Does removal of deep breathing exercises from a physiotherapy program including pre-operative education and early mobilisation after cardiac surgery alter patient outcomes?

The aim of this study was to establish whether removal of breathing exercises from a regimen including early mobilisation changes the incidence of post-operative pulmonary complications for patients after cardiac surgery. Two hundred and thirty patients undergoing open heart surgery at Monash Medical Centre, Melbourne, were enrolled in this randomised controlled trial. All patients received physiotherapy treatment pre-operatively and post-operatively for three days. Patients were mobilised as soon as possible after surgery. Breathing group (control) patients performed a set routine of deep breathing exercises at each physiotherapy visit while those in the intervention group did not perform this routine. Other than the breathing exercises, patient management was similar between groups in terms of assessment, positioning and mobility. The incidence of postoperative pulmonary complications, post-operative length of stay, oxyhaemoglobin saturation and pulmonary function were measured pre-operatively and post-operatively. Intention-to-treat analysis was performed for post-operative pulmonary complications and length of stay. Other data were analysed using t-tests, chi square and repeated measures analysis of variance. There were no significant differences between the groups in the primary dependent variables. It is concluded that removal of breathing exercises from the routine physiotherapy management of open heart surgery patients does not significantly alter patient outcome.     

Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial

Objective

To investigate whether the inclusion of deep breathing exercises in physiotherapy-directed early mobilisation confers any additional benefit in reducing postoperative pulmonary complications (PPCs) when patients are treated once daily after elective open upper abdominal surgery. This study also compared postoperative outcomes following early and delayed mobilisation.

Design

Cluster randomised controlled trial.

Setting

Single-centre study in a teaching hospital.

Participants

Eighty-six high-risk patients undergoing elective open upper abdominal surgery.

Intervention

Three groups: early mobilisation (Group A), early mobilisation plus breathing exercises (Group B), and delayed mobilisation (mobilised from third postoperative day) plus breathing exercises (Group C).

Main outcomes

PPCs and postoperative outcomes [number of days until discharge from physiotherapy, physiotherapy input and length of stay (LOS)].

Results

There was no significant difference in PPCs between Groups A and B. The LOS for Group A {mean 10.7 [standard deviation (SD) 5.0] days} was significantly shorter than the LOS for Groups B [mean 16.7 (SD 9.7) days] and C [mean 15.2 (SD 9.8) days; P = 0.036]. The greatest difference was between Groups A and B (mean difference −5.93, 95% confidence interval −10.22 to −1.65; P = 0.008). Group C had fewer smokers (26%) and patients with chronic obstructive pulmonary disease (0%) compared with Group B (53% and 14%, respectively). This may have led to fewer PPCs in Group C, but the difference was not significant. Despite Group C having fewer PPCs and less physiotherapy input, the number of days until discharge from physiotherapy and LOS were similar to Group B.

Conclusions

The addition of deep breathing exercises to physiotherapy-directed early mobilisation did not further reduce PPCs compared with mobility alone. PPCs can be reduced with once-daily physiotherapy if the patients are mobilised to a moderate level of exertion. Delayed mobilisation tended to increase physiotherapy input and the number of days until discharge from physiotherapy compared with early mobilisation.     

缩唇腹式呼吸预防骨科术后并发症的效果观察

目的：探讨缩唇腹式呼吸对骨科术后病人并发症的预防效果。方法：选择骨科手术病人202例,随机分为观察组102例和对照组100例,观察组术前实施缩唇腹式呼吸训练,术后每天坚持缩唇腹式呼吸锻炼;对照组实施常规护理。结果：观察组肺部感染、便秘的发生率均明显低于对照组。结论：缩唇腹式呼吸锻炼可有效预防骨科术后病人并发症的发生。     

Incentive spirometry: 2011

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1995 and April 2011. The update of this clinical practice guideline is the result of reviewing a total of 54 clinical trials and systematic reviews on incentive spirometry. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system. 1: Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 2: It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications. 3: It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 4: Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended. 5: Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended. 6: It is suggested that a volume-oriented device be selected as an incentive spirometry device.     

Effect of Cold Application on Chest Incision Pain Due to Deep Breathing and Cough Exercises

BackgroundWe determined the effect of cold application after coronary artery bypass graft surgery on chest incision pain due to deep breathing and coughing exercises. Thoracotomy performed for coronary artery bypass graft surgery is one of the most painful surgical procedures. This pain prevents deep breathing and effective coughing. These problems increase the risk of morbidity in the postoperative period.AimsThis study aimed to determine the effect of cold application after CABG surgery on chest incision pain due to deep breathing and cough exercises.DesignExperimental study with control group and repeated measurements.SettingsPatients were selected through convenience sampling in the Cardiovascular Surgery Intensive Care Unit at a hospital.ParticipantsThe study was conducted with 57 patients who underwent open heart surgery (29 and 28 in the experimental and control groups, respectively).MethodsRepeated pain assessment was performed before, immediately after, and 5 min after deep breathing and coughing exercises performed in 4 periods at 2-h intervals. The first pain assessment was performed 24 h postoperatively. In the first and third assessments of the experimental group, pain was recorded before the exercise; the exercise was performed 15 min after cold gel pack application to the incision area. Pain was assessed before, immediately after, and 5 min after exercise using the Short- Form McGill Melzack Pain Questionnaire.ResultsReduction in pain severity within and between the groups was statistically significant in the first and third evaluations (p = .001).ConclusionsThe results provide evidence to support the use of cold gel pack.     

Physiotherapy for patients following coronary artery bypass graft (CABG) surgery: limited uptake of evidence into practice

The efficacy of physiotherapy techniques used for patients following uncomplicated coronary artery bypass surgery (CABG) is well documented. Previous research showed that some of this evidence was not rapidly adopted into practice by cardiothoracic physiotherapists; however, there has been no recent evaluation of the uptake of evidence. Our aim was to identify current physiotherapy interventions in use for patients following uncomplicated CABG surgery. A survey was sent to senior cardiothoracic physiotherapists from all Australian and New Zealand hospitals that perform CABG surgery. Fifty-four surveys were returned (response rate 88%). The most common treatments used were mobilisation (94% of hospitals), range of motion exercises (79%), deep breathing and/or cough (77%), cardiovascular exercise (42%), and incentive spirometry (40%). Respondents with a bachelor or diploma in physiotherapy were more likely to implement deep breathing exercises or coughing than those who obtained a postgraduate degree (p?=?0.045). Respondents perceived personal experience as the most influential factor on postoperative treatment choices. Physiotherapists treating patients following uncomplicated CABG surgery continue to use interventions such as deep breathing exercises that are not supported by best available evidence. Standardised guidelines may be required to better match clinical practice with current literature.     

Effectiveness of breathing exercises in preventing pulmonary complications following open heart surgery.

The effectiveness of breathing exercises in preventing pulmonary complications was studied in 40 patients undergoing open-heart surgery. Both high- and low-risk patients in the experimental group received one preoperative teaching session and treatment twice a day for the first four days postextubation. Routine postoperative care was given to all 40 patients. Breathing exercises reduced the incidence of pulmonary complications and the necessity for percutaneous endotracheal catheters in the high-risk group. These results justify the use of breathing exercises with the high-risk open-heart surgical patient.     

Physiotherapy for patients following coronary artery bypass graft (CABG) surgery: Limited uptake of evidence into practice

The efficacy of physiotherapy techniques used for patients following uncomplicated coronary artery bypass surgery (CABG) is well documented. Previous research showed that some of this evidence was not rapidly adopted into practice by cardiothoracic physiotherapists; however, there has been no recent evaluation of the uptake of evidence. Our aim was to identify current physiotherapy interventions in use for patients following uncomplicated CABG surgery. A survey was sent to senior cardiothoracic physiotherapists from all Australian and New Zealand hospitals that perform CABG surgery. Fifty-four surveys were returned (response rate 88%). The most common treatments used were mobilisation (94% of hospitals), range of motion exercises (79%), deep breathing and/or cough (77%), cardiovascular exercise (42%), and incentive spirometry (40%). Respondents with a bachelor or diploma in physiotherapy were more likely to implement deep breathing exercises or coughing than those who obtained a postgraduate degree (p?=?0.045). Respondents perceived personal experience as the most influential factor on postoperative treatment choices. Physiotherapists treating patients following uncomplicated CABG surgery continue to use interventions such as deep breathing exercises that are not supported by best available evidence. Standardised guidelines may be required to better match clinical practice with current literature.     

Effects of cardiothoracic physiotherapy on intrapulmonary shunt in abdominal surgical patients

This study investigated the provision of additional evening physiotherapy on pulmonary complications and intrapulmonary shunt (Qs/Qt) after abdominal surgery. Thirty-one elderly patients received either daylight only or daylight plus evening physiotherapy for up to 48 hours. Physiotherapy included combinations of positioning, gravity assisted drainage, breathing exercises, manual techniques, coughing and airway suctioning. Measurements included Qs/Qt and post-operative pulmonary complications. While no significant difference in atelectasis was found, the post-operative Qs/Qt data averaged into six-hour time frames demonstrated significantly lower mean Qs/Qt for the daylight plus evening physiotherapy group between 18 and 24 hours post-surgery. Additional evening physiotherapy may reduce post-operative deterioration in gas exchange after major abdominal surgery.     

开胸术后病人有效深呼吸与咳嗽方法的探讨

目的:探讨开胸患者有效深呼吸、咳嗽方法,以提高开胸患者术后呼吸道护理水平,减少肺部并发症。方法:将1027例开胸患者随机分为观察组514例和对照组513例。对照组给予常规的健康宣教及护理,观察组除上述护理外,入院就对患者进行有效深呼吸、咳嗽训练,术前患者掌握有效深呼吸、咳嗽方法,术后进行有效深呼吸和咳嗽指导。观察患者的深呼吸和咳痰效果。结果:术后观察组深呼吸及有效咳嗽效果明显高于对照组(P<0.01),术后针对患者的具体情况采取相应的有效深呼吸、咳嗽方法,采取两种方法最好。结论:有效深呼吸、咳嗽训练应在入院后就进行训练,术前掌握方法和技巧;健康教育要有针对性,注意检查深呼吸、咳嗽效果;根据患者的具体情况,采取不同的深呼吸训练和咳嗽的方法;使用两种或以上的深呼吸和咳嗽的方法可以达到满意效果;为患者提供深呼吸、咳嗽排痰的有利条件。     

高龄患者围手术期行呼吸训练预防呼吸道并发症的探讨

通过对160例高龄骨科手术患者进行术前和术后呼吸功能训练和指导,患者均未发生肺部并发症.认为围手术期的呼吸训练和指导对减少高龄骨科手术患者的术后并发症,促进其早日康复具有重要意义.     

重度脊柱侧弯患者围术期呼吸道护理

目的探讨重度脊柱侧弯患者围手术期呼吸道护理要点。方法对26例重度脊柱侧弯患者实施矫形手术,术前指导患者进行呼吸功能训练,术后给予呼吸道管理,保持呼吸道通畅,有效疼痛管理及加强呼吸道并发症观察和护理。结果呼吸训练前后患者用力肺活量（forced vital capacity, FVC）平均为45．9％与52．1％,第1S用力呼气容积（forced expiratory volum in one second,FEV1）平均为43．8％与48．8％;肺功能有改善患者18例,占69．2％;术后10d内2例患者发生血、气胸,3例患者发生轻、中度胸腔积液,经有效治疗和护理均能安全渡过围手术期。结论围手术期系统、有效的呼吸功能训练以及呼吸道管理能改善患者肺功能,提高手术安全性及减少术后肺部并发症的发生,促进患者早期康复。     

Pulmonary rehabilitation of patients following thoracic and upper abdominal surgery

The incidence of pulmonary complications is high in patients undergoing thoracic and upper abdominal surgery. Such surgery requires that an incision be made into the patient's respiratory muscles. As a result, each respiration taken induces great pain, which makes patients breathe shallowly and prevents their taking deep breaths and coughing. This article takes a pathophysiological approach in examining the mechanisms involved in the development of pulmonary complications and critiques the effectiveness of rehabilitative interventions that are described in the published literature. Upper arm exercise is suggested as an effective and acceptable intervention to promote pulmonary rehabilitation for this group of patients.     

老年人腹部手术后肺脏并发症的临床研究

目的 探讨老年人腹部手术后肺脏并发症的影响因素.方法 回顾性分析60岁以上老年人择期腹部手术患者95例的临床资料(分为肺脏并发症组和无肺脏并发症组),分析2组患者的年龄、性别、吸烟史、手术时间、手术部位、术前肺功能指标及麻醉方式7个相关因素,以及这些因素与术后肺脏并发症的关系.结果 95例患者中19例发生肺脏并发症;肺脏并发症组患者手术时间(3.4±1.1)h,明显高于无肺脏并发症组患者手术时间(2.6±0.9)h(P＜0.05).肺脏并发症组患者术前肺功能测定中,第1秒用力呼气量占预计值百分比(FEV1%)为(59.2±9.5)%,第1秒用力呼气量与用力肺活量比值(FEV1/FVC)为(61.3±7.7)%,最大通气量占预计值百分比(MVV%)为(59.3±8.6)%,与无肺脏并发症组比较[FEV1%:(79.7±11.5)%、FEV1/FVC:(73.2±8.3)%、MVV%:(74.2±6.4)%],差异均有统计学意义(P均＜0.05).肺脏并发症组患者上腹部手术、全麻术后发生肺脏并发症的危险性增加,与无肺脏并发症组比较差异均有统计学意义(P＜0.05或P＜0.01).结论 手术时间、手术部位、术前肺脏功能异常及麻醉方式可能是老年人腹部手术患者发生术后肺脏并发症的危险因素.     

Effects of early mobilization on pulmonary parameters and complications post coronary artery bypass graft surgery

This study compared the effects of a four-phase and a three-phase early mobilization protocol on respiratory parameters and complications in patients following coronary artery bypass graft surgery. This is a three-arm, parallel-group, randomized controlled clinical trial with 120 candidates for coronary artery bypass graft surgery. Participants were randomly allocated to three groups: four-phase early mobilization protocol, three-phase early mobilization protocol, and control. Arterial blood gases, oxygen saturation, and incidence of pulmonary complications were compared among the groups. Mean arterial blood gases and oxygen saturation improved significantly over time in both four-phase early mobilization protocol and three-phase early mobilization protocol groups compared to control (p < 0.05). There were observed trends for greater improvements in the study outcomes with three-phase early mobilization protocol than four-phase early mobilization protocol; however, did not reach statistically significant levels. The incidence of pulmonary complications was significantly in both intervention groups compared to control (odds ratio: 0.48, 95 % CI 0.007–0.537; p < 0.001). Both four-phase early mobilization and the three-phase early mobilization protocols improved respiratory parameters and reduced pulmonary complications. Statistically insignificant trends were found trends in the three-phase early mobilization protocol, focusing on chest physiotherapy and breathing exercises.     

腹部手术后肺并发症的临床分析

目的探讨腹部手术后肺并发症的影响因素。方法193 例腹部手术患者分为肺并发症组和无肺并发症组,比较两组患者的年龄、吸烟史、手术时间、手术部位、术前肺功能指标,监测术前及术后血气分析。结果共有29 例发生肺并发症。肺并发症组患者平均年龄高于无肺并发症组,手术时间长于无肺并发症组(P<0.05)。吸烟,术前第1 秒用力呼气量(FEV1%)、FEV1/用力肺活量(FVC)%、最大通气量(MVV%)异常者术后发生肺并发症的危险性增加(P<0.05)。两组患者动脉血气分析指标有显著性差异(P<0.05)。结论年龄、吸烟史、手术时间、术前肺功能异常可能是腹部手术患者发生术后肺并发症的危险因素,加强术后血气分析监测有着重要临床意义。     

Chest physical therapy: comparative efficacy of preoperative and postoperative in the elderly

Although chest physical therapy (PT) immediately after surgery lowers the risk of postoperative pulmonary complications, several reports indicate preoperative chest PT results in further improvement. This study compares the effects of initiating chest PT either before and/or after chest surgery in patients over age 65. We studied two groups: 130 patients (the PRE group) undergoing both pre- and postoperative therapy and 150 patients (the POST group) undergoing only postoperative therapy, dividing them into four surgical subgroups: lung, cardiac and other thoracic surgery, upper abdominal, and lower abdominal (considered low risk compared with the other three). Overall complication rates and atelectasis rates were significantly lower in the PRE high-risk subgroups. PRE and POST pneumonia rates, however, were statistically equivalent in all surgical subgroups. Since the low rate of pulmonary complications for PRE-group patients undergoing thoracic or upper abdominal procedures is comparable to that for PRE-group therapy in much younger populations, advanced age alone does not appear to be a significant risk factor. The lack of effect on incidence of pneumonia indicates that preoperative chest PT only counters the altered pulmonary mechanics responsible for atelectasis, but has no effect on pulmonary complications due to infection.     

Patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery

BackgroundClinical interventions aimed at reducing the incidence of postoperative pulmonary complications necessitate patient engagement and participation in care. Patients’ ability and willingness to participate in care to reduce postoperative complications is unclear. Further, nurses’ facilitation of patient participation in pulmonary interventions has not been explored.ObjectiveTo explore patients’ ability and willingness to participate in pulmonary interventions and nurses’ facilitation of pulmonary interventions.DesignSingle institution, case study design. Multiple methods of data collection were used including preadmission (n = 130) and pre-discharge (n = 98) patient interviews, naturalistic observations (n = 48) and nursing focus group interviews (n = 2).SettingA cardiac surgical ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia.ParticipantsOne hundred and thirty patients admitted for cardiac surgery via the preadmission clinic during a 1-year period and 40 registered nurses who were part of the permanent workforce on the cardiac surgical ward.Outcome measuresPatients’ understanding of their role in pulmonary interventions and patients’ preference for and reported involvement in pulmonary management. Nurses’ facilitation of patients to participate in pulmonary interventions.ResultsPatients displayed a greater understanding of their role in pulmonary interventions after their surgical admission than they did at preadmission. While 55% of patients preferred to make decisions about deep breathing and coughing exercises, three-quarters of patients (75%) reported they made decisions about deep breathing and coughing during their surgical admission. Nurses missed opportunities to engage patients in this aspect of pulmonary management.ConclusionsPatients appear willing to take responsibility for pulmonary management in the postoperative period. Nurses could enhance patient participation in pulmonary interventions by ensuring adequate information and education is provided. Facilitation of patients’ participation in their recovery is a fundamental aspect of care delivery in this context.     

呼吸功能训练对开胸手术病人康复的研究

目的探讨术前呼吸功能训练对开胸手术病人康复的影响。方法选自我科2005年1月～12月在我科开胸手术患者100例为观察对象，随机分为实验组50例，对照组50例，对照组按临床常规护理进行指导，实验组行深慢呼吸、缩唇呼吸、咳嗽训练、吹气球训练等呼吸训练，观察比较2组患者术后并发症、胸管留置时间、住院天数，并用进行统计分析。结果实验组明显优于对照组。结论术前呼吸功能训练可减少开胸手术病人术后呼吸系统并发症的发生，促进病人早日康复。