待機的心臓外科手術のプレハビリテーション

待機的心臓外科手術に対する術前理学療法（プレハビリテーション）のコクランレビューを紹介します。

Hulzebos EH, Smit Y, Helders PP, van Meeteren NL.　Preoperative physical therapy for elective cardiac surgery patients.　Cochrane Database Syst Rev. 2012 Nov 14;11:CD010118. doi: 10.1002/14651858.CD010118.pub2.

8つのRCT論文で856人が対象です。理学療法の内容は、3論文は有酸素運動や呼吸リハの混合介入、5論文は吸気筋トレーニングです。結果ですが、術後の無気肺や肺炎は有意に減少しましたが、気胸と48時間以上の人工呼吸器管理は減少しませんでした。術後死亡率にも有意差を認めませんでした。

介入による合併症は記載のあった3論文では認めませんでした。入院期間は介入群で有意に短かったです。1論文では介入群で6分間歩行距離が低下しました。他の1論文では健康関連QOLが有意に改善しました。呼吸器疾患によ死亡率には有意差がなく、コストに関するデータはありませんでした。

以上より待機的心臓外科手術患者に対するプレハビリテーションは、無気肺や肺炎といった術後合併症を減少させ、入院期間を短縮させるという結論です。一方、気胸、48時間以上の人工呼吸器管理、死亡率には有意差を認めませんでした。

呼吸リハを主としたプレハビリテーションによって、無気肺や肺炎が減少することは納得できる結果です。こちらも対象者を選定して、プログラムを運動のみでなくより包括的なものにすれば、よりよいアウトカムを出せるのではないかと考えます。呼吸リハは待機的心臓外科手術の全患者に行ってもよいと思いますが。

Abstract

BACKGROUND:

After cardiac surgery, physical therapy is a routine procedure delivered with the aim of preventing postoperative pulmonary complications.

OBJECTIVES:

To determine if preoperative physical therapy with an exercise component can prevent postoperative pulmonary complications in cardiac surgery patients, and to evaluate which type of patient benefits and which type of physical therapy is most effective.

SEARCH METHODS:

Searches were run on the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (2011, Issue 12 ); MEDLINE (1966 to 12 December 2011); EMBASE (1980 to week 49, 2011); the Physical Therapy Evidence Database (PEDro) (to 12 December 2011) and CINAHL (1982 to 12 December 2011).

SELECTION CRITERIA:

Randomised controlled trials or quasi-randomised trials comparing preoperative physical therapy with no preoperative physical therapy or sham therapy in adult patients undergoing elective cardiac surgery.

DATA COLLECTION AND ANALYSIS:

Data were collected on the type of study, participants, treatments used, primary outcomes (postoperative pulmonary complications grade 2 to 4: atelectasis, pneumonia, pneumothorax, mechanical ventilation > 48 hours, all-cause death, adverse events) and secondary outcomes (length of hospital stay, physical function measures, health-related quality of life, respiratory death, costs). Data were extracted by one review author and checked by a second review author. Review Manager 5.1 software was used for the analysis.

MAIN RESULTS:

Eight randomised controlled trials with 856 patients were included. Three studies used a mixed intervention (including either aerobic exercises or breathing exercises); five studies used inspiratory muscle training. Only one study used sham training in the controls. Patients that received preoperative physical therapy had a reduced risk of postoperative atelectasis (four studies including 379 participants, relative risk (RR) 0.52; 95% CI 0.32 to 0.87; P = 0.01) and pneumonia (five studies including 448 participants, RR 0.45; 95% CI 0.24 to 0.83; P = 0.01) but not of pneumothorax (one study with 45 participants, RR 0.12; 95% CI 0.01 to 2.11; P = 0.15) or mechanical ventilation for > 48 hours after surgery (two studies with 306 participants, RR 0.55; 95% CI 0.03 to 9.20; P = 0.68). Postoperative death from all causes did not differ between groups (three studies with 552 participants, RR 0.66; 95% CI 0.02 to 18.48; P = 0.81). Adverse events were not detected in the three studies that reported on them. The length of postoperative hospital stay was significantly shorter in experimental patients versus controls (three studies with 347 participants, mean difference -3.21 days; 95% CI -5.73 to -0.69; P = 0.01). One study reported a reduced physical function measure on the six-minute walking test in experimental patients compared to controls. One other study reported a better health-related quality of life in experimental patients compared to controls. Postoperative death from respiratory causes did not differ between groups (one study with 276 participants, RR 0.14; 95% CI 0.01 to 2.70; P = 0.19). Cost data were not reported on.

AUTHORS' CONCLUSIONS:

Evidence derived from small trials suggests that preoperative physical therapy reduces postoperative pulmonary complications (atelectasis and pneumonia) and length of hospital stay in patients undergoing elective cardiac surgery. There is a lack of evidence that preoperative physical therapy reduces postoperative pneumothorax, prolonged mechanical ventilation or all-cause deaths.