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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY April 2013 | Archived Issues

Chest Physiotherapy No Longer Routine Post-Op Order

A drop-down menu has been added on CS-Link™ to help remind physicians when it is appropriate to order chest physiotherapy (CPT), which is no longer a routine post-operative order.

According to best practices, indications for the therapy are as follows:

  • Significant sputum production in patients who need help clearing secretions with volume of 30ml/day or more;
  • Acute segmental or lobar atelectasis (lung collapse) due to secretion retention/ mucus plugging;
  • Conditions such as cystic fibrosis, bronchiectasis or lung abscess in which mucus clearance is an integral part of evidence-based therapy.

CPT is a manual therapy that employs percussion, postural drainage and vibration to loosen secretions in the respiratory tract. Despite guidelines used by the Respiratory Therapy (RT) Department over many years, very high utilization at Cedars-Sinai was noted in mid-2012, especially among surgical patients. In collaboration with members of the Cedars-Sinai Medicine team, Respiratory Therapy staff reviewed the latest literature and provided educational feedback to the medical staff in September 2012. However, CPT numbers remained high and even exceeded the previous year's numbers, according to Michael Lewis, MD, director of Cedars-Sinai's Respiratory Therapy Department.

C-S Medicine and RT investigators later discovered a major culprit: CPT remained in more than 30 order sets on CS-Link as routine prophylactic orders post-operatively for conditions that, upon review, were not compliant with established guidelines. The order sets were subsequently revised.

Chest physiotherapy has a long history as a prophylactic treatment for patients at risk of post-operative pulmonary complications. But studies dating back to the 1970s have shown that the treatment is not effective, and is potentially harmful to many groups of patients who routinely received it in the past.

"There was a perception that chest physiotherapy may prevent complications in many post-operative patients, but there is no good evidence to support that," says Lewis. "In fact, studies show the intervention in the wrong patient can worsen chest mechanics short-term and cause the amount of oxygen in the blood to fall."

"If there are significant amount of secretions, by all means, go ahead and use CPT. It's justified," Lewis adds. "But in patients who lack the indications, there is the potential for harm and no benefit."

CPT orders have dropped significantly in the past few months, due to several interventions that include the revised order sets, weekly monitoring reports and one-on-one education with high users. The following graph depicts the considerable progress made:

In conjunction with RT leadership, chest physiotherapy guidelines are one of several best practices developed by Cedars-Sinai Medicine teams, under the direction of Glenn D. Braunstein, MD, vice president for Clinical Innovation.

For more information, please contact Lewis at Michael.Lewis@cshs.org.