Acta Anaesthesiol Scand 2010; 54: 261–267 Printed in Singapore.

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r 2009 The Authors Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2009.02143.x

Review Article

Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review
¨ ¨ Department of Intensive Care, Linkoping University Hospital, Linkoping, Sweden, 2Department of Medical Sciences, Clinical Physiology, ¨ Uppsala University Hospital, Uppsala, Sweden and 3Department of Physiotherapy and Centre for Health Care Sciences, Orebro University ¨ Hospital, Orebro, Sweden

¨ J. ORMAN1 and E. WESTERDAHL2,3
1

A variety of chest physiotherapy techniques are used following abdominal and thoracic surgery to prevent or reduce post-operative complications. Breathing techniques with a positive expiratory pressure (PEP) are used to increase airway pressure and improve pulmonary function. No systematic review of the effects of PEP in surgery patients has been performed previously. The purpose of this systematic review was to determine the effect of PEP breathing after an open upper abdominal or thoracic surgery. A literature search of randomised-controlled trials (RCT) was performed in five databases. The trials included were systematically reviewed by two independent observers and critically assessed for methodological quality. We selected six RCT evaluating the PEP technique performed with a mechanical device in spontaneously breathing adult patients after abdominal or thoracic sur-

gery via thoracotomy. The methodological quality score varied between 4 and 6 on the Physiotherapy Evidence Database score. The studies were published between 1979 and 1993. Only one of the included trials showed any positive effects of PEP compared to other breathing techniques. Today, there is scarce scientific evidence that PEP treatment is better than other physiotherapy breathing techniques in patients undergoing abdominal or thoracic surgery. There is a lack of studies investigating the effect of PEP over placebo or no physiotherapy treatment.
Accepted for publication 16 September 2009 r 2009 The Authors Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation

BDOMINAL and thoracic surgery is associated with a high incidence of post-operative pulmonary complications leading to longer hospital stays and increased mortality.1 Several interventions and strategies are used to diminish these problems.2,3 Chest physiotherapy has long been a standard component of post-operative care, with the aim of preventing or reducing complications such as impaired pulmonary function, atelectasis, pneumonia, and sputum retention.4,5 In a recent systematic review, it has been concluded that continuous positive airway pressure (CPAP) decreases the risk of pulmonary complications, atelectasis, and pneumonia after abdominal surgery.6 Simple systems for positive expiratory pressure (PEP) breathing have been developed, for example, systems where a mask or a mouthpiece is connected to a resistance nipple to provide positive pressure during expiration and the blow-

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bottle device in which the resistance consists of a water seal. In clinical practice, the resistance is often regulated to achieve 5–20 cmH2O during slightly active expiration. The pressure achieved is dependent on the performance of the manoeuvre, the adjustable expiratory resistance, and the patients’ active expiratory flow. The rationale for the PEP technique post-operatively is to increase pulmonary volumes, decrease atelectasis, and promote secretion removal.7,8 The physiological effects of PEP in spontaneously breathing post-operative patients are unknown, but an increased functional residual capacity (FRC) is considered essential. PEP treatment has been systematically reviewed in patients with cystic fibrosis9 and chronic obstructive pulmonary disease.10 No clear evidence was found that breathing exercises performed with PEP were more effective than other forms of

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last accessed 16 March 2009.18 The studies were published between 1979 and 1993 and were mainly performed in Scandinavia. Breathing exercises with PEP are often provided routinely in Scandinavia for patients undergoing surgery.12 Methods Search strategy and study selection A literature search was initially performed in October 2007 and updated in November 2008. The Physiotherapy Evidence Database (PEDro).11 The methodological quality scale consists of 10 criteria for internal validity (criteria 2–9) and statistical information (criteria 10–11).10 No systematic review of the effects of PEP in surgery patients has been found. we selected all randomised-controlled trials (RCT) evaluating the PEP technique performed with a mechanical device in spontaneously breathing adult patients after an open upper abdominal or thoracic surgery via thoracotomy. and The Cochrane Central Register of Controlled Trials on the Cochrane Library.18 incentive spirometry. The reviewers independently extracted the data on the type of surgery. Methodological quality assessment The eligible trials were systematically analysed with an instrument for methodological quality assessment. ‘physical therapy’. and the result was then compared and discussed until agreement was achieved. as presented in the study flow chart (Fig. ‘respiratory physiotherapy’.15–18 The PEP treatments were performed by a PEP-mask15–18 or by a blow-bottle system. PEP-mask treatment was compared with other breathing techniques: CPAP (10–15 cmH2O).17. Orman and E.13–18 Four of the studies were performed on patients after an open abdominal surgery. Based on the titles and abstracts. W.pedro.org. 1). In the study by Heister*http://www. We therefore undertook a systematic review to assess the effectiveness of breathing exercises performed with PEP in patients after open abdominal or thoracic surgery. Reference lists of the retrieved articles were searched to identify any additional studies. exact pressure not given. in accordance with the suggestions at the PEDro website. and the number of patients included in the studies varied between 5016 and 160. ‘atelectasis’.16. Westerdahl treatment. and the study achieves one score for each fulfilled criteria.13.17 and the remaining two following thoracic surgery performed through thoracotomy. 262 .* The individual criteria were marked as ‘Yes’ (positive) or ‘No’ (negative). O. No exclusions were made in selected trials in consideration of the outcome measures chosen.14 The evaluation period in the studies varied from the first day after surgery to approximately 9 days post-operatively.9.18 The main characteristics of the studies are shown in Table 1. ¨ Two reviewers (J. ‘respiratory therapy’.html. ‘post-operative pulmonary complications’.15. ‘positive expiratory pressure (PEP)’.16. Abstracts in conference proceedings or unpublished sources were not included. ‘breathing exercises’. Two reviewers assessed the methodological quality of the studies independently.13.¨ J. The following search words were used individually or in combinations: ‘abdominal surgery’.14–18 the evaluated PEP was given in addition to conventional chest physiotherapy.15 In five of the studies.* based on the Delphi list developed by Verhagen et al. six studies satisfied the inclusion criteria and were included in the review. The studies had to include at least one treatment group in which the PEP technique was compared with other chest physiotherapy techniques or with no intervention. E. Results Of over 470 potentially eligible studies retrieved in the databases and reference lists. methods of the study.13.14. types of intervention. The quality criteria list used in this study was the PEDro scale. Studies with a score of 5 or more on the PEDro scale were considered to be of moderate or high quality.) independently assessed which trials should be included. Cumulative Index to Nursing and Allied Health Literature (CINAHL).18 inspiratory resistance-positive expiratory pressure (IR-PEP). Allied and Complementary Medicine Database (AMED).. The effect of PEP in post-operative care has not yet been summarised. The additional criterion 1 that relates to the external validity was not used to calculate the PEDro score in the present review. and outcome. The search was performed in the following databases: MEDLINE/PubMed. and ‘thoracic surgery’. Studies were excluded if the study population had undergone thoracic surgery via sternotomy.16 or placebo PEP (no resistance). Data were considered missing if they were not mentioned explicitly in the text. In four of the studies. ‘physiotherapy’.au/scale_item. ‘blow bottle’. finally. The literature search was limited to the English language.

was used as an outcome measure in all six studies. two evaluated a blow-bottle device for expiratory pressure. atelectatic consolidation was significantly lower in the PEP group on the third post-operative day.18 post-operative complications.13..18 and the study by Frolund and Madsen15 was the only one with blinded subjects. compared with other breathing techniques15–18 or in addition to routine chest 263 .13.15. ABG. pulse rate. and pulmonary auscultation. Furthermore.17 Thoracic surgery Neither of the two studies evaluating PEP-mask treatment after thoracotomy showed any significant effect of PEP compared with other treatments.14 alveolar–arteriolar oxygen difference16 and cough.13 the patients in the intervention group were requested to use PEP treatment only.14. antibiotics. Study flow chart.15. use of bronchodilators. arterial blood gases (ABG) in four studies. performed for 10 min every fourth hour..18 Patients performing PEP-mask treatment for 10 min/h when awake during the daytime with an expiratory pressure of 10 cmH2O in the study by Frolund and Madsen15 did not show any positive effects on chest roentgenograms or ABG compared with a control group using a face-mask set without expiratory resistance..16. 30 breaths every waking hour. and atelectatic consolidation.14 the addition of 20 breaths performed with a blow-bottle system (110 cmH2O) every second hour in addition to standard preand post-operative physiotherapy did not show any significant improvements regarding post-operative pulmonary complications.17 no significant differences were found between patients performing PEP-mask breathing (5–15 cmH2O) once per hour during daytime compared with a respiratory muscle-training group or a conventional physiotherapy group. In the study by Heisterberg et al.17 berg et al. The alveolar–arteriolar oxygen difference was significantly lower and PaO2 and forced vital capacity were significantly higher compared to the control group on the second post-operative day.16.18 showed that PEP-mask treatment (10–15 cmH2O) 5 min/h awake after thoracotomy was comparable to CPAP or IRPEP treatment regarding the effects on lung volumes. with reasons Guideline or review articles Non-RCT studies Surgery performed via sternotomy Pediatric sample Intubated patients Inspiratory muscle training (IMT) trials Positive end expiratory pressure (PEEP) trials Medical interventions Non-English-language Duplicate trials 23 full manuscripts reviewed for inclusion 14 trials potentially relevant 6 trials included in the systematic review Fig.16 compared PEP-mask treatment (10–15 cmH2O). Atelectasis.. oxygen.18 subjective experiences and time to chest tube removal. dyspnoea.16–18 Other outcome measures used were temperature. All studies fulfilled the last criteria on the PEDro scale.17 to 5–6 points (medium quality).18 as reported in Table 2. No significant difference was found between the treatments regarding scoring of atelectasis. Discussion Of the six RCTs found investigating the effects of post-operative PEP. without the specific physiotherapy treatment that was given to the control group. Abdominal surgery Of the four trials investigating PEP after abdominal surgery. mobilisation. Ingwersen et al. evaluated in chest roentgenograms. In the study by Campbell et al. was compared with the blow-bottle technique.17. pain. In no article was it reported whether the randomisation was concealed or not. but four studies used blinded assessors.15–18 and pulmonary function measured by spirometry in four of the studies. Methodological quality of the studies The methodological quality assessment ranged from four points (low quality) on the PEDro scale14.15. expectoration. Ricksten et al.Positive expiratory pressure review 471 potentially relevant trials identified through electronic databases and reference lists 108 trials retrieved for more detailed evaluation 102 trials excluded. with CPAP and with a control group receiving basic physiotherapy with incentive spirometry. with two daily visits by the physiotherapist.13 conventional chest physiotherapy consisting of breathing exercises and postural drainage. point and variability measures. 1. In the study by Christensen et al. No studies described a blinded therapist.

4 days Post-operative complications X-ray pre-op. 8 days1when needed or if complication was suspected ABG pre-op. deep breathing exercise. FRC. FVC%. FEV1. forced expiration technique. FVC% pre-op No significant 2days. 2 days. Po0. forced vital capacity. forced expiratory volume 1 s. pre-op. Diaphragm breathing. change of position. first night. pre-operatively. IR-PEP. 4 days. *Breathing exercises in supine and sitting positions. diaphragm breathing. coughing. until expectoration stopped. temp. PaO2. PEP. subjective X-ray pre-op. VC. FET. arterial blood gas. 6 h. 3 days ABG pre-op. PT. FET. walking exercises. FVC. for 3 days IR-PEP 1/h 5–10 breaths1huff pause. physiotherapy.05) 3 days. tipping was added. Orman and E. PEF pre-op. daily reminder of PT for 5 days PT self-training/2 h Blow bottle 2 Â 10 breaths/2 h Evaluation X-ray pre-op. FRC daily Subjective pain score. ABG. CPAP. 3 days X-ray pre-op.05) PEP: Lower [A–a]O2-diff. expectoration.001). exud chest tubes or time to removal. 9 days difference ABG pre-op. help in coughing. higher FVC (Po0. proper use of mask. pulse rate. functional residual capacity. 1 day. huffing.01) X-ray pre-op. 3 days [A–a]O2-diff calculated No significant difference wInspiratory diaphragmatic and lateral costal breathing. FiO2. zRapid mobilisation. inspiratory resistance-positive expiratory pressure. peak expiratory flow. Westerdahl Table 1 Characteristics of the included studies. continuous positive airway pressure.¨ J. dyspnoea registered daily X-ray. FET. §DBE. If side lying was inadequate for secretions clearance postural drainage. No significant 3 days1when needed difference FEV1. for 3 days PT twice/day Mask 5 min/h No significant difference (higher PaO2in control group than PEP group 2 days. Study Heisterberg13 Surgery/ subjects (n) Abdominal surgery 98 Groups and intervention PT* Blow bottle Treatment duration and frequency PT 30130 min/ day1self training twice/h for 5 days Blow bottle 10 min/4 h. postural drainage. forced vital capacity percent of vital capacity. if previous lung problems VC. active mobilisation. until expectoration stopped. partial pressure of carbon dioxide in arterial blood. PEP 30 breaths/h Started 1 h postoperative until day 3 Christensen17 Abdominal surgery 51 PTz PTz1PEP 5– 15 cmH2O PTz1IR-PEP inspiration pressure tolerated 2 min/15– 7 cmH2O Ingwersen18 Thoracic surgery 144 PT k 1CPAP 15 cmH2O PT k 1PEP mask 10–15 cmH2O PT k 1IR-PEP20 cmH2O/unknown PT twice/day for 3 days PEP 1/h 5–10 breaths1huff pause. vital capacity. PaCO2. alveolar–arteriolar oxygen difference. 1 day. medicine. positive expiratory pressure. 264 . 4 days. huffings in alternating positions. 4 days. [A–a]O2-diff. incidence of atelectasis 3 days (Po0. turning in bed. PEF. arm exercises. PPC. FEV1 pre-op. mobilisation. pursed-lip breathing. and coughing in sitting position. CPAP. 4 days Primary result No significant difference Campbell14 Abdominal surgery 71 PTw PTw1blow bottle 10 cmH2O (5–15) Frolund15 Thoracic surgery 56 PTz1placebo PEP mask (no resistance) PTz1PEP mask 10 cmH2O (9–12) PT twice/day Intervention 10 min/h awake daytime Ricksten16 Abdominal surgery 43 PT§1Triflo PT§1CPAP 10–15 cmH2O PT§1PEP mask 10– 15 cmH2O PT 30–40 min twice/ day Triflo. 1 day. DBE. post-operative pulmonary complications. higher PaO2 3 days (Po0. Mobilisation as early as possible. partial pressure of oxygen in arterial blood. ABG. kGeneral information about chest PT and mask treatment. and early mobilisation day after operation. 30 min after PT FVC. zDiaphragm breathing. temperature. 2 days. FVC. 9 days PaO2.

18 and that there is no evidence suggesting that PEP is inferior to other techniques. The pursed-lip breathing technique and the flutter technique. Ricksten et al. however.10 If the goal is to improve post-operative pulmonary function.17 It is obvious that there is a need for more evaluation to verify the benefit of the treatment. but no comparison with PEP was made. No trials were found evaluating PEP treatment in comparison with an untreated control group.15 offered an active intervention with some kind of anticipated effect to control groups.19 CPAP has also been shown to be more effective in preventing reintubation than IR-PEP in the study by ´ Fagevik Olsen. we decided not to restrict the inclusion of trials by year of publication.14 and the PEP mask system. All studies.18 and IR-PEP17.15–18 In clinical practice.14. even the placebo-controlled study by Frolund and Madsen. it has been concluded that CPAP decrease the risk of postoperative complications after abdominal surgery6 and that it is more effective than deep breathing exercises in cardiac surgery patients. there are several different devices available. There is. and prevention of atelectasis. The individual Methodological quality of studies as assessed by the Physiotherapy Evidence Database (PEDro) scale. Studies with a score of 5 or more on the PEDro scale were considered to be of moderate or high quality. oxygenation. Heisterberg13 Campbell14 Frolund15 Ricksten16 Christensen17 Ingwersen18 Table 2 Study criteria were marked as: ‘yes’ (positive) or ‘no’ (negative). the device may change the breathing pattern and affect the outcome. Even if the pressure were low or missing. Possibly there are positive effects. but they have not yet been proven. according to the internal validity score of the PEDro scale. Several of the included studies were of a lower methodological quality. have not been evaluated in this patient category. no additional effects of PEP were described in the trials. Data were considered missing if they were not mentioned explicitly in the text. One of the reasons for this could be that the studies were published many years ago.14. Compared with routine chest physiotherapy.20 The present results indicate that the PEP technique has an effect similar to that of other treatments such as CPAP16. The studies achieved one score for each fulfilled criterion. In a recent systematic review.13. The PEP technique can be used both to decrease and to increase lung volumes. a large and sustained deep breath is important to *The methodological quality for internal validity and statistical information was assessed by PEDro score. Because publications in this area are scarce. using a high-density ball creating an oscillation during expiration.16 concluded that the PEP mask was better than incentive spirometry and as effective as CPAP with respect to preservation of lung volumes. The only PEP devices that were evaluated were the blow-bottle technique13. a lack of evidence for PEP conferring an added benefit when used in combination with other physiotherapy modalities.Positive expiratory pressure review physiotherapy treatment. Total score Point and variability measures Betweengroup comparisons Intentionto-treat analyses Adequate follow-up Blind assessors Blind therapists Blind subjects Baseline comparability Concealed allocation Random allocation Eligibility criteria Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No NO No No No No Yes Yes Yes Yes No No Yes No No No No No No No No No Yes No Yes Yes No Yes Yes Yes No Yes No Yes No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 5/10* 4/10 6/10* 6/10* 4/10 6/10* 265 .17 only one study16 showed the effects of PEP.13.

The significance of prophylactic chest physiotherapy. 4. So far. the effect of the treatment is uncertain. Positiveexpiratory-pressure mask therapy: theoretical and practical considerations and a review of the literature. different modalities of PEP.16. 144: 596–608. have been reviewed. To blind the patients as well as care providers is often impossible. Mascia L.23 The instructions to the patient on how to perform the technique were not very well described in the trials. Four of the trials in this review had a score of 5 or more. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery.18 although the articles were published at an early date. but the PEP technique is not yet a treatment technique that is used worldwide. 8. van der Schans C. Fagevik Olsen M. Serejo LG. In light of this. Smetana GW. Orman and E. Physiotherapy for respiratory and cardiac problems. Hoffman GL.21 The theoretical basis of the technique is that PEP increases FRC. although no obvious effect of this method has been distinguished in the prevention of pulmonary complications. 5. Richiardi L. References 1. the technique is mostly used in European countries. da Silva-Junior FP. de Bruin PF. as are early mobilisation and an upright position. Mahlmeister MJ. and perhaps the given treatment duration and frequency in the included trials were not the best possible. although it has started to be familiar in other countries. Edinburgh: Churchill Livingstone. Risk factors for pulmonary complications after emergency abdominal surgery. the reviewed articles represent a fairly good quality. Mota RM. but to date. Pasquina P. Warner DO. 92: 1467–72. 36: 1218–29. In this review.12 Earlier trials often do not state whether treatment allocation was concealed and how. Preventing postoperative pulmonary complications: the role of the anesthesiologist. If no maximal inspirations were achieved. According to this result. 101: 808–13. Fink JB. only one of the six included trials showed any positive effects of PEP compared with other physiotherapy breathing techniques. Bastos JP. de Bruin GS. Del Sorbo L. especially after low-risk surgery. Today there is no agreement on the optimal training intensity recommended for the patient. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. this review will stimulate new research to increase knowledge of the treatment. 7. Tramer MR. this could possibly explain why no effects on atelectasis were shown. In this study. Chest 2006. allocation was performed. The treatment effects of PEP were only evaluated during the first post-operative days. The criteria are not listed in order of precedence. Br J Surg 1997. which can be considered a shortcoming. Respir Med 2007. Westerdahl obtain effect from the PEP treatment. and instructions on how and when to perform the breathing exercises are essential.5 Breathing exercises with PEP are provided routinely for patients following surgery. 2. Hahn I. Ann Surg 2008. Prasad SA.15. Optimal pain relief.22.¨ J. Cornell JE. Baussano I. 247: 617–26.4. Squadrone V.13. Lundholm K. Elkins MR. Lawrence VA. 9. Walder B. and especially long-term treatment evaluations are needed. 266 . Lonroth H. and new research must be performed to draw any conclusions about the effects of PEP treatment in patients undergoing abdominal or thoracic surgery. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. and neither does the scale take the size of the studies or the effect size of the intervention into account. has been questioned. none of the included trials presented any sample size calculations and statistical analysis was not very well described. with diverse duration and pressure and different administration of the breathing exercises. Hopefully. 130: 1887–99. Conclusion In this review. Nordgren S. Pryor JA. Deep breathing exercises performed with no mechanical device may prove as effective as treatment with a PEP device after abdominal and thoracic surgery. Cochrane Database Syst Rev 2006: CD003147. 2002. Jones A. considering that the quality has increased over time. Ranieri VM. 3rd edn. Exclusion of trials published in languages other than English might be considered a bias. Respir Care 1991. in detail. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Merletti F. 3. this has not been studied. Only one of the studies was performed outside Scandinavia. Ferreyra GP. 84: 1535–8. Anesthesiology 2000. adults and paediatrics. Fully randomized and controlled studies with large materials are needed to verify the treatment. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis.14 It is a challenge to evaluate methodological quality. although chest roentgenograms were used as outcome measures in all the trials included. Fifer LF. Marchiaro G. Ann Intern Med 2006. Granier JM. 6.

89: 1228–34. 51: 1235–41.Positive expiratory pressure review 10. Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques. 19: 294–8. McKinlay RG. Schultz P. Acta Chir Scand 1979. Knipschild PG. Lundell L. Bach K. 22. Acta Anaesthesiol Scand 2000. Respiration 1985. 21. 19. Campbell T. 48: 277–84. Lonroth H. Resistance breathing (blow bottles) and sustained hyperinflations in the treatment of atelectasis. Bertelsen MT. 5th edn. Fanning GL. 48: 43–9. Respiration 2009. Verhagen AP. 20. 2000. Goenen M. 13. de Bie RA. Maher CG. 23. Sandermann J. 89: 774–81. Matte P. Johnsson E. J Clin Epidemiol 1998. Bengtsson A. 12. Juhl B. 145: 505–7. Heitz M. Engberg M. Intensive Care Med 1993. Positive expiratory pressure in patients with chronic obstructive pulmonary disease – a systematic review.orman@lio. 72: 498–500. Kessels AG. Comparison of the effect of continuous positive airway pressure and blowing bottles on functional residual capacity after abdominal surgery. Bouter LM. Fagevik Olsen M. Christensen EF. 11. 18. Fagevik Olsen M. Gron I. Physiotherapy 1986. Acta Anaesthesiol Scand 1986. Egebo K. continuous positive airway pressure and non-invasive ventilatory support with bilevel positive airway pressure after coronary artery bypass grafting. Wennberg E. Ferguson N. Nunn’s applied respiratory physiology. Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Herbert RD. Lumb AB. Thorden M. Kiil-Nielsen K. Holzach P. Laub M. 77: 110–8. 35: 97–104. Aust J Physiother 2002. Dittmann M. Sherrington C. Anesthesiology 1970. 17. Van Dyck M. Kvist H. de Vet HC. Ingwersen UM. Postoperative pulmonary complications and lung function in high-risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia. Oxford: Butterworth-Heinemann. Address: ¨ Jenny Orman Department of Intensive Care Linkoping University Hospital ¨ SE-581 85 Linkoping ¨ Sweden e-mail: jenny.se 267 . Hansen H. Jensen OV. Acta Anaesthesiol Scand 1991. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. Postoperative pulmonary complications in upper abdominal surgery. Mahoney PD. 44: 75–81. Johansen TS. Larsen HW. Effects of conventional physiotherapy. Boers M. 14. Jacquet L. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Josefson K. Larsen KR. Colgan FJ. Three different mask physiotherapy regimens for prevention of postoperative pulmonary complications after heart and pulmonary surgery. 30: 381–5. Moseley AM. Chest 1986. 32: 543–50. Frolund L. Ricksten SE. 16. 15. Br J Surg 2002. Holm M. Soderberg C. Madsen F. Heisterberg L. The use of a simple self-administered method of positive expiratory pressure (PEP) in chest physiotherapy after abdominal surgery. Andersen B. A randomized clinical comparison between physiotherapy and blow-bottles. Self-administered prophylactic postoperative positive expiratory pressure in thoracic surgery. Westerdahl E.

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