File
Schmidt Leuenberger J.M.1, Luder G.1, Hoksch B.2
1Inselspital, Bern University Hospital, Department of Physiotherapy, Bern, Switzerland, 2Inselspital, Bern University Hospital and University of Bern, Division of General Thoracic Surgery, Bern, Switzerland
Background: Aspiration resulting from oropharyngeal dysphagia is a common cause of pneumonia and has been recognized as a serious complication after pulmonary resection. Therefore, it has been recommended that dysphagia be assessed before the initiation of oral intake after surgery. Early detection of dysphagia reduces aspiration pneumonia in hospitalized patients after stroke, but the effect of those assessments has not been proved after elective pulmonary-resection surgery.
Purpose: The aim of this randomized controlled trial (RCT) was thus to investigate whether early detection of postoperative dysphagia and subsequent adequate interventions would reduce aspiration pneumonia in patients undergoing elective pulmonary-resection surgery. Secondly, the average hospital length of stay was assessed.
Methods: Between February 2014 and May 2016, 438 adult patients undergoing elective pulmonary-resection surgery were randomly assigned to either the intervention group (n = 219) or the control group (n = 219). Standard physiotherapy treatment was administered pre- and postoperatively to all patients in both groups. Patients in the intervention group additionally underwent a clinical assessment of dysphagia before the first oral intake after surgery. For patients with dysphagia, therapeutic interventions were implemented immediately. The primary outcome was the difference in the incidence of pneumonia between the two groups. Statistical analysis included a chi-square test and a t-test. The level of significance was set at p 0.05 with a power of 80%.
Results: Of the total of 492 patients who underwent elective pulmonary-resection surgery during the study period, 438 were included in the intention-to-treat analysis. 33 were operated twice or more but were enrolled only once, while 19 met an exclusion criterion and 2 refused participation.
In the intervention group 7 cases (3.2%) with postoperative dysphagia were detected. Pneumonia occurred in 15 cases (6.8 %) in the intervention group and in 27 cases (12.3 %) in the control group.
The resulting risk reduction for pneumonia of 5.5% in the intervention group was not statistically significant (95% CI -11.2 to 0.09; p = 0.051). Moreover, there was no statistically significant difference of the mean of the hospital length of stay [days] between the intervention group (7.7 ± 6.4) and the control group (8.6 ± 7.1) (p = 0.175).
Conclusion(s): Although statistical significance was not given, the physiotherapeutic intervention was effective in every patient with postoperative dysphagia, all of whom did not develop a pneumonia. Hence, there is reason to believe that early detection of dysphagia can prevent pneumonia in patients undergoing elective pulmonary-resection surgery. As a consequence, postoperative policies and protocols might accommodate this result.
Implications: The low incidence of just 7 cases with postoperative dysphagia in 219 patients (the number needed to treat = 31 respectively) is indicative of how difficult it is to select suitable patients for this intervention. Moreover, potential risk factors cannot be determined on the basis of 7 cases. Therefore, we recommend a risk stratification with a nurse-administered screening tool such as the one recommended by Perry and Love (2001), with subsequent physiotherapeutic assessment and intervention if the screening is positive.
Funding acknowledgements: Inselspital, Bern University Hospital, Bern, Switzerland
Topic: Cardiorespiratory
Ethics approval: The trial was approved by the Ethics Committee Bern, Switzerland and has been registered with the German Clinical Trials Register.
All authors, affiliations and abstracts have been published as submitted.
