C hest physiotherapy is routinely used after major

Transcription

1 Efficcy of Brething nd Coughing Exercises in the Prevention of Pulmonry Complictions After Coronry Artery Surgery* Kthy Stiller, B.App. Sc.; Joseph Montrello, M.B.B. S.; Mlcolm Wllce, M. B. B. S. ; Meredith Dft B.App. Sc.; Ruth Grnt, M.App.Sc.; Sue Jenkins, Ph.D.; Bob Hll, M.Sc.; Helen Ytes, B.Nurs. One hundred twenty ptients undergoing coronry rtery surgery completed rndomized controlled study designed to investigte whether prophylctic chest physiotherpy ffected the incidence of postopertive pulmonry complictions. ptients received no preopertive or postopertive chest physiotherpy. ptients received preopertive eduction nd instruction in brething nd coughing exercises nd postopertive supervision nd ssistnce in performing the sme. These exercises were supervised by physiotherpist twice per dy on the first postopertive dys nd once per dy on the rd nd 4th postopertive dys. Physiotherpy for group ptients ws the sme s for group ptients except tht ptients were seen by physiotherpist 4 times per dy on the first postopertive dys nd twice per dy on the rd nd 4th postopertive dys. nd ptients were instructed to prctice brething nd coughing exercises every hour. Overll, n mcidence of cliniclly significnt postopertive pulmonry complictions of 7.5 percent ws demonstrted. In generl, these ptients demonstrted lower levels of preopertive pulmonry function nd very low erly postopertive oxygention compred with those who did not develop pulmonry complictions. There ws no indiction tht the incidence or severity of fever, hypoxemi, chest roentgenologic bnormlities or cliniclly significnt postopertive pulmonry cornplictions ws different between groups. These resuits suggest tht the necessity for prophylctic chest physiotherpy fter routine coronry rtery surgery should be reviewed. (Chest 994; 05:74-4 7) BMI = body mss index; CAS = coronry rtery surgery; Fo = frction of Inspired oxygen; IMA = internl mmmry rtery; LVF = left ventriculr filure; RAil = Royl Adelide Hospitl; UAS = upper bdominl surgery C hest physiotherpy is routinely used fter mjor bdominl nd crdiothorcic surgery with the im of preventing postopertive pulmonry complictions. Two studies hve shown tht, compred with control groups which received no prophylctic chest physiotherpy postopertively, regulr chest physiotherpy significntly the incidence of pulmonry complictions fter upper bdominl surgery (UAS). To dte, no studies investigting the efficcy of chest physiotherpy following coronry rtery surgery (CAS) hve included true control group. The present study ws undertken to investigte whether prophylctic chest physiotherpy significntly the incidence of pulmonry complictions fter GAS. Ptients MATERIALS AND METHODS One hundred twenty-seven consecutive ptients undergoing elective CAS who gve informed written consent were included in the study. Ptients who were unble to understnd written or *:i;;;i Royl Adelide Hospitl, Adelide, South Austrli. Mnuscript received Mrch, 99; revision ccepted July 8. spoken English were excluded from prticiption. After obtining consent, ptients were rndomly llocted by mens of rndom numbers tble to one of three groups. The study ws pproved by the Humn Ethics Committee ofthe Royl Adelide Hospitl (RAH). : Ptients in this group received no chest physiotherpy preopertively or postopertively. : Tretment for this group consisted ofthe usul chest physiotherpy for ptients undergoing CAS t the RAH. This comprised preopertive eduction nd instruction in deep brething nd coughing exercises by physiotherpist. Postopertively, commencing on the morning of the first postopertive dy, physiotherpist supervised nd ssisted tretment twice dy on the first two postopertive dys nd once dy on the third nd fourth postopertive dys. During ny one tretment session, the ptient performed three to five deep breths interspersed with periods of quiet brething followed by two or three coughs or huffs (with wound support). This cycle ws repeted until the ptient s cough sounded dry. In ddition, ptients were instructed to perform these brething nd coughing exercises independently every wking hour. The physiotherpist used dditionl techniques such s positioning nd chest wll vibrtions if brething nd coughing exercises lone were not effective in clering excessive or retined pulmonry secretions. : Ptients in this group were seen by physiotherpist preopertively, four times per dy on the first two postopertive dys nd twice dily on the third nd fourth postopertive dys. Tretment techniques were the sme s for group. Ptients were instructed to perform brething nd coughing exercises every wking hour. CHEST I 05 I I MARCH,

2 Qulified physiotherpists crried out ll tretments s described. No physiotherpy ws given to ptients while they remined intubted. Nursing stff were instructed not to perform brething nd coughing exercises with ny ptients prticipting in the study. Whenever possible, ptients were mobilized by nursing stff ccording to the norml protocol used t the RAH, nmely sitting out of bed on the second postopertive dy, wlking from the third postopertive dy, nd climbing stirs on the seventh postopertive dy. Nursing stff were not informed of the groups to which the ptients were ssigned. Ptients were withdrwn from the study if they required more thn 4 h of mechnicl ventiltion postopertively or if they developed neurologic or crdic complictions which interfered with their bility to cooperte with tretment. Mesurements Preopertively, the ptient s ge, gender, height nd weight were recorded. The body mss index (BMI) ws clculted nd obesity grded. Informtion regrding history nd symptoms of pulmonry disese, current mediction, nd other relevnt pst medicl history were obtined. Ptients were clssified s being ex-smokers if they hd cesed smoking more thn 6 weeks prior to surgery.4 With the ptient sitting out of bed or on the edge of the bed nd wering nose clip, three forced vitl cpcity (FVC) mneuvers were performed using clibrted portble spirometer (Pony model, Cosmed), nd the best of these ws recorded. The following detils were noted from the opertion records: surgeon, left ventriculr function, number of grfts performed nd conduits used, presence of pleurotomy, crdiopulmonry bypss time, nd durtion of nesthesi. Postopertively, time from completion of nesthesi to extubtion, mediction dministered, nd durtion of postopertive hospitl sty were documented. Orl temperture ws documented preopertively, nd the mximum tempertures on the first nd fourth postopertive dys were recorded from the nurses observtion chrts. Arteril blood smples were tken by medicl stff who were blinded to the ptients tretment groups preopertively nd on the first nd fourth postopertive dys. From these, the bsolute vlues of the PO, PCO, nd ph were mesured. Frction of inspired oxygen (Fo) ws recorded with every mesurement nd from this the PO/Fo rtio ws clculted. Postopertively, this rtio ws expressed s percentge ofthe preopertive vlue. Chest roentgenogrms, tken preopertively nd on the first nd fourth postopertive dys, were evluted by rdiologist (MW.) who ws blind to the ptients groups. For ech film, the extent of telectsis, consolidtion, or other pulmonry infiltrte ws noted nd scored s: 0, no bnormlity;, miniml; 7, moderte; 5, mjor. Ech lung ws scored seprtely, the totl score ws clculted, nd the loction nd type of bnormlity were recorded. Other roentgenologic bnormlities were lso documented. The preceding mesurements were tken preopertively to identify preexisting bnormlities nd on the first postopertive dy to indicte ech ptient s sttus s result of surgery. Those tken on the fourth postopertive dy were used to reflect the effect of the presence or bsence of prophylctic chest physiotherpy. Ptients were reviewed by the crdiologist ffilited with the Crdiothorcic Surgicl Unit (J.M.) who identified ptients with cliniclly significnt pulmonry complictions which required tht the ptient no longer remin in his or her llocted group but receive definitive chest physiotherpy. All medicl stff were blind to the ptients groups. Sttisticl Anlysis Anlyses were completed using the JMP sttisticl softwre pckge on McIntosh Powerbook 70 computer. Log-liner modeling ws employed for ctegoricl dt, nlysis of vrince techniques were used for continuous scores, nd nonprmetric tests (Wilcoxon/Kruskl-Wllis tests) were implemented where skewed distributions were encountered. Probbility vlues of less thn 0.05 were deemed significnt. Exminer Relibility Study To investigte the intr-exminer relibility of the rdiologist, the rdiologist ssigned scores to series of chest roentgenogrms obtined from ptients who hd undergone CAS nd repeted this procedure with the sme films 4 to 6 weeks lter. The rdiologist chieved identicl scores for 9 films (88 percent) nd ws within one grde for the other four films ( percent). RESULTS Of the initil 0 ptients included in the study, seven were erly withdrwls following surgery: two from group, three from group, nd two from group. Resons for withdrwl were mechnicl ventiltion for more thn 4 h (four ptients) nd neurologic complictions (three ptients). These seven ptients were replced so tht n equl num- Tble - Preopertive Profiles ofthe 0 Ptients Completing the Study*,- ( = 40) ( = 40) ( = 40) Sex, F/M () 7/ 7/ 8/ Age, yr 6 ± 6 ± 9 6 ± 8 Weight, kg 77.7 ± ± ± 0. Height, cm 7.8 ± ± ± 7.9 BMI 6. ±. 6.7 ± ±.9 Obesity grdet 0() Respirtory history Smokers, Ex-smokers 6 4 Non-smokers Pck yers 7 ± 6 ± 0 6 ± Using () Pulmonry function tests FVC, L.55 ± ± ± 0.9 % predicted 9.8 ±. 9.4 ± ± 9.6 FEV, L.58 ± ± ± 0.7 % predicted 84.8 ± ± ±.0 Pek expritory flow, L s 6.6 ±. 6.0 ± ±. % predicted 79.5 ± ± ± 4.6 FEV,/FVC% 7.0 ± ± ± 6.5 % predicted 90.5 ± ± ± 7.7 FEF5-75%, L s(.4 ±.0. ±..6 ± 0.9 % predicted 6. ± ± ±.6 *Vlues re mens ± SD unless otherwise noted. tobesity grde: 0, BMI of 0 to 4.9;, BMI of 5 to 9.9;, BMI ofo to 40. FEF5-75% = forced expirtory flow between 5 nd 75 percent of FVC. 74 Efficcy of Exercises in Preventing Pulmonry Complictions fter Coronry Artery Surgery (Stiller et!)

3 Tble -Opertive nd Postopertive Profsles* Tble -Arteril Blood Gs Anlyses5 Surgeon /, Totl of grfts Unilterl IMA grfts, Bilterl IMA grfts. Vlve replcement, Pleurotomy, Left ventriculr function, T i pre-opertive 4 ( = 40) 6/4.5 ±.0 8 Dys fter opertion F;unE. Men orl tempertures. Solid br, group ; htched br, group ; open br, group. ( = 40) 8/.8 ±.0 6 ( = 40) 8/.48 ±. 0 Good 0 5 Moderte 0 Poor 4 Not stted 4 Return to OR., Durtion of 9.6 ± ±.5 9. ± 6.9 crdiopulmonry bypss, mm Durtion of nes ± ± ±.7 thesi, mm Time to extubtion, h 0. ±.8 9. ± ±. Totl dosge omnopon, 8. ± ± ± 50.9 mg Additionl ntibiotics, Bronchodiltors, 6 8 Inotropic, diuretic, ntirrhythmic drugs, Length of postopertive sty, d 9.0 ± 5.7 4Vdties re mens ± SDs unless otherwi se noted ± 6.9 ber of ptients remined in ech group ±.6 Descriptive dt, including results of pulmonry function testing, for the 0 ptients who completed the study re given in Tble. Of the 0 ptients, 98 were mle, nd the men ge ws 6.0 yers (rnge, 9 to 79 yers). There were no significnt differences between the groups in the ptients preopertive profiles or pulmonry function test results. Similrly, opertive nd postopertive detils were not significntly different between groups 8.0 Preopertive PO, mm Hg 8.8 ± ± ± 0.5 PCO, mm Hg 9.4 ±.4 9. ± ±.9 ph 7.4 ± ± ± 0.0 Dy P0 5.4 ± ± ± 5.4 PCO 46.6 ± 7, 46. ± ± 5. ph 7,5 ± ± ± 0.04 PO/Fo preopt 50.7 ± ± ± 8. Dy 4 PO 68.7 ± ± ± 4.7 PCO 8. ± ± ±.9 ph 7.44 ± ± ±0.04 PO/FI0 % preopt 77.0 ± ± ± 0. 5Vlues re mens ± SDs. The numbers in ech group preopertively nd on dys nd 4 were group - 9, 9, nd 9; group - 7, 8, nd 8; group - 9, 9, nd 9. fvlue is PO/Fo s percentge of the preopertive vlue. (Tble ). Sixty-nine percent of ptients hd n internl mmmry rtery (IMA) grft s the sole conduit or in combintion with sphenous vein grft. There were no significnt differences between groups in the number of ptients receiving IMA grfts. Six ptients who were reoperted on for control of hemorrhge were included in the study, since they were extubted within 4 h of completion of the initil nesthetic. Figure compres the men orl temperture of ptients llocted to groups,, or. There were no significnt differences between groups t ny stge. Postopertive fever (defined s temperture of 8#{76}Cor higher) on dy ws detected in ptients (, group ;, group ; 8, group ) nd in six ptients on dy 4 (4, group ;, group ;, group ). The incidence of fever ws not significntly different between groups. The bsolute vlues of the rteril blood gs nlyses nd the PO,/Fo rtio vlues (expressed s percentge of the preopertive vlue) re given in Tble. On dy, ll ptients were receiving dditionl oxygen, wheres by dy 4 the mjority of ptients were brething ir. In ll groups, the PO/ FIo rtio ws significntly reduced on the first postopertive dy compred with preopertive vlues (p < 0.00). By the fourth postopertive dy, oxygention hd improved but ws still significntly reduced (p < 0.00) compred with preopertive vlues. There were no significnt differences between groups in these mesurements t ny stge. Chest roentgenogrm findings re shown in Figure. Preopertively, ll except nine ptients hd score of zero. In these nine ptients, evidence of minor telectsis ws present. On the first postop- CHEST 05 I I MARCH,

4 8T I I, I 0 7 t U. l -4 4J n V0 U 4+ 6t 5 + I ri pre-opertive 4 Dys fter opertion 00 I M J Lii Ii nil UI only Rh only bilterl Li other loction I o. Iw 50 on 4J 5 0 $4. nil ertive dy, minor pulmonry infiltrtes were detected in the mjority of ptients (Fig, top). The predominnt findings consisted of telectsis locted in the lower lobes, with the left lower lobe most commonly ffected (Figure, center). Similr findings were detected on the fourth postopertive dy (Fig, bottom). There were insufficient numbers in some ctegories to enble detiled sttisticl nlysis. However, since the frequencies differed by only smll numbers, even in the more commonly occurring ctegories, there ws clerly no suggestion tht significnt differences were present between groups in the chest roentgenogrm scores, the incidence, or the loction of the bnormlities preopertively or postopertively. Pleurl effusions were noted in 7.5 percent of ptients on dy nd in 80.5 percent of ptients on dy 4. On dy, the mjority of the effusions were smll nd locted on the left side, wheres by dy 4 smll bilterl effusions were most common. Neither the mcidence nor severity of pleurl effusions ws obviously different between the groups. Bsed on the crdiologist s review, nine ptients were clssified s hving cliniclly significnt pulmonry complictions necessitting chest physio- FIGuRE. Top, Men roentgenologic scores. Solid br, group ; htched br, group ; open br, group. Center, Incidence nd loction of telectsis on the first postopertive dy. Left lower lobe, LLL; right lower lobe, RLL; lower UI only RLL only bilterl Li other loction lobes, LL. Bottom, Incidence nd loction of telectsis on the fourth postopertive dy. therpy. Dt from these nine ptients re summrized in Tble 4. Of these ptients, three developed pulmonry complictions within h of completion of surgery before chest physiotherpy ws scheduled to commence, indicting tht the complictions could not be ttributed to the presence or bsence of prophylctic chest physiotherpy. For the other six ptients, dignosis of sputum retention or chest infection, or both, ws mde from lte in the fternoon of the first postopertive dy to the third postopertive dy, time when it could be expected tht the presence or bsence of prophylctic chest physiotherpy my hve hd n effect. The low incidence of complictions does not llow detiled sttisticl nlysis; however, there ws certinly no indiction tht the incidence of these complictions ws different between groups (, group ; 4, group ;, group ). All nine ptients, in ddition to intensive chest physiotherpy, required medicl tretment in excess of the stndrd cre given for routine postopertive GAS ptients. The postopertive length of sty of these ptients ws lso significntly prolonged (p = [Tble 4]). Five of the nine ptients who developed cliniclly significnt pulmonry complictions lso hd left 744 Efficcy of Exercises in Preventing Pulmonry Complictions fter CoronryArtery Surgery (Sti!!eretl)

5 Tble 4 - Profiles ofthe Nine Ptients With Cliniclly Significnt Pulmonnj Complictions* Dy Dignosis of Initil Dignostic Signs Dignosis Medicl Mngement Length Postopertive Sty, d of 0- Confused, drowsy, 0-0- ppernce, usculttion, incresed RH & HR, S0 Appernce, usculttion, incresed RH & JVP, Confused, incresed SO usculttion, JVP, SO Appernce, usculttion, incresed HR & HR, SO Appernce, usculttion, fever, incresed RR & HR. SO Appernce, usculttion, fever, incresed HR & hr. SO Appernce, usculttion, fever, incresed RR & FIR, SO Appernce, usculttion, fever, incresed RR, SO Appernce, usculttion, fever, incresed RR & FIR, SO Acute respirtory filure, sputum retention Acute respirtory filure, LVF LVF infection infection, LVF infection, AF, LVF IPPV, inotropes, ntibiotics, 0, CPAP, inotropes, diuretics, 0, diuretics IPPV, ntibiotics, IPPV, ntibiotics,, mnotropes, 0, ntibiotics,, diuretics, gents Chest infection 0, ntibiotics, Chest infection 0, ntibiotics, infection, LVF 0, ntibiotics,, diuretics diuretics ntirrhythmic *RR = respirtory rte; HR = hert rte; SO = sturtion of oxygen; JVP = jugulr venous pressure; AF = tril fibrilltion; IPPV = intermittent positive pressure ventiltion; CPAP = continuous positive irwy pressure. ventriculr filure (LVF). Four of these five ptients hd evidence of respirtory disese (ie, sputum retention nd chest infection) nd the LVF occurred subsequent to the pulmonry compliction. Gonversely, while the other ptient hd severe pulmonry dysfunction, there ws no evidence of respirtory disese nd it becme pprent, with the benefit of retrospection, tht the primry problem ws one of LVF. Compred with the ptients who did not hve cliniclly significnt pulmonry complictions, the nine ptients with these complictions generlly hd lower vlues for preopertive pulmonry function nd very low erly postopertive oxygention. Indeed, the men vlue for these nine ptients ws significntly lower for forced vitl cpcity, percent predicted (p = 0.0), pek expirtory flow (p = 0.04), nd pek expirtory flow, percent predicted (p = 0.009), nd lower for FEY, percent predicted (p = 0.07). On the first postopertive dy, PO ws significntly lower (p = 0.00) s ws the PO/FIo rtio (expressed s percentge of the preopertive vlue) (p = 0.0). However, there were ptients with low vlues for these prmeters who did not develop pulmonry complictions. Results of other pulmonry function tests nd preopertive nd opertive dt were not significntly different between ptients with nd without pulmonry complictions. DIScUSSIoN Although routine chest physiotherpy is widely used fter CAS with the im of preventing pulmonry complictions, reltively few studies could be found which evluted the efficcy of this tretment. 5 In these studies, different regimens of tretment such s brething nd coughing exercises, incentive spirometry, intermittent positive pressure brething, nd periodic ppliction of continuous positive irwy pressure were compred. No tretment regimen ws found to be superior to ny other in the prevention of pulmonry complictions. Dull nd Dull6 nd Jenkins et l found tht the ddition of brething exercises or incentive spirometry to regimen of erly mobiliztion nd coughing conferred no extr benefit fter CAS. However, since no control group ws included in either study, it is not certin if ny prophylctic chest physiotherpy CHEST I 05 I I MARCH,

6 ws required. In the pst, the clinicl importnce of the pulmonry complictions identified in mny studies of postopertive ptients hs been poorly ddressed. In mny instnces, it is likely tht complictions were cliniclly insignificnt, self-limiting, nd my hve resolved spontneously without specific tretment. 6 7 In the mjority of ptients in the present study, the bnormlities of temperture, rteril blood gs vlues, nd roentgenologic findings detected on the first nd fourth postopertive dys were not ccompnied by ny obvious signs of illness, nor did they require specific medicl intervention. On mny occsions the severity of the hypoxemi nd roentgenologic bnormlities did not pper to correlte with the ptient s clinicl condition. Conversely, those ptients identified by the crdiologist s hving cliniclly importnt pulmonry complictions ppered distressed nd demonstrted overt signs of mrked pulmonry dysfunclion. Furthermore, the extent nd type of intervention required in the tretment ofthese ptients nd their extended length of postopertive sty, confirm the clinicl significnce of the pulmonry complictions dignosed in this study. The present study demonstrted n overll mcidence of cliniclly significnt pulmonry complictions of 7.5 percent. There ws no obvious difference between control group nd tretment groups in the incidence of these complictions. Thus, prophylctic chest physiotherpy, t lest s performed in this study, did not seem to decrese the incidence nd severity of fever, hypoxemi, roentgenologic bnormlities, cliniclly significnt pulmonry complictions, or length of postopertive sty. The frequency nd extent of these findings were similr to those previously reported In this study, ptients who developed cliniclly significnt pulmonry complictions hd lower preopertive pulmonry function test results nd very low erly postopertive oxygention, lthough it is recognized tht not ll ptients with low vlues for these prmeters will necessrily develop cliniclly significnt pulmonry complictions. The reson for the filure of prophylctic chest physiotherpy to hve beneficil effect on the prmeters mesured in this study is not certin. The preopertive chrcteristics of the popultion studied were typicl of ptients undergoing CAS, in terms of their ge, the predominnce of mles, degree of obesity, nd their positive smoking history. Certinly, no ttempts were mde to select ptients who were considered to be t low risk of developing postopertive pulmonry complictions. In ddition, there were no significnt differences between groups in these preopertive chrcteristics. Thus, it would seem unlikely tht the filure of prophylctic chest physiotherpy to ffect the mcidence of fever, hypoxemi, roentgenologic bnormlities, nd cliniclly significnt pulmonry complictions could be ttributed to n overll helthier smple of ptients with fewer preopertive risk fctors, or control group comprised ofthe helthier ptients. Similrly, since the opertive detils were comprble between groups this is unlikely to hve influenced the results. It could be rgued tht different chest physiotherpy techniques my hve been more effective. However, given the results ofprevious studies which found no significnt dvntge ssocited with the use of other modlities of tretment, this would seem unlikely. As fr s the frequency of tretment is concerned, no significnt benefit ws identified in the tretment group in this study which received supervised brething nd coughing exercises more frequently. Although ptients were instructed to perform independent brething nd coughing exercises every wking hour, their complince with this ws not mesured. Thus, it is possible, lthough perhps remote, tht greter frequency of supervised chest physiotherpy my hve been of benefit. Since the decrements in pulmonry function which occur fter GAS re s severe if not more so thn those seen fter UAS, it could be nticipted tht UAS nd CAS ptients not receiving prophylctic chest physiotherpy should hve similr incidence of postopertive pulmonry complictions. In the two controlled studies of ptients fter UAS, the incidence ofpulmonry complictions in the control groups ws 88 nd 60 percent, wheres it ws reduced to pproximtely nd 9 percent, respectively, for those groups which received prophylctic chest physiotherpy regimens. Thus, chest physiotherpy in these studies ws significntly nd drmticlly effective. Although direct comprison of results is difficult in view of the different popultions studied nd the vried methods used to dignose pulmonry complictions, some interesting observtions cn be mde. Becuse the ptients received similr tretment regimens, it is unlikely tht vritions in tretment influenced the results to significnt degree. It is certin tht the overll low incidence of pulmonry complictions detected in this study mde it difficult to detect differences between groups. Thus, it would seem tht fctors unique to UAS, such s the incision site nd severity of pin, cough suppression, nd diphrgmtic inhibition, my predispose these ptients to the development of higher incidence of complictions thn tht seen in the GAS popultion, nd thus they would be more responsive to prophylctic therpy. After CAS, ptients pper to be ble to cough nd 746 Efficcy of Exercises in Preventing Pulmonry Complictions fter Coronry Artery Surgery (Stilleret!)

7 cler pulmonry secretions more effectively thn their UAS counterprts, t lest in our experience, nd thus they my not require ssistnce with secretion clernce to prevent pulmonry complictions. While prophylctic chest physiotherpy did not prevent pulmonry complictions fter GAS in this study, it is importnt to stress tht no ttempt ws mde to investigte the effectiveness of chest physiotherpy in the tretment of pulmonry complictions once they occurred. Similrly, the role of physiotherpy in rehbilittion following GAS ws not exmined. The results of this study suggest tht the physiotherpist s role in the mngement of ptients fter routine GAS should chnge. The physiotherpist should continue to ssess ll ptients to detect the presence of cliniclly significnt pulmonry complictions nd selectively tret only these ptients. It is recommended tht institutions where ptients receive prophylctic chest physiotherpy fter GAS should review the necessity for such tretment. ACKNOWLEDGMENT: We wish to thnk D. Crddock nd J. Stubberfield, crdiothorcic surgeons, the interns, registrrs, nd nursing stff of the Crdiothorcic Surgicl Unit nd members of the Physiotherpy Deprtment, RAH, for their coopertion. Also, we cknowledge Nomi Hensel, Physiotherpy Deprtment, for her support nd encourgement. REFERENCES Celli BR, Rodriguez KS, Snider GL. A controlled tril of intermittent positive pressure brething, incentive spirometry, nd deep brething exercises in preventing pulmonry complictions fter bdominl surgery. Am Rev Respir Dis 984; 0:-5 Roukem JA, Crol EJ, Prins JG. The prevention of pulmonry complictions fter upper bdominl surgery in ptients with noncompromised pulmonry sttus. Arch Surg 988; :0-4 Grrow JS. Obesity nd relted diseses. Edinburgh, Scotlnd: Churchill Livingstone, 988; - 4 Perce AS, Jones RM. Smoking nd nesthesi: preopertive bstinence nd periopertive morbidity. Anesthesiol 98; 6: Pien FD, Ho PWL, Fergusson DJG. Fever nd infection fter crdic opertion. Ann Thorc Surg 98; : Dull JL, Dull WL. Are mximl inspirtory brething exercises or incentive spirometry better thn erly mobiliztion fter crdiopulmonry bypss? Phys Ther 98; 6: Vrciu JK, Vrciu RA. Effectiveness ofbrething exercises in preventing pulmonry complictions following open hert surgery. Phys Ther 977; 57: Iverson LIG, Ecker RR, Fox HE, My IA. A comprtive study of IPPB, the incentive spirometer, nd blow bottles: the prevention of telectsis following crdic surgery. Ann Thorc Surg 978; 5: Gle GD, Snders DE. Incentive spirometry: its vlue fter crdic surgery. Cn Anesth Soc J 980; 7: Oulton JL, Hobbs GM, Hicken P. Incentive brething devices nd chest physiotherpy: controlled tril. Cn J Surg 98; 4:68-40 Stock MC, Downs JB, Cooper RB, Lebenson IM, Clevelnd Wever DE, et l. Comprison of continuous positive irwy pressure, incentive spirometry, nd conservtive therpy fter crdic opertions. Crit Cre Med 984; :969-7 Ru JL, Thoms L, Hynes RL. The effect of method of dministering incentive spirometry on postopertive pulmonry complictions in coronry rtery bypss ptients. Respir Cre 988; :77-78 Jenkins SC, Soutr SA, Loukot JM, Johnson LC, Moxhm J. Physiotherpy fter coronry rtery surgery: re brething exercises necessry? Thorx 989; 44: PinillJC, Oleniuk FH, Tn L, Rebeyk I, Tnn N, Wilkinson A, et l Use of nsl continuous positive irwy pressure msk in the tretment of postopertive telectsis in ortocoronry bypss surgery. Crit Cre Med 990; 8: Oikkonen M, Krjlinen K, Khr V, Kuos R, Schvikin L. Comprison of incentive spirometry nd intermittent positive pressure brething fter coronry rtery bypss grft. Chest 99; 99: O Donohue WJ. Postopertive pulmonry complictions. Postgrd Med 99; 9: Stiller KR, Mundy RM. Chest physiotherpy for the surgicl ptient. Br J Surg 99; 79: Jm U, Ro TLK, Kumr P, Kleinmn BS, Belusko RJ, Knuri DP, et l. Rdiogrphic pulmonry bnormlities fter different types of crdic surgery. J Crdiothor Vsc Anesth 99; 5: Singh NP, Vrgs FS, Cukier A, Terr-Filho M, Teixeir LR, Light RW. Arteril blood gses fter coronry rtery bypss surgery. Chest 99; 0:7-4 CHEST I 05 I I MARCH,