Abstract
Dear Editor,
We read the recent article by Lockstone et al. [1] with great interest. They found that physiotherapist-administered non-invasive ventilation (NIV) was able to reduce postoperative pulmonary complications in patients undergoing upper abdominal surgery. We wish to congratulate the authors for their intriguing concept and work, but feel that a few critical points need to be addressed.
Firstly, while we agree with Lockstone et al. that there is little evidence of the superiority of one mode over the other, the background statement that the bi-level may be more appropriate than continuous positive airway pressure (CPAP) needs examination. The authors cited the study conducted by Yağlıoğlu et al. [2] to support this statement, but Yağlıoğlu et al. found that low-flow CPAP was better.
Secondly, expiratory and inspiratory positive airway pressure were managed in accordance with tolerance; this lacks objectivity and has inherent bias. Data on gas exchange and pulse oximetry are likely to be more helpful for judging the efficacy of the treatment and its contribution to the outcome.
Thirdly, while we welcome physiotherapist-administered NIV, the reason given by the authors (i.e. intermittent sessions of postoperative NIV can be provided without proper resources) needs more evidence. While the authors emphasise the need for a multidisciplinary approach, which is also advocated by international experts in a consensus document on NIV education and training [3], involvement of a multidisciplinary team in the project is not apparent. More information about NIV monitoring and the training that physiotherapists received before administering NIV would be helpful.
Fourthly, NIV was administered on the first two postoperative days, during working hours on weekdays and within a 4-hour period on Saturdays. As maximum diaphragm dysfunction and atelectasis is expected in the immediate postoperative period, it is felt that a crucial period may have been missed. Data on this aspect, as well as admissions to the high-dependency unit, length of hospital stay and re-admissions (if any), will help readers to make conscious decisions.
Physiotherapists are an integral part of respiratory care and can play a crucial role in education and training [4]. A recent consensus document [3] and the European Respiratory Society recognise their potential ability [5]. We welcome the concept of physiotherapist-led NIV, but further study is required. Conflict of interest: None declared.
Citation
Physiotherapist-administered non-invasive ventilation to reduce postoperative pulmonary complications