RAJIVGANDHI UNIVERSITY OF THE HEALTH SCIENCESKARNATAKA,BANGALORE
SYNOPSIS
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATE / Mrs. CAROLINE STELLA2 / NAME OF THE INSTITUTION / Diana college of nursing,
No-68,chokkanahalli,jakkur post,Bangalore-64
3 / COURSE OF THE STUDY AND SUBJECT / Master of science in nursing
Medical and surgical nursing
4 / DATE ADMISSION TO COURSE / 16.06.2012
5 / TITLE OF THE TOPIC / To assess the effectiveness of breathing exercises among patients undergoing coronary artery bypass graft surgery at selected fortis hospital in bangalore.
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION:
Chest physiotherapy and breathing exercises are often prescribed to patients undergoing cardiac surgery in order to prevent or reduce postoperative pulmonary complications. There is an agreement on the value of pre and post operative breathing exercises and physiotherapytreatment. Physiotherapy intervention have no benefit following uncomplicated CABG surgery include treatment during the intubation period , deep breathing exercise ( DBE), percussion , incentive spirometry , intermittentpositive pressure breathing and continuous positive pressure breathing and continuous positive airwaypressure. Techniques shown to be of benefit include positive expiratory pressure (PEP), early and progressive mobilization and walking training. Upper limb and thoracic range of movement exercises have shown benefits 9.
The aspect of physiotherapy intervention that research has shown to be of greatest benefit is early and progressive mobilization and walking. Walking more often and for longer periods helps patients to achieve functional milestones more quickly, cope better with walking after discharge and have greater satisfaction with their treatment than patients who walk less . When patients mobilize their
ventilation perfusion match is optimized , tidal volume will increase and respiratory rate will rise . Therefore, it is logical that mobilizing is an effective method of ensuring deep , effective breathing 6.
The litreature contains examples of different breathing techniques with and without mechincal devices after cardiac sugery(3,5-7) but there is controversy regarding which bretahing techniques are the most effective. Surveys describing chest physiotherpy mangament of pateinets undergoing cardiac surgery have been carried out in Austrilia and Newzeland [8] and Canda [9]. The use of postive preassure devices during hospitalization in Brazil has also recently been presented[10]. It appears to be various recommendation of breathing excersices for patients undergoing cardiac surgery around the world.To date,no survey describing the use of post –oprative breathing excersices for cardiac surgery patients in Europe has been carried out12 .
The aim of the present study was to determine current physiotheraphy practice regarding breathing exercise for patients undergoing cardiac surgery in Sweden.
The effectivness of prophlyactic deep breathing excercises in patients undergoing cardiac surgery has been questioned (dull and dull 1983,jenkins et al 1989,silleret al 1994) and although the results of these studies are well known they do not appear to have significantly influenced clinical practise in Australlia (Tucker et al 1996)5.
Research indiactes physiotheraphy interventions that have no benefit following uncomplicated CABG suregery include treatment during the intubation period,deep breathing excersises (DBE),percussion,incentive spirometry,intermettent postive pressure breathing and continous postive airway pressure .Techniques shown to be of benefit include positive expiratory pressure(PEP),early and progressive moblistation and walking.3
6.1 NEED FOR THE STUDY:
Atelactasis and arterial hypoxemia are commonly seen after cardiac surgery . Chest physical therapy is widely used postoperatively for the prevention of pulmonary complications.8
A variety of treatment techniques are used , and there are differences in the management between countries . In later years , the routine use of breathing exercises after cardiac surgery has been questioned .Breathing exercises combined with physical exercise after coronary artery bypass graft ( CABG ) surgery have been reported not to be more effective than physical therapy , including early mobilization alone in reducing atelactasis , pneumonia , gas exchange and lung function impairment or other kinds of pulmonary complications . 6
We have shown an immediate effect of a single session of voluntary deep – breathing exercises on atelectasis and oxygenation on the second post operative day after CABG surgery . Incentive spirometry remains a frequently used tecnique for the prophylaxis and treatment of respiratory complications in post surgical patients , but the evidence does not support the use of INCENTIVE SPIROMETRY for decreasing the incidence of atelectasis and pulmonary complications following cardiac surgery .4
Post-operative pulmonary complications after coronary artery bypass graft ( CABG ) surgery are still a major cause of morbidity and mortality . Impairment of pulmonary function , and post operative atelectasis are common in patients with CABG .Respiratory physiotherapy is routinely used in the prevention and treatment of post operative pulmonary complications after cardiac surgery . The goals of physiotherapy are to improve ventilation- perfusion matching , increase lung volume , enhance mucocilliary clearence and decrease pain .Post operative physiotherapy techniques include early mobilization, change of position , breathing exercises , cough , huffing , and various mechanical devices such as INCENTIVE SPIROMETER , POSITIVE EXPIRATORY PRESSURE MASK therapy and CONTINUOUS POSITIVE AIRWAY PRESSURE .
Early mobilization has been accepted as the most important therapy after surgery in the prevention and treatment of pulmonary impairment.13
Post –operative complications are realtivly frequent after cardiac surgery.it has earlier been
surgery gested that breathing exercise after uncomplishmented cardiac surgery confers no
extra benefit [21,22]. Since than several articles showing the effect of both pre and
postoprative chest physiotherahy techiques have been published [1,2,4,15] . how ever
there is currently no evidence to support one brathing techinque over another[6,15,23,24].
Chest physiotheraphy treatment was routinely given to patients,at the thoratic intensive
care unit(ICU), during the frist post operative morning after surgery.twenty of the
physiotheraphy had expiernce from working in the ICU.written guidelines or protocols
for the physiotherapist treatment of extubated patients in the ICU were
available according to 14 of the respondents,wheras physiotheraphy guidelines for intubated patients were less accesiable (n=4).9
During the intial post –oprative days the patients usally recived 1 to 3 treatment sessions a
day by the physiotherapist detailed information on post operative moblistaion,range of
motion excericeses , and sterna precautions has been published previously [11].coughing
support was provided to the patients ,according to all 29 physiotherapist . several methods
were used patient performance with a small pillow ,without a pillow manual support from
the physiotherapist ,or sterna support with a device such as the heart hugger harness.7
All of the physiotherapist intstructed the patients to peform breathing excercises on a
regular basis post operatively . breathing excersises usally provided to the patients on the
frist post operative days of after surgery .The two most frequently used breathing
techniques were positive experitaory preassure (PEP) device breathing and deep
breathing performed without any mechanical device.PEP device breathing was routinely
used as frist choice treatment by 24(83%) of the respondence. Expiratory preasure used
for PEP treatment was in the range of 2 to 20cm of water .The instruction of the patient
on how to perform the breathing excercises with the PEP device (mask,mouth pieceor
blow bottle)..Instructions to the patients to continue breathing excersises after distcharge
varied considarebly.10
6.2 . REVIEW OF LITERATURE ;
Patients undergoing cardiac surgery are at risk of postoperative complications such as pneumonia . These complications prolong postoperative recovery and may even lead to death . Increased physical fitness improves people's functional capacity, including their lungs, and could result in individuals being better prepared to withstand the consequences of the physical stress of surgery.
Review of literature is discussed under following headings :
1)PRE OPERATIVE PHYSICAL THERAPY FOR ELECTIVE CARDIAC SURGERY PATIENTS
2)PHYSIOTHERAPY AFTER CORONARY ATERY SURGERY : ARE BREATHING EXERCISES NECESSARY?
3)ACTIVE CYCLE OF BREATHING TECNIQUES AND INCENTIVE SPIROMETER IN CORONARY ARTERY BYPASS GRAFT SURGERY .
1 Literature related to Preoperative physical therapy for elective cardiac surgery patients
From the pertinent literature , eight studies met the inclusion criteria , compromising a total of 856 participants . The resshowed that preoperative physical therapy reduced the number of participants who experienced atelectasis or pneumonia but not the number of patients who experienced pnemothorax , prolonged ventilation or postoperative death . Patients who had preoperative physical therapy had an earlier ( on average by more than three days ) discharge from the hospital . Information on adverse events was limited but those studies that did report on adverse events reported none . None of the studies reported on the costs of preoprative physical therapy .
The authors concluded that postoperative physical therapy , especially inspiratory muscle training , prevents some postoperative complications including atelectasis , pneumonia , and length of hospital stay . After cardiac surgery , physical therapy is a routine procedure delivered with the aim of preventing postoperative pulmonary complications . Searches were run on the Cochrane central Register of controlled trials ( CENTRAL ) on the Cochrane library ( 2011, issue 12 ) : MEDLINE ( 1966 to 12 December 2011 ) : EMBASE ( 1980 to week 49, 2011 ); the physical Therapy Evidence Database ( PEDro ) ( to 12 December 2011) and CINAHL ( 1982 to 12 December 2011 ) .
Randomized controlled trials or quasi- randomized trials comparing preoperative physical therapy with no preoperative physical therapy or sham therapy in adult patients undergoing elective cardiac surgery .
Data were collected on the type of study , participants , treatments used , primary outcomes ( post operative pulmonary complications grade 2 to 4 ; atelectasis , pneumonia , pnemothorax , mechanical ventilation > 48 hrs , all- cause death , adverse events ) and secondary outcomes ( length of hospital stay , physical function measures , health – related quality of life , respiratory death rate , costs ) .Data were extracted by one review author and checked by a second review author .
Eight randomized controlled trials with 856 patients were included. Three studies used a mixed intervention ( including either aerobic exercises or breathing exercises ) ; five studies used aspiratory muscle training . Only one study used sham training in the controls . Patients that received preoperative physical therapy had a reduced risk of postoperative atelectasis ( four studies included 379 participants , relative risk (RR) 0.52;
2. Literature related to Physiotherapy after coronary artery surgery ; Are breathing exercises necessary ?
One hundred and ten men undergoing coronary artery bypass grafting took part in a prospective randomized study comparing three physiotherapy protocols . All patients were taught self-supported huffing and coughing by a physioth( group 3 ). Additional physiotherapy included breathing exercises for the 35 patients in group 1 and use of an incentive spirometer for the 38 patients in group 2 . Functional residual capacity ( FRC ) was measured daily at the bedside until the fifth postoperative day and arterial blood gas tensions were measured on the second and fourth postoperative days . After surgery patients developed a severe restrictive ventilator defect and profound arterial hypoxemia . There were no differences between the three groups . Mean FRC on day 2 was 1,90 liters ( 61 % of the preoperative value . ) , increasing to 2321 by day 5 ( 76% of the preoperative value ) . The mean arterial oxygen tension was 7.37 kpa on day 4 . Four patients in group 1 , two in group 2 , and five in group 3 developed a chest infection . It is concluded that the addition of breathing exercises or incentive spirometry to a regimen of early mobilization and huffing and coughing confers no extra benefit after uncomplicatedcoronary artery bypass grafting.
After coronary artery bypass grafting physiotherapy – consisting of breathing exercises emphasizing inspiration. Incentive spirometry, techniques to clear bronchial secretions, and early mobilization – is given with the aim of increasing lung ventilation and preventing chest infections.
So far all studies comprising physiotherapeutic techniques in patients who have had coronary artery bypass grafting have carried out in the united states or Canada , and with the exception of one study have included patients undergoing cardio pulmonary bypass for other surgical procedures . The number of patients randomized to a study group has been eight or less in some cases , and the physiotherapy techniques have on occasions differed considerably from those used in Britain .
The present study was undertaken to investigate whether the addition of breathing exercises or incentive spirometry to a regimen of early mobilization and instruction in huffing and coughing would prove more effective in improving lung functions and preventing chest infection in men recovering from coronary artery bypass grafting .
Consecutive white men undergoing elective coronary artery bypass grafting during one year were considered for inclusion in the study . Patients who had previously had cardiac surgery and those unable to walk the length of the ward ( 64 meters ) for reasons other than angina were excluded . The study was supposed by the hospital ethics committee and informed written consent was obtained from all patients .
Patients were first studied in the afternoon during the 48 hours before surgery . Pulmonary function was measured at the bedside with the patient sitting upright in a chair as follows .
Lung volumes function residual capacity ( FRC ) was measured by the steady state helium dilution method with a portable spirometer . Three vital capacity ( VC ) breaths were taken at the end of the test and the height value was used in the calculation .
3. Literature related Active cycle of breathing techniques and incentive spirometer in coronary artery bypass graft surgery.
The purpose of this study was to evaluate the efficacy of incentive spirometer ( IS ) and active cycle of breathing techniques ( ACBT ) following coronary artery bypass graft ( CABG ) surgery . Sixty male patients( 41.75 yrs ) with CABG were included in this prospective randomized study . Thirty patients underwent ACBT and 30 patients underwent IS combined with mobilization , patients were evaluated using pulmonary function tests , arterial blood gases , 6-minute walk test ( 6MWT ), chest radiography, and a 10-cm visual analogue scale for pain perception . Fifth day post-operatively , pulmonary function variables were similarly but significantly decreased in both groups compared to pre-operative values ( vital capacity decreased 15% and 18% in ACBT and IS , respectively , p<0.05 ). First day post- operatively , there was significant increase in oxygen saturation after the treatments in both groups . Incidence of atelectasis and pain perception was similar between the groups ( p>0.05) . No significant difference was found in 6MWT distance obtained before and on the fifth day following CABG surgery within and between ACBT and IS groups ( p>0.05 ) .Both treatments improved arterial oxygenation from the first day postoperatively . After a 5 – day treatment , functional capacity was well preserved with the usage of ACBT or IS . Both physiotherapy methods had similar effects on the rate of atelectasis , pulmonary function , and pain perception .
The study was conducted in a military academy hospital , for a 1 year period between May 2003 and May 2004 . The institution review board approved the study protocol . Inclusion criteria were elective CABG procedure , age of greater than 18yrs, and an ejection fraction above 50%. Exclusion criteria were current smoking , a history of a cerebrovascular accident , renal dysfunction requiring dialysis , use of immunosuppressive treatments during the 30-day period before surgery , the presence of neuromuscular disorders or chronic obstructive pulmonary disease, or a history of previous open heart or pulmonary surgery, cardiovascular instability or an aneurysm . Eligible patients were random sly allocated to receive either ACBT or IS .
The following pre -operative risk factors were assessed ; Pulmonary function tests were performed pre- operatively and on the fifth post – operative day using a spirometer . The vital capacity ( VC ) , forced vital capacity ( FVC ) , forced expiratory volume in one second ( FEV1 ) and peek expiratory flow rate ( PEF ) were recorded . The highest value from at least three technically acceptable maneuvers was expressed as the percentage of predicted value .
STATEMENT OF THE PROBLEM:
THE EFFECTIVENESS OF BREATHING EXERCISES ON RESPIRATORY STATUS OF PATIENT UNDERGOING CORONARY ARTERY BYPASS GRAFT WILL BE CARRIED OUT IN SELECTED CARDIAC HOSPITALS IN BANGALORE.
6.3 OBJECTIVES OF THE STUDY :
1) To provide breathing exercise for patients undergoing coronary artery bypass graft surgery .
2) To associate the respiratory status of the patients who undergo variables .
3) To compare the post test respiratory status of the patients with coronary artery bypass graft surgery between experimental and control group .
4)To provide breathing exercise to all patients who undergo coronary artery bypass graft surgery pre and post operatively .
5)To assessthe respiratory status of the patients who undergo CABG surgery in experimental and control group .
6.4OPERATIONAL DEFINITIONS :
1.Effectiveness:
To study the effectiveness of Deep Breathing exercises on patients undergoing Coronary Artery Bypass Graft Surgery.
2.Breathing exercise :
It is work out to the muscle of respiration to improve the gas exchange and oxygenation . It includes Diaphragmatic breathing exercises and Respiratory muscles exercises .
3.Respiratory status :
Respiratory status denotes the condition of the respiratory system , assessed by using respiratory parameters such as maximum inspiratory reserve volume , peak volume , peak expiratory flow rate , chest expansion ,breathe holding time,respiratory rateand oxygen saturation.
4.Patients undergoing CABG :
The individual who is planned to undergo coronary artery bypass graft surgery and coming to the hospital as inpatient and out patient .
6.5 HYPOTHESIS :
Null hypothesis :
The deep breathing exercises have no significant effect in improving respiratory status of patients undergoing coronary artery bypass graft surgeries .
Alternate hypothesis :
The deep breathing exercises have significant effect in improving the respiratory status of patients undergoing coronary artery bypass graft surgery .