Deep-Breathing Exercises Reduce PDF

Deep-Breathing Exercises Reduce
Atelectasis and Improve Pulmonary Function

After Coronary Artery Bypass Surgery
Elisabeth Westerdahl, Birgitta Lindmark, Tomas Eriksson, rjan Friberg,
Gran Hedenstierna and Arne Tenling
Chest 2005;128;3482-3488
DOI 10.1378/chest.128.5.3482
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Copyright 2005 by American College of Chest Physicians
Deep-Breathing Exercises Reduce

Atelectasis and Improve Pulmonary
Function After Coronary Artery Bypass
Surgery*
Elisabeth Westerdahl, RPT, PhD; Birgitta Lindmark, RPT, PhD;
rjan Friberg, MD;
Tomas Eriksson, MD; O
Goran Hedenstierna, MD, PhD, FCCP; and Arne Tenling, MD, PhD
Study objectives: To investigate the effects of deep-breathing exercises on pulmonary function,

atelectasis, and arterial blood gas levels after coronary artery bypass graft (CABG) surgery.
Design, setting, and patients: In a prospective, randomized trial, patients performing deepbreathing exercises (n 48) were compared to a control group (n 42) who performed no
breathing exercises postoperatively. Patient management was similar in the groups in terms of
assessment, positioning, and mobility.
Interventions: The patients in the deep-breathing group were instructed to perform breathing
exercises hourly during daytime for the first 4 postoperative days. The exercises consisted of 30
slow, deep breaths performed with a positive expiratory pressure blow-bottle device ( 10 cm
H2O).
Measurements and results: Spirometric measurements, spiral CT (three transverse levels), arterial
blood gas analysis, and scoring of subjective experience of the breathing exercises were
performed on the fourth postoperative day. Atelectasis was only half the size in the deepbreathing group compared to the control group, amounting to 2.6 2.2% vs 4.7 5.7%
(p 0.045) at the basal level and 0.1 0.2% vs 0.3 0.5% (mean SD) [p 0.01] at the apical
level. Compared to the control subjects, the patients in the deep-breathing group had a
significantly smaller reduction in FVC (to 71 12%, vs 64 13% of the preoperative values;
p 0.01) and FEV1 (to 71 11%, vs 65 13% of the preoperative values; p 0.01). Arterial
oxygen tension, carbon dioxide tension, fever, or length of ICU or hospital stay did not differ
between the groups. In the deep-breathing group, 72% of the patients experienced a subjective
benefit from the exercises.
Conclusions: Patients performing deep-breathing exercises after CABG surgery had significantly
smaller atelectatic areas and better pulmonary function on the fourth postoperative day
compared to a control group performing no exercises.
(CHEST 2005; 128:34823488)
Key words: atelectasis; breathing exercises; cardiac surgery; coronary artery bypass; CT; physical therapy; postoperative
care; postoperative complications; thoracic surgery
Abbreviations: BMI body mass index; CABG coronary artery bypass graft; FRC functional residual capacity;
HU Hounsfield unit; IC inspiratory capacity; PEP positive expiratory pressure; VC vital capacity
and arterial hypoxemia are commonly

A telectasis
seen after cardiac surgery. Chest physical therapy is widely used postoperatively for the prevention
of pulmonary complications.
A variety of treatment techniques are used, and
there are differences in the management between
*From the Department of Medical Sciences, Clinical Physiology
(Drs. Westerdahl and Hedenstierna) and Department of Neuroscience, Section of Physiotherapy (Dr. Lindmark), University
Hospital, Uppsala; the Departments of Cardiothoracic Surgery
rebro University
(Dr. Friberg) and Radiology (Dr Eriksson), O
rebro; and the Department of Cardiothoracic AnesHospital, O
thesia (Dr, Tenling), Karolinska University Hospital, Huddinge,
Sweden.
countries. In later years, the routine use of breathing

exercises after cardiac surgery has been questioned.
Breathing exercises combined with physical therapy
This study was supported by financial grants from the Heart and
Lung Patients National Association, Sweden; the Karolinska
rebro County
Institute, Stockholm; the Research Committee of O
rebro; and the Swedish Heart Lung Foundation and
Council, O
Uppsala University.
Manuscript received July 9, 2004; revision accepted June 9, 2005.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Elisabeth Westerdahl, RPT, PhD, Depart rebro University Hospital, SE-701 85
ment of Physiotherapy, O
rebro, Sweden; e-mail: [email protected]
O
3482
Clinical Investigations

after coronary artery bypass graft (CABG) surgery

have been reported not to be more effective than
physical therapy, including early mobilization alone
in reducing atelectasis,1 pneumonia,2 gas exchange
and lung function impairment,3 or other kinds of
pulmonary complications.4,5 Pasquina et al6 concluded that evidence is lacking on benefit from any
method of prophylactic respiratory physical therapy
after cardiac surgery, and that it is more comprehensive than justified by findings of clinical research.
We have shown7 an immediate effect of a single
session of voluntary deep-breathing exercises on
atelectasis and oxygenation on the second postoperative day after CABG surgery. Incentive spirometry
remains a frequently used technique for the prophylaxis and treatment of respiratory complications in
postsurgical patients, but the evidence does not
support the use of incentive spirometry for decreasing the incidence of atelectasis and pulmonary complications following cardiac surgery.1,8,9 The objective of this study was to evaluate the effectiveness of
voluntary deep-breathing exercises performed with a
positive expiratory pressure (PEP) blow-bottle device on pulmonary function, atelectasis, arterial
blood gas levels, and subjective experience in CABG
patients compared to a control group who performed
no breathing exercises.
Materials and Methods

Patients
A sample of 115 patients undergoing CABG surgery at a
university hospital were invited to participate in the study.
Patients who had an emergency operation, previous cardiac
surgery, severe renal dysfunction, or difficulties in cooperating
during measurements were not included. Three patients declined
participation. The patients were randomized to a deep-breathing
group (n 57) that performed deep-breathing exercises postoperatively and to a control group (n 55) that performed no
breathing exercises. Informed consent was obtained from each
patient, and the study was approved by the local research ethics
committee.
Surgical and Postoperative Procedure
All patients received general anesthesia, and the CABG was
performed with saphenous veins and in most cases the left
internal mammary artery. During anesthesia and following surgery, all patients inspired oxygen with a concentration of 40 to
80%. The surgical approach was through a median sternotomy.
Cold-blood cardioplegia and occasionally topical cooling of the
heart were used. An insulation pad was used to protect the
phrenic nerve. The pericardium, the mediastinum and, occasionally one or both pleura were drained, usually 24 h after
surgery. Postoperatively, the patients received mechanical ventilation with a positive end-expiratory pressure of 5 to 10 cm H2O.
The patients were extubated when they had resumed normothermia, were hemodynamically stable, had adequate diuresis and no
www.chestjournal.org
severe bleeding in the drain, and were able to breathe normally

without distress, in accordance with the ordinary clinical routines.
Pain
All patients were administered pain relief according to standard routines at the clinic. At the time of the pulmonary function
test on the fourth postoperative day, the patients were asked to
quantify the pain from the median sternotomy incision. A
continuous visual analog scale from 0 (no pain) to 10 (the worst
imaginable pain) was used.
Study Groups and Chest Physical Therapy
The day before the operation, or the week before if operated
on a Monday, the patients received general information about
postoperative routines by one of three physical therapists. All
patients received chest physical therapy once or twice daily as
normally performed at the clinic during the first 4 postoperative
days. Therapy consisted of early mobilization, instructions in
efficient coughing techniques, daily active exercises of the shoulder girdle and upper back and instructions, and assistance to turn
from side to side and get out of bed. The patients were mobilized
as early as possible by the nursing staff. The patients were sitting
out of bed and/or standing on the first postoperative day, walked
in the room or a short distance in the corridor on the second day,
and walking a longer distance in the corridor on the third
postoperative day. On the third and fourth postoperative days,
the patients participated in a sitting group exercise program.
The patients in the deep-breathing group were informed and
practiced the breathing technique preoperatively. The exercises
were started approximately 1 h after extubation, and the patients
were encouraged to perform 30 deep breaths once per hour
when awake (in daytime) for the first 4 postoperative days. The
exercise included three sets of 10 deep breaths with a 30- to 60-s
pause between each set. If needed, the patients were asked to
cough during the pause to mobilize secretions. The patients were
instructed to perform the deep breathing in the sitting position,
if possible. A 50-cm plastic tube (1 cm in internal diameter) in a
bottle containing 10 cm of water (the blow-bottle) was used to
create an expiratory resistance of 10 cm H2O. If the patient
initially was unable to expire through the tube, a PEP/respiratory
muscle training facemask (Astra Tech AB; Molndal, Sweden) was
used to create the expiratory pressure. One of three experienced
physical therapists supervised the breathing exercises, and the
patients were instructed to perform slow maximal inspirations,
while expiration was aimed to end approximately at functional
residual capacity (FRC) to minimize airway closure and alveolar
collapse. Compliance with treatment was documented in the
patient record until the morning of the second postoperative day,
and after that it was self-reported. The patients in the control
group were not instructed to do any breathing exercises.
Measurements
Pulmonary function measurements were performed preoperatively and on the fourth postoperative day (Jaeger MasterScreen
PFT/Bodybox; Spiropharma Cardiopulmonary Diagnostics;
Klampenborg, Denmark) with proprietary software. The equipment was calibrated every morning prior to measurements. Six
medical laboratory technicians who were unaware of the patients
randomization performed the tests. The patients were in a sitting
position, and a nose clip was used. Predicted values for pulmonary function were related to age, sex, and height according to
the values reported by Quanjer et al.10 Spirometry was performed
according to the recommendations of the European Respiratory
CHEST / 128 / 5 / NOVEMBER, 2005

3483
Society. The highest value of three technically satisfactory maneuvers was retained. First an inspiratory maneuver was obtained
for measurement of vital capacity (VC). Then measurements of
FVC and FEV1 were performed, followed by recording of the
inspiratory capacity (IC) and FRC. Total lung capacity (TLC) was
calculated as FRC IC.
Atelectasis and aeration of the lungs were assessed by spiral CT
(Philips CT Secura; Philips Medical Systems; Eindhoven, the
Netherlands)1113 on the fourth postoperative day. The patients
were transported to the Department of Radiology in a wheelchair. One radiologist and one radiographer who were blinded to
study group assignments made all measurements. The patients
lay in the supine position with their arms raised above their
heads, and the examination was made during apnea at FRC.
First, a frontal scanogram covering the chest was obtained for
positioning. The scan time was 9 s for a 12-cm volume scan at 280
mA and 120 kV. Slice thickness was 1.0 cm, and a matrix of
512 512 elements was used. The total estimated effective dose
was 1.5 millisieverts. Three of the CT scans were used for
subsequent analysis, positioned 1 cm, 5 cm, and 9 cm above the
top of the right diaphragm. A radiologist delineated the lung area
manually from the inner margins of the thoracic cage, excluding
pleural fluid and tissue between the ribs, mediastinum, or any
part of the diaphragm. The computer identified the border
between inflated lung tissue and atelectasis. Aerated lung area
was defined as volume elements with attenuation values between
100 Hounsfield units (HU) and 1,000 HU, and atelectasis
was defined as values between 100 and 100 HU.12,14 The
most cephalad point of the diaphragm was determined in relation
to the carina.
Arterial blood gas measurements were done before induction
of anesthesia and on the fourth postoperative day for blood gas
analysis (Radiometer ABL 505; Inter Bio-Lab; Orlando, FL). The
patients had been without supplementary oxygen for 15 min.
Body temperature was measured preoperatively and on postoperative days 1, 2, 3, and 4. On the fourth postoperative day, the
patients in the deep-breathing group were asked to score their
subjective benefit and/or discomfort of the breathing exercise on
an arbitrary scale.
Statistical Analysis
All data were collected and analyzed in a statistical computer
program (StatView; Abacus Concepts; Berkeley, CA) and presented as mean values SD. Baseline data were compared by
unpaired t test or by 2 test. The relative decrease in pulmonary
function after the operation, the atelectatic area, and arterial
blood gases were compared by an unpaired t test. Including 45
patients per group would yield 80% power ( 0.05) to detect a
decrease from 2.5 to 1.9% (percentage reduction, 20 to 25%) in
bilateral atelectatic area in percentage of total lung area between
groups, assuming a SD of 1.0%. This difference is assumed by the
authors to be of clinical relevance. Dropout was anticipated to be
up to 20%, and hence another 10 patients were included in each
group. All results refer to two-sided tests, and p 0.05 was
considered significant.
Results
Five women and 17 men (mean age SD,
68 11 years) were excluded for various reasons, as
reported in Table 1. In total, 90 patients (23 women
and 67 men) were investigated. Demographic (Table
2) and surgical (Table 3) data did not significantly
Table 1Causes of Exclusion From the Study*
Causes
Circulatory instability
Respiratory instability
Neurologic complication
Reoperation
Pneumothorax
Pleural effusion ( 3 cm)
Sternal infection
Failure to cooperate
Ad mortem
Treatment
Group
(n 9)
Control
Group
(n 13)
1
1
1
2
1
1
1
3
3
1
1
1
4
*Data are presented as No.
differ between the two groups. Pain from the sternotomy did not differ between the two groups. Mean
value for the visual analog scale at rest was 1.4 1.6
cm; while taking a deep breath, 2.5 2.1 cm; while
coughing, 4.3 2.8 cm; and during pulmonary function testing, 2.4 2.2 cm. No significant differences
in length of ICU stay (deep-breathing group,
17.9 5.3 h; control group, 18.8 4.0 h), postoperative hospital stay (5.5 2.8 days vs 5.3 2.6 days),
or fever (mean value for the 4 postoperative days,
37.5 0.3C vs 37.6 0.4C) were noticed. None
of the patients had signs of pneumonia during the
hospital stay. One of the excluded patients received
antibiotics because of a sternal infection.
Pulmonary Function
The preoperative lung function showed a VC at or
below 2 SD in five patients in the treatment group
and one patient in the control group. There was no
Table 2Demographic Data*
Variables
Male/female gender
Age, yr
Weight, kg
Height, cm
BMI, kg/m2
Smoking status
Never
Stopped
Current smoker
New York Heart Association class
I-II
IIIA-B
IV
Left ventricular ejection fraction, %
Treatment
Group
(n 48)
Control
Group
(n 42)
36/12
66 9
80 15
171 8
27 4
31/11
65 9
81 12
172 8
27 3
21
17
10
16
20
6
14
32
2
56 14
16
22
1
54 14
*Data are presented as mean SD or No. of patients. No significant

differences were found between groups.
3484

Table 3Surgical Data*
Variables
Treatment
Group
(n 48)
Control
Group
(n 42)
Operation time, h
Extracorporeal circulation time, min
Aortic occlusion time, min
Saphenous vein grafts, per patient
Left internal mammary artery graft
Left pleural space entered
Bilateral pleural space entered
Postoperative mechanical ventilation, h
2.5 0.8
79 18
47 15
3.6 0.9
46
36
5
5.0 2.1
2.8 0.8
83 27
49 16
4.0 1.1
40
26
8
5.0 1.7
*Data are presented as mean SD or No. of patients. No significant

differences were found between groups.
significant difference between the two groups. On

the fourth postoperative day, the patients in the
deep-breathing group had a significantly smaller
reduction in FVC, down to 71 12% of the preoperative value, than patients in the control group
(64 13%; p 0.01). Similarly, FEV1 was reduced
less in the deep-breathing group than the control
group, to 71 11% vs 65 13% of the preoperative
values (p 0.01; Fig 1).
Atelectasis
Four days after CABG surgery, all examined patients had signs of atelectasis (missing data in the
treatment group [n 11] and in the control group
[n 6] because of technical and scheduling difficulties). The atelectatic area was largest at the basal
level, close to the diaphragm, and minor at the upper

level, near the apex. A significantly smaller atelectatic area in the deep-breathing group, of one half
the size, compared to the control group (p 0.05)
was found at the basal and apical levels. The mean
values from both lungs at the three CT levels are
shown in Table 4, and examples of CT scans are
shown in Figure 2. The amount of atelectasis at the
basal level (in percentage of the total lung area)
correlated to FEV1 on the fourth postoperative day
(r 0.32, r2 0.10, p 0.01) as well as to the
postoperative relative decrease in FEV1 (r 0.37,
r2 0.14, p 0.01). Patients with a body mass index
(BMI) 30 (n 19) had the same amount of
atelectasis as those with a BMI 30; there no
significant differences in the results of breathing
exercises between the groups. The distance between
the diaphragm and the carina did not differ between
the treatment group (7.8 1.6 cm in the right lung
and 9.9 1.3 cm in the left lung) and in the control
group (7.9 1.6 cm and 9.2 1.8 cm, respectively).
Arterial Blood Gas Levels
No significant differences in Pao2, arterial oxygen
saturation, or Paco2 between the two groups were
found (Table 5).
Subjective Experience and Self-Report of the
Breathing Exercises
All 46 patients (2 patients with missing data) in the
deep-breathing group answered that the breathing
Figure 1. Pulmonary function values on the fourth postoperative day in percentage of preoperative
values in the treatment group, performing deep-breathing exercises, and the control group. Error lines
indicate 95% confidence intervals; p values refer to the difference in pulmonary function between the
deep-breathing group and the control group. *p 0.05. TLC total lung capacity.

3485
Table 4 Atelectasis on the Fourth Postoperative Day*

CT
Level
Treatment Group
(n 37)
Control Group
(n 36)
p Value
Upper
Middle
Basal
Total
0.1 0.2 (0.1 0.3)

0.7 0.6 (1.2 1.1)
2.6 2.2 (4.9 3.7)
1.2 0.8 (8.5 5.9)
0.3 0.5 (0.4 0.6)

1.3 2.2 (2.0 2.8)
4.7 5.7 (7.3 7.5)
2.2 2.8 (13.0 13.6)
0.011
0.09
0.045
0.046
*Data are presented as mean SD areas of bilateral atelectasis in %

of total lung area (cm2).
The basal level is 1 cm above the top of the diaphragm, the middle
level is 5 cm above the top of the diaphragm, and the upper level is
9 cm above the top of the diaphragm. The total atelectatic area is the
mean of both lungs at the three CT levels.
Difference in atelectasis in % of total lung area between the
deep-breathing group and the control group.
technique was easy to perform. Of these, 33 patients

(72%) experienced a subjective benefit of the exercises, 2 patients found no benefit, and 11 patients
had no opinion. Only five patients experienced discomfort during the exercises. The patients answered
that they had performed the deep-breathing exercises 7 2 times per day (range, 2 to 12 times per
day) postoperatively and that each session had consisted of 25 8 breaths (range, 8 to 30 breaths).
Discussion
In the present investigation, it was found that
chest physical therapy including deep-breathing exercises significantly decreased atelectasis and improved spirometry values compared to a regime
without breathing instructions following CABG surgery. Atelectasis on the fourth postoperative day was
decreased by one half compared to the control
group. The amount of atelectasis in the lungs expressed in percentage of the total transverse lung
area was less in the present study (2 to 5% just above
the diaphragm) than in a study7 performed on the
second postoperative day (10 to 12%) after CABG

surgery. A decrease of atelectasis during the succeeding postoperative days has been shown after
abdominal surgery,15 and a similar spontaneous recovery after cardiac surgery could be expected.
Another possible explanation could be better preservation of pulmonary function because of shorter
operation and extracorporeal circulation time in the
present study.
However, between the two groups we saw no
difference in ICU or hospital stay, and there were no
records of pulmonary infection in any patient. It
must be clear that the study was not designed to
evaluate clinical outcome: the material was too small
and limited by the inclusion of CT in the study.
Atelectasis could be a reason for pneumonia, but the
diagnosis should be based on the presence of clinical
signs and symptoms of pneumonia coupled with the
identification of pathogenic bacteria, rather than
radiographic identification of atelectasis.16,17
Despite the common use of breathing exercises in
the management of CABG patients in many countries, scientific evidence for the efficacy of this
treatment has been lacking.1,4,5,9 The physical therapy treatment has even been considered to cause
adverse effects and costs only.6
In a previous investigation,7 we showed an immediate decrease in atelectatic area and an increase in
oxygenation after a session of 30 deep breaths performed on the second postoperative day after CABG
surgery. The effect was achieved by just one series of
deep breathing; however, no significant differences
between patients performing the breathing with or
without a PEP device were present. In the present
investigation, we examined deep breathing performed with a blow-bottle device because it is the
standard technique at the university hospital where
the study took place. The focus was to facilitate deep
breaths, and the patients were instructed to perform
Figure 2. CT scans of a patients in the control group (left) and the treatment group (right) 1 cm above
the diaphragm on the fourth postoperative day. Left: Atelectatic areas of 6 cm2 in the right lung and
7 cm2 in the left lung. Right: Atelectatic areas of 1 cm2 in the respective lungs.
3486

Table 5Arterial Blood Gas Analysis*

Before Surgery
After Surgery
Variables
Treatment
Group
Control
Group
Treatment
Group
Control
Group
p Value
Pao2, kPa
Sao2 , %
Paco2, kPa
9.7 1.5
94.2 4.0
5.8 0.8
9.8 1.1
94.9 2.3
6.0 0.7
8.7 1.2
92.6 3.1
5.1 0.5
9.0 1.2
93.3 1.9
5.0 0.4
0.49
0.91
0.17
*Data are presented as mean ( SD). The measurements were performed before and four days after surgery. Sao2 arterial oxygen saturation.
Difference between the deep-breathing group and the control group.
maximal slow inspirations. The expiration was relaxed, and an expiratory pressure of 10 cm H2O was
achieved if the patients were breathing out correctly.
It is possible that the same results could have been
obtained even without using the blow-bottle device.7
The patients were encouraged to perform the
deep-breathing exercises once per hour throughout
the day. The frequency (three sets of 10 breaths) was
chosen according to the ordinary routines at the
clinic. Compliance with the suggested exercises was
not objectively measured, but it was self-reported by
the patients in the deep-breathing group. The reported number of exercise sessions performed each
day might be considered acceptable and is in accordance with what one can achieve in a clinical situation. At present, it is not known if increasing the
frequency and intensity of the exercises is likely to be
more efficacious. All patients found the breathing
technique easy to perform, and most of the patients
experienced a subjective benefit of the exercises; this
is important for completion of the treatment.
In our study, pulmonary function measurement
was performed preoperatively and repeated on the
fourth postoperative day. A marked reduction in lung
volumes was present on the fourth postoperative day,
which was of the same extent as found in previous
investigations after CABG surgery.18 20 A slightly
better preservation of spirometric variables was also
seen in the deep-breathing group compared to the
control group on the fourth postoperative day; however, the effect on atelectasis was more obvious than
the spirometric results. However, a correlation was
found between atelectasis and worsening in FEV1,
similar to a previous study15 on postoperative atelectasis after abdominal surgery.
CT can give reliable measurement of atelectasis,
but it is worth noting that up to this time CT has not
been used in the evaluation of prophylactic chest
physical therapy following cardiac surgery. Clear
effects of deep breathing on pulmonary function
parameters after cardiac surgery have earlier not
been documented, and this could possibly be explained by the choice of outcome measures. Studies
including control group patients who did not receive
chest physiotherapy at all have been limited,3,4 and
none of these studies have shown benefits from

treatment regimens. Even though our patients were
seen by a physical therapist daily and were instructed
in active exercises and mobilized early, the patients
in the deep-breathing group still had better pulmonary function and smaller atelectatic areas.
A weak correlation between atelectatic areas and
Pao2 has earlier been presented,7 but in the present
study no significant difference in oxygenation was
apparent between the deep-breathing group and the
control group. Recruited lung tissue is most likely
converted from a shunt region to a zone with low
ventilation in relation to perfusion, still contributing
to poor oxygenation of blood.21,22 Arterial oxygenation is also influenced by nonpulmonary factors
such as mixed venous oxygen tension or cardiac
output and efficiency of hypoxic pulmonary vasoconstriction.23
It should also be emphasized that atelectasis is a
locus for inflammation. A variety of signs and symptoms can identify a postoperative pulmonary complication. The presence of atelectasis in combination
with other chosen factors is often a criterion for the
definition. Whether a reduced amount of atelectasis
can decrease postoperative lung complications, if
atelectasis is not considered a complication, remains
to be tested.
Conclusion
Patients who performed deep-breathing exercises
after CABG surgery showed a significantly smaller
amount of atelectasis and had less reduction in FVC
and FEV1 on the fourth postoperative day compared
to patients who performed no breathing exercises.
ACKNOWLEDGMENT: We thank the staff at the Departments
of Cardiothoracic Surgery, Physiotherapy, and Clinical Physiology for support and measurements, and Martin Gustavsson,
rebro University Hospital, for perDepartment of Radiology, O
forming all CT measurements.
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3488

Deep-Breathing Exercises Reduce Atelectasis and Improve Pulmonary

Function After Coronary Artery Bypass Surgery
Elisabeth Westerdahl, Birgitta Lindmark, Tomas Eriksson, rjan Friberg,
Gran Hedenstierna and Arne Tenling
Chest 2005;128;3482-3488
DOI 10.1378/chest.128.5.3482
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Deep-Breathing Exercises Reduce

Atelectasis and Improve Pulmonary Function

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