Effects of Physical Therapy on Cardiac Surgery
Effects of Physical Therapy on Cardiac Surgery
Background: Although respiratory physiotherapy has been used in patients undergoing cardiac
 surgery, evidence lacks concerning its effectiveness. The aim of this study was to evaluate
 the efficacy of three physiotherapeutic protocols used to recover respiratory volumes in the
 postoperative period.

 Methods: Thirty five patients were randomly allocated into three groups. Exercise group (E)
 was oriented to progressive mobilization. Incentive Spirometry group (IS) performed deep
 breathings using VoldyneTM, while Breath-Stacking group (BS) performed successive inspiratory
 efforts using a facial mask adapted to an unidirectional valve. Both BS and IS also performed
 progressive mobilization. Forced spirometry was carried out in the pre-operative period and
 from the first to the fifth postoperative day. Statistical analysis used student t-test and
 ANOVA, and the differences were considered significant when p<0.05.
This was a prospective, controlled and randomized clinical trial, conducted with patients
 undergoing cardiac surgery at Hospital de Força Aérea do Galeão (HFAG - Rio de Janeiro, RJ,
 Brazil). According to Helsinki declaration, the protocol was approved by UNISUAM Ethics
 Committee (process: 15/2007) and written informed consent was obtained from all participants.
 All patients at the HFAG, who were scheduled for cardiac surgery between November 2007 and
 February 2009 were eligible to participate in this study.

 Patients were not included if any of the following criteria was present: informed consent
 could not be obtained, they could not perform the preoperative tests, cognitive impairments
 to perform the IS, intolerance to the use of BS mask. Exclusion criteria included:
 hemodynamic complications (intraoperative myocardial infarction, major blood loss, marked
 hypotension, reduced cardiac output requiring the use of an intra-aortic balloon pump or
 extraordinary use of medications) and intubation period longer than 72 hours following
 arrival in the intensive care unit. In all patients the surgical procedure was through a
 median sternotomy, and the postoperative routine was the same, including optimal treatment
 for pain control. A verbal pain score was obtained using a visual analog scale and all
 patients initiated the physiotherapeutic treatment at the first postoperative day, following
 extubation. Demographic data, clinical history and preoperative risk factors were recorded.

 In the preoperative period all patients were instructed about the importance of early
 mobilization and excessive bronchial secretion removal. Patients were taught huffing (forced
 expiration while the glottis is opened), supported cough (with patient's hands placed on the
 sternotomy incision) and mobilization, including active limb exercises, sit out of bed and
 deambulation (starting on the third postoperative day). Then, they were randomly allocated
 into three groups. Exercise group (E) performed only the procedures described above.
 Incentive Spirometry group (IS) was oriented to take a deep breathing through Voldyne 5000TM
 (Sherwood Medical; St Loius, MO, USA) from Functional Residual Capacity (FRC) to Total Lung
 Capacity (TLC). Breath-Stacking group (BS) performed inspiratory efforts using a facial mask
 adapted to an unidirectional valve. Since the mask was set to allow only inspiration (the
 expiratory branch was occluded), the patient carried through successive inspiratory efforts
 for a period of 20 seconds. Then, the expiratory branch was released allowing exhalation.
 These three treatments were applied for five days, with three series of five maneuvers twice
 a day. Patients management was similar among groups in terms of assessment, mobilization
 protocol and cough orientation.

 For safety purposes, vital signs and oxygen saturation (SpO2) were monitored throughout the
 interventions. SpO2 was measured continuously for seven minutes using a portable pulse
 oximeter (Model 2500A, Nonin Medical INC; Plymouth, USA) with patient breathing room air.
 After seven minutes the most consistent value for 30 seconds was recorded and previous oxygen
 therapy was reinitiated. If during the assessment, patient's SpO2 dropped to below 85%,
 oxygen was recommenced and it was registered.

 All procedures were performed under the supervision of an experienced physical therapist.
 Forced spirometry was carried out in the preoperative period and from the first to the fifth
 postoperative day, using a Pony Fx® spirometer (Cosmed; Rome, Italy). A Wright® ventilometer
 (British Oxygen Company; London, England) was properly attached to Voldyne and to
 Breath-Stacking mask, allowing to measure the Inspiratory Capacity (IC) during the
 procedures.

 Postoperative risk was evaluated by means of Torrington Scale, using clinical and functional
 data.

 Statistical Analysis Statistical analysis was done using Sigma Stat 3.1 (Jandel Scientific,
 San Rafael, CA, USA). Data are presented as average and standard error of the mean. They
 presented normal distributions (Kolmogorov-Smirnov test with Lilliefors' correction) and
 homogeneous variances (Levene median test). Comparisons of FVC between IS, BS and E were done
 with ANOVA, followed by Tukey test whenever multiple comparisons were required. Student's
 t-test was used to compare IC between IS and BS. The significance level was always set at 5%.
Inclusion Criteria:

 Patients were not included if any of the following criteria was present:

 -  Informed consent could not be obtained

 -  Could not perform the preoperative tests

 -  Cognitive impairments to perform the IS

 -  Intolerance to the use of BS mask

 Exclusion Criteria:

 Exclusion criteria included:

 -  Hemodynamic complications (intraoperative myocardial infarction

 -  Major blood loss

 -  Marked hypotension

 -  Reduced cardiac output requiring the use of an intra-aortic balloon pump or
 extraordinary use of medications) and intubation period longer than 72 hours following
 arrival in the intensive care unit