Incentive spirometry with expiratory positive airway pressure reduces pulmonary complications, improves pulmonary function and 6-minute walk distance in patients undergoing coronary artery bypass graft surgery

Effect of Positive Expiratory Pressure Therapy on Lung Volumes and Health Outcomes in Adults With Chest Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The purposes of this study were to evaluate the effect of positive expiratory pressure (PEP) therapy on lung volumes and health outcomes in adults with chest trauma and to investigate any adverse effects and optimal dosages leading to the greatest positive impact on lung volumes and recovery.

METHODS

Data sources were MEDLINE/PubMed, Embase, Cochrane Library, Physiotherapy Evidence Database, CINAHL, Open Access Thesis/Dissertations, EBSCO Open Dissertations, and OpenSIGLE/Open Grey. Randomized controlled trials investigating PEP therapy compared with usual care or other physical therapist interventions were included. Participants were >18 years old and who were admitted to the hospital with any form of chest trauma, including lung or cardiac surgery, blunt chest trauma, and rib fractures. Methodological quality was assessed using the Physiotherapy Evidence Database Scale, and the level of evidence was downgraded using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Eleven studies involving 661 participants met inclusion eligibility. There was very low-level evidence that PEP improved forced vital capacity (standardized mean difference = -0.50; 95% CI = -0.79 to -0.21), forced expiratory volume in 1 second (standardized mean difference = -0.38; 95% CI = -0.62 to -0.13), and reduced the incidence of pneumonia (relative risk = 0.16; 95% CI = 0.03 to 0.85). Respiratory muscle strength also significantly improved in all 3 studies reporting this outcome. There was very low-level evidence that PEP did not improve other lung function measures, arterial blood gases, atelectasis, or hospital length of stay. Both PEP devices and dosages varied among the studies, and no adverse events were reported.

CONCLUSION

PEP therapy is a safe intervention with very low-level evidence showing improvements in forced vital capacity, forced expiratory volume in 1 second, respiratory muscle strength, and incidence of pneumonia. It does not improve arterial blood gases, atelectasis, or hospital length of stay. Because the evidence is very low level, more rigorous physiological and dose-response studies are required to understand the true impact of PEP on the lungs after chest trauma.

IMPACT

There is currently no strong evidence for physical therapists to routinely use PEP devices following chest trauma. However, there is no evidence of adverse events; therefore, in specific clinical situations, PEP therapy may be considered.

Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis

To determine the effect of inspiratory muscle training (IMT) on pulmonary function, respiratory muscle strength (RMS), and functional capacity in patients undergoing cardiac surgery. The PubMed, PEDro, CINAHL, Web of Science, CENTRAL, and EMBASE databases were searched from inception to June 2020. Randomized controlled trials (RCTs) that evaluated patients who underwent cardiac surgery were included in this review. Meta-analysis performed using a random-effects model showed that the mean difference in forced vital capacity, forced expiratory volume in 1 second, 6-minute walk distance, and RMS was 3.47% (95% confidence interval [CI], 0.57 to 6.36), 5.80% (95% CI, 2.03 to 9.56), 78.05 m (95% CI, 60.92 to 95.18), and 4.8 cmH2O (95% CI, -4.00 to 13.4), respectively. There is strong evidence that IMT improves inspiratory muscle strength, pulmonary function, and functional capacity, and reduces the length of hospital stay in patients undergoing cardiac surgery.

Effect of a Breathing Exercise on Respiratory Function and 6-Minute Walking Distance in Patients Under Hemodialysis: A Randomized Controlled Trial

BACKGROUND

Pulmonary disorders and poor functional capacity are common complications in patients under hemodialysis. Although breathing exercise is frequently prescribed to improve respiratory function, its efficacy in this patient community is not well established.

PURPOSE

Our study was designed to determine the effectiveness of a breathing exercise on respiratory function and 6-minute walk (6MW) distance in patients under hemodialysis.

METHODS

A randomized controlled trial approach was used. The sample consisted of 52 patients under hemodialysis from a university teaching hospital in Iran. The experimental group (n = 26) received the breathing exercise program and was encouraged to perform incentive spirometry for 2 months. The control group (n = 26) received only routine hospital care. The respiratory function test and 6MW test were performed at baseline and at 2 months after the intervention (posttest).

RESULTS

The two groups were homogeneous in terms of respiratory function parameters, 6MW distance, and demographic characteristics at baseline. Forced expiratory volume in 1 second and forced vital capacity were significantly better in the experimental group compared with the control group at 2 months after intervention. No significant difference was found in 6MW distance between the groups at the 2-month posttest.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The 2-month breathing exercise effectively improved pulmonary function parameters (forced vital capacity, forced expiratory volume in 1 second) in patients under hemodialysis but did not affect 6MW distance. Hemodialysis nurses should strengthen their clinical health education and apply breathing exercise programs to reduce the pulmonary complications experienced by patients under hemodialysis.

Positive expiratory pressure in postoperative cardiac patients in intensive care: A randomized controlled trial

OBJECTIVE

To evaluate effectiveness of positive expiratory pressure blow-bottle device compared to expiratory positive airway pressure and conventional physiotherapy on pulmonary function in postoperative cardiac surgery patients in intensive care unit.

DESIGN

A randomized controlled trial.

SETTINGS

Tertiary care.

SUBJECTS

48 patients (16 in each group; aged 64.5 ± 9.1 years, 38 male) submitted to cardiac surgery.

INTERVENTIONS

Patients were randomized into conventional physiotherapy (G1), positive expiratory pressure blow-bottle device (G2) or expiratory positive airway pressure, both associated with conventional physiotherapy (G3). G2 and G3 performed three sets of 10 repetitions in each session for each technique.

MAIN MEASURES

Pulmonary function (primary); respiratory muscle strength, radiological changes, pulmonary complications, length of intensive care unit and hospital stay (secondary) assessed preoperatively and on the 3rd postoperative day.

RESULTS

Pulmonary function (except for forced expiratory volume in one second/ forced vital capacity % predicted) and respiratory muscle strength showed significant reduction from the preoperative to the 3rd postoperative in all groups (P < 0.001), with no difference between groups (P > 0.05). Regarding radiological changes, length of intensive care unit stay and length of hospital stay, there was no significant difference between groups (P > 0.05).

CONCLUSION

Both positive expiratory pressure techniques associated with conventional physiotherapy were similar, but there was no difference regarding the use of positive expiratory pressure compared to conventional physiotherapy.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03639974.https://clinicaltrials.gov/ct2/show/NCT03639974.

Comparison the Effect of Active Cyclic Breathing Technique and Routine Chest Physiotherapy on Pain and Respiratory Parameters After Coronary Artery Graft Surgery: A Randomized Clinical Trial

Background

There are limited reports available on preferred chest physiotherapy methods in patients with coronary artery graft (CABG) surgery.

Objectives

The aim of this study was to compare the effect of active cyclic breathing technique (ACBT) and routine chest physiotherapy on pain and respiratory parameters in patients undergoing CABG surgery.

Methods

This randomized clinical trial was carried out from July to November 2018. Seventy patients were selected randomly after CABG according to inclusion criteria and then assigned in two groups (35 in ACBT and 35 in routine physiotherapy) by random minimization method. The arterial blood gas levels, pain, heart rate, and respiratory rate were measured for both groups before and after the intervention on two consecutive days after surgery. Data were analyzed by SPSS software V.22, at a significance level of 0.05.

Results

The two groups were similar in terms of demographic variables. In within group comparison in the physiotherapy group, the level of PaO₂, HR, RR, and pain increased significantly on both days (P = 0.001), SaO₂ on the first day (P = 0.005) and second day (P = 0.001), and PaCO₂ on the first day (P = 0.02). In ACBT group, the level of SaO₂, HR, RR, and pain increased significantly on both days (P = 0.001), HCO₃ on the first day (P = 0.021), and PaO₂ on the second day (P = 0.001) post intervention. In between group comparison, on the first day, the level of PH (P = 0.034), and on the second day HCO₃ (P = 0.032) decreased, while RR (P = 0.011) increased significantly in the physiotherapy group, at post-intervention phase.

Conclusions

ACBT and routine physiotherapy had similar effects on arterial oxygenation, HR, and pain perception following CABG surgery. The physiotherapy on the second day increased the RR to an abnormal range.

Myofascial release in patients during the early postoperative period after revascularisation of coronary arteries

Purpose: The evaluation of the impact of soft tissue manual therapy with a myofascial release on pulmonary function, postoperative pain, fatigue, breathing difficulties and physical fitness, in patients during the early postoperative period after coronary artery bypass grafting and off-pump coronary artery bypass grafting surgery.Materials and methods: The study included 80 subjects (59 males) with an average age of 64.13 years old. They were randomised into two groups: group I (n = 40) received a conventional form of rehabilitation and group II (n = 40) additionally, from day 3 to day 6 post-surgery, was provided the Carol Manheim form of myofascial release. Subjects were evaluated three times: before the surgery, on day 4 and 6 post-surgery. Using the visual analogue scale, the following symptoms were measured: pain intensity, breathing difficulties and level of physical endurance. Fatigue after performing physical exercises was measured using the Borg scale. Spirometry was used to measure the one-second forced expiratory volume and forced vital capacity.Results: Positive changes were observed in both groups with regard to all analysed variables. However, group II compared to group I showed a significantly greater improvement (p < 0.05; the Mann-Whitney U test) in relation to: pain intensity on day 4 (mean 5.46 vs 6.58) and on day 6 (mean 3.05 vs 5.35) after the surgery; lower breathing difficulties on day 6 post-surgery (mean 4.08 vs 5.63); limiting physical fitness on day 6 post-surgery (mean 6.35 vs 5.13). Between the condition prior to the surgery and day 6 post-surgery in group II compared to group I, there was a significantly smaller (p < 0.05; Student's t-test) decrease in one-second forced expiratory volume (mean -0.65 vs -0.9 L/s) and the volume of forced vital capacity (mean -0.63 vs -1.33 L). Between day 4 and 6 post-surgery in group II compared to group I, there was a significantly higher (p < 0.05; Student's t-test) increase in the one-second forced expiratory volume (mean 0.21 vs 0.11 L/s) and forced vital capacity (mean 0.32 vs 0.12 L).Conclusions: Implementing myofascial release techniques in the conventional form of cardiosurgical rehabilitation might enhance the improvement in pulmonary function, lessen breathing difficulties, pain intensity and fatigue, it might augment the increase in physical endurance among patients during the early postoperative period after coronary artery bypass grafting and off-pump coronary artery bypass grafting surgery.Implications for rehabilitationThe implementation of myofascial release techniques in conventional cardiac rehabilitation may improve the pulmonary function in patients during the early postoperative period, after revascularisation of coronary arteries.The adoption of myofascial release techniques in conventional cardiac rehabilitation may decrease breathing difficulties, pain intensity, fatigue and increase the physical fitness in patients during the early postoperative period, after the revascularisation of the coronary arteries.The implementation of myofascial release techniques in conventional cardiac rehabilitation may enhance patients' improvement during the early postoperative period, after the revascularisation of the coronary arteries.

Acute effects of three pulmonary reexpansion modalities on thoracoabdominal motion of healthy subjects: Randomized crossover study

BACKGROUND

Chest physiotherapy can be an alternative to increase lung volumes through pulmonary expansion therapies, but there is still inconsistency in the literature in order to determine which device can promote a greater volume increase at the expense of a better ventilatory pattern. Therefore, the aim of this study was to evaluate and compare the chest wall kinematics of healthy subjects submitted to the use of three different devices for pulmonary reexpansion.

METHODS

Chest wall compartmental and operational volumes, breathing pattern and thoracoabdominal asynchrony were evaluated in 12 healthy individuals through optoelectronic plethysmography during quiet breathing, pulmonary reexpansion and recovery. Three different devices (volume-oriented incentive spirometer-IS-v; positive expiratory pressure-PEP; and incentive spirometer volume and pressure oriented-IS-vp) were administered in a random order with at least 48h between the devices.

RESULTS

A greater volume variation in the chest wall and its compartments was observed when the IS-vp was used in comparison with the other devices (p<0.05). Furthermore, the IS-vp mobilizes a greater amount of volume accompanied by greater synchronism between the compartments when compared to IS-v (p <0.05).

CONCLUSION

The IS-vp may be able to increase total and compartmental chest wall volumes, as well as improve synchrony among compartments when compared to IS-v and PEP devices, thus constituting an important tool for treating patients with restrictive ventilatory pattern.

Potential benefits of incentive spirometry following a rib fracture: a propensity score analysis

CLINICIAN'S CAPSULEWhat is known about the topic?Literature regarding the impact of incentive spirometry on patients with rib fractures is unclear; there are no recommendations for its use in the emergency department (ED).What did this study ask?The objective of this study was to assess the impact of incentive spirometry on delayed complications in patients with rib fractures in the ED.What did this study find?Unsupervised incentive spirometry use does not have a protective effect against delayed pulmonary complications after a rib fracture.Why does this study matter to clinicians?Clear guidelines for incentive spirometry use for patients with rib fractures and further research to assess its usefulness in other ED populations are needed.

A Randomized Study Comparing the Incidence of Postoperative Pain After Phrenic Nerve Infiltration Vs Nonphrenic Nerve Infiltration During Thoracotomy

Thoracotomy is a common surgical procedure performed worldwide for lung disease. Despite major advances in analgesia, patients still experience severe shoulder, central back and surgical incision site pain in the postoperative period. This study aimed to assess whether intraoperative phrenic nerve infiltration reduces the incidence of postoperative pain and improves peak flow volume measurements during incentive spirometry. 90 patients undergoing open lobectomy were randomly assigned to have phrenic nerve infiltration (n = 46) or not (n = 44). The phrenic nerve infiltration group received 10 mL of 0.25% bupivacaine into the periphrenic fat pad. Preoperative assessments of spirometry and pain scores were recorded (at rest and with movement). Postoperative assessments included peak flow and pain measurements at intervals up to 72 hours. Less shoulder pain was experienced with phrenic nerve infiltration up to 6 hours postsurgery at rest (P = 0.005) and up to 12 hours with movement (P < 0.001). Reduced back pain was reported in the phrenic nerve infiltration group up to 6 hours after surgery both at rest (P = 0.001) and with movement (P = 0.00). Phrenic nerve infiltration reduced pain at the incision site for up to 3 hours both at rest (P < 0.001) and with movement (P = 0.001). Spirometry readings dropped in both groups with consistently lower readings at baseline and follow-up in the PNI group (P = 0.007). Lower analgesic usage of patient controlled analgesia morphine (P < 0.0001), epipleural bupivacaine (P = 0.001), and oramorph/zomorph (P = 0.0002) were recorded. Our findings indicate that the use of phrenic nerve infiltration significantly reduced patient pain scores during the early postoperative period, particularly during movement. We believe that each technique has advantages and disadvantages; however, further studies with large sample size are warranted.

Physiotherapy mobility and walking management of uncomplicated coronary artery bypass graft (CABG) surgery patients: a survey of clinicians' perspectives in Australia and New Zealand

Background: This study aimed to determine current mobility and walking management by physiotherapists of patients undergoing coronary artery bypass graft (CABG) surgery, the clinical milestones expected and physiotherapists' perception of the severity of pain experienced by patients after surgery. Design: Cross sectional study using a questionnaire. Methods: All hospitals in Australia and New Zealand that perform cardiac surgery (n = 54) were invited to complete a questionnaire. Findings: Forty-one questionnaires were returned and analysed (response rate 76%). Walking distance was a clinical milestone after CABG surgery. Walking and transferring patients from bed to chair required the most time of physiotherapists during one treatment session. Physiotherapists perceived that patients experienced most pain on day one after surgery [mean (SD)] visual analogue scale (VAS) 41 (16) mm and this reduced by day four to VAS 15 (10) mm. Patients' pain was perceived to be significantly higher after physiotherapy sessions compared with before (p < 0.01). Thirty-seven respondents (90%) believed that patients' pain was well managed for physiotherapy treatments. A majority of the respondents (68%) believed that pain was not a limiting factor in the distance patients walked in a physiotherapy session and most (90%) believed that general fatigue limited walk distance. Conclusion: This research provides current mobility and walking management by physiotherapists of patients undergoing CABG surgery in Australia and New Zealand.

The effect of pleasant olfactory mental imagery on the incidence and extent of atelectasis in patients after open heart surgery

BACKGROUND AND PURPOSE

Atelectasis is the most common pulmonary complication after open heart surgery. This study was intended to examine the effects of pleasant olfactory mental imagery on postoperative atelectasis in patients undergoing open heart surgery.

MATERIALS AND METHODS

This is a randomized controlled clinical trial. The sample consisted of 80 patients who were randomly assigned to either practice olfactory mental imagery (test group) or receive routine care (control group). A card with the image of roses was given to patients and they were asked to look at the image, visualize the scent of roses in the mind, and then sniff as much as possible, hold their breath for 2s and eventually exhale slowly through the nose. This procedure was consecutively repeated five times. After a fifteen-minute break, patients proceeded to practice olfactory mental imagery with other fruit images (banana, apple, and lemon). The test group executed the olfactory mental imagery for two hours in the morning and two hours in the afternoon on postoperative days 1 and 2. The control group received the routine ICU care. A questionnaire collected information on sociodemographic characteristics and clinical parameters. Chest radiographs were used to diagnose atelectasis, which were evaluated by the hospital radiologist.

RESULTS

No statistically significant differences were observed between the two groups regarding sociodemographic, medical and surgical information. The incidence of atelectasis in the test group (40%, n=16) was significantly lower than in the control group (67.5%, n=27) on postoperative day 2 (p=0.02).

CONCLUSION

Our findings suggest that olfactory mental imagery can improve respiratory function and reduce the risk of atelectasis in patients with cardiac surgery.

Effects of pleasant olfactory mental imagery on the arterial oxygenation in patients with open heart surgery: A randomized controlled trial

BACKGROUND AND PURPOSE

Arterial hypoxemia is one of the most common respiratory complications following cardiac surgery. This study was intended to examine the effects of pleasant olfactory mental imagery on postoperative hypoxemia in patients undergoing open heart surgery.

MATERIALS AND METHODS

This is a randomized controlled clinical trial. The sample consisted of 80 patients who were randomly assigned to either practice olfactory mental imagery (experimental group) or receive routine care (control group). A card with the image of roses was given to patients and they were asked to look at the image, visualize the scent of roses in the mind, and then sniff as much as possible, hold their breath for 2 s and eventually exhale slowly through the nose. This procedure was consecutively repeated five times. After a fifteen-minute break, patients proceeded to practice olfactory mental imagery with other fruit images. The experimental group executed the olfactory mental imagery for two hours in the morning and two hours in the afternoon on postoperative days 1 and 2.

RESULTS

No statistically significant differences were observed between the experimental and control groups regarding sociodemographic characteristics, medical and surgical information. This study also demonstrated that the mean Spao2 was significantly higher in the experimental group (97.400 ± 1.70) than the control group (96.465 ± 1.70) (p = 0.015).

CONCLUSION

The results of this study suggest that olfactory mental imagery can improve arterial oxygenation in patients with cardiac surgery.

Cardiothoracic Critical Care

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.

Methodological Quality of Randomized Clinical Trials of Respiratory Physiotherapy in Coronary Artery Bypass Grafting Patients in the Intensive Care Unit: a Systematic Review

OBJECTIVE

To assess methodological quality of the randomized controlled trials of physiotherapy in patients undergoing coronary artery bypass grafting in the intensive care unit.

METHODS

The studies published until May 2015, in MEDLINE, Cochrane and PEDro were included. The primary outcome extracted was proper filling of the Cochrane Collaboration's tool's items and the secondary was suitability to the requirements of the CONSORT Statement and its extension.

RESULTS

From 807 studies identified, 39 were included. Most at CONSORT items showed a better adequacy after the statement's publication. Studies with positive outcomes presented better methodological quality.

CONCLUSION

The methodological quality of the studies has been improving over the years. However, many aspects can still be better designed.

Positive expiratory pressure - Common clinical applications and physiological effects

Breathing out against resistance, in order to achieve positive expiratory pressure (PEP), is applied by many patient groups. Pursed lips breathing and a variety of devices can be used to create the resistance giving the increased expiratory pressure. Effects on pulmonary outcomes have been discussed in several publications, but the expected underlying physiology of the effect is seldom discussed. The aim of this article is to describe the purpose, performance, clinical application and underlying physiology of PEP when it is used to increase lung volumes, decrease hyperinflation or improve airway clearance. In clinical practice, the instruction how to use an expiratory resistance is of major importance since it varies. Different breathing patterns during PEP increase or reduce expiratory flow, result in movement of EPP centrally or peripherally and can increase or decrease lung volume. It is therefore necessary to give the right instructions to obtain the desired effects. As the different PEP techniques are being used by diverse patient groups it is not possible to give standard instructions. Based on the information given in this article the instructions have to be adjusted to give the optimal effect. There is no consensus regarding optimal treatment frequency and number of cycles included in each treatment session and must also be individualized. In future research, more precise descriptions are needed about physiological aims and specific instructions of how the treatments have been performed to assure as good treatment quality as possible and to be able to evaluate and compare treatment effects.

Incentive spirometry combined with expiratory positive airway pressure improves asthma control and quality of life in asthma: a randomised controlled trial

OBJECTIVES

The use of the incentive spirometer (IS) and expiratory positive airway pressure (EPAP) provides several benefits in patients with respiratory disorders. However, the effects of the use of these devices coupled (IS + EPAP) are still unknown in asthmatic patients. The aim of this study was to evaluate the effect of IS associated with EPAP on exercise tolerance (six-minute walk test - 6MWT), lung function (by spirometry), asthma control (Asthma Control Questionnaire - ACQ) and quality of life (Asthma Quality of Life Questionnaire - AQLQ) in patients with severe asthma.

METHODS

Patients were randomised into two groups: IS + EPAP (n = 8) and control (n = 6). The IS + EPAP group performed breathing exercises at home, twice daily for 20 min, over a period of 5 weeks.

RESULTS

There was no significant difference in spirometric variables and in the distance walked in the 6MWT in both groups. However, the IS + EPAP group showed an improvement in asthma control (p = 0.002) and quality of life (p = 0.02).

CONCLUSIONS

These findings demonstrate that the IS + EPAP protocol, when performed at home, provides an improvement in asthma control and quality of life for patients with severe asthma when evaluated by ACQ and AQLQ, respectively.

Center-level variation in infection rates after coronary artery bypass grafting

BACKGROUND

Health-care-acquired infections (HAIs) are a leading cause of morbidity and mortality after cardiac surgery. Prior work has identified several patient-related risk factors associated with HAIs. We hypothesized that rates of HAIs would differ across institutions, in part attributed to differences in case mix.

METHODS AND RESULTS

We analyzed 20 896 patients undergoing isolated coronary artery bypass grafting surgery at 33 medical centers in Michigan between January 1, 2009, and June 30, 2012. Overall HAIs included pneumonia, sepsis/septicemia, and surgical site infections, including deep sternal wound, thoracotomy, and harvest/cannulation site infections. We excluded patients presenting with endocarditis. Predicted rates of HAIs were estimated using multivariable logistic regression. Overall rate of HAI was 5.1% (1071 of 20 896; isolated pneumonia, 3.1% [n=644]; isolated sepsis/septicemia, 0.5% [n=99]; isolated deep sternal wound infection, 0.5% [n=96]; isolated harvest/cannulation site, 0.5% [n=97]; isolated thoracotomy, 0.02% [n=5]; multiple infections, 0.6% [n=130]). HAI subtypes differed across strata of center-level HAI rates. Although predicted risk of HAI differed in absolute terms by 2.8% across centers (3.9-6.7%; min:max), observed rates varied by 18.2% (0.9-19.1%).

CONCLUSIONS

There was a 18.2% difference in observed HAI rates across medical centers among patients undergoing isolated coronary artery bypass grafting surgery. This variability could not be explained by patient case mix. Future work should focus on the impact of other factors (eg, organizational and systems of clinical care) on risk of HAIs.

Efeitos da aplicação da EPAP (Expiratory Positive Airway Pressure) sobre a tolerância ao esforço em pacientes portadores de insuficiência cardíaca

INTRODUÇÃO: Novas abordagens terapêuticas que objetivam melhorar a sensação de dispneia e fadiga em pacientes com insuficiência cardíaca, como a aplicação de pressão positiva expiratória nas vias aéreas (EPAP), podem ser aplicadas na tentativa de melhorar a capacidade funcional e a qualidade de vida. OBJETIVO: Avaliar os efeitos da utilização da EPAP ( Expiratory Positive Airway Pressure) durante o esforço em indivíduos portadores de IC classe funcional II e III (NYHA). MÉTODOS: Dos 390 pacientes, foram selecionados 28 com FEVE < 40%. O Teste de Caminhada de seis minutos (TC6') foi realizado três vezes: o primeiro para a familiarização, um com a máscara e o outro sem a máscara de EPAP, sendo válido os dois últimos. A comparação entre os dados obtidos foi realizada por meio de teste t de Student pareado ou teste de Wilcoxon, conforme a normalidade dos dados. RESULTADOS: a percepção de esforço foi maior após a caminhada com a utilização da máscara quando comparado na ausência da máscara. Houve elevação significativa na saturação de oxigênio quando os pacientes estavam usando a máscara de EPAP. CONCLUSÃO: O uso da máscara de EPAP aumenta a percepção de esforço e o trabalho ventilatório, porém, não aumentou a distância percorrida no TC6, sendo sua aplicabilidade questionável em programas de reabilitação cardiovascular.

Use of positive expiratory pressure during six minute walk test: results in patients with moderate to severe chronic obstructive pulmonary disease

Background

The six-minute walk test (6MWT) is widely used because it is both simple and reliable as a measure of exercise capacity. Individuals with chronic obstructive pulmonary disease (COPD) usually show a limited capacity to perform exercise.

Methods

Our study is a prospective, randomized controlled trial which uses the 6MWT in one hundred consecutive in and out- patients with moderate to severe COPD to assess the benefit of a simple positive expiratory pressure (PEP) device. PEP device consisted of a PEP valve 5 cmH₂O connected to 1-meter tube and a mouthpiece. All the enrolled patients performed a 6MWT before randomization. The following day PEP group patients performed the 6MWT using PEP device. Control group patients performed the 6MWT without this device. The primary outcome was the difference in distance (meters) walked.

Results

Functional capacity assessed by the distance covered during 6MWT improved in the PEP group more than in the control group. The difference was statistically significant (p < 0.001).Oxygen saturation improved to a statistically significant level during 6MWT (p < 0.01). Heart rate was also reduced (p < 0.03).

Conclusions

There are few studies demonstrating that PEP devices enhance exercise capacity in COPD patients. Our results has been obtained using only a low positive expiratory pressure (5 cmH₂O). In our opinion the strength of this study is the simplicity and the lower cost when compared to other devices and approaches. The study was registered as Chi CTR-ORC-12002173 at http://www.chictr.org.

Does the mode of exercise influence recovery of functional capacity in the early postoperative period after coronary artery bypass graft surgery? A randomized controlled trial

OBJECTIVES

The purpose of this study was to compare the effectiveness of moderate-intensity stationary cycling and walking exercise programmes in the early postoperative period after first-time coronary artery bypass graft surgery.

METHODS

In this prospective trial, 64 patients (57 men, 7 women, mean age = 66 ± 9 years) performed twice daily, moderate-intensity exercise sessions, of 10-min duration, from postoperative day 3 until discharge from hospital. Patients were randomly assigned to stationary cycling or walking exercise intervention groups. Preoperative and discharge functional exercise capacity and health-related quality of life were assessed using 6-min walk and cycle assessments and the SF-36 version 2.0 questionnaire. Compliance with exercise was calculated as the proportion of scheduled exercise sessions completed.

RESULTS

There were no significant differences between intervention groups at hospital discharge for 6-min walk distance (cyclists: 402 ± 93 m vs walkers: 417 ± 86 m, P = 0.803), 6-min cycle work (cyclists: 15.0 ± 6.4 kJ vs walkers: 14.0 ± 6.3 kJ, P = 0.798) or health-related quality of life. There was no significant difference between intervention groups for postoperative length of hospital stay (P = 0.335). Compliance rates for intervention groups were cyclists: 185/246 (75%) scheduled exercise sessions completed vs walkers: 199/242 (82%) scheduled exercise sessions completed (P = 0.162).

CONCLUSIONS

Stationary cycling provides a well-tolerated and clinically effective alternative to walking in the early postoperative period after coronary artery bypass graft surgery. The optimal frequency, intensity and duration of exercise in the early postoperative period require further investigation. (Clinical trials register: Australian New Zealand Clinical Trials Registry; identification number: ACTRN12608000359336; http://www.anzctr.org.au/trial_view.aspx?ID=82978).

Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft

BACKGROUND

Incentive spirometry (IS) is a treatment technique that uses a mechanical device to reduce pulmonary complications during postoperative care. This is an update of a Cochrane review first published in 2007.

OBJECTIVES

Update the previously published systematic review to compare the effects of IS for preventing postoperative pulmonary complications in adults undergoing coronary artery bypass graft (CABG).

SEARCH METHODS

We searched CENTRAL and DARE on The Cochrane Library (Issue 2 of 4 2011), MEDLINE OVID (1948 to May 2011), EMBASE (1980 to Week 20 2011), LILACS (1982 to July 2011) , the Physiotherapy Evidence Database (PEDro) (1980 to July 2011), Allied & Complementary Medicine (AMED) (1985 to May 2011), CINAHL (1982 to May 2011).

SELECTION CRITERIA

Randomised controlled trials comparing IS with any type of prophylactic physiotherapy for prevention of postoperative pulmonary complications in adults undergoing CABG.

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated trial quality using the guidelines of the Cochrane Handbook for Systematic Reviews and extracted data from included trials. For continuous outcomes, we used the generic inverse variance method for meta-analysis and for dichotomous data we used the Peto Odds Ratio.

MAIN RESULTS

This update included 592 participants from seven studies (two new and one that had been excluded in the previous review in 2007. There was no evidence of a difference between groups in the incidence of any pulmonary complications and functional capacity between treatment with IS and treatment with physical therapy, positive pressure breathing techniques (including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and intermittent positive pressure breathing (IPPB), active cycle of breathing techniques (ACBT) or preoperative patient education. Patients treated with IS had worse pulmonary function and arterial oxygenation compared with positive pressure breathing. Based on these studies there was no improvement in the muscle strength between groups who received IS demonstrated by maximal inspiratory pressure and maximal expiratory pressure .

AUTHORS' CONCLUSIONS

Our update review suggests there is no evidence of benefit from IS in reducing pulmonary complications and in decreasing the negative effects on pulmonary function in patients undergoing CABG. In view of the modest number of patients studied, methodological shortcomings and poor reporting of the included trials, these results should still be interpreted cautiously. An appropriately powered trial of high methodological rigour is needed to determine if there are patients who may derive benefit from IS following CABG.

Lung Function before and Two Days after Open-Heart Surgery

Reduced lung volumes and atelectasis are common after open-heart surgery, and pronounced restrictive lung volume impairment has been found. The aim of this study was to investigate factors influencing lung volumes on the second postoperative day. Open-heart surgery patients (n = 107, 68 yrs, 80% male) performed spirometry both before surgery and on the second postoperative day. The factors influencing postoperative lung volumes and decrease in lung volumes were investigated with univariate and multivariate analyses. Associations between pain (measured by numeric rating scale) and decrease in postoperative lung volumes were calculated with Spearman rank correlation test. Lung volumes decreased by 50% and were less than 40% of the predictive values postoperatively. Patients with BMI >25 had lower postoperative inspiratory capacity (IC) (33 ± 14% pred.) than normal-weight patients (39 ± 15% pred.), (P = 0.04). More pain during mobilisation was associated with higher decreases in postoperative lung volumes (VC: r = 0.33, P = 0.001; FEV₁: r = 0.35, P ≤ 0.0001; IC: r = 0.25, P = 0.01). Patients with high BMI are a risk group for decreased postoperative lung volumes and should therefore receive extra attention during postoperative care. As pain is related to a larger decrease in postoperative lung volumes, optimal pain relief for the patients should be identified.

Short-term effects of inspiratory muscle training in coronary artery bypass graft surgery: a randomized controlled trial

OBJECTIVE

To investigate the efficiency of inspiratory muscle training (IMT) on postoperative respiratory muscle strength, functional capacity, quality of life, and psychosocial status in patients with coronary artery bypass graft (CABG) surgery.

DESIGN

Forty-three patients undergoing CABG surgery were randomly assigned to the one of two groups. All subjects received usual care. In addition, subjects in the intervention group received IMT training pre- and postoperatively. Pulmonary function testing, six minute walk test (6MWT), quality of life and psychosocial parameters were assessed preoperatively and the fifth day after the surgery.

RESULTS

The mean inspiratory muscle strength increased from 82.64 cmH(2)O at baseline to 95.45 cmH(2)O five days postoperatively in the intervention group. The intervention group (319.55 ± 72.17 m before and 387.91 ± 65.69 m after surgery) covered further distance during the 6MWT than usual care (355.43 ± 56.08 m before and 357.69 ± 43.42 m after surgery). The improvement in quality of life was greater in the intervention group for the dimension of sleep. The anxiety scores were significantly lower in the intervention group than the usual care group. The length of intensive care unit stay was significantly shorter in the intervention group than the usual care group (p < 0.05).

CONCLUSION

IMT results in faster recovery of inspiratory muscle strength, functional capacity, intensive care unit stay, quality of life and psychosocial status after CABG.

Longitudinal evaluation the pulmonary function of the pre and postoperative periods in the coronary artery bypass graft surgery of patients treated with a physiotherapy protocol

Background

The treatment of coronary artery disease (CAD) seeks to reduce or prevent its complications and decrease morbidity and mortality. For certain subgroups of patients, coronary artery bypass graft surgery (CABG) may accomplish these goals. The objective of this study was to assess the pulmonary function in the CABG postoperative period of patients treated with a physiotherapy protocol.

Methods

Forty-two volunteers with an average age of 63 ± 2 years were included and separated into three groups: healthy volunteers (n = 09), patients with CAD (n = 9) and patients who underwent CABG (n = 20). Patients from the CABG group received preoperative and postoperative evaluations on days 3, 6, 15 and 30. Patients from the CAD group had evaluations on days 1 and 30 of the study, and the healthy volunteers were evaluated on day 1. Pulmonary function was evaluated by measuring forced vital capacity (FVC), maximum expiratory pressure (MEP) and Maximum inspiratory pressure (MIP).

Results

After CABG, there was a significant decrease in pulmonary function (p < 0.05), which was the worst on postoperative day 3 and returned to the preoperative baseline on postoperative day 30.

Conclusion

Pulmonary function decreased after CABG. Pulmonary function was the worst on postoperative day 3 and began to improve on postoperative day 15. Pulmonary function returned to the preoperative baseline on postoperative day 30.

Mobilidade diafragmática durante espirometria de incentivo orientada a fluxo e a volume em indivíduos sadios

OBJETIVO: Comparar a mobilidade diafragmática de indivíduos sadios durante a espirometria de incentivo orientada a volume, durante a espirometria de incentivo orientada a fluxo e durante exercícios diafragmáticos. Comparar a mobilidade diafragmática entre homens e mulheres durante esses três tipos de exercícios respiratórios. MÉTODOS: Foram avaliadas a função pulmonar e a mobilidade diafragmática de 17 voluntários sadios adultos (9 mulheres e 8 homens). A avaliação da mobilidade do diafragma foi realizada durante a execução de exercícios diafragmáticos e durante o uso dos dois tipos de espirômetros de incentivo, por meio de um método ultrassonográfico. RESULTADOS: A mobilidade diafragmática avaliada durante a utilização do espirômetro orientado a volume foi significativamente maior que aquela durante o uso do espirômetro orientado a fluxo (70,16 ± 12,83 mm vs. 63,66 ± 10,82 mm; p = 0,02). Os exercícios diafragmáticos promoveram maior mobilidade diafragmática do que o uso do espirômetro orientado a fluxo (69,62 ± 11,83 mm vs. 63,66 ± 10,82 mm; p = 0,02). Durante os três tipos de exercícios respiratórios, a relação mobilidade/CVF foi significativamente maior nas mulheres do que nos homens. CONCLUSÕES: A espirometria de incentivo orientada a volume e o exercício diafragmático promoveram maior mobilidade diafragmática do que a espirometria de incentivo orientada a fluxo. As mulheres apresentaram um melhor desempenho nos três tipos de exercícios respiratórios avaliados do que os homens.

Efeitos de duas técnicas de incentivo respiratório na mobilidade toracoabdominal após cirurgia abdominal alta

A cirurgia abdominal alta está associada a um risco elevado de complicações pulmonares que podem ser reduzidas pelo uso criterioso de manobras terapêuticas visando a expansão pulmonar. O objetivo foi comparar duas técnicas de incentivo respiratório na recuperação da dinâmica toracoabdominal em pacientes submetidos à cirurgia abdominal alta. O grupo de estudo experimental foi constituído por 16 pacientes internados na Clínica Cirúrgica do Hospital Universitário de Santa Maria distribuídos aleatoriamente em dois grupos: o grupo 1 foi constituído por dez pacientes que usaram o dispositivo Voldyne e o grupo 2, por seis pacientes submetidos ao padrão ventilatório com inspiração fracionada em três tempos. A expansibilidade toracoabdominal foi avaliada por cirtometria antes da cirurgia e no 1º, 3º¸ e 5º dias do pós-operatório (PO). Observou-se redução significativa dos valores de cirtometria no 1º PO que, gradualmente, foram sendo recuperados, não mais havendo diferença significativa no 5o PO em relação aos valores pré-operatórios em ambos os grupos. O grupo 1 obteve significativamente melhores índices de recuperação da mobilidade toracoabdominal do que o grupo 2. Também o tempo de recuperação do grupo 1 atingiu médias mais elevadas durante todo o período de PO investigado. Embora ambas as técnicas utilizadas fossem efetivas, o incentivo inspiratório por meio do Voldyne mostrou melhores resultados na recuperação da expansibilidade pulmonar após cirurgia abdominal alta.

Physiotherapy-supervised mobilization and exercise following cardiac surgery: a national questionnaire survey in Sweden

Background

Limited published data are available on how patients are mobilized and exercised during the postoperative hospital stay following cardiac surgery. The aim of this survey was to determine current practice of physiotherapy-supervised mobilization and exercise following cardiac surgery in Sweden.

Methods

A prospective survey was carried out among physiotherapists treating adult cardiac surgery patients. A total population sample was identified and postal questionnaires were sent to the 33 physiotherapists currently working at the departments of thoracic surgery in Sweden. In total, 29 physiotherapists (response rate 88%) from eight hospitals completed the survey.

Results

The majority (90%) of the physiotherapists offered preoperative information. The main rationale of physiotherapy treatment after cardiac surgery was to prevent and treat postoperative complications, improve pulmonary function and promote physical activity. In general, one to three treatment sessions were given by a physiotherapist on postoperative day 1 and one to two treatment sessions were given during postoperative days 2 and 3. During weekends, physiotherapy was given to a lesser degree (59% on Saturdays and 31% on Sundays to patients on postoperative day 1). No physiotherapy treatment was given in the evenings. The routine use of early mobilization and shoulder range of motion exercises was common during the first postoperative days, but the choice of exercises and duration of treatment varied. Patients were reminded to adhere to sternal precautions. There were great variations of instructions to the patients concerning weight bearing and exercises involving the sternotomy. All respondents considered physiotherapy necessary after cardiac surgery, but only half of them considered the physiotherapy treatment offered as optimal.

Conclusions

The results of this survey show that there are small variations in physiotherapy-supervised mobilization and exercise following cardiac surgery in Sweden. However, the frequency and duration of exercises and recommendations for sternal precautions reinforced for the healing period differ between physiotherapists. This survey provides an initial insight into physiotherapy management in Sweden. Comparison with surveys in other countries is warranted to improve the physiotherapy management and postoperative recovery of the cardiac surgery patient.

Effects of breathing exercises on breathing pattern and thoracoabdominal motion after gastroplasty

OBJECTIVE: To evaluate breathing pattern and thoracoabdominal motion during breathing exercises. METHODS: Twenty-four patients with class II or III obesity (18 women; 6 men) were studied on the second postoperative day after gastroplasty. The mean age was 37 ± 11 years, and the mean BMI was 44 ± 3 kg/m². Diaphragmatic breathing, incentive spirometry with a flow-oriented device and incentive spirometry with a volume-oriented device were performed in random order. Respiratory inductive plethysmography was used in order to measure respiratory variables and thoracoabdominal motion. RESULTS: Comparisons among the three exercises showed significant differences: tidal volume was higher during incentive spirometry (with the flow-oriented device or with the volume-oriented device) than during diaphragmatic breathing; the respiratory rate was lower during incentive spirometry with the volume-oriented device than during incentive spirometry with the flow-oriented device; and minute ventilation was higher during incentive spirometry (with the flow-oriented device or with the volume-oriented device) than during diaphragmatic breathing. Rib cage motion did not vary during breathing exercises, although there was an increase in thoracoabdominal asynchrony, especially during incentive spirometry with the flow-oriented device. CONCLUSIONS: Among the breathing exercises evaluated, incentive spirometry with the volume-oriented device provided the best results, because it allowed slower, deeper inhalation.

Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery

Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery.

OBJECTIVE

To evaluate the effects of a 6-day postoperative in-hospital cardiopulmonary rehabilitation program on inspiratory muscle strength and its potential association with improved functional capacity after coronary artery bypass graft (CABG) surgery.

DESIGN

Prospective, randomized controlled trial.

SETTING

Tertiary public hospital in Brazil.

PARTICIPANTS

Men (N=20) after CABG were randomized to cardiopulmonary rehabilitation (n=10; age, 64+/-8y) or to usual care (n=10; age, 63+/-7y).

INTERVENTIONS

Ten subjects underwent a 6-day postoperative in-hospital program, which included the use of expiratory positive airway pressure mask and bronchial hygiene techniques, coupled with progressive distance walking and calisthenics as well as cardiopulmonary training. Ten controls were followed by their own physicians and received routine nursing assistance but were not exposed to any specific respiratory or motor physical intervention.

MAIN OUTCOME MEASURES

Maximal inspiratory and expiratory pressure were measured by a pressure transducer, and the highest pressure obtained in 6 measurements was used for analysis (before surgery, and 7 and 30d after surgery). The six-minute walk test (6MWT) was performed 7 days after surgery, and maximal cardiopulmonary exercise testing was performed 30 days after CABG.

RESULTS

After randomization, clinical and functional characteristics were similar in the 2 groups. Rehabilitation resulted in maintenance of maximal inspiratory pressure (PImax) measured at 7 and 30 days postoperatively, respectively (from 68+/-19% at baseline to 58+/-22% and to 61+/-22% predicted), while it was significantly reduced in the control group. 6MWT distance was longer 7 days after CABG in rehabilitation subjects (416+/-78m) than controls (323+/-67m). Peak oxygen uptake (Vo(2)peak) at day 30 was also higher (28%) in the rehabilitation group and was correlated with PImax (r=.90).

CONCLUSIONS

A 6-day rehabilitation program attenuated the postoperative reduction in respiratory muscle strength and also improved the recovery of functional capacity after CABG. The correlation between PImax and Vo(2)peak during the late postoperative period suggests that inspiratory muscle strength is an important determinant of functional capacity after CABG.

Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft

BACKGROUND

Following coronary artery bypass graft (CABG), the main causes of postoperative morbidity and mortality are postoperative pulmonary complications, respiratory dysfunction and arterial hypoxemia. Incentive spirometry is a treatment technique that uses a mechanical device (an incentive spirometer) to reduce such pulmonary complications during postoperative care.

OBJECTIVES

To assess the effects of incentive spirometry for preventing postoperative pulmonary complications in adults undergoing CABG.

SEARCH STRATEGY

We searched CENTRAL on The Cochrane Library (Issue 2, 2004), MEDLINE (1966 to December 2004), EMBASE (1980 to December 2004), LILACS (1982 to December 2004), the Physiotherapy Evidence Database (PEDro) (1980 to December 2004), Allied & Complementary Medicine (AMED) (1985 to December 2004), CINAHL (1982 to December 2004), and the Database of Abstracts of Reviews of Effects (DARE) (1994 to December 2004). References were checked and authors contacted. No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials comparing incentive spirometry with any type of prophylactic physiotherapy for prevention of postoperative pulmonary complications in adults undergoing CABG.

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated the quality of trials using the guidelines of the Cochrane Reviewers' Handbook and extracted data from included trials.

MAIN RESULTS

Four trials with 443 participants contributed to this review. There was no significant difference in pulmonary complications (atelectasis and pneumonia) between treatment with incentive spirometry and treatment with positive pressure breathing techniques (continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and intermittent positive pressure breathing (IPPB)) or preoperative patient education. Patients treated with incentive spirometry had worse pulmonary function and arterial oxygenation compared with positive pressure breathing (CPAP, BiPAP, IPPB).

AUTHORS' CONCLUSIONS

Individual small trials suggest that there is no evidence of benefit from incentive spirometry in reducing pulmonary complications and in decreasing the negative effects on pulmonary function in patients undergoing CABG. In view of the modest number of patients studied, methodological shortcomings and poor reporting of the included trials, these results should be interpreted cautiously. An appropriately powered trial of high methodological rigour is needed to determine those patients who may derive benefit from incentive spirometry following CABG.