SYNOPSIS FOR REGISTRATION OF SUBJECT

FORDISSERTATION

SUBMITTED TO:

RAJIB GANDHI UNIVERSITY OF HEALTH SCIENCES

IN PARTIAL FULFILLMENT

OF

M.SC (N) IN CHILD HEALTH NURSING

SUBMITTED BY:

ARPITA HALDER

1ST YEAR M.SC (N)

UNDER THE GUIDENCE OF:

MRS. JEYASUTHA

ASSISTANT PROFESSOR

NARAYANA HRUDAYALAYA COLLEGE OF NURSING

NO: 258/A BOMMASANDRA INDUSTRIAL AREA

ANEKAL TALUK, BANGALORE-99

1 / NAME OF THE CANDIDATE AND ADDRESS / ARPITA HALDER
NARAYANA HRUDAYALAYA COLLEGE OF NURSING
NO:258/A BOMMASANDRA INDUSTRIAL AREA ANEKAL TALUK, BANGALORE
2 / NAME OF THE INSTITUTION / NARAYANA HRUDAYALAYA COLLEGE OF NURSING
3 / COURSE OF THE STUDY AND SUBJECT / 1ST YEAR MSC (N)
CHILD HEALTH NURSING
4 / DATE OF ADMISSION TO COURSE / 15-07-2013
5 / TITLE OF THE TOPIC / A STUDY TO COMPARE THE EFFECTIVENESS OF CHEST PHYSIOTHERAPY WITH INCENTIVE SPIROMETER VERSUS ONLY CHEST PHYSIOTHERAPY ON RESPIRATORY FUNCTION AFTER CARDIAC SURGERY AMONG CHILDREN IN SELECTED HOSPITAL, BANGALORE.

STATEMENT OF THE PROBLEM:

A study to compare the effectiveness of chest physiotherapy with incentive spirometer versus only chest physiotherapy on respiratory function after cardiac surgery among children in selected hospital, Bangalore.

ANNEXURE-I

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Breathing involves a continual oscillation between exhaling and inhaling, offering ourselves to the world at one moment and drawing the world into ourselves”

Cardiac surgery is life- threatening experience for everyone, especially for children. The prevalence of paediatric cardiac surgery is high, around 110 per 100000 populations annually in western world. There are approximately 1, 25,000 children born with congenital heart diseases every year in India. There has been a steady increase in incidence of heart diseases, both in India as well as in Karnataka -- around 2% in 1960 and currently 12%-13%. Among those paediatric patients, 65% may have atelectasis and 3% may develop pneumonia.(1)

Pulmonary complication is a general and central airway problem for the children which causes delayed period of recovery after cardiac surgery. The extra causes of pulmonary complication after cardiac surgery exceed 2800 for each paediatric patient. (1)

Postoperative pulmonary dysfunction in patients undergoing cardiac surgery is a significant clinical problem recognized by cardiac surgeons, anaesthetists, intensive-care physicians and intensive-care nurse. Innovations in surgical technique improve preoperative and postoperative care that helps for successful surgical repair and reduce postoperative complication.(1)

Pulmonary complications after cardiac surgery prolongs hospital stay and increase health care cost. Children those who undergo cardiac surgery treated by respiratory therapies which helps to prevent such pulmonary complications.(1)

“ Breathe easy at night, sleep with a respiratory therapist”

Respiratory therapy is a therapeutic treatment for respiratory diseases. In recent year patient with respiratory disease uses various respiratory therapies, which helps to remove the mucus from airways and improve the pulmonary function. All the respiratory therapies used for the child who undergoes cardiac surgery.Among all respiratory therapies,Chest physiotherapy and Incentive spirometer play important role.(1)

Chest physiotherapy consist of external mechanical maneuvres, such as chest percussion, postural drainage, vibration. Along with the chest physiotherapy other exercises such as diaphragmatic breathing with pursed lip, Coughing and controlled coughing.(2)

After cardiac surgery, patients who receive mechanical ventilation have problem in mobilizing the pulmonary secretion. Those patients have a tendency to retain secretion. chest physiotherapy is helpful for those patients to loosen the secretions after cardiac surgery. (2)

Incentive spirometer is a method of encouraging voluntary deep breathing by providing visual feedback about inspiratory volume. Specially designed Incentive spirometer helps the patient to inhale until to reach preset volume, and then sustain the inspiratory volume by holding his or her breath for 3 to 5 seconds.(3)

During cardiac surgery, prolong uses of anaesthesia may affect the lung expansion. Incentive spirometer encourages the alveoli to inflate the lungs that help for lung expansion.(3)

6.1: NEED FOR STUDY

Postoperative pulmonary complications are significant source of morbidity and mortality among children such as pneumonia, bronchospasm, respiratory failure and prolonged mechanical ventilation. (4)

The cardiac operations are relatively high risk for pulmonary complications. Recent research work suggests that significant pulmonary complications may be more common than cardiac complications and associated with longer length of stay. (4)

A descriptive study shows that the mortality rate associated with ARDS is > 50% after cardiac surgery.A prevalence study shows that 34% (55/162 at-risk recipients) have risk of pulmonary complication and mortality of 25% (14/55 affected recipients) is affected in pulmonary complication.(5, 6)

A prospective study conducted to determine the pulmonary complications after cardiac surgery. 108 paediatric children who were able to achieve exercise criteria, among those cases 10 patients (9.3%) developed cardiac or pulmonary complication, with one death (0.9%). 69 patients who were unable to exercise satisfactorily, among those cases 29 patients (42%) developed cardiac pulmonary complication, with five total deaths (7.2%). (7)

A study conducted to assess the incidence and hospital stay for cardiac and pulmonary complication after cardiac surgery. Out of 412 patients 192 patients selected randomly matched by operation type and age within ten years. Among these patients, 19 patients died, 26% of patients had Combined cardiopulmonary complications, remaining patients had more pulmonary complications than cardiac complications (p<0.00001) and were associated with significantly longer hospital stays (22.7 vs 10.4 days, p=0.001). (8)

Respiratory complications occur after major surgery, particularly after general anaesthesia. Respiratory complications are prevented by Varies Respiratory therapies after cardiac surgery such as physical therapy, breathing exercise, chest physiotherapy, continuous positive airway pressure, incentive Spirometer, non-invasive pressure support ventilation etc. Among all Respiratory therapies, Chest physiotherapy and Incentivespirometer play a vital role.(9)

Chest Physiotherapy is often prescribed for children after cardiac surgery due to negative pathological changes occur during postoperative period. Neonates are even more predisposed for postoperative respiratory failure due to poor development of intercostals muscles and compliant chest wall. (10)

Chest physiotherapy is the standard treatment for mobilization and removal of secretion from the airway in various aspects of respiratory dysfunction especially in chronic lung disease, bronchiectasis, atelectasis, bronchitis. The chest physiotherapy has been effective in maintaining pulmonary function and prevention or reduction of respiratory complication after cardiac surgery. (11)

A prospective study conducted to assess the effectiveness of chest physiotherapy to prevent ventilator-associated pneumonia. In this study intervention group received chest physiotherapy and control group not received chest physiotherapy. The study findings reveal that only 8% of intervention group developed ventilation associated pneumonia and 39 % control group developed ventilation associated pneumonia. (12)

A prospective study conducted to assess the chest physiotherapy and deep breathing exercise to prevent pulmonary complication after cardiac surgery. All the physiotherapists instructed the patients to perform breathing exercises on a regular basis post-operatively along with the regular chest physiotherapy. The study finding reveals that 83% case there had no chance in pulmonary complication. (13)

Incentive Spirometer is a medical device widely used in clinical practice for lung expansion. Incentive spirometer used every 1-2 hours, which helps to improve lung expansion. Incentive spirometer remains a widely used technique for the prophylaxis and treatment of respiratory complications in post surgical patients.(14)

A study conducted to assess the effectiveness of the Incentive spirometer in the post-operative treatment. 34 paediatric patients were selected after open-heart surgery by measuring vital capacity, arterial oxygen tension. The study result says that vital capacity fell after surgery to 41.5 per cent of the pre-operative level, but after the use of the incentive spirometer by an average of 15.5 per cent, which helps the patient to protect from atelectasis. Arterial oxygen tensions were unaltered by the use of incentive spirometer.(15)

A greater number of the published studies (36 studies) compared the devices of respiratory physiotherapy with standard chest physiotherapy. The eighteen studies (percentage 26%) referred to the effectiveness of each device separately, while a small number of reports (8 report- 12%) compare the devices between them. Limited number of studies compares the devices with other active techniques of respiratory physiotherapy (6 studies-9percentage). (16,17,18,19)

The nurse researcher with her clinical experience in paediatric ward has been assessed the children after cardiac surgery had suffering some respiratory problem. Some types of respiratory physiotherapy are used to improve the respiratory function. There are many studies conducted regarding effectiveness of chest physiotherapy on respiratory function but very few studies conducted to assess the effectiveness of chest physiotherapy with incentive spirometer, which made nurse researcher to take up this study to assess the effectiveness of chest physiotherapy with incentive spirometer and only chest physiotherapy on respiratory function among children after cardiac surgery.

6.2: REVIEW OF LITERAURE

Review of literature is a process of reading, analyzing, evaluating, and summarizing scholarly materials about a specific topic.The results of a literature review may be compiled in a report or they may serve as part of a research article, thesis, or grant proposal.(20)

Review of literature is divided in the following headings

SECTION A :Effectiveness of chest physiotherapy after cardiac surgery

SECTION B :Effectiveness of incentive spirometer after cardiac surgery

SECTION C: Compare the Effectiveness between chest physiotherapy and incentive spirometer

SECTION A: LITERATURE REVIEW ON EFFECTIVENESS OF CHEST PHYSIOTHERAPY AFTER CARDIAC SURGERY

Chest physiotherapy consists of external mechanical manoeuvres, such as chest percussion, postural drainage, vibration. Along with the chest physiotherapy other exercises such as diaphragmatic breathing with pursed-lips, coughing and controlled coughing. (11)

Chest physiotherapy(CPT) is method of treatment to improve the breathing pattern by the indirect removal of mucus from the breathing passage. (11)

Postoperative physiotherapy has been effective to reduce the incidence of postoperative pulmonary complications after cardiac surgery. (21)

A study conducted to assess the incidence of pulmonary complication. 87 samples were treated with chest physiotherapy, 87 samples are without chest physiotherapy. The study result shows that Postoperative pulmonary complications occurred in 6 per cent of patients in the experimental group and 27 per cent of patient in the control group (P<0·001). Both the groups was noted no difference in peak expiratory flow rate. (22)

Prophylactic chest physiotherapy reduces morbidity after major cardiac surgery. A study reported that prophylactic chest physiotherapy reduce the incidence of pulmonary complications after major surgery from 27% to 6%.(23)

Chest physiotherapy is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized secretion such conditions are cystic fibrosis, Bronchiectasis, Atelctasis , Lung abscess , Neuromuscular diseases and Pneumonias in dependent lung regions.

Chest physiotherapy is effective to

  • Decrease the incidence of post operative pulmonary complication
  • Reduce the length of hospital stay and cost.
  • Increase oxygen and haemoglobin saturation.
  • Improve chest wall mobility and lung ventilation (24)

A randomized controlled study evaluated the clinical benefit and physiological effects of prophylactic chest physiotherapy in cardiac surgery.174 patients received chest physiotherapy including breathing with pursed lips, huffing and coughing, and information about the importance of early mobilization. The study result found that patient received chest physiotherapy had no chance of developing pulmonary complication.(25)

A study evaluated the effectiveness of chest physiotherapy after cardiac surgery.56 patients undergoing open cardiac surgery, at high risk of developing postoperative pulmonary complications. Experimental group1 received only mobilization and Experimental group2 received mobilisation, deep breathing and chest physiotherapy. The study result shows that group 2 have reduced chance of pulmonary complication than group 1.(26)

Chest physiotherapy aims to decrease the pulmonary complications and hasten recovery. In a non-randomised pilot study reported that among 263 patients found that chest physiotherapy decreased the occurrence of pulmonary complications (17%, p=0.01) and length of stay on the surgical high dependency unit (3.1 vs. 4 days p=0.03). (27)

A study evaluated the effectiveness of chest physiotherapy after cardiac surgery.15 samples received chest physiotherapy in the post-anaesthesia care unit, 16 samples without chest physiotherapy. Experimental group has shown improved oxygen-haemoglobin saturation than control group.(28)

A prospective, randomized study conducted to assess the effectiveness of chestphysiotherapy (CPT) to prevent postoperative atelectasis in children after cardiac surgery. Postoperative clinical variables and chest x-ray findings of atelectasis were compared between experimental group and control group. The study result shows that less chance of atelectasis in experimental group compare

to control group. .(29)

SECTION B: LITERATURE REVIEW ON EFFECTIVENESS OF INCENTIVE SPIROMETER AFTER CARDIAC SURGERY

Incentive spirometry is a method of deep breathing that provides visual feedback to the patient who inhale slowly and deeply to maximize lung inflation.(30)

Incentive spirometer is an apparatus for measuring the volume of air inspired and expired by the lungs. The spirometer records the amount of air that is breathed in and out over a specific period.(30)

Incentive spirometer has been effective to reduce the incidence of postoperative pulmonary complications after cardiac surgery. Many studies reported that 17% to 88% of people suffered from pulmonary complications after cardiac surgery. (31)

A study conducted to assess the uses of spirometer to PreventPulmonary Complications after cardiac Surgery .The study result shows that the incidence of unspecified pulmonary complications was decreased from 47.7% to 21.4 to 22.2% with using incentive spirometry.(32)

A study to assess the effectiveness of incentive spirometer to reduce the pulmonary complication. The search yielded 85 articles. Studies dealt with the use of Incentive spirometer for preventing pulmonary complications. 35 studies shows that the incentive spirometer reduce the pulmonary complication after cardiac surgery. (33)

A prospective, randomized study conducted to assess the effectiveness of incentive spirometer. Experimental group received incentive spirometer and control group not received incentive spirometer. The study result shows that after 5 days continuous use of incentive spirometer reduces the postoperative pulmonary complication. (34)

Incentive spirometer has more advantages such as

  • Healthcare personnel time and cost is minimized
  • Prophylactic technique
  • Patient potentially receives more frequent therapy
  • Incentive spirometry is more convenient than large IPPB machines due to the machine simplicity (35)

Incentive spirometer is a medical device used for patients to improve lungsfunction. During surgery prolong uses of anaesthesia may affect the lung expansion. The incentive spirometer is helpful for lung expansion. It helps to minimize the chance of fluid collection in the lung during postoperative period. (36)

11 studies review reported that Incentive spirometers are very helpful forpatient who takes long, deep, and slow breaths to increase lung inflation.(37)

SECTION C: LITERATURE REVIEW ON COMPARE THE EFFECTIVENESS BETWEEN CHEST PHYSIOTHERAPY AND INCENTIVE SPIROMETER

A clinical trial done to prevent pulmonary complications after cardiac surgery .Group 1 received chest physiotherapy , group 2 received incentive spirometer .The result concluded that prophylactic chest physiotherpy and incentive spirometer are equivalent clinical efficacy prevent pulmonary complications after cardiac surgery. (38)

A study conducted to compare the early mobilization, chest physiotherapy and incentive spirometer after cardiac surgery. A total of 131 children allocated to receive any one of three treatments. The study result reported that no treatment is superior in restoring lung function after cardiac surgery.(39)

A randomized study conducted to compare the chest physiotherapy and incentive spirometer after cardiac surgery. Slow vital capacity and peak expiratory flow readings decreased rapidly equal extent in both groups.Arterial po2 values similar for both groups.The study result reported that based on three variables, both devices equal efficiency after cardiac surgery.(40)

.

A greater number of published studies compare the devices of respiratory physiotherapy with standard chest physiotherapy. 26% referred to the effectiveness of each device separately, 12% compare the devices between them and 9% compares the devices with other active techniques of respiratory physiotherapy.(41)

A study evaluated the uses of incentive spirometer with chest physiotherapy to improve lung function after cardiac surgery. One group received incentive spirometer as part of their postoperative chest physiotherapy, those in the other received routine postoperative physiotherapy. The study result shows that use of incentive spirometer with chest physiotherapy is more effective than chest physiotherapy to prevent pulmonary complications.(42)

A prospective randomised study compared the chest physiotherapy with Incentive spirometer. 35 patients in experimental group1 received chest physiotherapy with Incentive spirometer, 37 patients in experimental group2 received only chest physiotherapy. The study result shows that experimental group1 are able to do early mobilization and they have not developed any pulmonary complication compare to experimental group 2.(43)

STATEMENT OF THE PROBLEM

A study to compare the effectiveness of chest physiotherapy with incentive spirometer versus only chest physiotherapy on respiratory function after cardiac surgery among children in selected hospital, Bangalore.

6.3: OBJECTIVE OF THE STUDY-

  1. To assess the baseline respiratory variable among children under cardiac surgery.
  2. To determine the respiratory function among experimental group and control group children after cardiac surgery.
  3. To compare the respiratory function between experimental group and control group after cardiac surgery among children.
  4. To find the association between pre test respiratory score of children undergoing cardiac surgery with selected demographic variables.

6.4: ASSUMPTIONS-

Respiratory intervention may help to reduce the risk factors for developing pulmonary complications after cardiac surgery.

6.5: HYPOTHESIS-

H 1: The mean post test respiratory function of experimental group will be higher than mean pre test respiratory function.