Post-CABG Physiotherapy Management in Hospital - Essay Example

Post-CABG Physiotherapy Management in Hospital: The Importance of Breathing Exercises One of the most common complications that follow a cardiac surgery is decline in pulmonary function. This sometimes turns out to be so complicated that it necessitates prolonged mechanical ventilator support. One of the most significant risk factors in the use of prolonged ventilator support is age. Advanced age can complicate prolonged mechanical ventilation, thus complicating the pulmonary dysfunction post cardiac surgical treatment. Postoperative pulmonary dysfunction is a significant clinical complication in patients undergoing cardiopulmonary bypass (CPB). The complications may range from sub-clinical functional changes to full-blown ARDS (acute respiratory distress syndrome) with the latter occurring in less than 2% of the cases post CPB (Ng et al. 2002). ARDS leads to prolonged hospital stays and recoveries, and in more than half the cases, death. There are several triggering factors for pulmonary dysfunction post cardiac surgery. A very significant triggering factor is the general anaesthesia that the patient undergoes, which causes atelectasis. There could also be lung injury and delayed pulmonary recovery due to the damaging effects of a systemic inflammatory response associated with cardiopulmonary bypass (Ng et al. 2002). Oxygenation which may induce increased free radical activity is a potential risk of ARDS after CPB. The use of CPB can also lead to the development of pulmonary edema. Arterial hypoxaemia is another aftermath that is usually associated with CABG. Post-operative chest therapy Chest physical therapy has been a widely used treatment option for prevention of pulmonary complications post cardiac surgery. Different countries use different techniques of treatment. However, the routine use of breathing exercises following cardiac surgery has been subject to controversy in the recent years (Westerdahl et al. 2005, p. 3482). Breathing exercises along with physical therapy have not been found to be more beneficial than physical therapy with early mobilisation alone in reducing atelectasis, pneumonia, gas exchange and lung function impairment and such other pulmonary complications post cardiac surgery. Are breathing exercises necessary A study was conducted by Jenkins et al. (1989), to investigate whether breathing exercises or incentive spirometry along with early mobilisation and training in huffing and coughing can help improve lung function and prevent chest infection in post-CABG patients (Jenkins et al. 1989, p. 634). The study included consecutive white men undergoing elective coronary artery bypass grafting during one year. Lung volumes were measured before surgery and the highest values were used for the study. Arterial oxygen and carbon dioxide tensions were measured. Forced vital capacity, forced expiratory volume in one second and peak expiratory flow were measured, and the highest of five maximal forced expirations were taken. Patients with forced expiratory ratio less than 60% were not included in the study. Before surgery, all patients were advised of the need to move about after surgery and to expectorate excess bronchial secretions. The Group 3 patients participating in the study were trained in huffing or forced expirations with the glottis open, coughing with sternal support, and exercises of the upper and lower limbs (Jenkins et al. 1989, p. 635). The patients sat up in a chair when they were able to, walked on the second postoperative day and climbed stairs on the fourth postoperative day. In addition to the above treatment, group 1 patients were advised on the need for taking deep breaths and group 2 patients on using an incentive spirometer. Maximum oral temperature and medication received, distance walked by the patient, patients' subjective assessments of chest discomfort and the number of self-treatment sessions undergone were recorded every day over the course of the study. Measurements were taken for five days only, as most hospitals gave postoperative physiotherapy for five days only, after which the patients are transferred. The study showed that "a severe and persistent restrictive ventilatory defect and arterial hypoxaemia occurred after coronary artery bypass grafting" (Jenkins et al. 1989, p. 637). Addition of breathing exercises or incentive spirometry to early mobilisation and huffing and coughing did not lead to rapid improvement in postoperative lung function. The researchers concluded that post-CABG patients should be assessed by a physiotherapist and advised on huffing and coughing and early mobilisation before and after surgery, and additional physiotherapy need be considered only in the event of declining respiratory condition or impossible mobilisation. Stiller et al. had conducted a study in 1994 to investigate the effectiveness of prophylactic chest physiotherapy in reducing the incidence of pulmonary complications after coronary artery surgery (p. 741). The patients under study were segregated into three groups. Patients in group 1 received no chest physiotherapy preoperatively or postoperatively. The patients of group 2 received chest physiotherapy that included deep-breathing and coughing exercises. The breathing exercises consisted of performing three to five deep breaths with intervals of quiet breathing followed by two or three coughs or huffs with wound support (Stiller et al. 1994, p. 741). This cycle was repeated until the cough sounded dry and if this did not clear excessive secretions, the patient used techniques such as positioning and chest wall vibrations. The breathing and coughing exercises were performed every waking hour. Group 3 patients were trained in the same techniques as group 2, but they were seen and assisted by the physiotherapist more frequently. All patients were sitting out of bed on postoperative day 2, walking from postoperative day 3 and climbing on postoperative day 7 (Stiller et al. 1994, p. 741). There were no remarkable differences among the patients of the three groups in their preoperative profiles or pulmonary function test values as well as operative and preoperative details. The incidence of fever was not significantly different among patients of all groups. The arterial blood gas levels also did not show major differences. Chest x-rays preoperatively showed a score of zero for all except nine patients who had minor atelectasis. On postoperative day 1, the majority of the patients showed evidence of minor pulmonary infiltrates. Similar findings were found on the fourth postoperative day. There were no significant differences in scores, the incidence or the location of abnormalities before or after surgery. Similarly, there was no significant difference in the incidence or severity of pleural effusion between the groups (Stiller et al. 1994, p. 744). There was no significant difference between the control group and the treatment groups in the incidence of pulmonary complications. The prophylactic chest physiotherapy did not decrease the incidence of fever, hypoxemia, x-ray evidence of abnormalities, clinically significant pulmonary complications, or length of postoperative hospital stay. Moreover, while prophylactic chest physiotherapy did not prevent pulmonary complications, the effectiveness of the therapy on the complications once they occurred was not investigated in the study. The study suggests that the physiotherapist should assess and select those patients with clinically significant pulmonary complications and treat them with chest physiotherapy (Stiller et al. 1994, p. 747). Another study was conducted by Westerdahl et al. to investigate the effects of deep-breathing exercises on post-CABG pulmonary function, atelectasis and arterial blood gas levels. The study compared the effectiveness of voluntary deep-breathing exercises when performed with a positive expiratory pressure blow-bottle device as compared to the recovery course of a control group, the members of which did not perform breathing exercises. The patients under study were divided into a deep-breathing group that performed deep-breathing exercises postoperatively and a control group that did not perform deep-breathing exercises. All the patients had similar preoperative details in that they had all undergone median sternotomy under general anaesthesia and the CABG involved the use of saphenous veins and, in most cases, the left internal mammary artery. All patients inspired oxygen of similar concentrations during anaesthesia and post surgery. Cold-blood cardioplegia was used and an insulation pad protected the phrenic nerve. Twenty-four hours after surgery, the pericardium, the mediastinum, and sometimes one or both pleura were drained. The patients received mechanical ventilation following surgery with similar positive end-expiratory pressures (Westerdahl et al. 2005, p. 3483). The patients were extubated once they resumed normothermia, became hemodynamically stable with adequate diuresis and no excessive bleeding. The patients were able to breathe normally. All patients received pain relief according to standard norms. All the patients participating in the study received chest physiotherapy on the first four postoperative days. Therapy included early mobilisation, training in coughing techniques, active exercises of the shoulder girdle and upper back, and support for turning from side to side and out of bed. The patients were sitting up or standing on the first postoperative day, walking short distances on the second day and longer distances on the third day. On the third and fourth days, they participated in sitting exercise program (Westerdahl et al. 2005, p. 3483). Deep-breathing exercises for the deep-breathing group started one hour after extubation. The exercise included three sets of 10 deep breaths with a 30- to 60-second pause in between sets. This was done once per hour when awake, in the sitting position, with coughing during the pauses. A 50-cm plastic tube, one centimetre in internal diameter, in a bottle containing 10 cm of water, called the blow bottle, was used. This was to create an expiratory resistance of +10 cm of water (Westerdahl et al. 2005, p. 3483). Patients who could not use the bottle, used a PEP/respiratory muscle training facemask. They performed slow inspirations with expirations ending at approximately functional residual capacity in order to minimize airway closure and alveolar collapse (Westerdahl et al. 2005, p. 3483). The results showed that pain from the sternotomy were almost similar for patients of both groups. None of them showed signs of pneumonia. There was no remarkable difference in the length of hospital stay between patients. On the fourth postoperative day, the patients in deep-breathing group showed significant reduction in FVC and FEV1 as compared to patients in the control group. While all examined patients had atelectasis, the deep-breathing group patients had an atelectatic area half the size as compared to the control group. There were no considerable differences in the arterial blood gas levels between the patients of both the groups. The study showed that deep-breathing exercises helped in significantly reducing atelectasis and improving spirometry values. The study did not confirm the effectiveness of the blow-bottle technique, as the same result could have been achieved even without using the device. Overall, the study did not confirm the necessity of increasing the breathing exercises for increased benefit (Westerdahl et al. 2005, p. 3487). An attempt to understand the significance of the role of breathing exercises in improving the postoperative outcomes in patients who have undergone cardiac surgery was made by Brasher et al. through a study conducted in 2003. The patients were divided into a breathing exercise or control group and an intervention group. The patients in the intervention group were educated on the effects of surgery on lung function, positions to improve lung function, progression of mobilisation post surgery and coughing with support (Brasher et al. 2003, p. 167). Subjects of the breathing exercise group were taught all of the above along with the techniques of performing deep-breathing exercises. On the first postoperative day, the subjects were sat out of bed at the afternoon treatment. On the second day, the subjects were ambulated for a distance of 10 metres, sat out of bed and encouraged with supported cough. On the third day, subjects were ambulated for about 30 metres as able. In addition to these exercises, the subjects of the breathing group performed an exercise of four sets of five deep breaths from functional residual capacity to total lung capacity, with a 3-second hold at the end of each inspiration. The exercise was performed with the physiotherapist's hands placed on the subjects' lateral costal margin (Brasher et al. 2003, p. 167). A supported cough was performed after the second and the final set of breaths and the exercises were performed in upright sitting or flat sidelying position. These exercises were performed every waking hour. During the study, three subjects from each group developed postoperative pulmonary complications. Two subjects who were withdrawn from the study had also developed pulmonary complications. There was no significant difference between the groups in the verbal pain scores, which decreased over the course of three days. Nine subjects from the breathing exercise group and 14 from the intervention group were readmitted to hospital within 28 days of discharge. None of the readmissions were for significant pulmonary complications. There were no considerable differences between the groups in pulmonary function measurements. The study concluded that breathing exercises did not have any significant effect on the complications that usually follow coronary surgery. In yet another study, Westerdahl et al. (2001) compared the effectiveness of three different deep-breathing techniques, including deep breathing with no mechanical device, with blow-bottle device, and with inspiratory resistance-positive expiratory pressure (IR-PEP) mask (p. 79). The IR-PEP helped mobilise secretions and enhance the function of the diaphragm following open heart surgery. Four days postoperatively, all pulmonary function variables showed significant decrease in all the three groups, but there was no significant difference among the results showed by the three groups. The impairment in pulmonary function was less, however, in subjects who used the blow-bottle technique. The results of the study pointed to the importance of assistance from the physiotherapist and patient collaboration and motivation in administering efficacious treatment. Besides, it was also suggested that the lack of control of the deep breathing exercises cast on them a degree of uncertainty. A study was conducted by Dull and Dull (1983) to determine whether maximal inspiratory breathing exercises or incentive spirometry was better than early mobilisation for management post cardiopulmonary bypass. Patients participating in the study were assigned to one of the three exercise programs under study (Dull & Dull 1983, p. 655). Physical examination and pulmonary function tests were performed on the patients at the start of the exercise program as well as 24 and 48 hours later. The lung volumes reduced significantly, with no airflow obstruction in patients who had CABG. In addition to lung volume reduction, mild airflow obstruction was noted in patients who had valve replacement. Postoperative pulmonary complications occurred in most of the patients, with no significant differences among the exercise programs in improving or preventing postoperative pulmonary complications. The study concluded that neither maximal inspiratory breathing exercises nor incentive spirometry presented any therapeutic advantage when used in addition to early mobilisation as compared to early mobilisation by itself (Dull & Dull 1983, p. 659). Early mobilisation alone is as effective in returning airflow and lung volumes to the preoperative levels. Conclusion None of the above researches have succeeded in validating positively the importance of including breathing exercises in the post-cardiac surgery physiotherapy management of patients until discharge, though they have been found to help lung volumes to some extent. References Brasher, P. A., McClelland, K. H., Denehy, L. & Story, I. 2003, 'Does removal of deep breathing exercises from a physiotherapy program including pre-operative education and early mobilisation after cardiac surgery alter patient outcomes', Australian Journal of Physiotherapy, vol. 49, pp. 165-173. Dull, J. L. & Dull, W. L. 1983, 'Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass', Physical Therapy, vol. 63, no. 5, pp. 655-659. Ng, C. H. S., Wan, S., Yim, A. P. C. & Arifi, A. A. 2002, 'Pulmonary dysfunction after cardiac surgery', Chest, vol. 121, no. 4, pp. 1269-1277, viewed 16 April 2009, http://www.chestjournal.org/content/121/4/1269.full Jenkins, S. C., Soutar, S. A., Loukota, J. M., Johnson, L. C. & Moxham, J. 1989, 'Physiotherapy after coronary artery surgery: are breathing exercises necessary', Thorax, vol. 44, pp.634-639. Stiller, K., Montarello, J., Wallace, M., Daff, M., Grant, R., Jenkins, S., Hall, B. & Yates, H. 1994, 'Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery', Chest, vol. 105, pp. 741-747. Westerdahl, E., Lindmark, B., Almgren, S. O. & Tenling, A. 2001, 'Chest physiotherapy after coronary artery bypass graft surgery - A comparison of three different deep breathing techniques', J Rehab Med, vol. 33, pp. 79-84. Westerdahl, E., Lindmark, B., Eriksson, T., Friberg, O., Hedenstierna, G. & Tenling, A. 2005, 'Deep-breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery', Chest, vol. 128, pp. 3482-3488. Read More