International journal of medical science and clinical Invention

Volume 1 issue 6 2014 page no. 333-338 ISSN: 2348-991X

Comparative Study of Breathing Techniques After Coronary

Artery By Pass Grafting
Sharick Shamsi1 , Shabana khan2
1
Raj Nursing and Paramedical College, Gorakhpur, U.P, India
[email protected]
2
Department of Health Rehabilitation, King Saud University, Riyadh Saudi Arabia

[email protected]

ABSTRACT

Study Objective: Comparative Study of Breathing Techniques after Coronary Artery by Pass Grafting
Design: A randomized trial.

Method and Measurements: The effectiveness of three deep breathing techniques was evaluated in 30 male
patientsafter coronary artery bypass graft in a randomized trial. Patient were randomly and equally assigned to Blow
bottle(group A), IR-PEP (group B), and deep breathing (group C). The techniques were deep breathing with a blow
bottle-device, Inspiratory resistance-positive expiratory pressure mask (IR-PEP) and performed with no mechanical
device.Pulmonary function and roentgenological changes were evaluated.
Results: No significant differences found between all three groups except for a longer duration of anesthesia in
thegroup B than the group C. Pain from the sternotomy measured by VAS while the patient take a deep breath
showingno significant difference between the group A (2.6± 1.8), Group B (2.8 ± 2.1) and Group (2.4 ± 2.2).
Conclusion: There were no major differences between the three treatment groups on the fourth post-operative
day. The relative decrease in pulmonary function tended to be less marked by chest physiotherapy using the
Blowbottle technique than by Deep breathing without any mechanical device and the technique was at least as good
as theIR-PEP technique. The Blow bottle is furthermore an inexpensive method that will be well accepted and
easilylearned by patients, and works as well as more complex techniques. However, a technique that offers even
bettersupervision and the assistance of a deep inspiration with optimal continuance may prevent further lung
functiondeterioration.

333
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

KEY WORDS: Physical therapy, breathing exercises, thoracic surgery, coronary artery bypass, respiratory function
tests, postoperative care

INTRODUCTION: secretions, and early mobilisation-is given with

the aim of increasing lung ventilation and
In order to prevent or diminish postoperative
preventing chest infections9. Recently, changes to
complications Physiotherapy treatment is often
the post-operative care of cardiac surgery patients
prescribed to patients undergoing cardiac surgery,
have been advocated. Patients could be managed
the physiotherapy treatment generally consists of
using “rapid recovery guidelines” without
early mobilization, range of motion exercises
compromising patient outcomes or levels of
during the hospital stay 1. Chest physiotherapy
satisfaction10. Early extubation (7-11 hours post-
and breathing exercises are also prescribed to
operatively) following cardiac surgery resulted in
patients undergoing cardiac surgery in order to
a decrease in length of intensive care unit (ICU)
prevent or reduce post-operative pulmonary
stay and no increase in clinically important post-
complications. There is an agreement on the value
operative complications11. Introduction of a “fast-
of pre- and post-operative breathing exercises and
track regime” (using shorter acting anesthesia, less
physiotherapy treatment2. The value of
reduction in intra-operative body core temperature
postoperative chest physiotherapy has recently
and defined clinical milestones) for patients
been established and accepted, but it is still
following coronary artery surgery did not increase
unclear which treatment techniques are the most
the incidence of post-operative pulmonary
effective3-5. In the literature a wide variety of
complications12. Respiratory physiotherapy is
treatments have been suggested. Many strategies
routinely used in the prevention and treatment of
and diverse therapies are applied postoperatively
post-operative pulmonary complications after
and these differ within and between countries.
cardiac surgery. The goals of physiotherapy are to
Early mobilization and physical activity is often
improve ventilation–perfusion matching, increase
the first choice of treatment, but evidence as to the
lung volume, enhance mucociliary clearance, and
optimal intensity, timing and choice of exercises
decrease pain13.
is scarce. There are only limited published data on
how the cardiac surgery patient should be
METHODS AND MATERIAL:
mobilized and exercised during the first
30 male patients scheduled for CABG at RNH
postoperative period in hospital6-8. After coronary
hospital were the study conducted. Patients who
artery bypass grafting physiotherapy-consisting of
had unstable angina, previous open heart surgery
breathing exercises emphasising inspiration,
or renal dysfunction requiring dialysis were not
incentive spirometry, techniques to clear bronchial
included. The study was approved by the Ethics
334
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

Committee of RNH hospital and informed consent patients in the group A were instructed to do deep
was obtained from each patient. The surgical breathing exercises with a blow bottle device. A
approach was through a median sternotomy and bottle with 10 cm of water and a 40 cm plastic
CABG was performed with saphenous vein grafts tube (1 cm diameter) were used. The manoeuvre
and/or the left and/or right internal mammary gives a resisted exhalation with an expiratory peak
artery. Cold blood cardioplegia and pericardial pressure of +10 (±1) cm H2O. In the group B the
cooling with ice were used. An insulation pad was deep breathing was performed through an
used to protect the phrenic nerve. The patient’s PEP/RMT. The system consisted of a face
lungs were kept deflated during the aortic mask/ventil connected to a T-tube where
occlusion. The pericardium, the mediastinum and inspiratory and expiratory airflows are separated
one or both pleura were drained, usually less than by a valve. Various resistance nipples were
24 hours after surgery. Post-operatively the applied to receive wanted pressure, measured by a
patients were artificially ventilated and a positive manometer. The expiratory pressure used was +10
end-expiratory pressure of 5 cm H2O was used. cm H2O and the inspiratory pressure -5 cm H2O.
Following surgery, inspired oxygen fraction in The nipples used for expiratory pressure were 2.5
nitrogen was 0.5–0.8. The patients were tracheally mm, 3.0 mm or 3.5 mm and for inspiratory
extubated, when hemodynamically stable and able pressure; 4.0 mm, 4.5 mm or 5.0 mm. In the group
to normoventilate without distress. All patients C the patients were instructed to inspire deeply
received basic post-operative chest physiotherapy through the nose and expire through the mouth
as conventionally used at the clinic by two without any mechanical device. In all three groups
physiotherapists once or twice the patients were instructed to perform a maximal
daily. The therapy consisted of mobilization and inspiration, while expiration was ended at
active exercises of the upper limbs and thorax, approximately functional residual capacity (FRC)
breathing exercises and instructions in coughing to avoid airway closure. Pre-operatively the
techniques. Patients were mobilized as early as patients practiced the different breathing
possible by the nursing staff and physiotherapists techniques and received general information about
according to the ordinary routines. The patients post-operative routines, early mobilization and
were instructed to sit out of bed and stand up on efficient coughing. All groups were instructed to
the first postoperative day, walk in the room or a perform 30 deep breaths with or without the
short distance in the corridor on the second day, mechanical device once an hour at daytime. The
and walk freely in the corridor on the third post- breathing exercises were, if possible, done in a
operative day. Before surgery the patients were sitting position and three sessions of 10 deep
randomly assigned in three treatment groups. The breaths each were performed, interrupted by a

334
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

pause and coughing or huffing, if needed. capacity (TLC) was calculated as VC + RV. The
Exercises were started 1 hour after extubation and pulmonary diffusing capacity for carbon
continued until the fourth post-operative day. The monoxide (DLCO) was measured. The gas
patients were actively encouraged to use the mixture used for the measurement was 0.5% neon,
suggested treatments by the staff during the 4 days 0.3% carbon monoxide, 21% oxygen, balance
of the investigation. nitrogen. The gas sample was aspirated
automatically into the chromatograph for analysis.
Measurements:
The patients were instructed to exhale slowly and
Pulmonary function measurements were
maximally to RV, and then rapidly inhale the gas
performed pre-operatively and on the fourth post-
mixture to TLC. The DLCO measurement was
operative day with a Medical Graphics Pulmonary
considered acceptable if the inspired volume was
Function System with proprietary software. The
greater than 90% of the patients’ VC. Two or
equipment was calibrated every morning prior to
three repeated tests were performed and the
measurements. Four medical laboratory
highest accepted value was retained. Repeated
technicians who were unaware
tests were separated by a washout period of at
of the patient’s randomization performed the tests.
least 5 minutes DLCO was expressed both in
The patients were in a sitting position and a nose-
absolute values and per liter of alveolar volume
clip was used. Predicted values for pulmonary
(DLCO/VA), measured by neon dilution during
function were related to age, sex, length and
the breath holding manoeuvre. The DLCO values
weight according to the values reported14 .The
were corrected for the patient’s current
results of the postoperative pulmonary function
haemoglobin concentration using the equation of
were expressed in percentage of the individual
Cotes . At the time of the pulmonary function test
pre-operative values, and the relative decrease in
the patients were asked to quantify the pain from
pulmonary function was compared between the
the median sternotomy incision while taking a
treatment groups. Three slow inspiratory vital
deep breath. A continuous visual analogue scale
capacities were obtained and the largest
(VAS) from 0 (no pain) to 10 (the worst
used for measurement of vital capacity (VC) and
imaginable pain) was used.
inspiratory capacity (IC). For the measurement of
An anteroposterior chest roentgenogram was
forced expiratory volume in 1 second (FEV1), the
taken in the standing position before the operation
highest value of two or three technically
and on the fourth post-operative day. Presence or
satisfactory
absence of atelectasis and/or pleural effusion was
manoeuvres was retained. FRC and residual
recorded.
volume (RV) were measured with the single
breath nitrogen washout technique. Total lung
335
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

Evaluation was performed by a radiologist who RESULTS:

was unaware of the patient’s randomization. The No significant differences between all three
size of atelectasis seen on the chest radiograph groups were found except for a longer duration of
was scored in the right and left lung separately. anesthesia in the IR-PEP group than the deep
breathing group. Pain from the sternotomy
An arbitrary
measured by VAS while the patient took a deep
scale was used for scoring of atelectasis: 0, no breath showed no significant difference between
abnormality; 1, minimal abnormality (plate the Blow bottle (2.6± 1.8),
atelectasis); 2, moderate abnormality (segmental IR-PEP (2.8 ± 2.1) and Deep breathing (2.4 ± 2.2)
atelectasis); 3, major abnormality (lobar groups.
atelectasis). The left hemidiaphragm was
Pulmonary function:
described as raised if the highest point was at the
same horizontal level or higher than that on the The preoperative lung function did not differ
right. between treatment groups in any of the measured
variables. The measured variables were normal as
Statistical analysis
related to predicted values with VC 86 ± 14% of

The pre-operative, demographic and operative predicted and FEV1 94 ± 19% of predicted.

variables for the groups were compared by one- Pulmonary function values before surgery and on

way analysis of variance or chi-square test. The the fourth post-operative day are given in Table

pre- and post-operative pulmonary function values II14. Four days post-operatively all pulmonary

were compared by a paired t-test for each variable. function variables were significantly decreased in

The relative decrease of the pulmonary function the three groups (p < 0.0001) compared to pre-

variables after the operation was calculated for operative values. The post-operative mean VC for

each patient and the mean value for the three all patients was 61 % of the pre-operative value,

groups were analysed with one-way analysis of and FEV1 was reduced to 64%.

variance. If a difference was found between the The relative decrease in pulmonary function

groups, the means were compared by Scheffe’s variables, on the fourth post-operative day,

test. Chest roentgenological scores were examined displayed a small difference between the three

and analysed separately in the left and the right treatment groups, when analysed with one-way

lung, and differences between the treatment analysis of variance. Post hoc analysis showed

groups were analysed with a chi-square test. All that the Blow bottle group had significantly less

results refer to two-sided tests and a probability reduction in TLC (p = 0.01)

value less than 0.05 was considered significant. and a tendency to less reduction in FRC (p = 0.05)
and FEV1 (p = 0.05), than the Deep breathing

336
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

group. The IR-PEP group fell in between and did significant differences among the three groups in
not significantly differ from the other two groups. the occurrence of atelectasis in the left lung (p =
DLCO on the fourth post-operative day was 0.46) or in the right lung (p = 0.71). 5 patient had
decreased to 57% (p < 0.0001) of pre-operative signs of elevated left hemidiaphragm; they were 7
values. No significant in the Blow bottle group, 9 in the IR-PEP group
difference between treatment groups was found. and 10 in the Deep breathing group. Two patients
had signs of elevated right hemidiapragm and they

Chest roentgenological changes: were both in the IR-PEP group. Pleural effusions
were found in 20 patients In 13 patients the
No patient showed signs of atelectasis before the
effusion was left side and in the remaining 7
operation. On the fourth post-operative day
patients it was bilateral. Of the patients with left
atelectasis was found 25 in of the patients. The
sided pleural effusion 6 were in the Blow bottle
incidence and severity of chest roentgenological
group, 5 in the IR-PEP group and 9 in the Deep
signs of atelectasis in the left and right lung are
breathing group. The incidence of left pleural
presented in Table III. Atelectasis was present
effusions did not significantly differ between
only in the left lung in 8 patients, only in the right
treatment groups. The incidence of right side
lung in 5 patients and in both lungs in 12 patients
pleural effusion was 3, 2 and 2.
on the fourth post-operative day. There were no

Table 1 Demographic and operative variables (mean ± SD)

Group A Group B Group C p-value
Age (years) 64.3 ± 8.4 63.8±8.6 61.5±8.9 0.40
Body mass 26.9±3.3 27.2±3.4 27.1±3.0 0.93
index (kg/m2)
Smokers/non- 6/4 3/7 4/6 0.80
smokers (n)
Operation time 4.0±0.6 3.7±0.6 3.7±0.6 0.14
(hours)
AoO (minutes) 59±15 55±20 53±15 0.17
IMA grafts (n) 5 7 8 0.55
Pleural space 5 8 9 0.34
entered (n)
Duration of 11.5±2.1 12.9±2.7 11.2±1.9 0.01
anesthesia
AoO = aortic occlusion time; IMA = intern mammary artery.

337
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

Table 2. Pulmonary function data before and on the fourth post-operative day following coronary
artery bypass surgery (mean ± SD)

Pre-operative Post-operative
Group Group B Group p- Group Group Group C p-
A C value A B value
* †
VC (l) 4.1±0.5 4.0±0.7 3.9±0.5 0.40
2.4±0.5 2.4±0.5 2.2±0.4 0.8
IC(1) 3.0±0.6 3.1±0.6 3.1±0.6 0.39
2.1±0.4 2.1±0.4 1.7±0.5 0.59
FEV1(1) 2.6±0.5 3.1±0.6 2.6±0.5 0.25
1.7±0.4 1.7±0.5 1.9±0.4 0.05
FRC(1) 3.2±0.5 3.0±0.7 3.1±0.5 0.35
2.1±0.5 2.4±0.6 2.1±0.5 0.05
TLC(1) 5.9±1.0 6.5±1.1 6.1±0.6 0.10
4.1±0.6 4.3±1.1 3.9±0.5 0.01
DLCO 20.6±5. 24.9±7.2 25.0±5. 0.05
14.3±3. 16.9±5.4 16.1±4.2 0.35
(ml/min/mmHg) 1 1 0
DLCO/VA 3.5±1.0 3.5±0.7 3.9±0.8 0.40 3.3±0.7 3.7±1.0 4.1±0.8 0.41
(ml/min/mmHg/
l)
* The difference between the means of the treatment groups.
† The difference between the means of the relative decrease in pulmonary function from before the
operation.
VC = vital capacity; IC = inspiratory capacity; FEV1 = forced expiratory volume in 1second; FRC =
functional residual capacity; TLC = total lung capacity; DLCO = single breath diffusing capacity for carbon
monoxide; DLCO/ VA = DLCO per unit alveolar volume.

Table 3. The incidence of chest roentgenological signs of atelectasis in the left/right lung on the
fourth Post-operative day after coronary artery bypass graft surgery.

Group A (n=10) Group B (n=10) Group C (n=10)

No abnormality 4 3 4
Plate atelectasis 2 2 3
Segmental atelectasis 3 3 2
Lobar atelectasis 1 2 1

DISCUSSION: reduction in lung volumes and expiratory flow

The pulmonary function after CABG were rates impairs cough and clearance of secretions,

severely reduced in all treatment groups on the and pain may reduce the ability to cough even

fourth post-operative day. The reduction is similar more. In the present study the scoring of post-

to what have been shown in several previous operative pain by VAS on the fourth post-

studies on the fourth post-operative day after open operative day was similar in the three treatment

heart surgery 15,16

. The reasons for the restrictive groups. The best technique for lung expansion is

impairment and atelectasis are multiple and claimed to be a maximal inspiration.

include, besides the effects of anaesthesia17, The There is some evidence that regular chest
physiotherapy significantly decreases the
334
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

incidence of pulmonary complications after volume and to finish expiration before closing
major abdominal and thoracic surgery13. The blow volume is reached. Improper performance of
bottle is a cheap and simple method of producing deep breathing exercise may decrease, rather than
a positive expiratory pressure. The use of the blow increase end-expiratory lung volume if a patient
bottle in post-operative care is aimed at increasing exhales forcefully toward residual volume22 . It is
the pulmonary volume and facilitating the release important to halt the expiration at or near FRC so
of pulmonary secretions, but documentation of that airway closure is prevented or limited as
efficacy in patients after heart surgery has been much as possible.The optimal frequency and
20
scarce . cardiac surgery patients treated with duration of the treatment are important factors to
blow bottles, intermittent positive pressure consider. In the present study the patients were
breathing (IPPB) and incentive spirometry. The encouraged to perform 30 deep breaths once per
incidence of pulmonary complications was 31% in hour except during the night, and the frequency
the IPPB group, 16% in the spirometry group but and duration of the exercises were chosen
only 7% in the Blow bottle group. The result was according to the ordinary routines at the clinic.
not statistically significant and the equipment and Deep breathing therapy is suggested to be
technique of the blow bottle was not in full detail provided at least every 1–2 hours, but the optimal
described. It is therefore difficult to know if our frequency is not yet
results support these findings. The IR-PEP system known9. Compared three physiotherapy regimes
is used to create an active inspiration in addition in 110 men undergoing CABG and concluded that
to PEP. The inspiratory resistance is believed to the addition of breathing exercises or incentive
increase demands on the diaphragm and improve spirometry to a regimen of early mobilization and
recovery of its function, but this has not been coughing confers no extra benefit after
clearly established. In this study the blow bottle uncomplicated CABG. The patients in the two
was found to be at least as effective as the IR-PEP treatment groups were instructed to take at least
mask in preventing pulmonary function decrease 10 deep breaths or use the incentive spirometer at
on the fourth post-operative day. Airway closure least 10 times in each waking hour. Perhaps are 10
is a normal physiological phenomenon during deep breaths per hour, or even 30, not enough to
deep expiration, which may occur already at give a clinical important improvement.
normal FRC in the elderly. Thus, the reduction in Atelectasis were found in some patients on the
FRC post-operatively will promote airway fourth post-operative day, which is equal to what
closure21 which may eventually lead to resorbtion have been found in earlier studies after
23,24
atelectasis, when breathing exercises are made. It CABG . The occurrence of atelectasis showed
is therefore important to start from a high lung no statistical difference between the groups in the

334
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

present study. Right-sided abnormalities were Post-operative complications are relatively

equally rare, as was found in a previous study.24 frequent after cardiac surgery. It has earlier been
Few data are available concerning post-operative suggested
diffusion capacity abnormalities in patients after that breathing exercises after uncomplicated
CABG. A decrease in DLCO by 25%, and a cardiac surgery confers no extra benefit30,31.
decrease in DLCO/VA by 17%, has been reported Deep breathing exercises are advocated to
2 hours post-operatively in 10 patients undergoing improve tidal volume and facilitate secretion
cardiac surgery requiring cardiopulmonary removal32,33.
bypass25. The In the present study, 93% of the physical
single-breath test, used in the present study, is the therapists instructed the patients to perform
most common method to measure pulmonary breathing exercises on a regular basis
diffusing capacity. The transfer of carbon postoperatively. Deep breathing was the first
monoxide is a complex phenomenon and there is a choice of breathing technique, and this is in
large inter-laboratory variability in the results for agreement with previous studies34,35.
the measurement of DLCO26, which necessitates
CONCLUSION
the use of the same
equipment pre- and post-operatively. Our results There were no major differences between the
showed a reduction in DLCO to 57% of the pre- three treatment groups on the fourth post-
operative value on the fourth post-operative day, operative day. The relative decrease in pulmonary
while corrected for lung volume, DLCO/VA function tended to be less marked by chest
remained almost unchanged. It is therefore physiotherapy using the Blow bottle technique
possible that the reduction in DLCO could be due than by Deep breathing without any mechanical
solely to the reduction device and the technique was at least as good as
in lung volume. the IR-PEP technique. The Blow bottle is
Deep breathing exercises was the first choice of furthermore an inexpensive method that will be
breathing technique and this in agreement with the well accepted and easily learned by patients, and
27
results . The use of breathing exercises with works as well as more complex techniques.
positive pressure devices is used extensively in However, a technique that offers even better
clinical supervision and the assistance of a deep
practice post-operatively in Brazil28 and after inspiration with optimal continuance may prevent
thoracic surgery in Australia and New Zealand29. further lung function deterioration.

335
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

References: 5- Stiller K, McInnes M, Huff N, Hall B: Do

Elisabeth Westerdahl, Margareta Möller , exercises prevent musculoskeletal

Physiotherapy-supervised mobilization and complications after cardiac surgery?
exercise following cardiac surgery: a national Physiotherapy Theory and Practice 1997,
questionnaire survey in Sweden. JCTS 2010, 5:67.
13:117-126.
1- E. Westerdahl, M. Fagevik Olsén, Chest 6- Cockram J, Jenkins S, Clugston R:
physiotherapy and breathing exercises for Cardiovascular and respiratory responses to
cardiac surgery early ambulation and star climbing following
patients in Sweden- Monaldi Arch Chest Dis coronary artery surgery. Physiother Theory
2011; 75: 2, 112-119. Pract 1999, 15:3-15.
2- Hulzebos EH, Helders PJ, Favie NJ, De Bie 7- Hirschhorn AD, Richards D, Mungovan SF,
RA, Brutel de la Riviere A, Van Meeteren NL: Morris NR, Adams L: Supervised moderate
Preoperative intensive inspiratory muscle intensity exercise improves distance walked at
training to prevent postoperative pulmonary hospital discharge following coronary artery
complications in high-risk patients undergoing bypass graft surgery–a randomized controlled
CABG surgery: a randomized clinical trial. trial. Heart Lung Circ 2008, 17:129-138.
JAMA 2006, 296:1851-1857. 8- Jenkins SC, Soutar SA. A survey into the use
3- Haeffener MP, Ferreira GM, Barreto SS, of incentive spirometry following coronary
Arena R, Dall’Ago P: Incentive spirometry artery bypass graft surgery. Physiotherapy
with expiratory positive airway pressure 1986;72:492-3.
reduces pulmonary complications, improves 9- Dunstan J and Riddle M (1997): Rapid
pulmonary function and 6-minute walk recovery management: the effects on the
distance in patients undergoing coronary artery patient who has
bypass graft surgery. Am Heart J 2008, undergone heart surgery. Heart and Lung 26:
156:900 e901-900 e908. 289-298.
4- Herdy AH, Marcchi PL, Vila A, Tavares C, 10- Reyes A, Vega G, Blancas R, Morato B,
Collaco J, Niebauer J, Ribeiro JP:Pre- and Moreno J, Torrecilla C and Cereijo E (1997):
postoperative cardiopulmonary rehabilitation Early vs conventional extubation after cardiac
in hospitalized patients undergoing coronary surgery with cardiopulmonary bypass. Chest
artery bypass surgery: a randomized controlled 112: 193-201.
trial. Am J Phys Med Rehabil 2008, 87:714- 11- Stafford R, Ho E and Jenkins S (1997): The
719. incidence of postoperative pulmonary
complications following coronary artery

336
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

surgery: traditional and fast-track regimens Effect of sternotomy and coronary bypass
compared. Proceedings of Australian surgery on postoperative pulmonary
Physiotherapy Association 5th National mechanics. Comparison of internal mammary
Cardiothoracic Special Group Conference. and saphenous vein bypass grafts. Chest 1989;
Fremantle, p. 58. 96: 873–876.
12- Stiller KR, Munday RM. Chest physiotherapy 19. Locke TJ, Griffiths TL, Mould H, Gibson GJ.
for the surgical patient. Br J Surg. 1992; Rib cage mechanics after median sternotomy.
79:745-749. Thorax
13- Grimby G, So¨derholm B. Spirometric studies 1990; 45: 465–468.
in normal subjects. Static lung volumes and 20. Iverson LI, Ecker RR, Fox HE, May IA. A
maximum voluntary ventilation in adults with comparative study of IPPB, the incentive
a note on physical fitness. Acta Med Scand spirometer, and
1963; 173: 199–206. blow bottles: the prevention of atelectasis
14- Oikkonen M, Karjalainen K, Kahara V, Kuosa following cardiac surgery. Ann Thorac Surg 1978;
R, Schavikin L.Comparison of incentive 25: 197–200.
spirometry and intermittent positive pressure 21. Alexander JI, Spence AA, Parikh RK, Stuart
breathing after coronary artery bypass graft. B. The role of airway closure in postoperative
Chest 1991;99: 60–65. hypoxaemia.
15- Ingwersen UM, Larsen KR, Bertelsen MT, Br J Anaesth 1973; 45: 34–40.
Kiil-Nielsen K, Laub M, Sandermann J, et al. 22. Pontoppidan H. Mechanical aids to lung
Three different mask physiotherapy regimens expansion in non-intubated surgical patients. Am
for prevention of post-operative pulmonary Rev Respir
complications after heart and pulmonary Dis 1980; 122: 109–119.
surgery. Intensive Care Med 1993; 19: 294– 23. Richter Larsen K, Ingwersen U, Thode S,
298. Jakobsen S. Mask physiotherapy in patients after
16- Hedenstierna G, Tokics L, Strandberg A, heart
Lundquist H, Brismar B. Correlation of gas surgery: a controlled study. Intensive Care
exchange impairment to development of Med 1995; 21: 469–474.
atelectasis during anaesthesia and muscle 24. Jain U, Rao TL, Kumar P, Kleinman BS,
paralysis. Acta Anaesthesiol Belusko RJ, Kanuri DP, et al. Radiographic
Scand 1986; 30: 183–191. pulmonary abnormalities after different types of
17- Berrizbeitia LD, Tessler S, Jacobowitz IJ, cardiac surgery. J Cardiothorac Vasc Anesth
Kaplan P, Budzilowicz L,Cunningham JN. 1991; 5: 592–595.

337
 Cite as: COMPARATIVE STUDY OF BREATHING TECHNIQUES AFTER CORONARY
ARTERY BY PASS GRAFTING; Vol 1|Issue 06|Pg:333-338
2014

25. MacNaughton PD, Braude S, Hunter DN, 31. Stiller K, Montarello J, Wallace M, et al.
Denison DM, Evans TW. Changes in lung Efficacy of breathing and coughing exercises in
function and the prevention
pulmonary capillary permeability after Of pulmonary complications after coronary
cardiopulmonary bypass. Crit Care Med; 20: artery surgery.Chest 1994; 105: 741-7.
1289–1294 1992. 32. Pryor JA, Webber BA. Physiotherapy
26. Crapo RO, Forster R, eds. Carbon monoxide techniques. In:Pryor JA, Prasad SA, eds.
diffusing capacity. Clin Chest Med 1989; 10: Physiotherapy for
187–198. Respiration and Cardiac Problems: Adults and
27. Overend TJ, Anderson CM, Jackson J, Lucy Pediatrics. 3rd ed. Edinburgh: Churchill
SD, Prendergast M, Sinclair S. Physical therapy Livingstone;
management for adult patients undergoing 2002:161-241.
cardiac surgery: A Canadian practice survey. 33. Blaney F, Sawyer T. Sonographic
Physiother measurement of diaphragmatic motion after upper
Can 2010; 62: 215-21. abdominal
28. Fiore JF, Chiavegato LD, Paisani DM, Colucci surgery: a comparison of three breathing
DB. Utilization of positive-pressure devices for manoeuvres. PhysiotherTheory Pract. 1997;
breathing 13:207-215.
exercises in the hospital setting: A regional 34. Tucker B, Jenkins S, Davies K, McGann R,
survey in Sao Paulo, Brazil. Respir Care 2010; 55: Waddell J, et al. (1996) The physiotherapy
719-24. management
29. Reeve J, Denehy L, Stiller K. The of patients undergoing coronary artery
physiotherapy management of patients undergoing surgery: A questionnaire survey. Aust J
thoracic surgery: Physiother 42: 129-137.
A survey of current practice in Australia and 35. Overend TJ, Anderson CM, Jackson J, Lucy
New Zealand. Physiother Res Int 2007; 12: 59-71. SD, Prendergast M, et al. (2010) Physical therapy
30. Jenkins SC, Soutar SA, Loukota JM, Johnson management for adult patients undergoing
LC, Moxham J. Physiotherapy after coronary cardiac surgery: A Canadian practice survey.
artery Physiother
surgery: are breathing exercises necessary? Can 62: 215-221.
Thorax 1989; 44: 634-9.

338