eficácia da implementação de uma diretriz de fisioterapia para doentes submetidos a cirurgia abdominal superior (UAS) na redução da incidência de atelectasia e no tempo de internamento no pós-operatório. Materiais e MétodosFoi usado um desenho de estudo de “antes e depois com controlo histórico. O período “antes” incluiu doentes consecutivos que foram submetidos a UAS antes da implementação da diretriz (intervenção). O período “depois” incluiu doentes consecutivos após a implementação da diretriz. Os doentes no período pré-intervenção foram submetidos a um programa de fisioterapia onde o planeamento do tratamento foi baseado na experiência individual de cada profissional. Por outro lado, os doentes que foram incluídos no período pós-intervenção foram submetidos a um programa padronizado de fisioterapia com um foco no uso de estratégias adicionais (EPAP, espirometria de incentivo e mobilização precoce). ResultadosOcorreu um aumento significativo do uso de espirometria de incentivo e pressão expiratória positiva nas vias aéreas após a implementação das diretrizes. Além disso, observou-se que ocorreu o levantamento precoce em todos os doentes durante o período pós-intervenção. Nenhum doente que aderiu totalmente à diretriz no período pós-intervenção desenvolveu atelectasia. Os indivíduos no período pós-intervenção apresentaram um menor tempo de internamento hospitalar (9.2±4.1 dias) em comparação com os doentes no período pré-intervenção (12.1±8.3 dias) (p<0.05). ConclusãoA implementação de uma diretriz de fisioterapia para doentes submetidos a UAS resultou na redução da incidência de atelectasia e na redução do tempo de internamento no pós-operatório." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiais e Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1726 "Ancho" => 2333 "Tamanyo" => 377856 ] ] "descripcion" => array:1 [ "en" => "Physical therapy program for patients undergoing open upper abdominal surgery (intervention group). UAS: upper abdominal surgery; CP: chest physical therapy; IS: incentive spirometry; EPAP: expiratory positive airway pressure; VTE: venous thromboembolism; Hb: hemoglobin." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1901 "Ancho" => 2304 "Tamanyo" => 281469 ] ] "descripcion" => array:1 [ "en" => "Flowchart for inclusion and exclusion of patients in the study for the CG (pre-guideline) and IG (post-guideline)." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "BMI: body mass index; ASA: American Society of Anesthesiologists (surgery risk)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group (n=133) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group (n=32) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gender (male:female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57:76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22:10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.008<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59.9±15.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.1±15.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.1±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.1±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Respiratory disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tobacco history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (21.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.02<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 (36.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (28.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (15%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (6.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (12.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (18%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neoplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">121 (91%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (81.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Type of surgery</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tumor resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">114 (85.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (75%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other causes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Surgical technique</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (31.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Subcostal+median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (33.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (34.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Subcostal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (24.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (34.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time of surgery (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">427±249.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">369.8±146.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">ASA scale</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Low risk (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">106 (89.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (86.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">High risk (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (10.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (13.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884609.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Statistically significant difference between groups." ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical characteristics of individuals included in the study." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "EPAP: expiratory positive airway pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resources and clinical outcomes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group (n=133) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group (n=32) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Conventional physical therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Incentive spirometry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 (66.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">EPAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Early ambulation (<48h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Incidence of atelectasis (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (15.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hospital stay (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.1±8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.2±4.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.036<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884608.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Statistically significant difference between groups." ] ] ] "descripcion" => array:1 [ "en" => "Frequency of use of different therapeutic resources and clinical outcomes (incidence of atelectasis and length of hospital stay)." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "BMI: body mass index; ASA: American Society of Anesthesiologists (surgery risk)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With atelectasis (n=21) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without atelectasis (n=112) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gender (male:female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11:10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65:47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.1±13.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59.2±15.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.9±4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.5±5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Respiratory disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tobacco history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (6.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (38%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41(36.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (15.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (12.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (23.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (17%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neoplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (85.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 (84.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Type of surgery</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tumor resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (85.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 (85.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other causes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Surgical technique</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (23.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (46.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Subcostal+median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (23.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 (34.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.004<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Subcostal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (52.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (18.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time of surgery (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">474±306.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">419.7±239 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">ASA scale</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Low risk (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (76.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 (90.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">High risk (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (15.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (9.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Late ambulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (47.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (29.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884610.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Statistically significant difference between groups." ] ] ] "descripcion" => array:1 [ "en" => "Possible risk factors associated with the development of atelectasis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for pulmonary complications after emergency abdominal surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.G. Serejo" 1 => "F.P. da Silva-Júnior" 2 => "J.P. Bastos" 3 => "G.S. de Bruin" 4 => "R.M. Mota" 5 => "P.F. de Bruin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rmed.2006.07.015" "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "2007" "volumen" => "101" "paginaInicial" => "808" "paginaFinal" => "813" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16963245" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.B. Dimick" 1 => "S.L. Chen" 2 => "P.A. Taheri" 3 => "W.G. Henderson" 4 => "S.F. Khuri" 5 => "D.A. 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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

A implementação de uma diretriz para a fisioterapia no período pós-operatório da cirurgia abdominal alta, reduz a incidência de atelectasia e o tempo de internamento

S. Souza Possaa,b, C. Braga Amadora, A. Meira Costaa, E. Takahama Sakamotoa, C. Seiko Kondoa,c, A.L. Maida Vasconcellosa,d, C.M. Moran de Britoa, W. Pereira Yamagutia,

Corresponding author

wellington.psyamaguti@hsl.org.br
wellpsy@yahoo.com.br

Corresponding author.

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

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Postoperative pulmonary complications &#40;PPCs&#41; are common in patients undergoing abdominal surgery and are responsible for the increased morbidity and mortality as well as length of hospital stay and health related cost of care&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The PPCs occur more frequently in surgeries where the incision is made above the umbilical scar&#44; the so called upper abdominal surgeries &#40;UAS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The incidence of PPCs in these subjects is related to the existence of preoperative risk factors such as advanced age&#44; smoking&#44; malnutrition&#44; obesity&#44; lung diseases&#44; and clinical diseases&#46; Surgical and anesthetic factors such as the time of surgery&#44; type of surgery&#44; and the effects of anesthetic drugs on the respiratory system also contribute to the development of PPCs&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Atelectasis&#44; pneumonia&#44; acute respiratory failure&#44; tracheobronchitis&#44; wheezing&#44; and prolonged mechanical ventilation are the most commonly observed PPCs&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is known that the decrease in lung volumes and capacities&#44; abnormal respiratory pattern&#44; abnormal gas exchange&#44; and pulmonary defenses in patients undergoing open UAS start with anesthetic induction and perpetuate in the postoperative period&#44; contributing to the occurrence of these PPCs&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> The respiratory muscle dysfunction has also been attributed to the development of PPCs&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Multiple factors may be involved in diaphragmatic dysfunction&#44; such as irritation and inflammation caused by trauma from manipulation close to the diaphragm&#44; reflex inhibition of afferent abdominal receptors&#44; and postoperative pain&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this context&#44; physical therapy assistance to open UAS aims to preserve pulmonary function and reverse physiological and&#47;or functional changes that may occur in the postoperative period due to these complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> Therefore&#44; physical therapy provides a variety of interventions that must be individually selected according to the needs of the patient&#46; Chest physical therapy acting with thoracic expansion exercises and diaphragmatic breathing exercises immediately after the UAS appears to improve oxygenation without triggering increase in pain or other complications&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Furthermore&#44; interventions that increase lung volume such as deep breathing exercises&#44; incentive spirometry and continuous positive airway pressure &#40;CPAP&#41; are associated with lower frequency PPCs&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; the number of clinical studies that highlight the benefits of applying prophylactic therapy in patients undergoing open UAS is still quite limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The main objective of the present study was to evaluate the effectiveness of the implementation of a guideline for physical therapy assistance for patients undergoing elective open UAS in reducing the incidence of atelectasis and length of hospital stay in the postoperative period&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study was conducted in a private and tertiary care center of 497 beds in the state of S&#227;o Paulo&#44; Brazil&#46; We analyzed data from patients hospitalized in intensive care units&#44; semi-intensive units&#44; and wards&#46; The study included adult patients &#40;age<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>18 years&#41; undergoing elective open UAS and who received physical therapy in the postoperative period&#46; It excluded patients undergoing lower abdominal surgeries&#44; laparoscopic surgeries&#44; emergency surgeries&#44; surgeries with associated chest manipulation&#44; those who underwent more than one surgical procedure during hospitalization&#44; patients who did not adhere properly to the physical therapy treatment &#40;performing physical therapy attendances &#60;75&#37; of scheduled therapy&#41;&#44; patients who initiated inpatient physical therapy before the surgery &#40;preoperative physical therapy&#41;&#44; individuals who died during hospitalization&#44; and patients requiring invasive mechanical ventilation over 24<span class="elsevierStyleHsp" style=""></span>hours&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We used a &#8220;before and after&#8221; model of retrospective study with historical control&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> The &#8220;before&#8221; period &#40;pre-intervention&#41; included all consecutive patients undergoing elective open UAS who met the criteria for inclusion in the study over six months &#40;from July to December 2010&#41; before guideline implementation &#40;intervention&#41;&#46; Teams of physical therapists were trained in the standardization of the new model of care during the month of January 2011&#46; During this period&#44; no data of patients undergoing UAS were collected&#46; The &#8220;after&#8221; period &#40;post-intervention&#41; included all consecutive patients who met the inclusion criteria of the study during the six months after guideline implementation &#40;from February to July 2011&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">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 30 days&#46; Fifteen training meetings were arranged in small groups for all the 126 physical therapists of the institution&#44; acting in intensive care units&#44; semi-intensive units&#44; and wards&#44; in relation to the guideline&#46; During the training sessions&#44; we presented flow diagrams for treatment&#44; the standardization of approaches of treatment&#44; orientations for hospital discharge&#44; and the scientific evidence that supported the elaboration of the guidelines&#46; Furthermore&#44; the training aimed to guide professionals in the use of physical therapy resources recommended in the care model &#40;i&#46;e&#46; incentive spirometry and positive expiratory pressure in the airways&#41;&#46; To disseminate the guideline&#44; printed copies of the document in the operating units were distributed&#44; in addition to providing the electronic file in the computerized system of the institution for consultations&#46; This material contains information about care flowcharts&#44; indications and contraindications&#44; criteria for discontinuing the program&#44; resources and frequency of physical therapy sessions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The document presented a total of 11 pages including flowcharts&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Patients included in the study in the pre-intervention period &#40;control group&#41; underwent a program of postoperative physical therapy treatment in which the therapeutic planning to be applied was determined by the professional providing patient care &#40;non-standard model&#41;&#46; In contrast&#44; patients who were included in the post-intervention &#40;intervention group&#41; underwent a standardized program of physical therapy treatment which structured the model of patient care&#44; focusing on the use of additional therapeutic resources &#40;volumetric incentive spirometry and positive expiratory pressure in the airways&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> early sitting position and ambulation &#40;onset &#60;48<span class="elsevierStyleHsp" style=""></span>h after surgery&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Patients undergoing the program preconized by the guideline should undergo at least two sessions of physical therapy daily until the 5th postoperative day&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Therapeutic treatment was discussed again and re-planned by the team of physical therapists after the 5th postoperative day&#44; to redefine the need for two sessions daily&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the present study&#44; total adhesion to the guideline was defined by the use of all the features recommended in the guideline&#46; When one of the resources was not applied&#44; it was considered partial compliance&#44; and when two or more features were not used&#44; it was considered as non-adherence to the guideline&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Data were collected from the analysis of medical records and electronic database of the hospital&#46; The information extracted from these sources was stored in electronic format previously designed for this study&#46; We collected data concerning characterization of each patient &#40;medical history&#44; demographics&#44; clinical and anthropometric data&#41;&#44; the surgical procedure &#40;type of surgery&#44; surgical technique&#44; surgical time&#44; and surgical risk&#41;&#44; and the physical therapy assistance provided to patients during hospitalization &#40;features used and treatment adherence&#41;&#46; Regarding the outcomes investigated&#44; the incidence of atelectasis was considered as the primary variable and the length of hospital stay as the secondary variable&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis of atelectasis was considered in the presence of imaging studies confirming this alteration&#46; All patients included in the study&#44; both in the control group &#40;CG&#41; and in the intervention group &#40;IG&#41;&#44; had radiographic evaluation from the first to fifth postoperative day&#46; We considered only the presence of pure atelectasis &#40;not associated with other complications such as pleural effusion or pneumothorax&#41; since the aim of the study was to determine the incidence of atelectasis secondary only to the surgery&#44; and not to other complications&#46; Radiologists who had read all the examinations did not know the study objectives&#46; We considered as possible risk factors for developing atelectasis&#58; age&#44; female gender&#44; high body mass index &#40;BMI&#41;&#44; lung disease&#44; history of smoking&#44; hypertension&#44; diabetes&#44; dyslipidemia&#44; heart disease&#44; cancer&#44; type of surgery&#44; surgical technique&#44; time of surgery&#44; and surgical risk &#40;American Society of Anesthesiologists scale&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The sample size calculation was performed based on a pilot study that showed a percentage of 25&#37; for the incidence of atelectasis among patients undergoing UAS who were not submitted to the guideline&#46; We also considered one previous study showing a reduction to a proportion of 6&#37; of atelectasis among patients undergoing a protocol of physical therapy in the postoperative&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> With a 5&#37; significance level and a power test of 90&#37;&#44; the sample was determined to be 66 patients for each group&#46; To reach this number&#44; we calculated that we needed 6 months for the post-intervention period&#46; For the final analysis&#44; a sensitive analysis was performed including only the patients with full adherence to the guideline as well as an analysis of all patients included in the post-intervention period&#46; Categorical variables are presented as frequency&#44; whereas continuous variables are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; Comparisons between groups were made by Mann&#8211;Whitney test &#40;nonparametric data&#41;&#44; in the case of numerical variables&#44; and by the chi-square test in the case of categorical variables&#46; The level of significance was 5&#37;&#46; Statistical analysis was performed using the statistical program SigmaPlot 11&#46;0 &#40;Systat Software Inc&#46;&#44; CA&#44; USA&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">This study was approved by the Ethics Committee of the hospital &#40;Registration number&#58; HSL 2010-58&#41;&#46; There was waiver shall of the Consent Form&#44; because it is a retrospective observational study analyzing standardization of institutional care process&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">We analyzed medical records of 535 patients undergoing UAS in the total period of the study&#44; 249 belonging to the stage prior to guideline implementation and 286 belonging to the subsequent stage&#46; After evaluation of inclusion and exclusion criteria&#44; 202 were eligible for the study&#46; The CG consisted of 133 patients and the IG of 69 patients &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Of the patients included in the IG&#44; 32 &#40;46&#46;4&#37;&#41; had total adherence to the guideline&#44; whereas 37 &#40;53&#46;6&#37;&#41; had partial adherence to the guideline &#40;did not undergo one of the additional therapeutic resources in the proposed guideline&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The clinical and demographic characteristics of the population studied in each group are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There was significant difference between the groups only in relation to smoking history and gender&#46; The IG patients presented a higher prevalence of tobacco use and a higher proportion of males&#46; The main reason for the surgery was the presence of tumor with resection indication for both CG &#40;91&#37;&#41; and IG &#40;81&#46;2&#37;&#41;&#46; There was no difference between groups in relation to surgical risk&#44; technique or surgery time&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The guideline implementation optimized the use of additional therapeutic resources during physical therapy assistance&#44; causing a significant increase in the use of incentive spirometry and expiratory positive airway pressure &#40;EPAP&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Furthermore&#44; it was observed that early ambulation occurred in all patients in the post-intervention period&#46; In contrast&#44; only 12&#37; of patients in the pre-intervention period managed early ambulation &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Regarding the clinical outcomes&#44; no patient in the IG showed pure atelectasis&#44; whereas the frequency of atelectasis in the CG was 15&#46;8&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41; with statistically significant difference between groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; When the intention-to-treat &#40;ITT&#41; analysis was performed &#40;including patients with partial adherence to the guideline&#41;&#44; the rate of atelectasis was 13&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; without statistically significant difference compared to the CG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;362&#41;&#46; There was also difference between groups in the length of hospital stay&#46; CG individuals remained hospitalized for a longer period of time &#40;12&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3 days&#41; when compared to the IG &#40;9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1 days&#41; in the postoperative period &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The ITT analysis also revealed that the length of hospital stay was still lower in the IG &#40;10&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;4 days&#41; when compared to the CG &#40;12&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3 days&#41;&#44; but without statistically significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;24&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes possible risk factors for the development of atelectasis&#46; These data are related only to the CG&#44; since there was no development of atelectasis in the IG&#46; In the present study&#44; the only risk factor associated with the development of atelectasis was the surgical technique&#46; The individuals undergoing subcostal incisions were more likely to develop this complication &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The present study showed that the optimization and standardization of the use of additional therapeutic resources through the implementation of a guideline for physical therapy assistance&#44; guiding the care of patients undergoing UAS&#44; is effective in reducing the incidence of atelectasis and length of hospital stay in the postoperative period&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Previous studies have reported that the incidence of atelectasis observed in the postoperative period can vary from 6&#37; to 42&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> In the present study&#44; the incidence of atelectasis among the CG patients &#40;pre-intervention period&#41; was 15&#46;8&#37;&#44; which is consistent with these previous reports&#46; The optimization of physical therapy treatment in the IG &#40;post-intervention&#41; reduced the incidence of atelectasis to 0&#37; in those patients who adhered totally to the guideline&#44; highlighting the importance of the adequacy of physical therapy in the postoperative care&#46; The intention-to-treat analysis &#40;including 37 patients who adhered partially to the guideline&#41; did not show a statistically significant difference in the rate of atelectasis or length of hospital stay when compared to the CG&#46; This finding reinforces the need for total adherence of the intervention packages for the clinical outcomes to be achieved&#46; Although the ITT analysis did not demonstrate a statistically significant difference for the length of hospital stay&#44; a reduction of up to 48<span class="elsevierStyleHsp" style=""></span>h in hospitalization can be considered clinically relevant and can be associated with a reduction in healthcare costs&#46; In association with these findings&#44; it was also observed that the length of hospitalization was higher among patients who developed atelectasis&#46; The longer length of stay among patients who develop pulmonary complications is a common finding in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Although physical therapy assistance is routinely used in the processes of functional rehabilitation of patients undergoing UAS&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> the results demonstrating its effectiveness in preventing atelectasis are still inconsistent&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The absence of consolidated scientific evidence can lead the therapist to carry their professional practice using clinical decisions based on their own experience&#44; which results in a wide range of care practices in a service&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Standardizing practical approaches becomes necessary to help teams to make the most appropriate decision&#44; favoring the clinical outcomes of patients&#46; In this context&#44; the development of care guidelines has been widely used in the routine in different fields of medical activity&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> providing practical recommendations when scientific evidence is still limited or questionable&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Therapeutic resources such as incentive spirometry&#44; CPAP&#44; EPAP&#44; early mobilization&#44; and conventional physical therapy&#44; based on deep breathing exercises&#44; are often used to prevent atelectasis in patients undergoing UAS&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Among these commonly used features&#44; incentive spirometry appears to be involved in more controversy&#46; Recent systematic reviews have found no evidence regarding the effectiveness of the use of incentive spirometry for preventing pulmonary complications in the postoperative period of UAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> However&#44; many of the studies investigating the effectiveness of this device still present methodological flaws&#44; making the elaboration of more rigorous studies necessary to define the real benefits of the use of incentive spirometry&#46; Despite these inconsistent results&#44; the latest recommendations on the use of incentive spirometry in preventing postoperative pulmonary complications indicate that this feature should be applied in combination with deep breathing techniques&#44; assisted cough&#44; early mobilization&#44; and optimized analgesia to obtain better preventive results&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> In the present study&#44; incentive spirometry was used in combination with other techniques recommended for postoperative&#44; which probably contributed to the reduction of the incidence of atelectasis&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another feature preconized for prophylaxis of atelectasis in patients undergoing UAS is the use of breathing exercises associated with positive pressure through EPAP or CPAP&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although the use of CPAP is a strategy recommended for prophylaxis of atelectasis for UAS&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> its application in clinical practice is quite limited by the risk of abdominal distension related to aerophagia&#44; which can be particularly harmful in the occurrence of fistulas or anastomosis leakage&#46; Ricksten et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> have demonstrated that both the use of CPAP and EPAP were effective in preserving lung volumes and preventing the development of atelectasis in the postoperative period of abdominal surgeries&#44; and that the use of these resources were superior to deep breathing exercises&#46; Other authors have also demonstrated that EPAP is as effective as CPAP for the prevention of PPCs after thoracic surgery and should be used concomitantly with conventional respiratory physical therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> In the present study&#44; it was found that in the period before guideline implementation EPAP was not a strategy used in routine&#46; In the post-intervention period&#44; EPAP was used in all patients who adhered to the guideline&#46; The reduction in the rate of atelectasis may have been largely explained as a result of the inclusion of this feature in clinical practice&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; early mobilization was another important feature recommended in the approach of patients undergoing open UAS after guideline implementation&#46; It is believed that early mobilization results in increased lung volume&#44; with consequent prevention of atelectasis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Brasher et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> have even suggested that early mobilization seems to be more effective than deep breathing exercises for the prevention of PPCs&#46; These findings further emphasize the importance of early mobilization in the postoperative period for UAS&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Risk factors such as age over 60&#44; smoking history&#44; presence of chronic lung disease and surgical time over 210<span class="elsevierStyleHsp" style=""></span>min are often related to the occurrence of pulmonary complications in the postoperative period of open UAS&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Interestingly&#44; the only risk factor associated with the development of atelectasis&#44; in the present study&#44; was the surgical technique&#44; with patients undergoing subcostal incisions presenting higher incidence of complications&#46; The relationship between subcostal incisions and the development of pulmonary complications after abdominal surgery has been previously demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The main limitation of the present study relates to the methodological design&#46; Although the use of a historical control hinders the establishment of a causal association&#44; its application in an institutional context becomes a more viable alternative&#46; It should also be noted that the implementation of the guideline was the only change incorporated into the care of these patients during the study period&#46; Another factor worth mentioning is the fact that radiological assessors were blinded to the study objectives ensuring the reliability of the diagnosis of atelectasis &#40;primary variable&#41;&#46; Moreover&#44; the short time between the historical control and the intervention period strengthens the assumption of a true association between the interventions and the observed outcomes&#46; Another limitation of the present study was the difference in the sample size of patients undergoing the guideline in the post-intervention period compared to the pre-intervention period&#46; It was observed that the reduction in the number of patients included in the post-intervention period was mainly for the accuracy of the selection criteria and a poor adherence to the guideline by the physical therapists&#46; However&#44; poor adherence in periods immediately after the implementation of healthcare guidelines was also observed in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;32</span></a> This fact emphasizes the need for continuing education work for the consolidation of long-term processes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">In the present study&#44; the efficacy of isolated conventional physical therapy&#44; incentive spirometry&#44; EPAP or early mobilization was not evaluated&#46; However&#44; it was possible to demonstrate that the physiotherapeutic approach based on packages of interventions resulted in reduced incidence of atelectasis and reduced length of hospital stay among patients undergoing elective open UAS&#46; The verification of these favorable outcomes strengthens initiatives for the development of other physical therapy practices based on managed guidelines&#44; providing foundation for the awareness of the teams on the importance of following these care models&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "Materiais e M&#233;todos"
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            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
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            3 => array:2 [
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              "titulo" => "Conclus&#227;o"
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        3 => array:2 [
          "identificador" => "xpalclavsec565533"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conclusions"
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        9 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Right to privacy and informed consent"
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          ]
        ]
        10 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflicts of interest"
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        11 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-04-24"
    "fechaAceptado" => "2013-07-16"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec565532"
          "palabras" => array:6 [
            0 => "Physical therapy modalities"
            1 => "Early ambulation"
            2 => "Guideline"
            3 => "Pulmonary atelectasis"
            4 => "Hospitalization"
            5 => "Postoperative care"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec565533"
          "palabras" => array:6 [
            0 => "Modalidades de fisioterapia"
            1 => "Deambula&#231;&#227;o precoce"
            2 => "Orienta&#231;&#227;o"
            3 => "Atelectasia pulmonar"
            4 => "Internamento"
            5 => "Cuidados p&#243;s-operat&#243;rios"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to evaluate the effectiveness of implementing a physical therapy guideline for patients undergoing upper abdominal surgery &#40;UAS&#41; in reducing the incidence of atelectasis and length of hospital stay in the postoperative period&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A &#8220;before and after&#8221; study design with historical control was used&#46; The &#8220;before&#8221; period included consecutive patients who underwent UAS before guideline implementation &#40;intervention&#41;&#46; The &#8220;after&#8221; period included consecutive patients after guideline implementation&#46; Patients in the pre-intervention period were submitted to a program of physical therapy in which the treatment planning was based on the individual experience of each professional&#46; On the other hand&#44; patients who were included in the post-intervention period underwent a standardized program of physical therapy with a focus on the use of additional strategies &#40;EPAP&#44; incentive spirometry and early mobilization&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There was a significant increase in the use of incentive spirometry and positive expiratory airway pressure after guideline implementation&#46; Moreover&#44; it was observed that early ambulation occurred in all patients in the post-intervention period&#46; No patient who adhered totally to the guideline in the post-intervention period developed atelectasis&#46; Individuals in the post-intervention period presented a shorter length of hospital stay &#40;9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1 days&#41; compared to patients in the pre-intervention period &#40;12&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3 days&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The implementation of a physical therapy guideline for patients undergoing UAS resulted in reduced incidence of atelectasis and reduction in length of hospital stay in the postoperative period&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O objetivo deste estudo foi avaliar a efic&#225;cia da implementa&#231;&#227;o de uma diretriz de fisioterapia para doentes submetidos a cirurgia abdominal superior &#40;UAS&#41; na redu&#231;&#227;o da incid&#234;ncia de atelectasia e no tempo de internamento no p&#243;s-operat&#243;rio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiais e M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi usado um desenho de estudo de &#8220;antes e depois com controlo hist&#243;rico&#46; O per&#237;odo &#8220;antes&#8221; incluiu doentes consecutivos que foram submetidos a UAS antes da implementa&#231;&#227;o da diretriz &#40;interven&#231;&#227;o&#41;&#46; O per&#237;odo &#8220;depois&#8221; incluiu doentes consecutivos ap&#243;s a implementa&#231;&#227;o da diretriz&#46; Os doentes no per&#237;odo pr&#233;-interven&#231;&#227;o foram submetidos a um programa de fisioterapia onde o planeamento do tratamento foi baseado na experi&#234;ncia individual de cada profissional&#46; Por outro lado&#44; os doentes que foram inclu&#237;dos no per&#237;odo p&#243;s-interven&#231;&#227;o foram submetidos a um programa padronizado de fisioterapia com um foco no uso de estrat&#233;gias adicionais &#40;EPAP&#44; espirometria de incentivo e mobiliza&#231;&#227;o precoce&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ocorreu um aumento significativo do uso de espirometria de incentivo e press&#227;o expirat&#243;ria positiva nas vias a&#233;reas ap&#243;s a implementa&#231;&#227;o das diretrizes&#46; Al&#233;m disso&#44; observou-se que ocorreu o levantamento precoce em todos os doentes durante o per&#237;odo p&#243;s-interven&#231;&#227;o&#46; Nenhum doente que aderiu totalmente &#224; diretriz no per&#237;odo p&#243;s-interven&#231;&#227;o desenvolveu atelectasia&#46; Os indiv&#237;duos no per&#237;odo p&#243;s-interven&#231;&#227;o apresentaram um menor tempo de internamento hospitalar &#40;9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1 dias&#41; em compara&#231;&#227;o com os doentes no per&#237;odo pr&#233;-interven&#231;&#227;o &#40;12&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3 dias&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A implementa&#231;&#227;o de uma diretriz de fisioterapia para doentes submetidos a UAS resultou na redu&#231;&#227;o da incid&#234;ncia de atelectasia e na redu&#231;&#227;o do tempo de internamento no p&#243;s-operat&#243;rio&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiais e M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
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        ]
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Physical therapy program for patients undergoing open upper abdominal surgery &#40;intervention group&#41;&#46; UAS&#58; upper abdominal surgery&#59; CP&#58; chest physical therapy&#59; IS&#58; incentive spirometry&#59; EPAP&#58; expiratory positive airway pressure&#59; VTE&#58; venous thromboembolism&#59; Hb&#58; hemoglobin&#46;</p>"
        ]
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Flowchart for inclusion and exclusion of patients in the study for the CG &#40;pre-guideline&#41; and IG &#40;post-guideline&#41;&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; ASA&#58; <span class="elsevierStyleItalic">American Society of Anesthesiologists</span> &#40;surgery risk&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>133&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;male&#58;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#58;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#58;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;008<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tobacco history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;7&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;21&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;02<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49 &#40;36&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;28&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;6&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">121 &#40;91&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;81&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Type of surgery</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumor resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">114 &#40;85&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;75&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Surgical technique</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;42&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;31&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subcostal<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;33&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;34&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subcostal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;24&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;34&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Time of surgery &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">427<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>249&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">369&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>146&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">ASA scale</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Low risk &#40;1&#8211;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">106 &#40;89&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;86&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High risk &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;10&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;13&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of individuals included in the study&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">EPAP&#58; expiratory positive airway pressure&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resources and clinical outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>133&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Conventional physical therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">133 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Incentive spirometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88 &#40;66&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">EPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Early ambulation &#40;&#60;48<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Incidence of atelectasis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;15&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospital stay &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;036<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Statistically significant difference between groups&#46;</p>"
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        ]
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Frequency of use of different therapeutic resources and clinical outcomes &#40;incidence of atelectasis and length of hospital stay&#41;&#46;</p>"
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; ASA&#58; <span class="elsevierStyleItalic">American Society of Anesthesiologists</span> &#40;surgery risk&#41;&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With atelectasis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without atelectasis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>112&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;male&#58;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#58;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#58;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tobacco history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;6&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#40;36&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;15&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;9&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;23&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;85&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95 &#40;84&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Type of surgery</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumor resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;85&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96 &#40;85&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Surgical technique</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Median&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;23&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33 &#40;29&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppneu.2013.07.005

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Year/Month	Html	Pdf	Total

2024 November	9	11	20
2024 October	62	62	124
2024 September	85	47	132
2024 August	94	47	141
2024 July	70	33	103
2024 June	71	34	105
2024 May	70	28	98
2024 April	76	33	109
2024 March	72	29	101
2024 February	59	36	95
2024 January	41	28	69
2023 December	41	22	63
2023 November	59	41	100
2023 October	58	40	98
2023 September	50	45	95
2023 August	53	15	68
2023 July	42	32	74
2023 June	42	19	61
2023 May	64	29	93
2023 April	64	29	93
2023 March	99	36	135
2023 February	96	27	123
2023 January	76	27	103
2022 December	94	24	118
2022 November	116	39	155
2022 October	75	46	121
2022 September	46	58	104
2022 August	57	43	100
2022 July	61	49	110
2022 June	43	38	81
2022 May	60	58	118
2022 April	76	49	125
2022 March	48	47	95
2022 February	51	40	91
2022 January	69	39	108
2021 December	40	44	84
2021 November	53	45	98
2021 October	65	60	125
2021 September	67	57	124
2021 August	65	29	94
2021 July	54	27	81
2021 June	49	31	80
2021 May	60	33	93
2021 April	139	132	271
2021 March	105	64	169
2021 February	80	18	98
2021 January	128	63	191
2020 December	91	17	108
2020 November	106	63	169
2020 October	98	64	162
2020 September	101	54	155
2020 August	135	45	180
2020 July	137	32	169
2020 June	149	38	187
2020 May	176	69	245
2020 April	135	64	199
2020 March	120	40	160
2020 February	146	42	188
2020 January	151	32	183
2019 December	150	37	187
2019 November	186	69	255
2019 October	235	60	295
2019 September	167	62	229
2019 August	264	45	309
2019 July	239	37	276
2019 June	249	48	297
2019 May	355	55	410
2019 April	286	69	355
2019 March	330	40	370
2019 February	279	44	323
2019 January	301	48	349
2018 December	178	10	188
2018 November	67	2	69
2018 October	71	10	81
2018 September	42	20	62
2018 August	93	38	131
2018 July	59	38	97
2018 June	43	12	55
2018 May	56	12	68
2018 April	55	13	68
2018 March	73	5	78
2018 February	26	7	33
2018 January	52	21	73
2017 December	80	34	114
2017 November	97	35	132
2017 October	82	28	110
2017 September	101	20	121
2017 August	71	22	93
2017 July	64	32	96
2017 June	74	30	104
2017 May	121	34	155
2017 April	46	5	51
2017 March	82	14	96
2017 February	35	10	45
2017 January	18	5	23
2016 December	23	20	43
2016 November	33	18	51
2016 October	41	11	52
2016 September	81	33	114
2016 August	18	6	24
2016 July	11	11	22
2016 April	115	2	117
2016 March	128	25	153
2016 February	174	26	200
2016 January	141	19	160
2015 December	153	30	183
2015 November	142	34	176
2015 October	184	19	203
2015 September	188	28	216
2015 August	212	39	251
2015 July	203	21	224
2015 June	92	15	107
2015 May	165	51	216
2015 April	158	38	196
2015 March	141	20	161
2015 February	128	24	152
2015 January	108	36	144
2014 December	108	44	152
2014 November	150	45	195
2014 October	148	48	196
2014 September	127	54	181
2014 August	107	35	142
2014 July	113	47	160
2014 June	120	32	152
2014 May	155	50	205
2014 April	163	85	248
2014 March	24	18	42

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