Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: a randomized controlled pilot study

Abstract

Objective: To investigate the feasibility and effects of preoperative inspiratory muscle training on the incidence of atelectasis in patients at high risk of postoperative pulmonary complications scheduled for elective abdominal aortic aneurysm surgery.

Design: Single-blind randomized controlled pilot study.

Setting: Gelderse Vallei Hospital Ede, the Netherlands.

Subjects: Twenty high-risk patients undergoing elective abdominal aortic aneurysm surgery were randomly assigned to receive preoperative inspiratory muscle training or usual care.

Main measures: Effectiveness outcome variables were atelectasis, inspiratory muscle strength and vital capacity, and feasibility outcome variables were adverse effects and patient satisfaction with inspiratory muscle training.

Results: Despite randomization, patients in the intervention group were significantly older than the patients in the control group (70 ± 6 years versus 59 ± 6 years, respectively; P = 0.001). Eight patients in the control group and three in the intervention group developed atelectasis (P = 0.07). The median duration of atelectasis was 0 days in the intervention group and 1.5 days in the control group (P = 0.07). No adverse effects of preoperative inspiratory muscle training were observed and patients considered that inspiratory muscle training was a good preparation for surgery. Mean postoperative inspiratory pressure was 10% higher in the intervention group.

Conclusion: Preoperative inspiratory muscle training is well tolerated and appreciated and seems to reduce the incidence of atelectasis in patients scheduled for elective abdominal aortic aneurysm surgery.

Get full access to this article

View all access options for this article.

References

Brooks Brunn JA Postoperative atelectasis and pneumonia. Heart Lung 1995; 24: 94—115.

Hayden SP , Mayer ME , Stoller JK Postoperative pulmonary complications: risk assessment, prevention, and treatment . Cleve Clin J Med 1995; 62: 401—407.

O.Donohue Jr. WJ

Postoperative pulmonary complications. When are preventive and therapeutic measures necessary?

Postgrad Med 1992; 91: 167—70.

McAlister FA , Bertsch K. , Man J. , Bradley J. , Jacka M. Incidence of and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med 2005; 171: 514—17.

Shea RA , Brooks JA , Dayhoff NE , Keck J. Pain intensity and postoperative pulmonary complications among the elderly after abdominal surgery. Heart Lung 2002; 31: 440—49.

Davies JM Pre-operative respiratory evaluation and management of patients for upper abdominal surgery. Yale J Biol Med 1991 ; 64: 329—49.

Fleischmann KE , Goldman L. , Young B. , Lee TH Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay. Am J Med 2003; 115: 515—20.

Hamel MB , Henderson WG , Khuri SF , Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc 2005; 53: 424—29.

Brooks D. , Crowe J. , Kelsey CJ , Lacy JB , Parsons J. , Solway S. A clinical practice guideline on perioperative cardiorespiratory physical therapy. Physiother Can 2001; 53: 9—25.

10.

Celli BR , Rodriguez KS , Snider GL A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984; 130: 12—15.

11.

Chumillas S. , Ponce JL , Delgado F. , Viciano V. , Mateu M. Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study. Arch Phys Med Rehabil 1998; 79: 5—9.

12.

Morran CG , Finlay IG , Mathieson M. , McKay AJ , Wilson N. , McArdle CS Randomized controlled trial of physiotherapy for postoperative pulmonary complications . Br J Anaesth 1983; 55: 1113—17.

13.

Roukema JA , Carol EJ , Prins JG The prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status. Arch Surg 1988; 123: 30—34.

14.

Weiner P. , Zeidan F. , Zamir D. et al. Prophylactic inspiratory muscle training in patients undergoing coronary artery bypass graft. World J Surg 1998; 22: 427—31.

15.

Nomori H. , Kobayashi R. , Fuyuno G. , Morinaga S. , Yashima H. Preoperative respiratory muscle training. Assessment in thoracic surgery patients with special reference to postoperative pulmonary complications. Chest 1994; 105: 1782—88.

16.

Hulzebos EH , Helders PJ , Favie NJ , De Bie RA, Brutel de la RA, van Meeteren NL. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA 2006; 296: 1851—57.

17.

Hulzebos EH , van Meeteren NL , van den Buijs BJ , De Bie RA, Brutel de la RA, Helders PJ. Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complications: a randomized controlled pilot study . Clin Rehabil 2006; 20: 949—59.

18.

Siafakas NM , Mitrouska I. , Bouros D. , Georgopoulos D. Surgery and the respiratory muscles. Thorax 1999; 54: 458—65.

19.

Duggan M. , Kavanagh BP Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology 2005; 102: 838—54.

20.

Smetana GW Preoperative pulmonary evaluation. N Engl J Med 1999; 340: 937—44.

21.

Smetana GW Preoperative pulmonary assessment of the older adult. Clin Geriatr Med 2003; 19: 35—55.

22.

Smetana GW , Cohn SL , Lawrence VA Update in perioperative medicine. Ann Intern Med 2004; 140: 452—61.

23.

Bekkering GE , Hendriks HJM , Chadwick-Straver RVM et al. Clinical practice guidelines for physical therapy in patients with chronic obstructive pulmonary disease. Ned T Fysiother 1998; 108: 1—44.

24.

Chuter TA , Weissman C. , Starker PM , Gump FE Effect of incentive spirometry on diaphragmatic function after surgery. Surgery 1989; 105: 488—93.

25.

Chuter TA , Weissman C. , Mathews DM , Starker PM Diaphragmatic breathing maneuvers and movement of the diaphragm after cholecystectomy . Chest 1990; 97: 1110—14.

26.

Ford GT , Rosenal TW , Clergue F. , Whitelaw WA Respiratory physiology in upper abdominal surgery. Clin Chest Med 1993; 14: 237—52.

27.

Ho SC , Chiang LL , Cheng HF et al. The effect of incentive spirometry on chest expansion and breathing work in patients with chronic obstructive airway diseases: comparison of two methods. Changgeng Yi Xue Za Zhi 2000; 23: 73—79.

28.

Katagiri H. , Katagiri M. , Kieser TM , Easton PA Diaphragm function during sighs in awake dogs after laparotomy. Am J Respir Crit Care Med 1998; 157: 1085—92.

29.

Overend TJ , Anderson CM , Lucy SD , Bhatia C. , Jonsson BI , Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest 2001; 120: 971—78.

30.

Wahba RW Perioperative functional residual capacity. Can J Anaesth 1991; 38: 384—400.

31.

ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med 2002; 166: 518—624.

32.

Martyn JB , Moreno RH , Pare PD , Pardy RL Measurement of inspiratory muscle performance with incremental threshold loading . Am Rev Respir Dis 1987; 135: 919—23.

33.

Standardization of Spirometry, 1994 Update. American Thoracic Society. Am J Respir Crit Care Med 1995; 152: 1107—36..

34.

Halaszynski TM , Juda R. , Silverman DG Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 2004; 32(suppl): S76—S86.

35.

John AD , Sieber FE Age associated issues: geriatrics. Anesthesiol Clin N Am 2004; 22: 45—58.

36.

Carli F. , Zavorsky GS Optimizing functional exercise capacity in the elderly surgical population . Curr Opin Clin Nutr Metab Care 2005; 8: 23—32.

37.

Sofaer S. , Firminger K. Patient perceptions of the quality of health services. Annu Rev Public Health 2005; 26: 513—59.

38.

Hautmann H. , Hefele S. , Schotten K. , Huber RM

Maximal inspiratory mouth pressures (PIMAX) in healthy subjects — what is the lower limit of normal?

Respir Med 2000 ; 94: 689—93.

39.

Arozullah AM , Khuri SF , Henderson WG , Daley J. Development and validation of a multi-factorial risk index for predicting postoperative pneumonia after major noncardiac surgery . Ann Intern Med 2001; 135: 847—57.

40.

Hulzebos EHJ , van Meeteren NLU , Uiterwaal Cspm , van Klarenbosch J. , Gigengack-Baars A. , Helders PJM. Validation of a preoperative risk model for pneumonia in patients undergoing CABG surgery. Submitted 2007.

41.

Lotters F. , van Tol B. , Kwakkel G. , Gosselink R. Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis. Eur Respir J 2002; 20: 570—76.