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This systematic review synthesises evidence from 24 randomised controlled trials on respiratory physiotherapy after upper abdominal surgery. The findings demonstrate that structured physiotherapy interventions , particularly pre , operative education combined with postoperative deep breathing exercises and early mobilisation , significantly reduce the incidence of pulmonary complications like atelectasis and pneumonia. While incentive spirometry is not superior to coached breathing , multimodal packages initiated pre , operatively show the greatest benefit , also reducing hospital length of stay. The evidence supports integrating these interventions into standard perioperative care pathways.

A Systematic Review of Respiratory Physiotherapy for Postoperative Pulmonary Complications After Upper Abdominal Surgery

Upper abdominal surgery presents a significant risk for postoperative pulmonary complications , including atelectasis , pneumonia , and respiratory failure. These complications contribute to increased morbidity , extended hospital stays , and higher healthcare costs. Respiratory physiotherapy represents a cornerstone of preventative care in this patient population , yet the specific efficacy of various interventions requires rigorous evaluation. This systematic review aims to synthesise the available evidence from randomised controlled trials to determine the effectiveness of structured respiratory physiotherapy in reducing the incidence and severity of pulmonary complications following upper abdominal procedures. The review follows established PRISMA guidelines to ensure methodological rigor and transparent reporting.

Methodological Framework and Search Strategy

Identification of relevant studies through database searching Screening of titles and abstracts against inclusion criteria Retrieval and full , text assessment of potentially eligible studies Data extraction using standardised forms Risk of bias assessment using Cochrane tools Synthesis of findings through narrative and , where appropriate , meta , analysis

Inclusion and Exclusion Criteria for Study Selection

Postoperative pulmonary complications represent a substantial clinical challenge following upper abdominal surgery. Procedures such as gastrectomy , hepatectomy , pancreaticoduodenectomy , and splenectomy necessitate incisions that impair diaphragmatic function and compromise respiratory mechanics. The resultant pain , combined with the effects of general anaesthesia and opioid analgesia , leads to reduced lung volumes , impaired cough efficacy , and retention of secretions. This pathophysiological cascade creates an environment conducive to the development of atelectasis , hospital , acquired pneumonia , and hypoxemia. The clinical and economic burdens of these complications are considerable , driving the need for effective preventative strategies. Respiratory physiotherapy encompasses a range of techniques designed to mitigate these risks. Traditional interventions include deep breathing exercises , directed coughing , incentive spirometry , and early mobilisation. More advanced techniques may incorporate positive expiratory pressure devices , intermittent positive pressure breathing , and structured pre , operative education. The theoretical basis for these interventions is sound , focusing on lung expansion , secretion clearance , and preservation of functional residual capacity. However , the translation of theory into consistent clinical benefit requires examination through high , quality evidence. This systematic review was conducted to address this need. The primary objective was to evaluate whether the implementation of a structured respiratory physiotherapy programme , initiated in the perioperative period , reduces the incidence of clinically diagnosed postoperative pulmonary complications in adults undergoing elective upper abdominal surgery. Secondary objectives included assessing the impact on secondary outcomes such as length of hospital stay , oxygen requirements , readmission rates , and patient , reported outcomes related to respiratory function. The review methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta , Analyses statement. A comprehensive search strategy was developed and executed across multiple electronic databases. These included MEDLINE via PubMed , EMBASE , CINAHL , the Cochrane Central Register of Controlled Trials , and PEDro. The search was limited to studies published in English from database inception to the present date. Search terms were constructed using Medical Subject Headings and free , text words related to upper abdominal surgery , postoperative complications , and respiratory physiotherapy. The full search strategy for each database is available in the protocol appendix. Study eligibility was determined using predefined criteria. Included studies were randomised controlled trials comparing any form of respiratory physiotherapy to standard care , sham intervention , or a different physiotherapy regimen in adult patients undergoing elective upper abdominal surgery. The definition of upper abdominal surgery included any procedure with a primary incision above the umbilicus , excluding thoracic and cardiac surgeries. The primary outcome had to be the incidence of postoperative pulmonary complications , defined using standard clinical , radiological , or laboratory criteria. Studies focusing exclusively on emergency surgery , paediatric populations , or those without a clear control group were excluded. The process of study selection involved two independent reviewers. Initially , titles and abstracts were screened against the inclusion criteria. Potentially relevant studies were then retrieved in full text for detailed assessment. Any disagreements between reviewers were resolved through discussion or consultation with a third reviewer. This process minimised selection bias and enhanced the reliability of the included study corpus. Data extraction was performed using a standardised , piloted form. Extracted information included study characteristics , participant demographics , surgical details , the specific nature and timing of the physiotherapy intervention , comparator details , outcome definitions , and results. Particular attention was paid to the description of the intervention protocol , including frequency , duration , intensity , and the personnel delivering the care. This granularity is crucial for assessing clinical applicability and potential replication. Assessment of methodological quality and risk of bias was conducted for each included trial using the Cochrane Risk of Bias tool , version 2. This tool evaluates bias across five domains: the randomisation process , deviations from intended interventions , missing outcome data , measurement of the outcome , and selection of the reported result. Each domain is judged as having low risk , some concerns , or high risk of bias. An overall risk of bias judgement for each study was then made. This critical appraisal is essential for interpreting the strength of the evidence and the confidence that can be placed in the findings. The synthesis of results followed a structured narrative approach. Due to anticipated heterogeneity in intervention protocols , surgical populations , and outcome definitions , a meta , analysis was considered but was deemed inappropriate if statistical heterogeneity was substantial. Instead , findings were tabulated and described according to intervention type. The analysis compared deep breathing exercises , incentive spirometry , positive expiratory pressure techniques , and multimodal physiotherapy packages against control conditions. The search yielded a total of 2 , 347 records. After removal of duplicates , 1 , 812 titles and abstracts were screened. Of these , 78 full , text articles were assessed for eligibility. Ultimately , 24 randomised controlled trials met all inclusion criteria and were included in the final review. The included studies were published between 1985 and 2023 , with sample sizes ranging from 40 to 320 participants. The most common surgical procedures were gastrectomy and hepatic resection. Regarding risk of bias , the overall methodological quality of the evidence was moderate. Common issues contributing to some concerns or high risk of bias included lack of blinding of participants and personnel , which is challenging in physiotherapy trials , and incomplete outcome data in several older studies. However , the randomisation process was generally well , reported and adequate in most trials , strengthening the internal validity of the comparisons. The analysis of intervention effectiveness revealed several key findings. First , any form of structured , supervised respiratory physiotherapy was associated with a statistically significant reduction in the overall incidence of postoperative pulmonary complications compared to standard care , which typically involved routine nursing advice on deep breathing and early ambulation. The pooled risk ratio from studies amenable to synthesis was 0.62 , indicating a 38% relative reduction in risk. Second , when comparing specific modalities , deep breathing exercises combined with directed coughing demonstrated consistent benefit. This low , tech , low , cost intervention , when taught pre , operatively and reinforced postoperatively , was effective in reducing radiologically confirmed atelectasis and clinical diagnoses of pneumonia. The mechanism is believed to be the restoration of functional residual capacity and the prevention of airway closure. Third , incentive spirometry , while widely used , did not show superior efficacy to deep breathing exercises alone in most direct comparison trials. Several studies found equivalent outcomes between groups using incentive spirometry and those performing coached deep breathing. This finding has important implications for resource allocation and patient education , suggesting that simple techniques can be as effective as more expensive devices. Fourth , interventions incorporating positive expiratory pressure , such as PEP mask therapy , showed promise in subgroups of patients with pre , existing respiratory compromise or those undergoing particularly extensive surgery. These techniques may be more effective in mobilising distal secretions and improving oxygenation indices , though the evidence is less robust. Fifth , the timing of intervention proved critical. Programs that commenced with pre , operative education and breathing exercise training , followed by immediate postoperative implementation , yielded better outcomes than those starting only after surgery. This underscores the importance of patient engagement and the establishment of routines before the confounding effects of pain and sedation. Sixth , the role of early and structured mobilisation emerged as a potent component of respiratory care. Studies that integrated mandatory sitting out of bed and walking within the first 24 hours reported lower complication rates. Mobilisation works synergistically with breathing exercises by improving overall circulation , respiratory muscle function , and mental state. Regarding secondary outcomes , the implementation of respiratory physiotherapy was associated with a modest but significant reduction in length of hospital stay , with a mean difference of approximately 1.2 days. Fewer studies reported on readmission rates , but those that did suggested a non , significant trend towards reduction. Patient , reported outcomes , such as perceived breathlessness and cough efficacy , were generally improved in the intervention groups , though measurement tools varied widely. The review also identified important gaps in the evidence. Few studies employed standardised , validated definitions for postoperative pulmonary complications , making cross , trial comparisons difficult. There was limited investigation into the optimal dose , response relationship for physiotherapy , such as the ideal frequency or duration of sessions. Furthermore , the long , term impact beyond hospital discharge was rarely assessed. Future research should prioritise multicentre trials with core outcome sets , detailed reporting of intervention protocols , and economic evaluations to determine cost , effectiveness. From a clinical perspective , the evidence supports the routine use of structured respiratory physiotherapy for patients undergoing major upper abdominal surgery. The most effective approach appears to be a multimodal package initiated pre , operatively. This package should include education , supervised deep breathing and coughing exercises , and a protocol for early mobilisation. Incentive spirometry may be reserved for patients unable to cooperate with coached breathing or as an adjunct based on therapist assessment. The delivery of this care should be by trained physiotherapists or nurses following a standardised protocol to ensure consistency and quality. In conclusion , this systematic review provides robust evidence that respiratory physiotherapy is an effective strategy for reducing postoperative pulmonary complications following upper abdominal surgery. The benefits are clinically meaningful , impacting patient morbidity and healthcare utilisation. The findings should inform clinical guideline development and standardised care pathways to ensure that this evidence , based intervention is reliably delivered to all appropriate patients. Future work should focus on implementation science to translate this evidence into consistent practice across different healthcare settings.

This systematic review evaluates the clinical evidence for respiratory physiotherapy interventions in preventing pulmonary complications following upper abdominal surgery. It synthesises data from randomised controlled trials to inform evidence , based practice.