Comparison of two methods of postoperative respiratory care

A Cross-Sectional Study on the Application of IS in Perioperative Pulmonary Function Training in Spine and Orthopedics

Background

The incentive spirometer (IS) is a mechanical device that promotes lung expansion and can be used to prevent and treat postoperative pulmonary complications. In this study, the preventive effect of pulmonary function training with IS on the improvement of pulmonary function and pulmonary complications was observed.

Methods

From May 2019 to April 2021, 69 scoliosis patients with impaired moderate and severe lung function were divided into the traditional pulmonary training group (n = 32) and IS-enhanced pulmonary training group (n = 35). The patient underwent lung function testing after admission and one week after the start of training and chest CT on the third day after surgery.

Results

The average age was 13.47 and 15.66, respectively (p = 0.223). The Cobb angles were 83.84 and 83.97 (p = 0.756), respectively, and no statistical difference between the parameters of lung function was detected. After 1 week of respiratory function training, significant improvement in lung function testing parameters including VC%, FVC%, FEV1%, FEV1/FVC, FEV1/VC, and MVV% was found in both groups. Analysis of covariance showed more significant improvement in IS-enhanced group compared to the conventional training group (p < 0.05). The incidence of postoperative pulmonary atelectasis was lower in IS-enhanced group than in traditional groups (2.9% vs. 21.9%, p = 0.043) with no difference in the overall incidence of pulmonary complications (p = 0.164) and shorter preoperative and total hospitalization in the IS-enhanced group.

Conclusion

Compared to traditional pulmonary function training, IS-enhanced training can significantly accelerate the improvement of pulmonary function testing parameters, shorten the preoperative pulmonary function training time, reduce the incidence of postoperative pulmonary tension complications, and accelerate postoperative rehabilitation.

Acute Respiratory Failure

Acute respiratory failure occurs when the lungs fail to oxygenate arterial blood adequately and it is one of the commonest postoperative complications. The preoperative identification of risk factors for postoperative acute respiratory failure allows identification of those patients who may benefit from preoperative optimization and increased postoperative vigilance. Multiple postoperative pulmonary complications are associated with acute hypoxemic respiratory failure and this chapter discusses atelectasis, pulmonary embolism, aspiration, and acute respiratory distress syndrome in detail, as well as providing a unified clinical approach to the acutely hypoxemic perioperative patient.

The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: a systematic review and meta-analysis

PURPOSE

Up to 30% of patients undergoing abdominal surgery suffer from postoperative pulmonary complications. The purpose of this systematic review and meta-analyses was to investigate whether postoperative respiratory interventions and mobilization interventions compared with usual care can prevent postoperative complications following abdominal surgery.

METHODS

The review was conducted in line with PRISMA and GRADE guidelines. MEDLINE, Embase, and PEDRO were searched for randomized controlled trials and observational studies comparing postoperative respiratory interventions and mobilization interventions with usual care in patients undergoing abdominal surgery. Meta-analyses with trial sequential analysis on the outcome pulmonary complications were performed. Review registration: PROSPERO (identifier: CRD42019133629) RESULTS: Pulmonary complications were addressed in 25 studies containing 2068 patients. Twenty-three studies were included in the meta-analyses. Patients predominantly underwent open elective upper abdominal surgery. Postoperative respiratory interventions consisted of expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV), assisted inspiratory flow modalities (IPPB, IPAP), patient-operated ventilation modalities (spirometry, PEP), and structured breathing exercises. Meta-analyses found that ventilation with high expiratory resistance (CPAP, EPAP, BiPAP, NIV) reduced the risk of pulmonary complications with OR 0.42 (95% CI 0.18-0.97, p = 0.04, I² = 0%) compared with usual care, however, the trial sequential analysis revealed that the required information size was not met. Neither postoperative assisted inspiratory flow therapy, patient-operated ventilation modalities, nor breathing exercises reduced the risk of pulmonary complications.

CONCLUSION

The use of postoperative expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV) after abdominal surgery might prevent pulmonary complications and it seems the preventive abilities were largely driven by postoperative treatment with CPAP.

Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial

Background

An incentive spirometer (IS) is a mechanical device that promotes lung expansion. It is commonly used to prevent postoperative lung atelectasis and decrease pulmonary complications after cardiac, lung, or abdominal surgery. This study explored its effect on lung function and pulmonary complication rates in patients with rib fractures.

Methods

Between June 2014 and May 2017, 50 adult patients with traumatic rib fractures were prospectively investigated. Patients who were unconscious, had a history of chronic obstructive pulmonary disease or asthma, or an Injury Severity Score (ISS) ≥ 16 were excluded. Patients were randomly divided into a study group (n = 24), who underwent IS therapy, and a control group (n = 26). All patients received the same analgesic protocol. Chest X-rays and pulmonary function tests (PFTs) were performed on the 5th and 7th days after trauma.

Results

The groups were considered demographically homogeneous. The mean age was 55.2 years and 68% were male. Mean pretreatment ISSs and mean number of ribs fractured were not significantly different (8.23 vs. 8.08 and 4 vs. 4, respectively). Of 50 patients, 28 (56%) developed pulmonary complications, which were more prevalent in the control group (80.7% vs. 29.2%; p = 0.001). Altogether, 25 patients had delayed hemothorax, which was more prevalent in the control group (69.2% vs. 29.2%; p = 0.005). Two patients in the control group developed atelectasis, one patient developed pneumothorax, and five patients required thoracostomy. PFT results showed decreased forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV₁) in the control group. Comparing pre- and posttreatment FVC and FEV₁, the study group had significantly greater improvements (p < 0.001).

Conclusions

In conclusion, the use of an IS reduced pulmonary complications and improved PFT results in patients with rib fractures. The IS is a cost-effective device for patients with rib fractures and its use has clinical benefits without harmful effects.

Trial registration

ClinicalTrials.gov, NCT04006587. Registered on 3 July 2019.

Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library 2008, Issue 3.Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry compared to no therapy or physiotherapy, including coughing and deep breathing, on all-cause postoperative pulmonary complications and mortality in adult patients admitted to hospital for upper abdominal surgery.

OBJECTIVES

Our primary objective was to assess the effect of incentive spirometry (IS), compared to no such therapy or other therapy, on postoperative pulmonary complications and mortality in adults undergoing upper abdominal surgery.Our secondary objectives were to evaluate the effects of IS, compared to no therapy or other therapy, on other postoperative complications, adverse events, and spirometric parameters.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE, EMBASE, and LILACS (from inception to August 2013). There were no language restrictions. The date of the most recent search was 12 August 2013. The original search was performed in June 2006.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of IS in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 12 studies with a total of 1834 participants in this updated review. The methodological quality of the included studies was difficult to assess as it was poorly reported, so the predominant classification of bias was 'unclear'; the studies did not report on compliance with the prescribed therapy. We were able to include data from only 1160 patients in the meta-analysis. Four trials (152 patients) compared the effects of IS with no respiratory treatment. We found no statistically significant difference between the participants receiving IS and those who had no respiratory treatment for clinical complications (relative risk (RR) 0.59, 95% confidence interval (CI) 0.30 to 1.18). Two trials (194 patients) IS compared incentive spirometry with deep breathing exercises (DBE). We found no statistically significant differences between the participants receiving IS and those receiving DBE in the meta-analysis for respiratory failure (RR 0.67, 95% CI 0.04 to 10.50). Two trials (946 patients) compared IS with other chest physiotherapy. We found no statistically significant differences between the participants receiving IS compared to those receiving physiotherapy in the risk of developing a pulmonary condition or the type of complication. There was no evidence that IS is effective in the prevention of pulmonary complications.

AUTHORS' CONCLUSIONS

There is low quality evidence regarding the lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large RCTs with high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.

Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery

BACKGROUND

Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry (IS) compared to no therapy, or physiotherapy including coughing and deep breathing, on all-cause postoperative pulmonary complications and mortality in adult patients admitted for upper abdominal surgery.

OBJECTIVES

To assess the effects of incentive spirometry compared to no such therapy (or other therapy) on all-cause postoperative pulmonary complications (atelectasis, acute respiratory inadequacy) and mortality in adult patients admitted for upper abdominal surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE, EMBASE, and LILACS (from inception to July 2006). There were no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials of incentive spirometry in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 11 studies with a total of 1754 participants. Many trials were of only moderate methodological quality and did not report on compliance with the prescribed therapy. Data from only 1160 patients could be included in the meta-analysis. Three trials (120 patients) compared the effects of incentive spirometry with no respiratory treatment. Two trials (194 patients) compared incentive spirometry with deep breathing exercises. Two trials (946 patients) compared incentive spirometry with other chest physiotherapy. All showed no evidence of a statistically significant effect of incentive spirometry. There was no evidence that incentive spirometry is effective in the prevention of pulmonary complications.

AUTHORS' CONCLUSIONS

We found no evidence regarding the effectiveness of the use of incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large randomized trials of high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.

Atelectasis in the perioperative patient

PURPOSE OF REVIEW

To report the impact of atelectasis on perioperative outcomes. Atelectasis occurs in the dependent parts of the lungs of most patients who are anesthetized. Development of atelectasis is associated with decreased lung compliance, impairment of oxygenation, increased pulmonary vascular resistance and development of lung injury. Here, we examine the etiology, contributing factors, consequences, diagnosis and treatment of atelectasis.

RECENT FINDINGS

Atelectasis describes the state of absent air in alveoli attributable to collapse, but recent findings suggest that alveoli are filled with foam and fluid. It is now known that atelectasis plays an important role beyond abnormal gas exchange and that prevention or reversal of atelectasis in some populations of postoperative patients may improve outcome.

SUMMARY

Atelectasis in the presence of preexisting lung disease or limited cardiopulmonary reserve may have significant consequences. Increasing understanding of the underlying nature of atelectasis and its contribution to acute lung injury will improve our approach to the prevention and management of atelectasis.

Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review

OBJECTIVES

To examine the efficacy of respiratory physiotherapy for prevention of pulmonary complications after abdominal surgery.

METHODS

We searched in databases and bibliographies for articles in all languages through November 2005. Randomized trials were included if they investigated prophylactic respiratory physiotherapy and pulmonary outcomes, and if the follow-up was at least 2 days. Efficacy data were expressed as risk differences (RDs) and number needed to treat (NNT), with 95% confidence intervals (CIs).

RESULTS

Thirty-five trials tested respiratory physiotherapy treatments. Of 13 trials with a "no intervention" control group, 9 studies (n = 883) did not report on significant differences, and 4 studies (n = 528) did: in 1 study, the incidence of pneumonia was decreased from 37.3 to 13.7% with deep breathing, directed cough, and postural drainage (RD, 23.6%; 95% CI, 7 to 40%; NNT, 4.3; 95% CI, 2.5 to 14); in 1 study, the incidence of atelectasis was decreased from 39 to 15% with deep breathing and directed cough (RD, 24%; 95% CI, 5 to 43%; NNT, 4.2; 95% CI, 2.4 to 18); in 1 study, the incidence of atelectasis was decreased from 77 to 59% with deep breathing, directed cough, and postural drainage (RD, 18%; 95% CI, 5 to 31%; NNT, 5.6; 95% CI, 3.3 to 19); in 1 study, the incidence of unspecified pulmonary complications was decreased from 47.7% to 21.4 to 22.2% with intermittent positive pressure breathing, or incentive spirometry, or deep breathing with directed cough (RD, 25.5 to 26.3%; NNT, 3.8 to 3.9). Twenty-two trials (n = 2,734) compared physiotherapy treatments without no intervention control subjects; no conclusions could be drawn.

CONCLUSIONS

There are only a few trials that support the usefulness of prophylactic respiratory physiotherapy. The routine use of respiratory physiotherapy after abdominal surgery does not seem to be justified.

Emergency department spirometric volume and base deficit delineate risk for torso injury in stable patients

Background

We sought to determine torso injury rates and sensitivities associated with fluid-positive abdominal ultrasound, metabolic acidosis (increased base deficit and lactate), and impaired pulmonary physiology (decreased spirometric volume and PaO₂/FiO₂).

Methods

Level I trauma center prospective pilot and post-pilot study (2000–2001) of stable patients. Increased base deficit was < 0.0 in ethanol-negative and ≤ -3.0 in ethanol-positive patients. Increased lactate was > 2.5 mmol/L in ethanol-negative and ≥ 3.0 mmol/L in ethanol-positive patients. Decreased PaO₂/FiO₂ was < 350 and decreased spirometric volume was < 1.8 L.

Results

Of 215 patients, 66 (30.7%) had a torso injury (abdominal/pelvic injury n = 35 and/or thoracic injury n = 43). Glasgow Coma Scale score was 14.8 ± 0.5 (13–15). Torso injury rates and sensitivities were: abdominal ultrasound negative and normal base deficit, lactate, PaO₂/FiO₂, and spirometric volume – 0.0% & 0.0%; normal base deficit and normal spirometric volume – 4.2% & 4.5%; chest/abdominal soft tissue injury – 37.8% & 47.0%; increased lactate – 39.7% & 47.0%; increased base deficit – 41.3% & 75.8%; increased base deficit and/or decreased spirometric volume – 43.8% & 95.5%; decreased PaO₂/FiO₂ – 48.9% & 33.3%; positive abdominal ultrasound – 62.5% & 7.6%; decreased spirometric volume – 73.4% & 71.2%; increased base deficit and decreased spirometric volume – 82.9% & 51.5%.

Conclusions

Trauma patients with normal base deficit and spirometric volume are unlikely to have a torso injury. Patients with increased base deficit or lactate, decreased spirometric volume, decreased PaO₂/FiO₂, or positive FAST have substantial risk for torso injury. Increased base deficit and/or decreased spirometric volume are highly sensitive for torso injury. Base deficit and spirometric volume values are readily available and increase or decrease the suspicion for torso injury.

A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery

BACKGROUND AND PURPOSE

Physiotherapists use a variety of techniques aimed at improving lung volumes and secretion clearance in patients after surgery. Periodic continuous positive airway pressure (PCPAP) is used to treat patients following elective upper abdominal surgery. However, the optimal method of application has not been identified, more specifically, the dosage of application of PCPAP. The present randomized controlled trial compared the effects of two dosages of PCPAP application and 'traditional' physiotherapy upon functional residual capacity (FRC), vital capacity (VC), oxyhaemoglobin saturation (SpO2), incidence of post-operative pulmonary complications and length of stay with a control group receiving 'traditional' physiotherapy only.

METHOD

Fifty-seven subjects were randomly allocated to one of three groups. All groups received 'traditional' physiotherapy twice daily for a minimum of three post-operative days. In addition, two groups received PCPAP for 15 or 30 minutes, four times per day, for three days.

RESULTS

Fifty subjects (39 male; 11 female) completed the study. There were no significant differences in any variables between the three groups. The overall incidence of post-operative pulmonary complications was 22% in the control group, 11% and 6% in the PCPAP 15-minute and PCPAP 30-minute groups, respectively. Length of hospital stay was not significantly different between the groups but for subjects who developed post-operative pulmonary complications, the length of stay was significantly greater (Z = -2.32; p = 0.021).

CONCLUSIONS

The addition of PCPAP to a traditional physiotherapy post-operative treatment regimen after upper abdominal surgery did not significantly affect physiological or clinical outcomes.

Incentive spirometry performance. A reliable indicator of pulmonary function in the early postoperative period after lobectomy?

OBJECTIVES

The purpose of our study was to validate the incentive spirometry (IS) as a simple mean to follow pulmonary function at the bedside after lung surgery.

MATERIALS AND METHODS

We studied prospectively 19 patients (16 men, 3 women; mean +/- SE age, 60 +/- 2.8 years) undergoing lobectomy for lung cancer. All the patients had an obstructive pattern with FEV1/FVC below 75%. Lung volumes, including functional residual capacity (FRC) and residual volume (RV), measured using spirometry and the helium dilution technique, and IS were measured preoperatively and postoperatively at days 1, 2, 3, and 8, and at 2 months.

RESULTS

Our results showed that in the postoperative period after lung resection, IS performance was well correlated (R) during the first 8 postoperative days with vital capacity (VC) (R between 0.667 and 0.870) mainly due to the excellent correlation with the inspiratory reserve volume (IRV, R between 0.680 and 0.895) but was poorly correlated with expiratory reserve volume (R below 0.340), RV (R below 0.180), and FRC (R below 0.470).

CONCLUSIONS

IS can be used as a simple mean to follow lung function, especially VC and IRV, in the postoperative period in spontaneously breathing patients. IS is noninvasive and can be performed repeatedly at the bedside in the intensive care setting.

[Prevention of respiratory complications after abdominal surgery]

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.

Incentive spirometry to prevent acute pulmonary complications in sickle cell diseases

BACKGROUND

This study was designed to determine the incidence of thoracic bone infarction in patients with sickle cell diseases who were hospitalized with acute chest or back pain above the diaphragm and to test the hypothesis that incentive spirometry can decrease the incidence of atelectasis and pulmonary infiltrates.

METHODS

We conducted a prospective, randomized trial in 29 patients between 8 and 21 years of age with sickle cell diseases who had 38 episodes of acute chest or back pain above the diaphragm and were hospitalized. Each episode of pain was considered to be an independent event. At each hospitalization, patients with normal or unchanged chest radiographs on admission were randomly assigned to treatment with spirometry or to a control nonspirometry group. Each patient in the spirometry group took 10 maximal inspirations using an incentive spirometer every two hours between 8 a.m. and 10 p.m. and while awake during the night until the chest pain subsided. A second radiograph was obtained three or more days after admission, or sooner if clinically necessary, to determine the incidence of pulmonary complications. Bone scanning was performed no sooner than two days after hospital admission to determine the incidence of thoracic bone infarction.

RESULTS

The incidence of thoracic bone infarction was 39.5 percent (15 of 38 hospitalizations). Pulmonary complications (atelectasis or infiltrates) developed during only 1 of 19 hospitalizations of patients assigned to the spirometry group, as compared with 8 of 19 hospitalizations of patients in the nonspirometry group (P = 0.019). Among patients with thoracic bone infarction, no pulmonary complications developed in those assigned to the spirometry group during a total of seven hospitalizations, whereas they developed during five of eight hospitalizations in the nonspirometry group (P = 0.025).

CONCLUSIONS

Thoracic bone infarction is common in patients with sickle cell diseases who are hospitalized with acute chest pain. Incentive spirometry can prevent the pulmonary complications (atelectasis and infiltrates) associated with the acute chest syndrome in patients with sickle cell diseases who are hospitalized with chest or back pain above the diaphragm.

Efficacy of selective intrabronchial air insufflation in acute lobar collapse

Flexible fiberoptic bronchoscopy (FFB) to remove mucous plugs followed by selective intrabronchial air insufflation (SII) to expand the atelectatic lung was used in 17 surgical intensive care unit (SICU) patients with pulmonary lobar collapse. Thirteen patients were admitted for acute trauma, and the remainder were elderly postoperative patients. Lobar collapses occurred on SICU days 1 to 18 (mean +/- SEM: 5 +/- 1 days), and duration ranged from 4 to 258 hours (mean: 77 +/- 18 hours). Indications for FFB with SII included critical hypoxemia in 5 patients, worsening collapse in 2, and failure to respond to aggressive respiratory care in 10 (59%). FFB with SII was effective in 14 (82%) patients: 10 achieved full lung re-expansion, and 4 partial lung re-expansion. When lobar collapse was of less than 72 hours' duration, 92% (12 of 13) of patients had lungs re-expanded compared with 50% (2 of 4) whose collapse existed for more than 72 hours. The mean PaO2/FIO2 (fraction inspired oxygen) ratio was 135 +/- 18 prior to FFB with SII and increased to 205 +/- 21 after FFB with SII. Complications were minor and clinically insignificant. In conclusion, SII appears to be a simple, safe, effective adjunct to FFB in the treatment of SICU patients with pulmonary lobar collapse.

Chest physiotherapy for the surgical patient

This article reviews the evidence that chest physiotherapy is effective in the prevention and treatment of pulmonary complications after major abdominal and thoracic surgery. There is some evidence that regular chest physiotherapy significantly decreases the incidence of pulmonary complications, although the mechanism of this effect is uncertain. It is not known whether chest physiotherapy is effective in the treatment of postoperative pulmonary complications after they have developed.

Postthoracotomy respiratory muscle mechanics during incentive spirometry using respiratory inductance plethysmography

We undertook this study to characterize the postthoracotomy compartmental displacement and respiratory mechanical changes occurring during and after the performance of the incentive spirometry maneuver. We also evaluated the effect of recumbency angle on compartmental recruitment. Sixteen patients were randomized to perform incentive spirometry either at 30 degrees or 60 degrees recumbency angle. They were studied using respiratory inductance plethysmography to measure tidal volume, respiratory frequency, inspiratory time, rib cage motion/tidal volume ratio, inspiratory duty cycle, and inspiratory flow. Patients were studied before surgery and on postoperative days 1 and 3. Statistical analysis was accomplished using multiple measures ANOVA with post-hoc Student's t-tests when appropriate. Preoperative incentive spirometry augmented VT by increasing both VT/TI and TI. Postoperatively, the incentive recruitment of VT was reduced, a result of a decrease in TI and TI/TTOT; VT/TI was unchanged. There was postoperative decrease of AB and AB/VT during incentive spirometry, greatest in the 60 degrees group. Our results characterize the nature of the respiratory recruitment afforded by incentive spirometry, before and after thoracotomy. We also found evidence of postthoracotomy diaphragmatic derecruitment during incentive spirometry exacerbated by a high recumbency angle.

A multivariate analysis of the risk of pulmonary complications after laparotomy

We evaluated the relationship between PPC and various putative risk factors in a prospective longitudinal study of 1,000 patients undergoing abdominal surgery. Transient subclinical events were excluded by defining PPC as positive clinical findings in combination with either positive sputum microbiology, unexplained pyrexia, or positive chest roentgenographic findings. The overall incidence of PPC was 23.2 percent (232/1,000). Multivariate analysis identified seven factors which were associated with PPC: ASA classification greater than 2, upper abdominal surgery, residual intraperitoneal sepsis, age greater than 59 years, BMI greater than 25, preoperative hospital stay greater than 4 days, and colorectal or gastroduodenal surgery (overall F score = 33.5, p less than 0.0001). The ASA classification was the most powerful indicator of risk in both the univariate and the multivariate analyses. The combination of ASA classification greater than 1 and age greater than 59 years identified 88 percent (205 of 232) of the patients who developed PPC. These findings provide clinicians and clinical investigators with a simple means of identifying patients who are at high risk of PPC after abdominal surgery.

Comparison of incentive spirometry and intermittent positive pressure breathing after coronary artery bypass graft

Fifty-two patients were randomized to receive either incentive spirometry (IS) or intermittent positive pressure breathing (IPPB) in addition to conventional chest physical therapy following coronary artery bypass grafting. Slow vital capacity and peak expiratory flow readings decreased rapidly and to an equal extent in both groups after surgery, and partly recovered by the sixth postoperative day (POP). Arterial PO2 values were similar for the groups on the first three POPs. On the POPs 2, 3, and 6, the number of chest films showing atelectases as well as the number of individual patients having atelectases revealed no statistically significant differences between the two groups. Based on the three variables studied, we consider both devices equal in efficiency after coronary surgery.

Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients

PURPOSE

Major cardiac and pulmonary complications associated with abdominal and noncardiac thoracic surgery are a common cause of mortality and serious morbidity in elderly patients. We postulated that a simple, inexpensive bicycle exercise test could provide objective documentation of cardiopulmonary reserve and, therefore, predict perioperative pulmonary as well as cardiac complications.

PATIENTS AND METHODS

Prior to elective surgery, 177 patients aged 65 years or older had assessment of the clinical history, results of physical examination, electrocardiogram, chest radiograph, blood chemistries, pulmonary function test findings, supine exercise test results, Dripps classification, and Goldman cardiac risk factors. Observations in patients with and without major perioperative cardiac and/or pulmonary complications were compared using univariate analysis followed by a multivariate logistic regression procedure.

RESULTS

Major perioperative complications were pulmonary in 24 patients, cardiac in 25 patients, and either cardiac or pulmonary in 39 patients. By multivariate analysis, inability to perform two minutes of supine bicycle exercise raising the heart rate above 99 beats/minute was the best predictor of perioperative pulmonary, cardiac, and combined cardiopulmonary complication (p less than 0.0005). Among 108 patients who were able to achieve these exercise criteria, cardiac or pulmonary complications occurred in 10 patients (9.3%), with one death (0.9%). Among 69 patients unable to exercise satisfactorily, cardiac or pulmonary complications occurred in 29 patients (42%), with five total deaths (7.2%).

CONCLUSION

Objective measurement of exercise capacity by supine bicycle ergometry appears to be of clinical value for preoperative risk stratification for both pulmonary and cardiac complications prior to major elective abdominal or noncardiac thoracic surgery in elderly patients.

Lung function during anesthesia and respiratory insufficiency in the postoperative period: physiological and clinical implications

This review covers the physiological and clinical implications of lung function during anesthesia and respiratory insufficiency in the postoperative period. We have divided it into 3 main sections: 1) lung function changes induced by anesthesia and surgery, in which the impact on pulmonary mechanics, ventilation/perfusion changes and gas exchange are examined; 2) physiological implications of postoperative respiratory function secondary to decreased alveolar ventilation, development of atelectasis, and interstitial lung edema; and 3) clinical implications of postoperative respiratory failure. In this last section we analyze the current therapeutic modalities available to reduce the incidence of postoperative respiratory failure, as well as related morbidity and mortality.

Utility of immediate postlobectomy fiberoptic bronchoscopy in preventing atelectasis

In a prospective randomized trial, we examined the value of routine postlobectomy fiberoptic bronchoscopy (FOB) in preventing postoperative atelectasis. Twenty patients who underwent lobectomy were randomly assigned to either chest physical therapy alone (group 1) or immediate bronchoscopy (group 2). Both group 1 and group 2 were placed on a standard physical therapy regimen consisting of aerosol bronchodilator therapy, chest percussion, and incentive spirometry. It was concluded that routine postlobectomy bronchoscopy offers no advantage over the usual physical therapy measures in preventing the development of postoperative atelectasis.

Authoritative medical direction can assure cost-beneficial bronchial hygiene therapy

A bronchial hygiene (BH) program for non-Intensive Care Unit (ICU) patients in which regimens are determined by respiratory therapy evaluators is described. The medical director of Respiratory Care was given control of orders by the medical staff and assumed responsibility for the evaluators' decisions. Patterns of BH utilization were analyzed for 24 months and were compared with BH utilization patterns in a preceding similar program in which orders were controlled by primary care physicians. Extra-ICU BH therapy (BHT) decreased by 61 percent and neither morbidity nor mortality was undesirably affected. Cost savings exceeded $250,000 per year. Authoritative medical direction of such a program results in cost-beneficial utilization of BHT, provides an excellent guide for resident physicians to learn appropriate utilization of such therapy, provides for quality assurance and medical necessity documentation, and is well accepted by the medical staff.

Nasal continuous positive airway pressure in atelectasis

Nasal continuous positive airway pressure (CPAP) has been widely and safely used in the treatment of sleep disorders but has not been previously utilized for therapy of pulmonary atelectasis in adults. We observed three patients with significant atelectasis which was refractory to conventional chest physiotherapy. Bronchoscopy was not a viable therapeutic option in any patient. Therapy with continuous nasal CPAP was initiated at 10 to 15 cm H2O. The patients tolerated the therapy well and had prompt resolution of atelectasis. Nasal CPAP may be an effective modality for therapy of pulmonary atelectasis in spontaneously breathing patients, particularly when conventional therapies are not tolerated or are ineffectual.

Effect of reductions in respiratory therapy on patient outcome

In 1981-1982, a Massachusetts Hospital Association and Massachusetts Blue Cross-Blue Shield task force reviewing ancillary services found that the use of respiratory therapy at New England Deaconess Hospital far exceeded the statewide average. These findings led to a hospital-wide effort to reduce ancillary services. As part of this effort, we studied the effect of the reductions in respiratory therapy on patient outcome. At the beginning of the study, senior respiratory therapists advised physicians about the optimal use of various respiratory-therapy services, including their discontinuation when no longer necessary. One year after the intervention began, we analyzed the use of respiratory therapy by employing data-collection techniques that were identical to those used by the task force. Marked reductions in all categories of respiratory therapy had occurred, but morbidity and mortality from pulmonary disorders had not increased. In the largest group studied--patients undergoing coronary-artery bypass surgery--the charges for respiratory therapy, the length of hospital stay, and pulmonary complications had all decreased. We conclude that consistent application of prescribed guidelines for respiratory therapy results in marked decreases in its use and that such decreases can be achieved without a reduction in the quality of care.

Effects of periodic positive airway pressure by mask on postoperative pulmonary function

Postoperative pulmonary complications, alveolar-arteriolar oxygen difference ([A-a]O2-diff), peak expiratory flow (PEF) and forced vital capacity (FVC) were compared in patients using continuous positive airway pressure (CPAP) and positive expiratory pressure (PEP) administered by face mask against those of a control group using a deep-breathing device (Triflo). Forty-three consecutive, randomized patients undergoing elective upper abdominal surgery were included. CPAP, PEP and Triflo were administered for 30 consecutive breaths in every waking hour for three days postoperatively. The (A-a)O2-difference increased equally and significantly in the three groups after surgery, reaching a maximum on the first postoperative day. After this day, however, (A-a)O2-diff decreased in the CPAP and PEP groups, being significantly lower in the PEP group compared to the control group, two days postoperatively (p less than 0.05) and significantly lower in both the PEP and CPAP groups three days postoperatively (p less than 0.001 and p less than 0.05, respectively.) PEF did not differ significantly between the groups before or after surgery, while FVC was significantly higher in the PEP and CPAP groups, compared to control, on the third postoperative day (p less than 0.05). Atelectatic consolidation was observed in six of 15 patients in the control group three days postoperatively, the incidence being significantly lower in both the PEP group (0 of 15, p less than 0.001) and the CPAP group (one of 13, p less than 0.05). We concluded that periodic face mask administration of CPAP and PEP are superior to deep breathing exercises with respect to gas exchange, preservation of lung volumes and development of atelectasis after upper abdominal surgery. We also conclude that the simple and commercially available PEP mask is as effective as the more complicated CPAP system.

Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy. A controlled randomized study

To determine the potential benefit of incentive spirometry, which has been advocated to prevent pulmonary complications after upper-abdominal surgery, we compared a group of patients receiving incentive spirometry to another group receiving no specialized postoperative respiratory care. Forty patients in the American Society of Anesthesiologists' class 1 and 2 who were undergoing cholecystectomy (through right subcostal incision) were included in the study and were randomly allocated to one of the two groups. Patients receiving incentive spirometry were encouraged by a specialized respiratory physiotherapist to breathe deeply for five minutes hourly, 12 times daily, for three postoperative days. No statistically significant difference between the two groups was found in the radiologic evidence of postoperative pulmonary complications, arterial oxygen pressure, spirometric measurement, and clinical evaluation at the second or fourth postoperative day (or both). In particular, deterioration on the chest x-ray film at the fourth postoperative day was observed in eight of 20 patients in the group receiving incentive spirometry and in six of 20 in the control group. Our study confirms the postoperative deterioration of respiratory function after upper-abdominal surgery and demonstrates the lack of therapeutic values of incentive spirometry in these patients at low risk for pulmonary complications.

Postoperative intermittent positive pressure breathing versus physiotherapy

Seventeen patients admitted to the hospital to undergo elective upper abdominal surgery were randomly assigned to one of the two treatment groups: intermittent positive pressure breathing or physiotherapy. Postoperative pulmonary care in the two groups differed only with regard to administration of intermittent positive pressure breathing and chest physical therapy. Prospective evaluation included clinical examination, whole body plethysmography and determination of arterial blood gases preoperatively and on the 3rd postoperative day. Preoperative pulmonary function data were remarkably similar in the two groups. There was no difference in postoperative plethysmographic status in the two groups. Although not statistically significant, the postoperative decrease in paitial arterial oxygen pressure was more pronounced in the physiotherapy group. Neither of the two therapeutic modalities is more effective than the other in preventing postoperative pulmonary complications. Considering the potential hazards, chest physical therapy is clearly the preferred treatment.

Methods of intermittent positive pressure breathing

Inspiratory capacity (IC) was evaluated in 60 patients during the following four respiratory maneuvers: (1) coached unassisted inspiration; (2) inspiratory positive-pressure breathing (IPPB) at 15 cm H2O with the patient passively inspiring; (3) IPPB at 15 cm H2O with the patient coached to actively inspire; and (4) IPPB at a peak pressure adjusted according to the judgment of the respiratory therapist, with the patient coached to actively inspire. The IC attained with these maneuvers were, respectively, as follows: (1) 1.29 +/- 0.75 L; (2) 1.13 +/- 0.52 L; (3) 1.77 +/- 0.11 L; and (4) 2.27 +/- 0.11 L (mean +/- SE). The peak ventilator pressure for maneuver 4 averaged 30 +/- 7 cm H2O (mean +/- SD), and no patient experienced harmful side effects from these peak pressures. These data indicate that the method of treatment with IPPB has profound effects upon the degree of pulmonary expansion. All research on therapy with IPPB should be carefully controlled for the method of administering IPPB, and the volumes obtained during the treatment should be carefully documented before general conclusions are drawn concerning the effects of IPPB on morbidity. For the present, we suggest that IPPB, when administered clinically, be given as described in method 4.

Comparison of three methods of respiratory care following upper abdominal surgery

Incentive spirometry, as a method for preventing postoperative atelectasis, was compared with intermittent positive-pressure breathing (IPPB) and resistance breathing in 126 patients undergoing upper-abdominal surgery, most of whom had cholecystectomy. There was no statistically significant difference in the incidence of atelectasis among the three groups, who were matched for age, sex, smoking history, previous respiratory disease, and duration of surgery. There was a significantly higher incidence of atelectasis in patients over the age of 50 years (P = 0.004) than in younger subjects, where the incidence was not different among the three groups. Incentive spirometric therapy, as used in this study, offered no advantage over the other methods of treatment.

Which deep breathing device should the postoperative patient use?

A study was undertaken to compare the use of three types of deep-breathing devices in patients undergoing upper-abdominal operations. Seventy-nine patients were divided into three groups, each receiving preoperative bedside testing of pulmonary function and instruction in the use of one of three randomly assigned deep-breathing devices thought to be representative of those currently available (Triflo II, Bartlett-Edwards Incentive Spirometer, or Spirocare). Repeat testing and instruction were provided daily during each of the first five postoperative days. There were few statistically significant differences in pulmonary function, vital signs and white blood cell count, and no difference in length of postoperative stay. No device was uniformly acceptable to patients, and none was used as frequently as recommended. When left at the bedside and only one daily reinforcement of instructions, the three devices showed no clinically important differences.