Pressão positiva nas vias aéreas vs. exercícios com carga inspiratória na funções pulmonar e muscular respiratória no pósoperatório

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1 ABCD Arq Bras Cir Dig 2018;31(2):e1363 DOI: /1590/ e1363 Original Article AIRWAY POSITIVE PRESSURE VS. EXERCISES WITH INSPIRATORY LOADING FOCUSED ON PULONARY AND RESPIRATORY USCULAR FUNCTIONS IN THE Pressão ositiva nas vias aéreas vs. exercícios com carga insiratória na funções ulmonar e muscular resiratória no ósoeratório de cirurgia bariátrica aura Rigoldi Simões da ROCHA¹, Stefane SOUZA¹, Carolina oraes da COSTA¹, Daniela Faleiros Bertelli ERINO¹, aria Imaculada de Lima ONTEBELO¹, Irineu RASERA-JÚNIOR², Eli aria PAZZIANOTTO-FORTI¹ How to cite this article: Rocha RS, Souza S, Costa C, erino DFB, ontebelo IL, Rasera-Júnior I, Pazzianotto-Forti F. Airway ositive ressure vs. Exercises with insiratory loading focused on ulmonary and resiratory muscular functions in the ostoerative eriod of bariatric surgery. ABCD Arq Bras Cir Dig. 2018;31(2):e1363. DOI: /1590/ e1363 From the ¹Universidade etodista de Piracicaba and ²Clínica Bariátrica de Piracicaba (¹ethodist University of Piracicaba and ²Piracicaba Bariatric Clinic, Piracicaba, SP, Brazil HEADINGS - Atelectasis. Resiratory exercises. Physiotheray. Gastrolasty. Obesity ABSTRACT - Background: Bariatric surgery can trigger ostoerative ulmonary comlications due to factors inherent to the rocedure, mainly due to diahragmatic dysfunction. Aim: To evaluate and comare the effects of two levels of ositive ressure and exercises with insiratory load on lung function, insiratory muscle strength and resiratory muscle resistance, and the revalence of atelectasis after gastrolasty. ethods: Clinical, randomized and blind trial, with subjects submitted to bariatric surgery, allocated to two grous: ositive ressure grou, who received ositive ressure at two levels during one hour and conventional resiratory hysiotheray and insiratory load grou, who erformed exercises with load linear insiratory ressure, six sets of 15 reetitions, in addition to conventional resiratory hysiotheray, both of which were alied twice in the immediate ostoerative eriod and three times a day on the first ostoerative day. Sirometry was erformed for ulmonary function analysis, nasal insiratory ressure for insiratory muscle strength and incremental test of resiratory muscle resistance for sustained maximal insiratory ressure, both reoeratively and on hosital discharge on the second ostoerative day. Results: There was no significant difference (> 0.05) in the exiratory reserve volume and in the tidal volume in the re and ostoerative eriods when comared intra and intergrou. There was no significant difference (>0.05) in the nasal insiratory ressure and the maximal insiratory ressure maintained in the insiratory load grou in the intragrou evaluation, but with a significant difference (<0.05) comared to the ositive ressure grou. The revalence of atelectasis was 5% in both grous with no significant difference (>0.05) between them. Conclusion: Both grous, associated with conventional resiratory hysiotheray, reserved exiratory reserve volume and tidal volume and had a low atelectasis rate. The insiratory loading grou still maintained insiratory muscle strength and resistance of resiratory muscles. Corresondence: Eli aria Pazzianotto-Forti emforti@unime.br Financial source: Fundação de Amaro e Pesquisa do Estado de São Paulo FAPESP (2013/ ), Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPQ (445981/2014-8) e Coordenação de Aerfeiçoamento de Pessoal de Nível Suerior (CAPES) Conflict of interest: none Received for ublication: 18/01/2018 Acceted for ublication: 06/03/2018 DESCRITORES - Atelectasia. Exercícios resiratórios. Fisioteraia. Gastrolastia. Obesidade RESUO Racional: A cirurgia bariátrica ode desencadear comlicações ulmonares no ósoeratório devido a fatores inerentes ao rocedimento, sobretudo ela disfunção diafragmática. Objetivo: Avaliar e comarar os efeitos da alicação de dois níveis de ressão ositiva e dos exercícios com carga insiratória na função ulmonar, força muscular insiratória e resistência muscular resiratória e na revalência de atelectasia aós gastrolastia. étodos: Ensaio clínico, randomizado e cego, com sujeitos submetidos à cirurgia bariátrica, alocados em dois gruos: gruo ressão ositiva, que recebeu ressão ositiva em dois níveis, durante uma hora e fisioteraia resiratória convencional e gruo carga insiratória, que realizou exercícios com carga linear ressórica insiratória, seis séries de 15 reetições, além da fisioteraia resiratória convencional, sendo ambos alicados duas vezes no ós-oeratório imediato e três vezes ao dia no rimeiro dia de ós-oeratório. Foram realizados esirometria ara análise da função ulmonar, ressão insiratória nasal ara força muscular insiratória e teste incremental de resistência muscular resiratória ara ressão insiratória máxima sustentada, no ré-oeratório e no dia da alta hositalar, no segundo dia de ós-oeratório. Resultados: Não houve diferença significativa (>0,05) no volume de reserva exiratório e no volume corrente no ré e no ós-oeratório quando comarados intra e intergruo. Não houve diferença significativa (>0,05) na ressão insiratória nasal e na ressão insiratória máxima sustentada no gruo carga insiratória na avaliação intragruo, mas com diferença significativa (<0,05) comarada ao gruo ressão ositiva. A revalência de atelectasias foi de 5% em ambos os gruos sem diferença significativa (>0,05) entre eles. Conclusão: Ambos os gruos, associados à fisioteraia resiratória convencional, reservaram o volume de reserva exiratório e o volume corrente e aresentaram baixo índice de atelectasias. O gruo carga insiratória ainda manteve a força muscular insiratória e a resistência dos músculos resiratórios. 1/5

2 Original Article INTRODUCTION Bariatric surgery is currently considered the most effective treatment for the control and treatment of morbid obesity 14. However, due to the factors associated with this intervention, such as anesthesia, maniulation of the viscera, loss of muscle integrity due to incision, mainly by laarotomy and consequent ain, lead to diahragmatic aresis 4 and restrictive ulmonary behavior 8, with decreasing volumes and ulmonary and resiratory muscle strength in the ostoerative eriod 24,31. Thus, the association of these factors contributes to the occurrence of ulmonary comlications, being the main causes of morbidity and mortality, increased hositalization time and hosital cost 18. In this sense, the use of different hysiotheray resources, including ositive ressure, which romotes ulmonary function restoration and equiment with insiratory resistive load that also aid in the recovery of ulmonary flows and volumes, through increased resiratory muscle strength and endurance 9, favors the reduction of atelectasis, neumonia and time of hositalization 17. However, due to the alication of ositive ressure, esecially in two levels (BIPAP), to decrease diahragmatic activity through artial muscular rest in obese atients 9, the hyothesis of this study was that the use of equiment with linear insiratory ressure load, restoring the insiratory muscle force, could contribute more effectively to the attenuation of the effects of diahragmatic dysfunction resent in the ostoerative eriod of bariatric surgery. Therefore, the objective of this study was to evaluate and comare the effects of ositive airway ressure and exercises with insiratory load on lung function, insiratory muscle strength, resiratory muscle resistance and ulmonary comlications in morbidly obese atients after bariatric surgery. ETHODS It is a rosective, randomized, blind clinical trial. The study was conducted according to Resolution 466/12 of the National Health Council and aroved by the Research Ethics Committee of the ethodist University of Piracicaba (UNIEP) no. 89/12, and the enrolled subjects signed a free and informed consent form. It was registered in Clinical Trials latform number NCT Women aged years with a BI 40 kg/m² and <55 kg/m², who underwent Roux-en-Y gastric byass by laarotomy, were included. They should have normal rior sirometry and chest X-rays, non-smokers, no history of chronic lung diseases, no obstructive slee anea syndrome, or requiring rior ositive airway ressure. Exclusion criteria were hemodynamic instability in the ostoerative eriod, with surgical comlications, remaining more than three days in the hosital (outside the rotocol of the surgical team), who refused to articiate in the study until its comletion or inability to evaluation. Once the inclusion criteria were met, the volunteers underwent a re-oerative evaluation, considered as baseline. After that, randomization by lottery was conducted, where they were allocated in two grous: Positive Pressure Grou (), which erformed ositive ressure in two levels associated with conventional resiratory hysiotheray (FRC) and Grou Load Insiratory (), which erformed insiratory load exercises in addition to the FRC. Of the 49 volunteers evaluated, four were excluded from the study and 45 were randomized, five were not reevaluated and were integrated into the intention-to-treat study, totaling 40 at the end (Figure 1). n=number of subjects in the grou; =ositive ressure grou; =insiratory loading grou; PREOP=reoerative; POSOP=ostoerative FIGURE 1 - Flowchart of the study casuistry, according to the CONSORT Evaluation All volunteers were assessed reoeratively and on hosital discharge on the second ostoerative day, and the researchers were blinded according to their assignments, evaluations, interventions, data treatment, as well as to two radiological examinations. In the ostoerative evaluation, a visual analogue scale was used to classify the ain10 in order to minimize its interference. If the referred ain intensity was greater than or equal to 4, analgesics were given as rescribed by the hysician. The evaluation was started after 30 min if the ain intensity was less than or equal to 3. Anthroometric data Body mass and height were obtained through a digital scale, and the body mass index (BI) was calculated by means of the equation: body mass (Kg) / stature 2 (m). Pulmonary function A comuterized ultrasound sirometer with flow sensor (icroquark; Cosmed, Rome, Italy) was used to evaluate lung volumes, flows and caacities, following the norms recommended by the American Thoracic Society 1 and the guidelines for lung function tests 25. Slow vital caacity maneuvers (SVC), forced vital caacity (FVC) and maximal voluntary ventilation (VV) were erformed, with the highest values of the variables being comuted. Insiratory muscle strength and maximal insiratory ressure (IP) It was erformed with the urose of rescribing the insiratory load of the insiratory owerbreathe K3, by means of the VD 300 digital manovacuometer (Globaled, RS, Brazil), from the residual volume (VR) 7, with sustained effort by at least 2 s. At least five maximal insiratory efforts, technically accetable and reroducible, with values close to each other ( 10%) were requested. For the analysis of the data, the highest value was recorded 22. Nasal insiratory ressure (PIN) For this measurement, the Sniff technique, generated by a nasal ressure eak from the functional residual caacity (CRF), was used through a silicone nasal lug connected to a VD 300 digital manovacuometer (Globaled, RS, Brazil). Ten maneuvers were requested 21, with an interval of 30 s between 2/5

3 AIRWAY POSITIVE PRESSURE VS. EXERCISES WITH INSPIRATORY LOADING FOCUSED ON PULONARY AND RESPIRATORY USCULAR FUNCTIONS IN THE each one, using as the criterion for selection of the accetable Sniff, generation of the highest ressure eak and duration between 0-5 s 30. It is a validated technique, with accuracy and high correlation with IP, being considered its more hysiological execution 27 besides romoting greater comfort, benefits that should be considered in ostoerative atients 15. Resistance of resiratory muscles and maximal sustained insiratory ressure (PImaxS) This test was erformed using Powerbreathe K3 equiment (Gaiam Ltd, Southam, Warwickshire, UK), and volunteers should generate strong, dee insirations followed by comlete exirations. At the end of the exiration, after the cessation of flow, an acoustic signal from the device was emitted, signaling the beginning of a new resiratory cycle 19. The test started with 30% of IP 2, and a load of 10 cm H 2 O was added to each hase of 30 resiratory cycles. After the end of each stage, the volunteer remained in rest for 1 min to restart it. The test was interruted when the redetermined ressure for three consecutive breaths was not reached or if there was a dysnea symtom, with the IP value being the highest sustained load for at least 15 breaths. This device has the differential to load digitally adjustment of the and rovides the data of ower, volume and training index (IT), which aid in the evaluation of the behavior of resiratory muscles. These data reflect, resectively, the energy of the insirations, the resiratory attern and the insiratory work generated 19. For the normal distribution of the data the Shairo-Wilk test was used. Student s t-test or ann-whitney test was alied for the comarison of anthroometric and age characteristics and for intergrou analysis, using the values of the differences between the re and ostoerative eriods. For the intragrou analysis, comaring the re and ostoerative, Student s or Wilcoxon s T tests were used. Fischer s exact test was erformed to assess the revalence of atelectasis in each grou, and a significance level of 5% was adoted for all analyzes. RESULTS Age and anthroometric characteristics The mean age was 38.2±9.40 for and 36.9±5.92 for, and BI of 46.94±4.54 for and 44.66±4.06 for, with no differences between grous for these variables (>0.05). Pulmonary function There was a significant reduction of variables, excet for VRE and VC in both grous (Table 1), but with no significant difference between grous (>0.05). TABLE 1 - Comarison of the measures of the sirometric variables in absolute values and ercentages of the redicted of the Slow Vital Caacity maneuver for each grou in the re and ostoerative eriods, exressed as mean and standard deviation Chest X-ray Thoracic radiograhs were erformed in the osteroanterior incidence, with the subjects in the orthostatic osition, on the day of discharge, and atelectasis were the reorts that mentioned the words atelectasis, ulmonary hyoexansion or hyoexansion of ulmonary field(s), regardless of location and size. Intervention Positive ressure grou This grou received non-invasive ositive ressure on two levels via the BIPAP Synchrony II-Phillis-Resironics (urrysville, Pennsylvania, USA) face mask. The insiratory ositive ressure (IPAP) was initially adjusted to 12 cmh 2 O and readjusted according to tolerance, maintaining resiratory rate (RR) below 30 breaths er minute (rm) and tidal volume around 8-10 ml/kg. Positive airway exiratory ressure (EPAP) was set at 8 cmh 2 O, both adjustments being determined from the Brazilian Recommendations on echanical Ventilation 5. The volunteers remained with the device for one hour, immediately after the return of the anesthetic recovery room and after 4 h and, on the first ostoerative day, three times a day, with interval of 6 h between the sessions. Insiratory loading grou This grou erformed insiratory load exercises using the Powerbreathe K3 equiment, being alied at the same frequency as the revious grou. 40% of the IP 4 value measured in the reoerative eriod was used as resistance. The volunteer was instructed to inhale to overcome the resistance of the device and later to erform normal exiration. Six series were erformed with 15 reetitions each, with a range of s between sets. Both grous also erformed CRF, which consisted of diahragmatic breathing exercises, dee and fractional insirations, resiratory exercises associated with uer limb movement and use of incentive sirometry, with a series of 10 reetitions each exercise, in addition to ambulation 12. Statistical analysis Data were analyzed using SPSS software version CVL (L) CVL (% rev) VRE (L) VRE (% rev) VRI (L) VC (L) ±0.58 ± * ±8.52 ± * ±0.22 ± ±16.16 ± ±0.50 ± ±7 ± ±0.42 ± ±8.24 ± ±0.23 ± ±17.94 ± ±0.31 ± ±4 ± Pre=reoerative; ost=ostoerative; n=number of subjects; =ositive ressure grou; =insiratory loading grou; CVL=slow vital caacity; VRE=exiratory reserve volume; VRI=insiratory reserve volume; VC=tidal volume; % rev=ercentage of redicted; L=liter; =average; SD=standard deviation; *=significant difference between re and ostoerative=<0.05 In relation to forced vital caacity (FVC) and its consequences, there was a significant difference (<0.05) with reduction of all ostoerative values in both grous, but without significant difference between them (>0.05). Regarding maximum voluntary ventilation (VV), desite the significant difference (<0.05), which was a reduction in relation to the reoerative eriod, in both grous ostoerative values were above 80% of redicted, that is, maintaining a normality attern (Table 2). There was no significant difference between grous (=0.08). Insiratory muscle strength and resiratory muscle resistance Table 3 shows a significant reduction of PIN, PImaxS and their unfolding, excet IT in, with maintenance of these values, excet volume in the. 3/5

4 Original Article TABLE 2 - VV values for each grou in the re and ostoerative eriods, exressed in absolute values and redicted ercentages, in mean and standard deviation. VV (L) VV (% rev) ±17.29 ± ±14.83 ± ±13.24 ± ±12.21 ± Pre=reoerative; ost=ostoerative; n=number of subjects; L=liter; =ositive ressure grou; =insiratory loading grou; VV=maximal voluntary ventilation; % rev=ercentage of redicted; =average; SD=standard deviation; significant difference between the re and ostoerative eriods=<0.05 TABLE 3 - Comarison of the measures of PIN, PImaxS, otency, volume and training index for each grou in the re and ostoerative eriod. Values exressed as mean and standard deviation. PIN (cmh20) PImáxS (cmh20) POTENCY (W) VOLUE (L) IT (%rev) ±16.35 ±19.80 ±15.14 ± * ±8.94 ± * ±1.19 ± * ±3.31 ± * ±31.4 ± ±10.56 ± ±1.23 ± ±0.43 ± * ±18.0 ± =ositive ressure grou; =insiratory loading grou; n=number of subjects; re=reoerative; ost=ostoerative; PIN=nasal insiratory ressure; CmH 2 0=centimeters of water; PImaxS=sustained maximum insiratory ressure; W=watt; L=liter; IT=training index; % rev=ercentage of redicted; =average; SD=standard deviation; * significant difference between the re and ostoerative eriods=<0.05 Comaring these values between the grous, there was a significant difference (=0.04) in PIN, demonstrating sueriority in maintaining this value in relation to GPG. The revalence of atelectasis in the resective grous was 5% in both grous, with no significant difference between them (=1). DISCUSSION The resent study demonstrated the maintenance of the sirometric values of VRE and VC in both grous, and the ICG still managed to maintain the PIN and PImaxS. These findings are of great relevance, since ulmonary mechanics is altered ostoeratively, with an increased risk of atelectasis 34. A review by Delgado and Lunardi 10 showed that the main and most frequent resiratory change in the ostoerative eriod of bariatric surgery was sirometry, with the reduction in CV being the most reorted. Regarding VRE, morbidly obese individuals resent, indeendently of having undergone abdominal surgery, a reduction in this value when comared to non-obese 20, being the most frequent finding in these individuals 28. It is known that its reservation in the ostoerative eriod may contribute to a decrease in atelectasis during this eriod, as observed by Baltieri et al. 4, who alied non-invasive ositive ressure in two levels for 1 h after the end of bariatric surgery, evidenced restoration of VRE and reduction of the revalence of atelectasis. Such benefits are romoted by the alication of ositive ressure at two levels by the combination of insiratory ressure with ositive ressure at the end of exiration, allowing recruitment of the collased alveolar zones, thereby imroving ulmonary function 30. In relation to the insiratory load devices, Westerdahl et al. 33 roosed that the more otent the muscle contraction, due to stronger the resiratory muscle romoted by them, greater is the transulmonary ressure gradient generated, thus mobilizingmore air volume 29. Postoeratively, in addition to the sirometric reduction, there is a decrease in IP, which reflects the diahragmatic dysfunction 13, also observed in this study, due to the decrease in PIN, identifying the muscular inefficiency romoted by the factors inherent to the surgical rocedure, reviously described. In the study by Casali et al. 9, desite the significant reduction in resiratory muscle strength on the second ostoerative day, the grou that erformed exercises with insiratory load showed a return of baseline values of insiratory muscle strength earlier than the control grou. Both grous were followed u until the 30 th ostoerative day, with an 8% loss in the IP of the control grou, whereas in the grou that carried insiratory muscle load, there was a gain of 13%. In the resent study, the ICG was able to maintain the PIN on the second ostoerative day. Regarding resiratory muscle resistance, it reflects the ability of the muscle to suort loads, which may be increased in situations that imly greater demands, such as resiratory comlications. The exercise rogram with insiratory load used as a roosal for intervention in the resent study should not be understood as insiratory muscle training, since the time of accomlishment was short, and it is not ossible during this eriod, a change in the tye of muscle fibers. However, it is suggested that the reservation of resiratory muscle resistance, evidenced in this study by the maintenance of IPs and normal values of VV (redicted %) in the ICG, may contribute to the reduction of dysnea and exercise tolerance, as found by Villiot -Danger et al. 32 and, consequently, in the revention of ulmonary comlications. For PImaxS and its consequences, there was a significant reduction in, excet for IT, in addition to the normal value of VV (redicted %), which could be justified by the imrovement of ulmonary mechanics romoted by ositive ressure, favoring a better erformance of the resiratory musculature. Regarding the maintenance of these variables, excet volume in the, it can be concluded that the insiratory load exercises with the PowerBreathe romoted maintenance of muscular erformance, combining strength and seed, but were not able to maintain the amount of air insired during the incremental test. The low revalence of atelectasis, 5% for both grous, is ossibly due to the maintenance of VRE, volume associated with CRF, which may have favored greater ulmonary stabilization. It is emhasized that all atelectases were subclinical, not romoting any functional imact. This result is relevant, since according to Baltieri et al. 3, the incidence of atelectasis in the ostoerative eriod of bariatric surgery reaches 37.8%. In addition, no other ulmonary imairment was found in the analysis of chest radiograhs, being justified by the early onset and number of sessions erformed in the hysiotheraeutic care. Thus, it is suggested that interventions in both grous be effective, demonstrating the imortance of hysiotheray in the revention of ulmonary comlications 23. 4/5

5 AIRWAY POSITIVE PRESSURE VS. EXERCISES WITH INSPIRATORY LOADING FOCUSED ON PULONARY AND RESPIRATORY USCULAR FUNCTIONS IN THE CONCLUSION Both two-level ositive ressure alication and the insiratory load exercises associated with conventional resiratory hysiotheray were beneficial in reserving imortant ulmonary volumes in the revention of ulmonary comlications, as evidenced by the low atelectasis rate. It s highlighted thatthe results romoted by the exercises with insiratory load, which demonstrated sueriority in maintaining insiratory muscle strength and resiratory muscle resistance, suggesting a greater attenuation of the effects of diahragmatic dysfunction resent in the ostoerative eriod of bariatric surgery. REFERENCES 1. American Thoracic Society, Euroean Resiratory Society.ATS/ERS. Task Force: Standardisation of lung function testing. Standardisation of Sirometry. Eur Resir J. 2005;26: American Thoracic Society, Euroean Resiratory Society.ATS/ERS. 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