Deep Breathing Exercise With Incentive Spirometer Started in the Preoperative Period

The Effect of Deep Breathing Exercise With Incentive Spirometer Started in the Preoperative Period in Patients Undergoing Open Cardiac Surgery on Pulmonary Function and Complications: A Randomized Controlled Study

Open cardiac surgery is an important treatment method that is frequently used in the treatment of complicated atherosclerotic ischemic heart disease and heart valve diseases.

It is emphasized that respiratory functions decrease significantly after cardiac surgery, especially in the immediate post-operative period. Therefore, despite significant progress in the field of cardiopulmonary bypass and anesthesia technique, pulmonary complications after cardiac surgery are still seen as the main cause of other negative outcomes such as morbidity, mortality, and long-term hospitalization.

Cardiac surgery patients are especially at high risk for the development of postoperative pulmonary complications (PPC).

It has been reported that deep breathing exercises improve postoperative lung expansion and ventilation, resulting in a significant reduction in pulmonary complications.

Postoperative respiratory physiotherapy techniques include techniques such as early mobilization, positioning, breathing exercises, active breathing techniques cycle, as well as the use of different mechanical devices such as incentive spirometry (IS), positive expiratory pressure mask therapy, and continuous positive airway pressure. Incentive spirometry (IS) is a mechanical breathing device that provides slow deep breathing and gives visual feedback and is used as one of the important interventions in the prevention of PPC in patients who have been undergoing open heart surgery for many years.

In studies examining the effectiveness of deep breathing exercise with IS on the development of PPC in open cardiac surgery patients, it is seen that IS application is performed in the postoperative period , it is noteworthy that there is no study examining the effectiveness of preoperative IS application. In the light of this information, the aim of this study is to evaluate the effect of deep breathing exercise with incentive spirometry initiated in the preoperative period on pulmonary function and complications in patients undergoing open heart surgery.

Study Overview

• Status: Completed
• Conditions: Breathing Exercises
• Intervention / Treatment: Behavioral: deep breathing exercises with a incentive spirometer

Detailed Description

Open cardiac surgery is an important treatment method that is frequently used in the treatment of complicated atherosclerotic ischemic heart disease and heart valve diseases. Complications after cardiac surgery include; supraventricular tachycardia, atrial fibrillation, bradycardia, perioperative myocardial infarction, cardiac arrest, Postoperative pulmonary complications (PPC) such as pneumonia, atelectasis and pleural effusion . It is emphasized that respiratory functions decrease significantly after cardiac surgery, especially in the immediate post-operative period. Therefore, despite significant progress in the field of cardiopulmonary bypass and anesthesia technique, pulmonary complications after cardiac surgery are still seen as the main cause of other negative outcomes such as morbidity, mortality, and long-term hospitalization. Cardiac surgery patients are especially at high risk for the development of PPC. In approximately one-quarter of patients who undergo cardiac surgery without chronic respiratory dysfunction, a mild respiratory tract infection develops ranging from oxygen therapy to acute respiratory failure requiring invasive or non-invasive mechanical ventilation support. Among the factors that cause the development of PPC; surgical stress and anesthesia, cardiopulmonary bypass causing a systemic inflammatory response and oxidative stress that causes pulmonary ischemia-reperfusion injury, type of surgery, pain management, anesthesia protocol, use of blood products, and diaphragmatic dysfunction.

Despite advances in surgical technique and pre- and postoperative care practices in cardiac surgery, PPC is still an important problem. PPC, cost of patient care, increased morbidity and mortality and length of hospital stay elongation. Due to the absence of effective deep inspiration and coughing due to postoperative pain and anxiety, secretion accumulation and gas exchange are ineffective. In a study, it was determined that after coronary artery bypass graft (CABG), 1-20% of patients were hospitalized again in the first 30 days after discharge due to respiratory system complications and 0.4-22.5% of pleural effusion. Various respiratory physiotherapy methods are used for the prevention and treatment of PPC after cardiac surgery. The main purpose of respiratory physiotherapy is to improve ventilation-perfusion compatibility, increase lung volume, increase mucociliary clearance and reduce pain. It has been reported that deep breathing exercises improve postoperative lung expansion and ventilation, resulting in a significant reduction in pulmonary complications. Postoperative respiratory physiotherapy techniques include techniques such as early mobilization, positioning, breathing exercises, active breathing techniques cycle, as well as the use of different mechanical devices such as incentive spirometry (IS), positive expiratory pressure mask therapy, and continuous positive airway pressure. Incentive spirometry (IS) is a mechanical breathing device that provides slow deep breathing and gives visual feedback and is used as one of the important interventions in the prevention of PPC in patients who have been undergoing open heart surgery for many years. Deep breathing exercise training with IS is given to the patients in the preoperative period, and its application is started in the postoperative period. However, it has been reported that insufficiency of physical adaptation and respiratory muscle weakness in the preoperative period are closely related to PPC, which causes prolonged hospital stay and increased mortality. In a meta-analysis study examining the effectiveness of preoperative exercise training for the prevention of PPC in adults undergoing major surgery, it was found that preoperative exercise training minimizes the use of hospital resources, improves physical fitness, and reduces the risk of developing PPC, regardless of the type of surgery. In a meta-analysis study examining the effectiveness of preoperative and postoperative rehabilitation in patients with lung cancer, it was determined that preoperative rehabilitation was effective in reducing postoperative pulmonary complications and hospital stay associated with lung cancer surgery. In studies examining the effectiveness of deep breathing exercise with IS on the development of PPC in cardiac surgery patients, it is seen that IS application is performed in the postoperative period, it is noteworthy that there is no study examining the effectiveness of preoperative IS application.

In the light of this information, the aim of this study is to evaluate the effect of deep breathing exercise with incentive spirometry initiated in the preoperative period on pulmonary function and complications in patients undergoing open heart surgery.

Research Hypotheses H1: Oxygen saturation measured using the pulse oximeter TBY200 will be significantly higher in patients undergoing open heart surgery and initiating deep breathing exercise with IS in the preoperative period.

H2: Arterial blood gas parameters (pH: 7.35-7.45, PaCO2:35-45 mmHg PaO2:80-100 mmHg, SaO2: 95-97%, HCO3:22-26 mEq/L) in patients who underwent open heart surgery and started deep breathing exercise with IS in the preoperative period will have significantly more normal values.

H3: Postoperative pulmonary complications will develop significantly less in patients undergoing open heart surgery and initiating deep breathing exercise with IS in the preoperative period.

H4: In patients undergoing open heart surgery and initiating deep breathing exercise with IS in the preoperative period, the duration of mechanical ventilation will be significantly shorter.

H5: In patients undergoing open heart surgery and initiating deep breathing exercise with IS in the preoperative period, the length of stay in the intensive care unit will be significantly shorter.

H6: In patients undergoing open heart surgery and initiating deep breathing exercise with IS in the preoperative period, the postoperative hospital stay will be significantly shorter.

• Study Type: Interventional
• Enrollment (Actual): 72
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Hatice ÖNER CENGİZ, PhD.; Phone Number: +905542672908; Email: htcnr8878@gmail.com
• Study Contact Backup: Name: Zeynep ULUŞAN ÖZKAN, MD; Phone Number: +905324740268; Email: ulusanzeynep@hotmail.com

Study Locations

• Turkey
  • Ankara
    • Altındağ, Ankara, Turkey
      • Hatice ÖNER CENGİZ
      • Contact: Hatice ÖNER CENGİZ, PhD.; Phone Number: +905542672908; Email: htcnr8878@gmail.com
      • Contact: Zeynep ULUŞAN ÖZKAN, MD; Phone Number: +905324740268; Email: ulusanzeynep@hotmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• 18 years and over,
• Able to speak and understand Turkish,
• Conscious, oriented and cooperative,
• First time undergoing cardiac surgery,
• In the Preoperative Chest Diseases Consultation, it was determined that there was no lung pathology and bronchodilator treatment was not started,
• Coronary artery bypass graft (CABG), heart valve surgery or combined open cardiac surgery,
• Having a score of 1 on the Medical Research Council Scale (MRCS),

Exclusion Criteria:

• Emergency surgical intervention applied,
• Complete (100%) occlusion of the left main coronary (LMCA) or right main coronary artery,
• With concomitant vascular aneurysm,
• Chronic respiratory system disease (Asthma, COPD, bronchiectasis, bullous lung, etc.),
• Those who do not agree to participate in the study,
• Died in the process of working,
• Patients for whom data cannot be collected will be excluded.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control group; The control group is the group that receives standard clinical care.
Experimental: deep breathing group; The intervention group is the group in which the investigators applied deep breathing exercises with incentive spirometer starting from the preoperative period.	Behavioral: deep breathing exercises with a incentive spirometer; Deep breathing exercise will be explained to the patients with an incentive spirometer (IS), it will be demonstrated in practice and it will be applied from the first day of hospitalization in addition to routine treatment and care. The patient will be informed about whether they are doing it right and their questions will be answered. It will be ensured that the patients start after breakfast in the morning and make 5-10 inspirations, hold her/his breath for 3 seconds and 5-10 expirations per hour with IS until they fall asleep. The research nurse will warn the patients that they should do the exercise every hour, and the alarms of the patients' mobile phones will be set to ring every hour to be a warning. The start and end time of the exercise will be decided together with the patient, and usually the time of waking and going to bed will be taken into account.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Respiratory rate1	the respiratory rate will be counted by the research nurse the first day of hospitalization.	within 24 hours of hospitalization
Respiratory rate3	the respiratory rate will be counted by the research nurse the day after surgery.	up to 24 hours
SpO2 level1	the SpO2 level of patients will be evaluated the first day of hospitalization.	within 24 hours of hospitalization
SpO2 level2	the SpO2 level of patients will be evaluated the day before surgery.	up to 24 hours
SpO2 level3	the SpO2 level of patients will be evaluated the day after surgery.	up to 24 hours
Arterial blood gas parameters-pH1	Arterial blood gas parameters of the patients on the first day of hospitalization will be evaluated	within 24 hours of hospitalization
Arterial blood gas parameters-O2-1	Arterial blood gas parameters of the patients on the first day of hospitalization will be evaluated	within 24 hours of hospitalization
Arterial blood gas parameters-CO2-1	Arterial blood gas parameters of the patients on the first day of hospitalization will be evaluated	within 24 hours of hospitalization
Posteroanterior chest X-ray-1	All patients' first PA X-rays taken on the first day of hospitalization will be evaluated by the investigator.	within 24 hours of hospitalization
Postoperative pulmonary complication	Defined as the occurrence of at least 1 pulmonary complication among atelectasis, pleural effusion, respiratory failure, pneumonia, pneumothorax, bronchospasm, or aspiration pneumonia. The presence of the developing condition, diagnosed by the doctor, was determined as the criterion. This will be evaluated by the Investigator physician and nurse.	Before discharge (up to 14 days)
Respiratory rate2	the respiratory rate will be counted by the research nurse the day before surgery.	up to 24 hours before surgery
Respiratory rate4	the respiratory rate will be counted by the research nurse on the day of discharge.	up to 24 hours
SpO2 level4	the SpO2 level of patients will be evaluated on the day of discharge.	up to 24 hours
Arterial blood gas parameters-saO2-1	Arterial blood gas parameters of the patients on the first day of hospitalization will be evaluated	within 24 hours of hospitalization
Arterial blood gas parameters-HCO3-1	Arterial blood gas parameters of the patients on the first day of hospitalization will be evaluated	within 24 hours of hospitalization
Arterial blood gas parameters-pH2	Arterial blood gas parameters of the patients before surgery will be evaluated .	up to 24 hours
Arterial blood gas parameters-O2-2	Arterial blood gas parameters of the patients before surgery will be evaluated	up to 24 hours
Arterial blood gas parameters-CO2-2	Arterial blood gas parameters of the patients before surgery will be evaluated	up to 24 hours
Arterial blood gas parameters-saO2-2	Arterial blood gas parameters of the patients before surgery will be evaluated	up to 24 hours
Arterial blood gas parameters-HCO3-2	Arterial blood gas parameters of the patients before surgery will be evaluated	up to 24 hours
Arterial blood gas parameters-pH-3	Arterial blood gas parameters of the patients postoperative first day will be evaluated .	up to 24 hours
Arterial blood gas parameters-pO2-3	Arterial blood gas parameters of the patients postoperative first day will be evaluated .	up to 24 hours
Arterial blood gas parameters-pCO2-3	Arterial blood gas parameters of the patients postoperative first day will be evaluated .	up to 24 hours
Arterial blood gas parameters-psaO2-3	Arterial blood gas parameters of the patients postoperative first day will be evaluated .	up to 24 hours
Arterial blood gas parameters-HCO3	Arterial blood gas parameters of the patients postoperative first day will be evaluated .	up to 24 hours
Arterial blood gas parameters-pH.4	Arterial blood gas parameters of the patients on the day of discharge will be evaluated .	up to 24 hours
Arterial blood gas parameters-pO2.4	Arterial blood gas parameters of the patients on the day of discharge will be evaluated .	up to 24 hours
Arterial blood gas parameters-pCO2.4	Arterial blood gas parameters of the patients on the day of discharge will be evaluated .	up to 24 hours
Arterial blood gas parameters-psaO2.4	Arterial blood gas parameters of the patients on the day of discharge will be evaluated .	up to 24 hours
Arterial blood gas parameters-HCO3.4	Arterial blood gas parameters of the patients on the day of discharge will be evaluated .	up to 24 hours
Posteroanterior chest X-ray-2	All patients' last PA X-rays taken on the day of dischargewill be evaluated by the investigator.	up to 24 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Length of stay in mechanical ventilation	The time from the moment the patients are intubated until they are extubated will be recorded in "hours".	up to 24 hours
Length of stay in intencive care unit(ICU)	The time from the moment the patients are ICU. It will be recorded in "days".	Before discharge ICU (up to 1 day)
Length of hospitalization	Postoperative stay will be calculated in days from the first postoperative day. This will be evaluated by the investigative nurse. It will be recorded in "days"	Before discharge (up to 14 days)

Collaborators and Investigators

• Sponsor: Ankara University
• Investigators: Study Director: Hatice Öner Cengiz, PhD., Ankara University; Principal Investigator: Zeynep ULUŞAN ÖZKAN, MD, university of health sciences ankara education and research hospital; Principal Investigator: Eylem GANİ, Nurse, university of health sciences ankara education and research hospital

Study record dates

Study Major Dates

• Study Start (Actual): June 25, 2022
• Primary Completion (Actual): January 26, 2023
• Study Completion (Actual): January 26, 2023

Study Registration Dates

• First Submitted: June 8, 2022
• First Submitted That Met QC Criteria: June 17, 2022
• First Posted (Actual): June 23, 2022

Study Record Updates

• Last Update Posted (Estimate): March 3, 2023
• Last Update Submitted That Met QC Criteria: March 1, 2023
• Last Verified: March 1, 2023

More Information

Terms related to this study

• Keywords: Postoperative Complications; Breathing Exercises; Cardiac Surgical Procedures
• Additional Relevant MeSH Terms: Pathologic Processes; Respiratory Tract Diseases; Respiration Disorders; Respiratory Aspiration
• Other Study ID Numbers: OnerCengizH

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No