Introduction:
“The term abdominal surgery broadly covers surgical procedures that involves
Opening the abdomen. (1)
During quiet breathing, the contraction of the abdominal muscles increases the intra abdominal pressure by lowering the ribs and flattening the abdomen there by pushing diaphragm upwards to achieve a better expiration.(2)
Recovery from abdominal surgery is primarily endangered by postoperative pulmonary complication, e.g. atelectasis, pneumonia which remains the major causes for postoperative morbidity and mortality (3) Based on many studies performed over a 40-year period reported incidence of postoperative pulmonary complication varies from 6% to 76% .( 4)
General anesthesia reduces functional capacity and predisposes to development of atelectasis and hypoxemia.( 4 )
Functional disruption of respiratory muscles such as intercostals and abdominal muscles by incisions even after surgical repair may impair their effectiveness. Like anesthesia, surgical trauma can also disrupt normal co-ordination of respiratory muscle action leading to persistent decrease in functional residual capacity and vital capacity, which can last for several days after surgery.( 5 )
A major contributor to the decreased lung volume after upper abdominal surgery is breathing pattern characterized by decreased tidal volume, increased respiratory rate and absence of signing .( 4)
Breathing exercise actively exerts the ventilatory muscles and through the recruitment of motor units increases the strength of ventilatory muscles. Improved muscle strength can be used to achieve maximum emptying. (2)
Incentive spirometer is activated by an inspiratory effort; hence incentive spirometer is used clinically as part of the routine prophylactic and therapeutic regimen in perioperative respiratory care. Incentive spirometer technique is activated by an inspiratory effort that is breathing is visualized by an uplifted plate or ball in a transparent cylinder during sustained inspiration.(3)
The relationship between pre-operative variables and postoperative pulmonary complication in surgical patients has been the subject of numerous studies. Despite recent advances in pre operative management post operative respiratory morbidity is still a common problem, especially following upper abdominal surgery.( 6)
Deep breathing and incentive spirometry may increase inspiratory reserve volume, promote maximum alveolar inflation and improve ventilation-perfusion ratio. Deep breathing may actually reverse microatelectasis related to hypoventilation. The incentive spirometer also provides a goal for the patient. (7)
Need for the study:
During review of literature we found no studies which covered both high risk and low risk patients treated with deep breathing exercise and incentive spirometer exercise. Also comparative studies exhibited contradictory results. Hence need arises to measure and compare the effectiveness of deep breathing exercise and incentive spirometer exercise following abdominal surgery on peak expiratory flow rate, thoracic cage expansion and other cardiovascular parameters..
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RESEARCH HYPOTHESIS:
Hypothesis: There will be difference in effectiveness of deep breathing exercises and incentive spirometer exercises following abdominal surgery on peak expiratory flow rate, thoracic cage expansion and other cardiovascular parameters.
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Null hypothesis: There will be no difference between effectiveness of deep breathing exercise and incentive spirometer exercise following abdominal surgery on peak expiratory flow rate, thoracic cage expansion and other cardiovascular parameters.
REVIEW OF LITERATURE
Usually a complication is defined as an unexpected second disease entity that requires special treatment. The most common pulmonary complications are atelectasis, respiratory infections, bronco constriction and respiratory failure. (7)
After abdominal surgery functional residual capacity can decrease to 60 % to 70% of pre operative levels and may return to only 70% of normal by postoperative 7 to 10 days. This is associated with a further reduction in compliance, possibly due to collapse of air spaces. (8)
Postoperative hypoxemia results predominantly due to gas exchange impairment during anesthesia. As a result of this there is reduced tone in the muscles of the chest wall and alterations in bronchomotor and vascular tone; these changes persist into the postoperative period. In addition, there is an abnormality of control of breathing which results in episodic obstructive apnea. These episodes continue for several days after operation. (9)
The incidence of hypoxemic events in postoperative adult patients was noted by monitoring the peripheral arterial oxygen saturation (SpO2) with pulse oximeter.
All these patients had Sp02 >97% before transfer to the recovery room. This study revealed that the overall incidence of hypoxemia in these patients was 42%. On arrival in the recovery room 28% patients had Sp02 <90%. This study concludes that hypoxemic events are common following abdominal surgery even in patients otherwise considered healthy. (10)
A randomized controlled trial was done on group of 174 patients to evaluate the clinical benefit and physiological effects of prophylactic chest physiotherapy in major open abdominal surgery. They all received breathing with pursed lips, huffing and coughing. It was concluded pre operative chest physiotherapy reduced the incidence of postoperative pulmonary complication and improved mobilization and oxygen saturation after abdominal surgery.( 11)
It was seen that prophylaxis against post-operative respiratory complications is optimal when it is based on techniques that promote a maximal inspiratory effort. The balances of evidence suggest that any form of maximal inspiratory therapy is beneficial.( 12)
A case control study was done to compare the incidence of postoperative pulmonary complications after laproscopic and open cholecystectomy .All patients were encouraged to use an incentive spirometer at least 10 times per hour while awake. The risk factors for postoperative pulmonary complication were equitably dispersed between the groups, and there was a significant difference in the incidence of complications between laproscopic group (2.7%) and then open surgery group (17.2%). (13)
A study investigated the effects of pre and post operative breathing exercise training on the vital capacity and peak expiratory flow rate of upper and lower abdominal surgery patients. The breathing exercise program included Apical, lateral costal, postero basal, and diaphragmatic breathing exercises. Vital capacity and peak expiratory flow rate measured after each exercise session. They concluded breathing exercise training improved vital capacity and peak expiratory flow rate.( 2)
A study was done to assess the reliability of using a cloth tape measure to determine thoracic respiratory excursion as a measurement of chest expansion or mobility. Upper thoracic excursion measurements were taken at the level of the fifth thoracic spinous process and the third intercostals space at the midclavicular line. Lower thoracic excursion measurements were taken at the level of the 10th thoracic spinous process and the xiphoid process. At peak inhalation and exhalation, three examiners measured thoracic excursion at both levels. The method of using a tape measure to assess thoracic excursion was highly reliable. (14)
A stratified randomized trial was done on patients undergoing abdominal surgery. The subjects were low risk patients of less than 60 years of age. Evaluation of the prevention of respiratory complication after abdominal surgery was carried out. A comparison of a global policy of incentive spirometry with a regime consisting deep breathing exercises of low risk patients and incentive spirometry plus physiotherapy for high-risk patients was conducted. They concluded that most efficient regime of prophylaxis against respiratory complication after abdominal surgery is deep breathing for low risk and incentive spirometry for high-risk patients. (12)
A clinical trial with 876 patients aimed at preventing pulmonary complication after abdominal surgery. Patients either received conventional chest physiotherapy or were encouraged to perform maximal inspiratory maneuvers for 5 min during each hour while awake, using an incentive spirometer. The incidence of pulmonary complication did not differ significantly between 2 groups. It was concluded that prophylactic incentive spirometer and chest physiotherapy are of equivalent clinical efficiency. (15)
In a randomized study, compared a group of patients receiving incentive spirometer exercise another group receiving no specialized postoperative respiratory care. Patients receiving incentive spirometer encouraged to breathe deeply for 5min hourly for 12 times daily. No statistically significant difference between 2 groups was found in radiological evidence, arterial oxygen pressure, spirometric measurement and clinical evaluation at 2nd and 4th postoperative day. This study concludes that lack of therapeutic values of incentive spirometer in patients following abdominal surgery in preventing postoperative pulmonary complication. (16)
In systematic review the evidence examining the use of incentive spirometer exercises for the prevention of post operative pulmonary complication. For the search they included incentive spirometer, deep breathing exercises, chest physical therapy and pulmonary complication. Each study was reviewed by 3 pairs of group members. They concluded that evidence does not support use of incentive spirometer for decreasing the incidence of postoperative pulmonary complications following cardiac or upper abdominal surgery. (17)
OBJECTIVES OF THE STUDY:
1. To measure the effectiveness of deep breathing exercises on peak expiratory flow rate and thoracic cage expansion following abdominal surgery.
2. To measure the effectiveness of incentive spirometer exercise on peak expiratory flow rate and thoracic cage expansion following abdominal surgery.
3. To compare efficacy of deep breathing exercises over incentive spirometer exercise on peak expiratory flow rate and thoracic cage expansion.
b) / PROCEDURE, MATERIALS AND METHODS:
SOURCE OF DATA COLLECTION:
S. D. M. College of Medical Sciences and Hospital, Dharwad.
METHOD OF DATA COLLECTION:
Material:
1. Data collection sheet.
2. Inch tape.
3. Peak expiratory flow meter.
4. Pulse oximeter.
5. Incentive spirometer.
6. Sphygmomanometer.
7. Pillows.
8. Sputum box.
Inclusion Criteria:
1. Elective abdominal surgical patients of either sex.
2. Age groups between 18 to 60 years.
3. Class I II will be selected of patient’s related risk factors, according to American Society of Anesthesiologist’s classification. (19)
Exclusion Criteria:
1. Unstable medical condition e.g. heart disease.
2. Subjects with other contagious or infectious disease that is, transmitted by upper respiratory tract.
3. Patient who cannot follow the commands.
4. Patient who had elective operation for hernia.
5. Hypertension.
6. Haemoptysis.
7. Aortic aneurysms.
8. Pulmonary oedema.
9. Cardiac arrhythmias.
10. Rib fractures.
11. Acute pleuritic pain.
Study Design: Experimental study
Study duration: 1 year
Sample: A convenient sample of thirty planned abdominal surgery subjects will be selected for the study from S.D.M. College of Medical Sciences and Hospital Dharwad.
PROCEDURE:
The written consent will be obtained from the subjects regarding the experimental procedure prior to the study. They will be divided into two groups (group 1 & 2) 15 each.
48 hours prior to the surgery physiotherapy treatment will be started.
The following exercise protocol patients will follow
Group 1
A. Routine chest physiotherapy.B. Deep breathing exercises – 1. Diaphragmatic breathing.
2. Lateral coastal expansion.
3. Middle or lingual expansion.
4. Apical breathing.
C. Ankle toe movements.
D. Upper limb active exercises.
Group 2
A. Routine chest physiotherapy.B. Incentive spirometer exercise.
C. Ankle toe movements.
D. Upper limb active exercises.
Dosage:
1. 10 breaths each time / breathing exercise.
2. Hourly during waking hours.
3. Follow up for 2 days preoperatively and 6 days post operatively.
4. Ankle and toe movements for 10 counts / session.
The following parameters will be recorded;
1.Respiratory rate.
2 Heart rate.
3 Blood pressure.
4 Chest expansion.
5 Peak expiratory flow rate.
6 Breathing pattern.
7 Oxygen saturation
Parameters 4 & 5 will be recorded preoperatively on day 1 & 2 before and after exercise, then 3rd and 6th day postoperatively before and after exercise.
Parameters 1,2,3,6,7 will be recorded preoperatively on day 1 & 2 before and after exercise, then postoperatively everyday, once in a day parameters will be recorded, before, after & 3min after exercise.
Statistical Test Used
1 .The student paired ‘t’ test.
2.The student unpaired ‘t’ test.
DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
IF SO DESCRIBE BRIEFLY – YES
1.Deep breathing exercise.
2. Incentive spirometer exercise.
3. Peak expiratory flow meter.
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HAS ETHICAL CLEARANCE BEEN OBTAINED BY YOU –YES
c) / REFERENCE LIST:
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