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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 21-29

A cross-sectional survey of perioperative lung protection in gastrointestinal surgery in Mainland China


1 Department of Emergency, The First Affiliated Hospital of Xiamen University, School of Medicine, Xia Men University, Xiamen, China
2 Department of Respiratory and Critical Care Medicine, Respiratory Medical Center of Fujian Province, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
3 Department of Critical Care Medicine, Jinjiang Municipal Hospital, Quanzhou, China

Date of Submission26-Jun-2021
Date of Decision11-May-2022
Date of Acceptance12-May-2022
Date of Web Publication17-Jun-2022

Correspondence Address:
Yuqi Liu
Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Fujian Medical University, Respiratory Medical Center of Fujian Province, Fujian Province, Quanzhou
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wjsi.wjsi_2_21

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  Abstract 


Objective: To understand the implementation status of perioperative lung protection (PLP) in gastrointestinal surgery patients and the awareness of PLP and respiratory care (RC) among gastrointestinal surgeons in Mainland China.
Methods: Taking the hospital of the investigator as the initiating unit, the questionnaire was distributed to gastrointestinal surgeons, intensive care unit doctors, and respiratory therapists (RTs) of hospitals in Chinese Mainland in the form of WeChat questionnaires. The investigation was divided into two rounds: preliminary screening and return visit.
Results: A total of 157 valid questionnaires were collected, including 89 hospitals in 24 provinces, autonomous regions, and municipalities in Mainland China. Thirty-two hospitals did not have RTs. In the 57 (64%) of 89 hospitals with RTs, there were 26 (57%) hospitals with RTs number of 2 or less, only 6 hospitals had full-time RTs, 33 (59%) of 56 hospitals had no more than 2 RTs with over 3 years working experience, and perioperative patients of gastrointestinal surgery in only 9 (16%) of 57 hospitals often received help from RTs. A total of 60 gastrointestinal surgeons were surveyed, among which 23 (38%) answered that they knew nothing about RC, 44 (73%) considered gastrointestinal surgery patients should receive RC, and 57 (95%) considered their hospitals should set up RC department. Three main resistance sources of RC development of gastrointestinal surgery from high to low were insufficient attention of leaders (67%), human resources' shortage (57%), and charging too cheaply or even without related services' charges (48%).
Conclusions: In Chinese Mainland, patients with gastrointestinal surgery were seriously lack of PLP support, and gastrointestinal surgeons lack awareness of RC. We appeal to pay more attention to PLP in gastrointestinal surgery patients and promote perioperative safety.

Keywords: Gastrointestinal surgery, intensive care unit, perioperative lung protection (PLP), respiratory care, respiratory therapists


How to cite this article:
Yang Y, Sun X, Jiang Z, Huang T, Wang J, Zhuang D, Liu Y. A cross-sectional survey of perioperative lung protection in gastrointestinal surgery in Mainland China. World J Surg Infect 2022;1:21-9

How to cite this URL:
Yang Y, Sun X, Jiang Z, Huang T, Wang J, Zhuang D, Liu Y. A cross-sectional survey of perioperative lung protection in gastrointestinal surgery in Mainland China. World J Surg Infect [serial online] 2022 [cited 2022 Aug 8];1:21-9. Available from: https://www.worldsurginfect.com/text.asp?2022/1/1/21/347765




  Introduction Top


Perioperative lung protection (PLP) is a set of treatment or prevention methods for reducing lung injury caused by various etiologies during the perioperative period. PLP measures are important to gastrointestinal surgery patients, because lying in bed, wound pain, abdominal bandage or abdominal hypertension, poor eating, and diaphragm disorders are more common.[1],[2],[3] As experts in evaluating and managing respiratory dysfunction,[4] respiratory therapists (RTs) would initiate PLP measurements on perioperative patients. By investigating the implementation of PLP in gastrointestinal surgery patients' and gastrointestinal surgeons' understanding of respiratory care (RC) in some hospitals in Mainland China, our goal was to call for strengthening the management of PLP in gastrointestinal surgery patients and improving patient safety.


  Methods Top


A web format questionnaire was designed and generated through the Questionnaire Star Software (RanXing Company, Changsha, China). It included 15 single-choice questions, 9 multiple-choice questions, and 4 fill-in-the-blank questions. The questionnaire can be found in Appendix 1.

The survey was conducted from January 01, 2019, to February 01, 2019, by using convenience sampling. Questionnaires were sent out to gastrointestinal surgeons, intensive care unit (ICU) physicians, and RTs in some hospitals in Mainland China through RT networking software WeChat. The respondents were required to finish and submit the questionnaires independently.

Questionnaires contents

Part 1: Basic information

The basic information included the name of the hospitals, their location, grade and level, occupation, and technical title of the respondents (According to the level given by the Chinese Government, doctors were classified as senior doctors, intermediate doctors, and junior doctors, and their working years were generally at least 15 years, 10 years, and more than 5 years, respectively).

Part 2: Discipline construction of respiratory care

In this part, whether the hospital has an independent respiratory therapy department, the number of RTs with systematic training, their affiliation, and length of service, as well as routine RC projects carried out by RTs in the whole hospital were investigated.

Part 3: Perioperative lung protection in gastrointestinal surgery patients

Items of preoperative and postoperative RC in gastrointestinal surgery patients were investigated, including smoking cessation health education, physical training, lung function examination, respiratory muscle training, early postoperative bed activity, family member-assisted back patting instruction, guidance on the use of breathing training equipment, directed cough, active humidification, high-flow oxygen therapy, cuff management, chest physiotherapy, as well as lung dilation treatment.

Part 4: Cognitive investigation of perioperative lung protection and respiratory care in gastrointestinal surgeons

In this section, we investigated gastrointestinal surgeons' awareness of perioperative complications, PLP and the nature of the work of RTs, and sources of resistance to the development of RC in gastrointestinal surgeons.

Inclusion criteria of respondents

Issue hospitals

The Grade A and Grade B tertiary referral hospitals (equivalent to university affiliated hospitals and tertiary hospitals in the United States) Grade A secondary referral hospitals (equivalent to a community hospital in the United States) were enrolled for the survey.

Survey objects

Gastrointestinal surgeons and ICU physicians with working experience longer than 2 years as well as RTs without requirement on working duration were qualified for the respondents.

Questionnaires processing

Initial screening stage

The integrity and authenticity of the questionnaires were reviewed by two independent reviewers. The questionnaires with obvious defects in the integrity and authenticity were regarded as invalid.

Return visit stage

A return visit would be made if there was a contradiction between different questionnaires from one hospital. The return visit was conducted through WeChat one-to-one contact to ensure the authenticity of the results.

Data analysis

Because the contents of part 2 and part 3 were based on the hospitals, those questionnaires would be screened if they were from a same hospital to ensure that each hospital only selected one representative questionnaire. Because the contents of part 4 were based on the gastrointestinal surgeon individuals, all valid questionnaires were collected for analysis no matter if the questionnaires came from a same hospital.

Statistical method

The proportion of each option was calculated and summarized by Questionnaire Star. SPSS 22.0 was used for further statistical analysis, mainly descriptive statistics. The rate comparison was tested by χ2 test; P < 0.05 was considered statistically significant.


  Results Top


Basic information

A total of 162 questionnaires were collected, in which 157 were valid. The enrolled questionnaires came from 89 hospitals distributed in 24 provinces, autonomous regions, and municipalities directly under the Central Government in Mainland China. The date of the grade and level of response hospitals, the questionnaire distribution, the occupation, and the technical title of respondents are summarized in [Table 1].
Table 1: Basic information and respondent demographics

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Discipline construction of respiratory care

The independent RC department was reported by 19 (21%) of 89 hospitals during the initial screening stage. After the return visit, only 3 (3%) of 89 hospitals were confirmed to have RC department. There was a significant difference in the rate of independent RC department between the results of primary screening and the return visit (χ2 = 9.64, P < 0.005).

Thirty-two hospitals did not have RTs. In the 57 (64%) of 89 hospitals with RTs, there were 26 (57%) hospitals with RTs number of 2 or less and only 6 had full-time RTs. The distribution of RTs in different grades and levels of hospitals is shown in [Table 2], and there was no significant difference in the proportion of RTs among different grades and levels of hospitals (P > 0.05). In these 57 hospitals, a survey of the number of RTs with more than 3 years of work experience showed that 30 (53%) hospitals had 1–2, 12 (21%) hospitals had 3–5, 4 (7%) hospitals had 6–9, 8 (9%) hospitals had 10 or more, and 3 (5%) hospitals had no RTs with more than 3 years working experience. The prevalence of RC technology in 89 surveyed hospitals is shown in [Figure 1].
Table 2: Comparison of the ratio of respiratory therapists with systematic training among the different grade and level hospitals (n=89)

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Figure 1: The prevalence of RC technology in 89 surveyed hospitals. RC: Respiratory care

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Perioperative lung protection in gastrointestinal surgery patients

Among 57 hospitals with RTs, perioperative patients of gastrointestinal surgery in only 9 (16%) hospitals often received help from RTs, 29 (51%) hospitals occasionally, and 19 (33%) hospitals never. The departments served by RTs and the popularization rate of preoperative and postoperative lung protection management among gastrointestinal surgical patients in 89 hospitals are summarized in [Table 3].
Table 3: The distribution of 0.82 served department, the popularization rate of preoperative and postoperative lung protection technology in gastrointestinal surgery patients in 89 hospitals

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Cognitive investigation of perioperative lung protection and respiratory care' in gastrointestinal surgeons

A total of 60 gastrointestinal surgeons were surveyed, among which 23 (38%) answered that they did not know the existence of RTs, 44 (73%) considered gastrointestinal surgery patients should receive RC, and 57 (95%) considered their hospitals should set up RC department.

The date of the most troublesome postoperative complications and the incidence rate of postoperative pulmonary infection in gastrointestinal surgery patients, the awareness of PLP and RC by gastrointestinal surgeons, as well as the resistance source on the development of RC in gastrointestinal surgeons of 89 hospitals are listed in [Table 4].
Table 4: The cognitive investigation of perioperative lung protection and respiratory care in gastrointestinal surgeons in 89 hospitals

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  Discussion Top


RC major has been introduced to China for more than 20 years, but the awareness rate is still not optimistic. Our investigation found that even well-developed tertiary and Grade A secondary hospitals in Chinese mainland have serious deficiencies in RC development, especially in the perioperative period of gastrointestinal surgery patients. The main problems included irregular discipline construction, shortage of personnel in RTs, incomplete RC technique, the inadequate implementation of PLP in gastrointestinal surgery patients, and gastrointestinal surgeons do not know much about the RC profession and technique.

In the investigation option of whether the investigated hospital had an independent RC department, we required the RC department must be independent instead of a respiratory therapy team attached to a certain department. In this option, the results of the initial screening and return visit were seriously inconsistent. Among the 157 questionnaires, 39 were confused (39/157, 28%), including 22 gastrointestinal surgeons, 8 ICU doctors, and 9 RTs. The main reasons for the difference in results were the absence of an accurate definition of the RC department and the absence of occupational classification of respiratory therapy in Mainland China at the time of the survey.

In the survey of the number of RTs, it was found that 32 (36%) of 89 hospitals did not have RTs at all, and there were only 12 (13%) of 89 hospitals with more than 6 RTs, and there was no significant advantage in the number of RTs in more advanced tertiary hospitals. In the 57 hospitals with RTs, only 6 (11%) hospitals had full-time RTs, and RTs in the other 51 hospitals (89%) were doing nursing work at the same time. Part-time RTs can only be regarded as a specialized nurse who had some RC knowledge, and the RC services they provided in hospitals were very limited. In the survey of the number of RTs with more than 3 years of work experience, 33 (58%) of the 57 hospitals with RTs had no or no more than two, which was also a serious situation. These data also objectively confirmed that both the quantity and quality of RT in Mainland China were seriously insufficient, which was mainly related to the late development of RC.

Our investigation found that even the best RC techniques used in hospitals were not well implemented in the perioperative period in gastroenterology patients, for example, high-flow oxygen therapy (65% vs. 28%), chest physiotherapy (66% vs. 51%), lung dilation therapy (43% vs. 21%), and cuff management (42% vs. 21%). This difference was mainly due to the lack of RTs and the insufficient service of RTs for gastrointestinal surgery, and of course, it was also related to the lack of understanding of RC by gastrointestinal surgeons themselves. We also found that gastrointestinal surgery patients appeared to be better educated than whole hospitals in preoperative smoking cessation (75% vs. 57%), respiratory muscle training (40% vs. 35%), physical training (44% vs. 25%), and postoperative active humidification (27% vs. 21%). However, further investigation showed that many of these measures to patients were urged by surgeons and nursing staff, which were lacked professional guidance and continuous supervision, and the implementation methods were also relatively simple. When the issues required the guidance and education by RTs, the popularity was low, for example, only in 27% of hospitals that gastroenterology patients were guided to use breathing training devices after surgery. Some more technical RC works were more difficult to be applied in the perioperative period in gastrointestinal surgery patients, such as respiratory mechanical monitoring, bedside pulmonary and diaphragm ultrasound monitoring, end-breath carbon dioxide monitoring, and vibrating screen atomization.

A retrospective cohort study[2] of more than 40,000 patients undergoing intestinal surgery found that the incidence of perioperative lung complications was about 20%, in which about 70% to 85% were pulmonary infections. Our investigation showed that pulmonary infection was also been considered the most troublesome postoperative complication by gastrointestinal surgeons in Mainland China (52/60, 87%). Although a large number of studies have confirmed that lung complications of patients in gastrointestinal surgery in perioperative can significantly be prevented by systematic RC intervention,[3],[5],[6] only small part of gastrointestinal surgery patients could get help from RTs in this investigation (9/89, 10%).

In our survey, 23 (38%) of 60 gastrointestinal surgeons knew nothing about RC specialty. Although 87% (52/60) of gastrointestinal surgeons believed that pulmonary complications were the most difficult perioperative problem for gastrointestinal surgery patients, 16 (27%) of gastrointestinal surgeons still believed that their perioperative patients did not need help from RTs. Gastrointestinal surgeons also knew little about the basic concept of RC, for example, the awareness rate of transpulmonary pressure and plateau pressure was only 8%, while the awareness rate of lung clearance treatment and lung expansion treatment was only 13% and 45%, respectively. We believed that surgeons' lack of basic RC was also one of the reasons for the insufficient treatment of PLP in gastrointestinal surgery patients.

About the investigation of resistance sources of RC development of gastrointestinal surgery, the three main reasons from high to low were insufficient attention of leaders (67%), human resources' shortage (57%), and charging too cheaply or even without related service charges (48%). In fact, the three reasons are interrelated.

Several limitations of this study have to be pointed out. The sample size from some provinces was small, which may not represent the whole situation of the province. In all the 89 hospitals, Grade A of Level III hospitals accounted for 78% (69/89), including 3 hospitals with independent RC department. However, Grade A of Level III hospitals accounted only for 12% (1442/12032) of all the public hospitals in Mainland China.[7] The true RC department setting rate in Mainland China may be far lower than the results of this study. There was a trend of centralized distribution of RTs in the interviewees, which may lead to bias.

In this investigation, we found human resources' shortage, lack of leadership attention, and charging too cheaply or even without related service charges were the greatest resistance the development of RC. In fact, the three reasons were interrelated. We should enhance the cultivation of RTs and pay more attention to PLP of gastrointestinal surgery patients to promote the patient's safety; however, the absence of credential and/or licensure and the lack of recognition of the value of RTs were deemed as the 2 key obstacles in the development of RC profession in Mainland China.[8] There is still a long way to develop RC, which requires many people to make joint efforts in discipline construction and promotion as well as more government support.

Acknowledgment

This study was supported by the Medical Innovation Project of Fujian Health Commission (2020CXA046).

Financial support and sponsorship

This study was supported by the Medical Innovation Project of Fujian Health Commission (2020CXA046).

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1

A cross-sectional survey of perioperative lung protection in gastrointestinal surgery in Mainland China

I. Investigation Objectives

Through the investigating the perioperative lung protection (PLP) situation of patients with gastrointestinal surgery in Chinese mainland, we aimed at strengthening surgeon's emphasis on PLP technology, improve perioperative lung security of gastrointestinal surgery.

II. Investigation Targets

  1. To understand the implements status of PLP in gastrointestinal surgery patients in Mainland China;
  2. To understand the awareness of PLP and respiratory therapy professionals among gastrointestinal surgeons in Mainland China;
  3. To investigate the resistance on development of PLP in Mainland China.


III. Investigation Unit

Department of Critical Care medicine, The Second Affiliated Hospital of Fujian Medical University

IV. Investigation Contacts

Liu Yuqi, chief physician, Tel: 13850772106

A cross-sectional survey of perioperative pulmonary protection in gastrointestinal surgery in Mainland China

Part 1, Basic information

1. Basic information of the adults who completed the questionnaire

  1. Name: _______________;
  2. Region (Province/city): ____________________
  3. Major:


  4. A: Gastrointestinal surgeon; B: Intensive-care physician; C: Respiratory therapist

  5. Technical Title:


A: Advanced; B: The intermediate; C: The primary

2. Basic information of the hospital in which the questionnaire was completed

  1. Name of your hospital: ________________________;
  2. Hospital level (multiple choices):


  1. Grade A of Tertiary referral hospitals
  2. Grade B of Tertiary referral hospitals
  3. Grade A of Secondary referral hospitals


Part 2, Discipline construction of RC

  1. Does your hospital have an independent respiratory therapy department? (Must be independent instead of a respiratory therapy team attached to a certain department)


    1. Yes, there are;
    2. no


  2. Does your hospital have professionals who have been systematically trained in respiratory therapy?


    1. Yes, there are;
    2. no


  3. If there are respiratory therapists (RTs), which department are they affiliated to?


    1. Respiratory therapy Department;
    2. Intensive care;
    3. Respiratory department;
    4. The emergency department


  4. If there are full-time RTs, the number is _____________;


  5. Among them - have over 3 years of work experience. (Please fill in Arabic numerals or 0 if not).

  6. Respiratory care (RC) projects carried out by RTs in the whole hospital


(It is recommended to ask a respiratory therapist to assist you in completing this form, if there is no respiratory therapy practitioner, it is not necessary to complete this form):

  • Ventilator maintenance and care
  • High-flow oxygen therapy
  • Chest physiotherapy
  • Lung dilation therapy
  • Quit smoking education
  • Respiratory mechanical monitoring
  • Lower limb barometric therapy
  • Cuff management
  • Transfer ventilator
  • Bedside pulmonary ultrasound monitoring
  • Respiratory muscle training
  • In-hospital transport of critically ill patients
  • Ventilator double heating line
  • End-breath carbon dioxide monitoring
  • Physiotherapy (upper and lower limbs)
  • Feeding type active humidification
  • Vibrating screen atomization
  • Esophageal pressure monitoring
  • Medium and short-wave therapy
  • Diaphragm ultrasonic


Part 3, PLP in gastrointestinal surgery patients

  1. Do you think gastrointestinal surgery patients in your hospital can receive regular guidance and help from RTs?


    1. Yes, there are;
    2. Occasionally.
    3. no


  2. which guidance did gastrointestinal surgery patients in your hospital receive before surgery? (Multiple options):


    • Smoking cessation health education;
    • Physical training.
    • Lung function examination;
    • Respiratory muscle training;
    • Hardly anything


  3. Which guidance did gastrointestinal surgery patients in your hospital receive after surgery? (Multiple options):


  • Directed cough;
  • Early postoperative bed activity;
  • Family member-assisted back patting instruction;
  • Guidance on the use of breathing training equipment;
  • Active humidification;
  • High-flow oxygen therapy;
  • Cuff management;
  • Sputum postural drainage
  • Lung dilation treatment;
  • Hardly anything


Part 4, Cognitive investigation of PLP in gastrointestinal surgeons

(Answer by Gastrointestinal surgeons)

  1. Have you ever heard of the occupation of respiratory therapist before?


    1. yes;
    2. no.


  2. What do you think is the most troublesome problem of surgical complications?


    1. Lung infection;
    2. Urinary tract infection;
    3. Liquid imbalance;
    4. Cardiac insufficiency;
    5. Malnutrition


  3. What is the proportion of postoperative pulmonary infection in gastrointestinal surgery patients in your department?


    1. Less than 10%;
    2. Between 10% and 20%.
    3. between 20% and 30%;
    4. Between 30% and 40%;
    5. More than 40%


  4. As a gastrointestinal surgeon, which of the following respiratory therapy concepts are quite clear to you? (Multiple options):


    • Active and passive humidification;
    • High-flow oxygen therapy and low-flow oxygen therapy;
    • Lung dilation treatment;
    • Lung clearance treatment;
    • Atomization therapy
    • Cross-lung pressure and plateau pressure
    • Do you think it is necessary to set up a respiratory treatment department?


    1. yes;
    2. No.


  5. Do you think it is necessary to have RTs in your department?


    1. yes;
    2. No.


  6. What do you think are the barriers to develop RC in your department?


  1. Shortage of human resources;
  2. Charging too cheaply or even without related service charges
  3. Insufficient attention of leaders;
  4. It's not necessary


Thank you for taking time out of your busy schedule to fill in this questionnaire.



 
  References Top

1.
Lawrence VA, Cornell JE, Smetana GW, American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: Systematic review for the American college of physicians. Ann Intern Med 2006;144:596-608.  Back to cited text no. 1
    
2.
Gajic O, Frutos-Vivar F, Esteban A, Hubmayr RD, Anzueto A. Ventilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated patients. Intensive Care Med 2005;31:922-6.  Back to cited text no. 2
    
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Fleisher LA, Linde-Zwirble WT. Incidence, outcome, and attributable resource use associated with pulmonary and cardiac complications after major small and large bowel procedures. Perioper Med (Lond) 2014;3:7.  Back to cited text no. 3
    
4.
Warner MA, Offord KP, Warner ME, Lennon RL, Conover MA, Jansson-Schumacher U. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: A blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 1989;64:609-16.  Back to cited text no. 4
    
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Smetana GW. Preoperative pulmonary evaluation: Identifying and reducing risks for pulmonary complications. Cleve Clin J Med 2006;73 Suppl 1:S36-41.  Back to cited text no. 5
    
6.
Smetana GW. Postoperative pulmonary complications: An update on risk assessment and reduction. Cleve Clin J Med 2009;76 Suppl 4:S60-5.  Back to cited text no. 6
    
7.
Statistical Bulletin on the Development of Health Career in China in 2018. National Health Promotion Committee. China; 2019.  Back to cited text no. 7
    
8.
Li J, Ni Y, Tu M, Ni J, Ge H, Shi Y, et al. Respiratory care education and clinical practice in mainland China. Respir Care 2018;63:1239-45.  Back to cited text no. 8
    


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