The five panelists allocated to the abdominal surgery panel were from Australia, Canada, Sweden and South Africa and included four physiotherapists and a trauma surgeon. The draft statements were edited and five additional statements were formulated (Table ).
In Category A: the panel agreed after the second round that it is essential to position the patient in a stable, supported upright sitting position and teach the patient to huff/cough with wound support as soon as possible following surgery. The panel agreed on the rating of all the statements in this category (4/4) after the third round.
The importance of coughing is supported by strong evidence from the systematic reviews [12
]. However the panel went further and decided it would be essential also to include management strategies to ensure effective secretion removal. These strategies are based on the collective clinical experience of this group. It includes positioning the patient out of bed and using interventions such as deep breathing, positive expiratory pressure (PEP), high-pressure PEP and CPAP in combination with forced expiration technique (or adjusted autogenic drainage). If these approaches failed, the inclusion of suctioning was rated as very important.
In Category B: two additional statements were formulated, and the structure of two statements was edited based on feedback from the panel. The structural editions of statements were related to being less prescriptive for example "Initiate mobilization when patient is presenting stable blood pressure and heart rate with less than 8/10 rating on pain scale at rest" was changed to "Perform a clinical evaluation of pain level". The panel agreed that prophylactic physiotherapy intervention following abdominal surgery was essential, but that the choice of intervention could either be mobilization or breathing exercises, but does not need to include both options.
The Delphi panel agreed that early directed mobilization was the first management option to consider. This choice is supported by the literature [16
] and in line with the accepted physiological benefit of being up and mobile [24
]. The panel chose to rate both the intensity and frequency of a mobilization protocol as essential to the effectiveness of a management algorithm. This is an interesting result, since few studies have been undertaken that examine the effectiveness of mobilization as a therapeutic option for reducing PPC's. Although one study reported that time spent upright in patients after abdominal surgery was low at an average total of three minutes on the first postoperative day [26
]. It is possible that this result and results from other patient populations may be influencing this panel consensus. There is a growing body of evidence that early mobility influences outcome in general ICU [27
] and randomized trials supporting the role of mobilization after cardiac surgery [30
]. Further research is needed to support the views of the panel in relation to mobilization practices in an abdominal surgical population.
In Category C:
three additional statements were formulated and the content and structure of the remaining statement was edited. The statements that were added were related to the frequency of breathing exercises and the indication of which breathing techniques to include. The structural change to the one statement was to direct breathing exercise preference. The panel reached consensus on the rating of all statements after the third round. Prescribing frequent breathing exercises was the only statement rated essential in this category. While the evidence suggests that there is no difference in the effectiveness of the type of breathing exercises used to prevent PPC's in this population [12
], the panel agreed to include a hierarchy of breathing methods into the algorithm. The GRADE system [31
] whereby the potential benefit (outcome) is weighed against the burden (financial and time related) of application and potential harm was used as a basis for the hierarchy. This hierarchy can be used as a guide by clinicians when choosing a breathing exercise. Deep breathing exercises (DBE)-using pursed lips breathing or inspiratory hold-was the first choice expressed through this Delphi process [32
]. This technique is not therapist or device dependent and was therefore accepted as the first choice.
The second choice agreed by the panel was positive expiratory pressure (PEP) by mask or bottle. This method is routinely used in the Nordic countries, and has been evaluated in several settings [10
]. While the PEP mask is costly and not always available, the same effect can be achieved with a blow-bottle technique and is thus regarded as a cheaper alternative of the PEP mask. The least likely choice is incentive spirometry (IS) [18
] followed by intermittent positive pressure breathing (IPPB). Both these techniques are dependent on specialized equipment and therefore costly to the patient. Two systematic reviews reported no added benefit to deep breathing exercises [13
]. In addition, IPPB would be the last choice because abdominal distention has been reported as potentially harmful and the technique is therapist dependent [14
Thirdly, the panel agreed that it is essential that the breathing exercises which are prescribed should be performed frequently. This decision is based on the clinical experience of this expert panel as no studies were identified through this process which could inform on the frequency of breathing exercises in this population. Studies investigating other populations, as well as the short-lived physiological effect of breathing exercises, could have influenced this panel's judgment [36
Finally, based on the literature, this Delphi panel was in accord that continuous positive airway pressure (CPAP) was useful as an adjunct to deep breathing exercises and as a preventative strategy in reducing complications [37
]. In the presence of persistent hypoxaemia which is unresponsive to first line physiotherapy management, there is moderate quality evidence to suggest that CPAP intervention will reduce the risk of PPC's [37
In Category D, two statements were reformulated into a single statement; while one statement was reformulated into two separate statements. The importance of the clinical judgment of the therapist in initiating mobilization is highlighted by the fact that the panel did not rate the inclusion of specific criteria as essential to the success of the algorithm. The two criteria that were rated as very important-the assessment of motor block in patients receiving epidural analgesia and the evaluation of pulmonary reserve-could guide this clinical decision. The panel rated the inclusion of active dorsiflexion while in bed as unimportant.