Comparative Study between Different Pulmonary Rehabilitation Programs in Patients Undergoing Coronary Artery Bypass Graft

Transcription

1 Med. J. Cairo Univ., Vol. 82, No. 2, June: , Comarative Study between Different Pulmonary Rehabilitation Programs in Patients Undergoing Coronary Artery Byass Graft EL SAYED H.A. MOHAMED, M.Sc.*; BASANT H. EL-REFAY, Ph.D.** and LOTFY M. ESSA, Ph.D.*** The Deartments of Physical Theray, Nasser General Hosital, Ministry of Health*, Physical Theray for Cardiovascular/Resiratory Disorder & Geriatrics, Faculty of Physical Theray, Cairo University** and National Heart Institute*** Abstract Background: Coronary artery byass graft (CABG) is still associated with frequent develoment of ostoerative ulmonary comlications, which are articularly concerning given its link to increased atient morbidity and mortality and resource utilization. Aim of the Work: The aim of this study was to comare between the effects of different rehabilitation rograms ost coronary artery byass graft. Subjects and Methodology: Forty-five atients of both sexes (22 women and 23 men) who underwent coronary artery byass graft were enrolled in that study for five days while inatient eriod. Their ages ranged from years. They were assigned into three s with equal numbers (control, Buteyko breathing technique and incentive sirometer ). Arterial blood gases (, PH, Hco 3 and PaCO2) were measured for the three s at the beginning of the study (1 st day ostoerative) and after the end of training (5 th day ostoerative). Results: There was significant imrovement in arterial blood gases including an increase in and PH, while there was significant decrease in PaCO 2 and Hco 3, (<.5) for three s. Significant difference was noted between three s ostoeratively, in favor of incentive sirometer. Conclusion: Both Buteyko breathing technique and incentive sirometer induce significant imrovement in arterial blood gases after Coronary Artery Byass Graft surgery, in favor of incentive sirometer. Key Words: Buteyko breathing technique Incentive sirometer Coronary artery byass graft. Introduction CORONARY Artery Byass Graft (CABG) is a surgical rocedure erformed to relieve angina and to reduce the risk of death from coronary artery Corresondence to: Dr. Basant H. El-Refay, The Deartment of Physical Theray for Cardiovascular/Resiratory Disorder & Geriatrics, Faculty of Physical Theray, Cairo University disease. Arteries or veins from elsewhere in the atient s body are grafted to the coronary arteries to byass atherosclerotic narrowing and to imrove the blood suly to the coronary circulation sulying the myocardium [1]. Postoerative ulmonary imairment is common in the early eriod after cardiac surgery. Chest hysiotheray is widely used in ostoerative care to revent ulmonary comlications such as decreased lung volumes, atelectasis, decreased oxygenation and neumonia [2]. Incentive sirometry () combined with hysical theray is more effective than ostoerative hysical theray alone in reducing ostoerative comlications after CABG surgery [3]. The benefits attributed to include the amelioration of atelectasis and imroved coughing mechanism due to imroved insiratory caacity and a strengthening of the diahragm. The atient can assume resonsibility for their own treatment, thus reducing the amount of direct atient contact time with the theraist [4]. The Buteyko method is a series of reduced-breathing exercises, although variations exist among teachers of the technique in different countries, the three core rinciles of Buteyko remain the same nasal-breathing, breath-holding and relaxation. The Buteyko method was designed to teach asthmatics to breathe less. The goal is to retrain breathing to a normal attern [5]. A number of clinical trials indicate that it is a successful treatment for asthma; however, there is little suort for the CO 2 theory that underins the Buteyko Method. There are, however, many other ossible reasons that the breathing techniques used by the Buteyko Method work. These reasons include change in symtom ercetion and imroved sense of control, imroved biomechanics of breathing, beneficial effects of low-volume breathing, altered nitric oxide (NO) levels, and resetting of resiratory rhythm generation by breath-holding techniques 183

2 184 Comarative Study between Different Pulmonary Rehabilitation [6]. vious studies have shown the effect of on ost oerative ulmonary comlications (PPCs) of CABG. The aim of this work was to evaluate the additive effect of Buteyko breathing technique to ost-oerative rehabilitation rogram and comare its effects versus incentive sirometer on arterial blood gases after CABG. Material and Methods Particiants: Forty-five atients of both sexes (22 women and 23 men), their ages ranged from years who underwent CABG and were selected randomly from National Heart Institute where the study was conducted. Patient s demograhic data, clinical characteristic and all medical history was collected from the admission sheets to ensure that all atients were clinically and medically stable. Their Body mass index (25: 29.9kg/m 2 ). Post oerative ain was controlled medically. They were assigned into three s with equal numbers:, Buteyko breathing technique () and incentive sirometer (). The study was conducted from March 212 March 214. Exclusion criteria: Patients who had met one of the following criteria were excluded from the study: Obese atients (BMI >_3Kg/m 2 ), atients who had develoed hemodynamic comlications (e.g. reoerative myocardial infarction, lung congestion or atients on Intra-aortic balloon), Post-oerative renal failure or arrhythmia needed for a acemaker, ost-oerative mechanical ventilation (more than 24 hours) and history of smoking. Instrumentation: 1- For assessment: Arterial blood gases analyzer: It was used to measure arterial blood gases via arterial blood samle. This was done for each atient before starting the rogram of training (1 st day ostoerative) and was measured also after five days of the training rogram. Arterial blood gases included PaO2, PaCO2, PH and HCO For treatment: Flow-oriented Incentive Sirometer: Triflow II tye (RESPIPROGRAM) was used. It is one tye of flow-centered incentive sirometer. Intervention rogram: oerative rocedures: All atients who were involved in this study had been attended the reoerative meeting and they signed a consent form. All atients had been instructed and taught about the traditional ost - oerative hysical theray modalities including (dee breathing exercises, teach the atient right way of cough mechanism, bed mobility and ambulation exercises). The atients in the were taught about the ost oerative training rogram (Buteyko breathing technique) and the atients in had received instructions for roer use of. Post oerative rocedures: Postoerative hysical theray rogram started when the atient was extubated from mechanical ventilation and hemodynamically stable in the first day ostoeratively and continued after discharge from the ICU for five days ostoerative. The atient's incisional ain had been controlled medically by analgesics if it was intolerable before the assessment. The arterial blood gasses were evaluated before the training rogram. Treatment rograms: The atient had been asked to remember the instructions that had been informed during the re oerative meeting. - The three s trained on traditional ostoerative hysical theray modalities including (dee breathing exercises, teach the atient right way of cough mechanism, bed mobility and ambulation exercise training). - : Patients in this underwent the traditional ost-oerative hysical theray only. - : In addition to the traditional ostoerative hysiotheray, the atients received the designed for 15 minutes, two times er day [7]. - : In addition to the traditional ostoerative hysiotheray, the atient received training for 15 minutes, two times er day [8]. Buteyko breathing technique: Ste 1: The control ause : a- The atient was sitting uright and adats a good osture with relaxed shoulders and rested lower back. b- She/he didn t change breathing before taking control ause (CP). Patient was asked to take a small breath in (insire two sec.) and a small breath out (exire three sec.) hold nose on the 'out' breath, with emty lungs but not too emty until feeling the first need to breathe in. Release nose and breathe in through it [9].

3 El Sayed H.A. Mohamed, et al. 185 Ste 2: Shallow breathing: To monitor the amount of air flowing through his/her nostrils, his/her finger was lacing under the nose in a horizontal osition. Then, to breathe air slightly into the ti of his/her nostrils. For examle, just take enough air to fill the nostrils and no more. Breathe in a flicker of air with each breath. The atient was asked to exhale that to retend that his/her finger is a feather, and to breathe out gently onto his/her finger so that the feather does not move. Breathe out and to concentrate on calming his/her breath to reduce the amount of warm air he/she feel on the finger. As the atient reduces the amount of warm air onto his/her finger, the atient will begin to feel a need or want for air [9]. Ste 3: Putting it together: [9]. Incentive sirometer training: Patient was asked to sit and relax quietly for a few min. and ay attention to their resent breathing. Then he/she hold the sirometer by one hand and the tube, mouthiece by the other hand. Take three to four slow, easy breaths and maximally exhale with the fourth breath. Then, he/she was asked to lace the in his/her mouth and maximally inhale through the sirometer to try to raise the ball in the chamber as high as he can, then hold the insiration for 2-3 sec. before exhaling normally. These stes were reeated for a total of four to five times, and then he/she was instructed to sto and rest for 6 sec. This sequence was reeated for 15min. [8]. Statistical analysis: Descritive statistics was done in the form of mean and standard deviation. Inferential statistics assessed Changes in arterial blood gases including: Paired t-test was used for each variable to comare between the re and ost treatment results for each, analysis of variance (ANOVA) was used for each variable to comare between the re and ost treatment results for the three s together, Least significance difference (LSD) to show the statistical difference between the three s ost treatment. Statistical significance was established at the convention <.5 level. Analysis was done using SPSS version 18 and ercentage of change was calculated according to: Relatives changes ercentage = Results Post x 1 No significant differences were recorded in all anthroometric measurements and clinical data including; age, weight, height and body mass index at the beginning of the study (>.5), as shown in Table (1). Table (1): Descritive data of the three s. Age 49.73±3.81 (yrs) Height 17.67±3.2 (cm) Weight 83.±4.34 (kg) F level 47.6± ± > ± ± > ± ± >..5 BMI 28.7± ± ± >.5 (Kg/m 2 ) BMI = Body mass index. - = Level of significance. The retreatment results of this study showed that there were no significant differences in all measured arameters among three s of atients in the blood gases (>.5) before treatment suggesting roer samle subdivision, as shown in Table (2). Table (2): ANOVA test of arterial blood gases, re treatment, among the three s. F ratio PH 7.34± ± ±.3.72 > ± ± ± >.5 PaCO ± ± ± >..5 HCO ± ± ±.14.6 >.5 - = Level of significance.

4 186 Comarative Study between Different Pulmonary Rehabilitation There were significant differences in all measured arameters of the blood gases for the control in comarison of the re and ost treatment mean s (<.5). The ercentages of imrovement were.14% and 3.1% increase in PH and resectively while 7.4% and 8.95% reduction in PaCO 2 and HCO 3 resectively, as shown in Table (3). Table (3): Statistical analysis of arterial blood gases, re and ost treatment, for the control. SD - * = Standard deviation. = Level of significance. = Significant at - <.5. = Mean difference. % = Percentage. = Increase. = Decrease. Table (4): Statistical analysis of arterial blood gases, re and ost treatment, for. PH 7.35±.2 Post 7.39± ± ±2.39 PaCO ±.8 Post ± HCO ± ± = Level of significance. * = Significant at - <.5. = Mean difference. % of t imrovement % of imrovement.54% 8.2% 7.41% 9.69% % t = Percentage. = Increase. = Decrease. PH 7.34± ± % ± ± % 1.2 PaCO ± ± % HCO ± ± % There were significant differences in all measured arameters of the blood gases for in comarison of the re and ost treatment mean s (<.5). The ercentages of imrovement were.54% and 8.2% increase in PH and resectively while 7.41% and 9.69% reduction in PaCO2 and HCO 3 resectively, as shown in Table (4). There were significant differences in all measured arameters of the blood gases for in comarison of the re and ost treatment mean s (<.5). The ercentages of imrovement were 1.23% and 14.1% increase in PH and resectively while 15.24% and 13.92% reduction in PaCO2 and HCO 3 resectively, as shown in Table (5). Table (5): Statistical analysis of arterial blood gases, re and ost treatment, for. PH PaCO 2 HCO ± ± ± ±.14 Post 7.43± ± ± ± = Level of significance. * = Significant at - <.5. = Mean difference. PH PaCO 2 HCO 3 SD - * 7.35± ± ± ± ± ± ± ±.19 = Standard deviation. = Level of significance. = Significant at - <.5. % of imrovement 1.23% 14.1% 15.24% 13.92% 7.43± ± ± ±.12 t % = Percentage. = Increase. = Decrease. There were significant differences in ost treatment mean s of all measured s between three s in favor of, as shown in Table (6) and Figs. (1-4). Table (6): ANOVA test of arterial blood gases, ost treatment, among the three s F ratio PH <..5 * Fig. (1): Mean s of PH, ost treatment, among the three s.

5 El Sayed H.A. Mohamed, et al Fig. (2): Mean s of, ost treatment, among the three s. Discussion Coronary artery byass graft surgery is erformed daily on a worldwide basis in atients with coronary artery disease. Desite advances in anesthesia rotocols [1], cardioulmonary byass techniques [11] and re and ostoerative care [12], CABG is still associated with the frequent develoment of PPC [13]. The incidence of ostoerative ulmonary comlications (PPC) will most likely continue to remain roblematic secondary to CABG rocedures being more frequently erformed in atients with multile comorbidities [14]. In addition, reoerative factors such as the reduction in functional residual caacity [15], ulmonary gas exchange [16], and cough strength as well as the increase in leural effusion, ain with breathing, and retention of secretions all contribute to increased PPC risk [17] PaCO Resiratory hysiotheray has been roosed to imrove lung function and revent or treat ulmonary comlications in the ostoerative eriod of CABG. Incentive sirometry () is currently used with the intention to PPC revention. To the best of our knowledge, this is the first clinical trial assessing the efficiency of ost CABG. This study aimed also to comare between the effect of and the sirometric training on arterial blood gases after CABG. The main results of the resent study is the demonstration that the use of and are effective in imroving arterial blood gases but is suerior to at inatient eriod after CABG. Fig. (3): Mean s of PaCO 2, ost treatment, among the three s HCO Fig. (4): Mean s of HCO3, ost treatment, among the three s. The change in all measured variables in osttreatment results of the control comes in agreement with Lamari et al., [18] who reorted that conventional chest hysiotheray was effective in bronchial hygiene due to the increased velocity of mucous transortation, the gas exchange and imrovement in the ulmonary function. The current study reflected that imrovement of the ABGs in which was better than conventional hysiotheray intervention only could be exlained by several ossible neurological, biochemicals, and biomechanical athways that may also exlain the Buteyko effect. One ossible biochemical mechanism of Buteyko may be through its influence on NO. Nitric oxide is involved in a large number of hysiological resonses including bronchodilation, vasodilatation, tissue ermeability, immune resonse, oxygen transort, neurotransmission, insulin resonse, memory, mood, and learning. Buteyko ractitioners insistence on nasal

6 188 Comarative Study between Different Pulmonary Rehabilitation breathing at all times is likely to affect NO levels, as a large ercentage of the body s NO levels are made in the aranasal sinuses [19]. The work of breathing is most efficient when coordinated contribution from the diahragm, abdominal muscles, and rib cage muscles results in balanced motion between the uer rib cage and the lower rib cage and abdomen. Unevenness of motion of the chest wall where the uer rib cage movement dominates and lower rib cage exansion is imaired can indicate biomechanically induced dysfunctional breathing that result in hyerinflation and contributes to breathing symtoms such as Dysnea. Peole racticing the Buteyko Method are taught to reduce their volume of breathing by using a combination of increased abdominal muscle tone and relaxation of all the other muscles of breathing, articularly the shoulders and chest [2]. It was roosed that altered breathing attern could contribute to breathing symtoms such as dysnea and that breathing theraies such as might influence symtoms by imroving the efficiency of the biomechanics of breathing [5]. The significant imrovement in all measured variables in could be exlained by resiratory muscle training which enhances lung exansion and insiratory muscle strength; increases roduction of surfactant which leads to reducing surface tension, increasing lung comliance, decreasing the work of breathing and better aeration of the alveoli. The imrovement of total lung and thoracic comliance may be contributed to increase and SaO 2 [21]. Incentive sirometer allows slow maximal insiratory (SMI). During insiration, there is the elevation of balls, which encourages the atient, through a visual feedback, to erform slow and dee insirations. This attern determines the increase of insiratory volumes, increase of transulmonary ressure, imrovement of the erformance of insiratory muscles, thus reestablishing the attern of ulmonary exansion [22]. There was significant difference between the effect of and, in favor of. Incentive sirometer rovides dee breathing exercises. Westerdahl et al., [23] mentioned that a mechanical device could hel atients to remember to carry out the resiratory exercises, and that atients find these devices both useful and motivating. As reviously mentioned, in our case the atients used a flow-based and carried out 3 SMI maneuvers, as well as a daily dee breathing exercises. They found immediate effects of dee breathing erformed on the second ost-oerative day after cardiac surgery, and concluded that there was a significant decrease of the atelectic area, increase in aerated lung area and a small increase in PO 2 after erformance of 3 dee breathing. The results are suorted by Roy [24], who conducted a study to comare between the effect of dee breathing technique and in atients with uer abdominal surgeries. She concluded that the atients in dee breathing technique (DBT) showed more imrovement after a single session of treatment. The chances of PPCs were reduced. As a result, the atient who underwent the intervention involving DBT demonstrates a better result than the of atients who received. Conclusion and Recommendations: The results obtained in the resent study revealed that, and in addition to routine ostoerative hysiotheray rogram in the form of dee breathing, bed mobility, coughing and early ambulation induce significant imrovement in arterial blood gases (, PaCO2, PH and HCO 3) of atients after CABG. Also, there was suer effect of in comarison with the effect of. A limitation of the resent study was short duration which showed incomlete effect of the intervention. It is recommended to add Buteyko breathing technique to the rehabilitation rogram for atients underwent CABG surgery. More researches are needed to study the effect of on CABG at home and to show its effect on other heart surgeries. Further studies are needed to comare between the effect of and PEEP device after CABG surgery. In future, a large study with a follow-u should be conducted to determine the long term effect of the treatment. References 1- SABIK M. and JOSEPH H.: Off-um byass surgery: imroving outcomes for coronary artery byass surgery. Cleveland Clinic Heart Center, the Cleveland Clinic Foundation, HERDY A.H., MARCCHI P.L., VILA A., et al.: -and ostoerative cardioulmonary rehabilitation in hositalized atients undergoing coronary artery byass surgery: A randomized controlled trial. Am. J. Phys. Med. Rehabil., 87: , AGOSTINI P. and SINGH S.: Incentive sirometry following thoracic surgery: What should we be doing? Physiotheray, 95: 76-82, RAFEA A., WAGIH K. and AMIN H.: Flow-oriented incentive sirometeversus volume-oriented sirometer training on ulmonary ventilation after uer abdominal surgery. Egytian Journal of Bronchoulmonary, 3: 2, 29.

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